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Women’s memories of childbirth and their perceptions of its personal impact have been the subject of a number of investigations, most of which indicate that women have vivid memories of the events and strong feelings about their birth experiences (Hodnett, 2002). Studies of long-term birth memories have found varying degrees of consistence (Bennett, 1985; Simkin, 1990; Simkin, 1991; Waldenstrom, 2003). The intensity of women’s positive or negative feelings often changes over time, especially when compared to their feelings a day or two after the birth.
The immediate relief felt by parents when labor is over and their enchantment with their baby lasts for a few weeks postpartum, and often temporarily overrides negative experiences. However, memories of unpleasant birth aspects, such as complications, frightening moments or decisions, or unexpected or coerced interventions can emerge later as this “halo effect” wears off (Bennett, 1985). Women’s impressions of the psychosocial care they received (i.e., sharing of information and decision making, respectful treatment, attentiveness and emotional support, a welcoming environment, an opportunity to process the birth afterwards) tend to remain consistent over time, and when these impressions are positive, they may be associated with overall satisfaction and positive impressions of their births (Simkin, 1991); Waldenstrom, 2004). When a high degree of attention is given to women’s psychosocial needs there is a long-term positive effect on women’s perceptions of their birth experience (Simkin, 1991).
During labor if a woman experiences unmanageable pain and emotional distress, her body produces hormones called catecholamines. High levels of this hormone can result in a physiological response known as the “fight or flight” response. Because the body cannot distinguish between physical danger and emotional distress, it reacts as if the distress could result in bodily harm. Blood flow to the uterus diverts to the skeletal muscles to aid in fighting or fleeing. This results in the slowing of contractions, and the stall of labor progress. The fetus’ movements and heart rate slow to conserve oxygen for the fetal brain, and in response to this reduction in blood flow the placenta receives less oxygen. This mechanism explains how maternal distress contributes to dysfunctional labor and fetal distress. From this it can be concluded that some labor complications are preventable if excessive pain and maternal distress are avoided (Taylor et al., 2000). If those caring for a laboring woman understand and respond appropriately to possible sources of distress, it may be possible to prevent the surge of catecholamines that interfere with normal labor progress. Doulas are trained to know this and make it a high priority to maintain a relaxed, non-stressful environment in which the woman feels empowered (Odent, 1999). When personal control and involvement in decision-making was present, a woman’s satisfaction with her birth experience was enhanced. Trials that examine this satisfaction level found increased levels of satisfaction among women who had doulas attend them during birth (Hodnett et al., 2004; Simkin & O’Hara, 2002).
“Birth trauma” is an event that can occur during the labor and delivery process that involves actual or perceived threatened serious injury, or death to the mother or her infant. The birthing mother experiences intense fear, helplessness, loss of control and horror (Beck, 2004a, 28). This definition of “birth trauma” is consistent with the definition of “trauma” that applies to any life event, as described in the authoritative Diagnostic and Statistical Manual of Mental Disorders (ADA, 1994). An extensive literature review reports that many studies have surveyed pregnant and/or postpartum women to determine the incidence and causes of birth trauma and Post Traumatic Stress Disorder (PTSD) (Beck, 2004a). Traumatic births are reported as occurring in 33% to 34% of births. Women suffering from these disorders will require time and effort of support to process and resolve their difficulties. Thankfully, most women with birth trauma do not go on to develop the full syndrome of PTSD, however 1.5% to 5.6% are affected (Creedy, Shochet, and Horsfall, 2000; Soet, Brack, & Diloria, 2003; Beck, 2004a). Numerous studies have identified a number of PTSD-associated factors that can occur during the birth process that are preventable. These would include a lack of support, a feeling of not being listened to, a perceived lack of communication or a feeling of being ignored, insensitive caregivers, negative comments from the medical staff, and a feeling of a lack of control by the mother (Beck, 2004b). PTSD can even occur when labor is normal. One study reported an incidence of 3% among 274 women who had normal births; that is they included no obvious physical trauma (Czarnocka, Slade, 2000).
There are no studies specifically investigating the impact of the doula on birth trauma and PTSD. The top priority of doula care, however, is to provide those elements that were almost always missing for women who have PTSD after childbirth – reassurance, expression of needs and feelings, continuing and undivided attention, and a sense of control. The doula supplies the kind of care that may prevent many traumatic births from progression to PTSD. Therefore, the doula plays an essential role in maintaining the psychological and physical well-being of laboring women. A doula can improve short and long-term birth outcomes by encouraging the reduction of catecholamine production in the first stage of labor through striving to maintain a consistent and relaxing environment during labor. A doula can empower the mother and encourage positive communication and information sharing between the parents and the caregivers. She can eliminate much of the fear by bringing her experience and knowledge into the birthing room, and support both parents by supporting a feeling of control in the labor room. A doula strives to nurture and protect a woman’s memories of her birth experience, and help her to process all that happens in a positive way.
In the United States, pregnant adolescent girls – particularly those living in poverty with an unintended pregnancy encounter overwhelming medical and psychosocial challenges. These challenges encompass not only their pregnancy but also their future (Corcoran, 1998). Adequate social support during pregnancy to disadvantaged and non-disadvantaged populations of women improves perinatal outcomes for the mother and her infant (Norbeck, DeJoseph & Smith, 1996; Schaffer & Hoagberg, 1997).
Teens from underserved communities can benefit from a connection to a doula. Goals of community doula programs include increasing knowledge of pregnancy physiology and nutrition; promoting the health benefit of breastfeeding; encouraging high school completion and further education; working toward higher cessation rates of smoking and lower rates of alcohol and illicit drug use; and connecting to community resources that lead to increased access to health care, as well as demonstrating a decreased rate of pregnancy-related illness and infant mortality and morbidity. It has been proven that with doula support teens experience similar benefits and positive birth outcomes with doula support. Teens have a significantly lower cesarean rates, as well as lower epidural rates in comparison to the general population. More than 80% initiate breastfeeding (Altfeld, 2003), and feel encouraged to hold and talk to their babies immediately following birth (Abramson, Altfeld, & Teibloom-Mishkin, 2000). This model of doula support is very personal, and rooted in and embraced by the communities that are being served. These doulas “hold” young families as they experience the challenges of pregnancy, birth and parenting, the value of this kind of support is being revealed through outcomes within the passage of time (Atfeld, 2003).
The program is currently meeting or exceeding its goals. With a cesarean section rate of 12.9%, it is far below the national level of non-doula attended births which is at 60%; low birth weight babies is at 4.8%, compared to the Oregon average of 6.1%; breastfeeding initiation rate is 99%. This is going to have a positive impact on the health of many children, saving future taxpayers and current insurance companies vast amounts of money.
The Chicago Health Connection (CHC) is a Federally-funded program held up as the model maternal-child health organization. They state that the measurable cost savings of community-based doula programs include the thousands of Medicaid dollars saved by an averted cesarean section ($10,000), or an epidural ($3,000), with an additional cost savings possible due to reduced length of hospital stay (24 hours for vaginal delivery, and four days for cesarean or complication birth). There is an additional cost savings to public health from increased breastfeeding, which can total anywhere from $300 to 1,400 per child per month, and $500 per family.
Promoting long-term health benefits such as breastfeeding and achieving personal educational success goals with help these teens to stand on their own two feet to be productive and health citizens. For many of these teen parents, this is the first time they have had a caring adult in their lives who listens to them, and provides useful suggestions and respects their individual choices. This model addresses the disparity of needs for teen parents as a result of diminishing resources, and shows that doulas can have a positive effect on birth outcomes for teens. Birth can be a transformative experience for a teenager. A positive birth experience can transform teens into parents and produce positive long-term benefit implications for their children and families.