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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.
The Many Benefits of Birth Doula Support
The experience of childbirth reverberates throughout a mother’s lifetime. The constantly changing sweep of personal, family, and community history are intertwined with the cultural and psychosocial meaning of birth — for the mother, the child, and the family. In this way, childbirth is seen as one of the critical life events that can either connect a family – or disconnect a family. It is society’s responsibility not to allow the moment of birth to shrink into an invisible, unacknowledged episode of medical intervention. As a society, it is imperative that to rally for the right to birth choice and support.
A great deal of research has been conducted that addresses the positive effects that supportive caregivers, such as doulas and labor assistants, can have on outcomes in women’s childbirth experiences. A doula is an advocate for a woman in labor. Drs. John Kennell and Marshall Klaus used the Greek word “doulos” (meaning a willing servant without the need for bondage), to describe a trained professional that recognizes birth as a key life experience (Klaus, Kennell, & Klaus, 1993). A doula is described as a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother during pregnancy, during labor, and just after childbirth (Klaus, Kennell & Klaus, 1993). Dr. Dana Raphael, an anthropologist, in her book published in 1973 called “The Tender Gift: Breastfeeding,” may have been the first person to publish the title “doula” to identify a female who gives psychological encouragement to a postnatal woman. A doula does not perform clinical tasks, or provide medical care. Instead she focuses on emotional and social support. She may provide education, logistical planning, and social support.
The use of a doula is an innovative option to address complex disparities in health care during pregnancy, labor and postpartum. In the broadest sense of role, a doula is a community health worker (or paraprofessional) who provides skilled and intimate continuity of care throughout the childbearing year.
A great deal of research has been conducted regarding the impact that supportive caregivers such as doulas and labor assistants can have on women’s birthing experiences. A doula’s role encompasses all non-clinical aspects of care. DONA is a certifying doula agency in the United States that trains women to be practicing doulas. Their core standard of ethic is that a doula can provide emotional, mental, and physical support to a mother – but she is unable to perform anything “medical.” She doesn’t take blood pressure, or do cervical checks for dilation, or provided I.V.’s or injections. She simply “mothers the mother.”
More than fourteen randomized clinical trials have been documented in a number of countries that have shown that continuous social, physical, and emotional support can help control pain, reduce the length of labor, and decrease the use of cesarean sections and other invasive procedures (Scott, Berkowitz, & Klaus, 1999; Hodnett, 2002). Other positive effects of support involve increased psychosocial benefits such as healthcare system cost savings, reduced resource utilization, and increased patient satisfaction. Labor support has also been correlated with improved breastfeeding rates (DONA International, 2005; Hodnett, Osborn, 1989; Hodnett, 2002a), and a decrease in postpartum depression (Beck, 2004b; Creedy, Shochet, Horsfall, 2000; Czarnocka, Slade, 2000).
Two hallmark studies were conducted in Guatemala, the first was a randomized control study by Sosa et al. (1980), which studied the amount of time women labored with a supportive birth companion, in comparison to women who did not. This study found that labors were significantly shorter labors for the women with support (8.8 versus 9.3 hours). The second randomized control study by Klaus et. al. (1986) found that supported women had a reduced incidence of cesarean section birth, had fewer perinatal complications, and had a decrease in oxytocin induction/augmentation (Madi et. al., 1999).
Several studies were conducted in North America to determine if these findings could be replicated. The studies all found the same positive outcomes with continuous doula care.
Pascoe (1993) studied nulliparous women who were referred to two community birth companion programs in Michigan from 1983 to 1987. Training was provided to the volunteer doulas (i.e., birth companions). Length of labor was shortened in the group who received continuous doula support during labor.
Gordon et al (1999) randomly assigned laboring women who received care from a health maintenance organization in northern California, to receive care from either a trained doula providing continuous labor support, or to a usual care group. A decrease in epidural anesthesia use was reported from the group of women who were supported by a trained doula.
Hodnett and Osborn (1989) studied the effects of continuous labor support in a North American hospital. Continuous labor support was provided by professional self-employed lay midwives or midwives in training who had previous experience providing continuous intrapartum support to a minimum of twenty laboring women. Although continuous labor support did not have an effect on the length of labor, or the cesarean rate, those participants who received continuous labor support were less likely to need pain relief, and to have episiotomies compared to those who received traditional nursing support.
Campero et. al., 1998 study examined women’s overall experiences with doula support. This qualitative study investigated the experiences of childbearing women who received doula support during the perinatal period. The doulas provided the same support as in the previous studies, and provided further evidence of the importance of forming trusting relationships with caregivers (Hodnett, 2002), and the value of being prepared for birth (Zwelling, 1996). The evidence provided by these trials suggests that lay labor support would be an invaluable addition to modern maternity care in the childbirth and the postpartum period. Despite the health and cost-effectiveness of doula care, one national survey indicated that only about 8% of women have used doulas at their births (Sakala, Declercq & Corry, 2002). It is believed, however that this number has increased substantially in the last decade (Lantz et al, 2005).
The range of doula support varies, as does who the doulas are themselves. The Association of Labor Assistants and Childbirth Educators (ALACE), Birth Works, Childbirth and Postpartum Professional Association (CAPPA), Doulas of North America (DONA), and the International Childbirth Education Association (ICEA) produced a survey recently to examine who doulas are. Current members who were residents of the United States and had started, or completed doula/labor assistant certification were surveyed. A random sample of 1,000 doulas was selected, including 700 certified doulas and 300 with certification in progress. Over 57% of the respondents were certified through DONA. The respondents had the following sociodemographic profile: 94% reported their ethnicity as white, 3% African American, 2% Hispanic, and 1% other ethnic groups. The average age was 40.3, with a range from 20 to 71 years old. The majority of doulas were currently married (82%) and had given birth at least once (88%). In terms of education, almost 49% reported that they had a college degree or more, with 20% credentialed as a nurse or midwife. In addition, one out of three respondents reported prior training in some type of childbirth preparation instruction. The average income in 2002 from doula work was $3,645 amount certified doulas with almost half reporting that they made less than $1,000. The research revealed that doulas represent individuals from a range of academic and professional backgrounds united in their desire to support and enhance the childbirth experience of women. The primary characteristic that differentiates the professional doula from other support people is the technique of continuous care. The professional doula is committed to being present with the laboring woman 100% of the time. The research revealed that doulas represent individuals from a wide range of academic and professional backgrounds whose commonality was in their desire to support and empower women birthing. The primary characteristic that differentiates the professional doula from other medical support professionals is simply that they have the ability to give continuous care. A doula is committed to being present with a laboring woman 100% of the time (Hodnett, 1996).
This blog post investigates how the presence of a birth doula positively impacts expecting parent’s labor and birth experience, thereby encouraging or discouraging closer bonding and positive long-term familial interrelations between parent and infant. The consistency of birth support, care given by a doula, as well as one-on-one doula support has been found to consistently result in positive birth outcomes throughout the newly formed familial system. These positive outcomes encompass the areas of psychosocial, interpersonal, and physiological health. Parents who do not receive the support of a doula have a higher correlation of medicalized births and use of pharmacological interventions, whose effects can cause a disruption of the long-term positive formation of a healthy parent-infant bond, which in effect interrupts a healthy, interactive familial system.
Key words: Doula, birth, childbirth, benefits, bonding, support, healthy family, medicalized birth, pharmacological interventions, natural pain relief measures, positive birth, empowered birth.
This blog post will be posted in sections over the next few weeks. Watch for sections. Today please enjoy the article introduction.
Women maintain vivid memories of the events during their labors and births. They formulate extremely strong feelings about their overall birth experience (Abramson, 2004: Bennett, 1985; Hodnett, 2002) that become embossed and embedded into their everyday lives. The birth of a child is a life-transforming event – a momentous and empowering occasion. A woman’s birth experience can change and revise their self-image. A positive birth experience can give rise to lifelong self-confidence, and feeling of empowerment. It can gift a woman with the idea that she can conquer anything in her life, which enables her to ascend to new heights of accomplishment. This transformation can enhance her quality of life, echoing into an ability to be a strong parent, solidifying her ability to form strong familial bonds, healthy bonds with her new baby.
There is a great deal of research regarding the impact birth doulas and labor assistants have on perinatal outcomes. Within the psychosocial and cultural context, more than fourteen randomized trials in several world countries have shown that provision of continuous, social, physical, and emotional support of a birthing mother can encourage long-term positive effects on a woman’s life (Breedlove, 2005; Brill, 2005; DONA, 2005). Women who are attended by doulas have a documented decrease in the need for pain medication, a reduction in intrapartum interventions used during labor and birth, a reduction in the incidence of cesarean delivery, and a significant increase in overall satisfaction with their birth experience (Hodnett, 1989, 2002, 2002b). In addition, labor support has been correlated with improved breastfeeding rates, a marked decrease in incidence of postpartum depression through decreasing maternal isolation, and successful initiation of breastfeeding. Positive results are particularly striking when labor support is given to mothers continuously, throughout active labor and birth, by lay women, versus medical professionals (Hodnett, Lowe, Hannah, Willan et. al, 2002). These findings suggest that labor support is an invaluable and necessary addition to modern maternity care.
Culturally competent, lay perinatal social support is an imperative component for multicultural populations of childbearing women. Having a doula from the same culture, who is also herself a mother, who speaks the same language, is tremendously reassuring to a birthing woman. Birth doula’s improve communication and encourage a positive birth experience for everyone involved (Kennell, Klaus, McGrath, Robertson, Hinkley, 1991; Kennell, Klaus, Klaus, 1993). Doulas fill in the gap where there is hospital understaffing, or a cultural separation between care provider and birthing parent (Berkowitz, Klaus, 1999; Romano, 2008; Shelp 2004).
Doulas provide comprehensive models of maternity care that include appropriate and sufficient psychosocial support, especially in those populations of at-risk women who would normally receive sub-standard birth and perinatal support. A community-based doula model can contribute to increased power among families living in fragmented communities (Atkins, 2009; Baldwin, Jones, 2000; Beck, 2002; Breedlove, 2005). In these environments, the daily stresses and limited availability of social and cultural support are magnified by poverty and are often associated with negative birth outcomes (Czarnocka, 2000; Fearn, 2004; Hodnett, 1989). Environmental, social and behavioral patterns within these communities greatly influence the level of stress experienced by mothers. According to (Romano, 2008) teen population births are again on the rise. All of these factors work for naught contributing to America’s high incidence of preterm births, and low birth weight infants within at-risk populations (Scott, Berkowitz, Klaus, 1999). Negative birth outcomes are associated with a lack of education and support, and are magnified by the fractionalized life-circumstances of poverty. With education and community doula support, these populations can grow and improve. Positive, supported birth practices have long-lasting implications for families and children.
Pregnant incarcerated women are an at risk population that can greatly benefit from the support of a doula. These women have birth experiences that fall extremely short of the healthy ideal birth conditions that are described in “Lamaze International’s (2007), Six Care Practices That Support Normal Birth.” These women experience a lack of screening and inappropriate medical treatment which leaves them and their babies at high risk for life-long mental and physical health problems (Baldwin, Jones, 2000; Beck, 2002). With adequate perinatal support, prenatal care and education, incarcerated expecting mothers can be encouraged to discard negative lifestyle choices that would affect them and their babies (Fearn, Parker, 2004; Fogel, Harris 1986). The Community Doula Model can provide the psychosocial support these women lack, and empowering them to grow into healthy parents.
Consistency of birth support provided by a doula which includes the giving of care, as well as one-on-one psychosocial and cultural support, has been found to improve overall birth outcomes. These positive outcomes strengthen familial systems by encouraging new parent and infant bonding within all populations. These positive outcomes encompass the areas of social, interpersonal, physiological, and psychological health of birthing parents. With an inexpensive intervention known as “doula support” it is possible to aid in the empowerment and strengthening of women and families in all populations through the childbearing year.