What is it about Sunday night? Are our bodies pre-programmed after years of schooling to go into automatic anxiety mode?

This Sunday, my moment of didn’t-do-my-homework anxiety came courtesy of a blast from my academic past.

In my Masters year, I wrote a thesis titled “Women Supporting Women: The Role of Doula’s in South African Birth Stories”. It was a qualitative research study in which I interviewed doulas and their clients to explore this relationship and demonstrate its relevance for modern psychology.

My big failing (oh there are so many) is that I never published this research. It was a good study. The findings were really interesting but I never bloody published. In terms of academic success I would self-diagnose myself with a serious case of failure to launch.

After presenting my research at Cape Town Midwifery and Birth Conference last year, I was implored by the ladies of the doula community to please publish my results and yet over a year later I still haven’t.

This thought took me down a bit of a shame cycle on Sunday night but then I realised that it’s not too late. I have this platform and I should use it, if not for anything else, as a way of vanquishing my own demons. So today I am going to share my findings with you. This is the most condensed version I could manage, as I know you don’t want to read 25000 words. Perhaps this will motivate me to write an actual academic paper one day.

Here’s to failures!

Introduction

I was introduced to the work of doulas by my mother and her neighbour at the time, Ruth Ehrhardt. I was fascinated by how they spoke of support being the primary tool of doulas or birth companions as they are sometimes known. I started to investigate further and discovered a huge body of scientific literature describing the medical benefits of doulas. My research was intended to explore the relational aspects of the role.

Birth

Birth is connected to and must be considered within a cultural and historical context. Historically, birth was an event in which women took centre stage. This was seen cross-culturally and around the world, in both industrialized and non-industrialized countries.

Since the beginning of the 20th century, the site of childbirth has moved from the home to the hospital setting resulting in a drastic increase in obstetric interventions such as analgesia and foetal monitoring.

The natural childbirth movement of the 1960s, aided by feminist voices, helped to bring another perspective. Since the late 1970s medical researchers have taken an interest in the benefits of having someone providing continuous support to a woman in labour.

Although an ancient role, this woman is commonly known as a doula today.

What is a doula?

Doula is a Greek term that roughly translates as a “woman who helps other women”. The role is technically defined as a woman who provides “continuous physical, emotional, and informational support to the mother before, during and after childbirth”.

A doula is not trained to provide medical or clinical care or assistance. A doula does not replace the role of the midwife or obstetrical nurse but instead offers a range of physical, emotional and social support.

Doulas in South Africa

One of the first studies done on labour support was conducted in Johannesburg in the early nineties. Currently, doulas can obtain certification through the organization WOMBS (Women Offering Mothers Best Support) in the Western Cape and DOSA (Doulas of South Africa) based in Johannesburg.

Their service includes a pre-birth visit, support throughout labour and birth and at least one post-natal visit.

Benefits of doula support

The benefits of doula support has been well documented over the last 30 years with over 16 randomised controlled trials (RCTs), at least two meta-analyses and a Cochrane library spanning over a decade of reviews.

Medical benefits:

  • Shortened duration of labour
  • Reduction in caesarean births
  • Reduced need for medical interventions such as forceps, fetal monitoring and oxytocin stimulation, epidural analgesia and other pain relief
  • Better breastfeeding outcomes

High obstetric intervention has been found to contribute to women’s experience of birth as traumatic, which can sometimes lead to symptoms of post-traumatic stress disorder. In particular emergency caesareans and intrusive obstetric interventions such as forceps, vacuum extraction as well as the use of analgesia are found to be the most related with trauma symptoms.

Research shows that women having an emergency caesarean section are at greater risk (six times) of developing postnatal depression. Mothers who undergo these invasive medical procedures and experience their birth as unpleasant may have feelings of low self-esteem and depression, impacting their relationship with their new infant.

These medical procedures, while establishing a remarkable decrease in infant mortality, are used due to the assumption that birth is a pathologic condition which must be treated, undermining the women’s body and her autonomy and diminishing her confidence.

Psychological benefits

  • More positive birth experience
  • Greater sense of control
  • Lower anxiety and depression
  • More affectionate mother-infant interaction
  • Greater maternal responsiveness and competence
  • NB for mother-infant bonding and attachment
  • “Has far-reaching and powerful psychological consequences”
  • Long-lasting effects on self-worth

The research shows that Mothers who received doula support reported having a more positive birth experience, felt a greater sense of control over their births, reported coping better, and had lower anxiety and depression scores. Doula support results in more affectionate mother-infant interaction, as well as greater maternal responsiveness and competence.

Mothers spent more time with their newborns, reported finding motherhood easy and their babies less fussy. Mothers who received doula care also commented that they felt more attuned to their babies and felt they sensed their needs better than mothers who had not received support.

This is very important for mother-infant bonding and attachment and “has far-reaching and powerful psychological consequences” (Hofmeyr et al., 1991, p. 762) for both mother and child. A woman’s experience of her birth has very important and long-lasting effects on her self-worth as a mother and a woman.

Aims

The broad aim was to investigate the nature of doula support, both what doulas do but also what is helpful and supportive about what they do.

I wanted to describe and explore the role of doulas in South Africa with specific interest in:

  1. The participants’ subjective notions of the ‘relationship’ that is formed between doula and client(s).
  2. The reasons for why and how this relationship is so helpful

Methods

I conducted a qualitative study. My sample included 8 qualified doulas, 1 trainee doula, 1 doula trainer, and 6 mothers and fathers who received doula care (3 women, 3 men). All particpants lived in Cape Town. Data collection involved open-ended, semi-structured interviews. Initially each participant was asked “what is/was your experience with doula care?” or “what is your experience of being a doula?” The data was then analysed using thematic analysis.

Results/Themes

Theme 1: The structural elements of doula support

  • the doula’s time and availability
  • suggestions and help
  • planning

These include the elements of doula support that ‘structure’ or ‘sculpt’ the relationship between doula and client(s) such as the doula’s time and availability, her ability to make suggestions and help plan the birth with parents and the doula’s help in planning, both before and during birth.

“…the other thing is she’s there the whole time. You know, the nurses, they’re in and out. She’s there, you’ve got a problem and she’s there, that was great…”

Theme 2: Professional qualities of doula support

  • Expertise and experience
  • Knowledge and training
  • Neutrality and objectivity
  • Insight and preparedness
  • Educating about medical and hospital procedures
  • Translating medical jargon

The professionalism of doula support entails the expertise and experience doulas bring to birth; their knowledge and training; as well as their identity as a neutral and objective third-party. The doula’s neutrality and objectivity offers her client unbiased and sound professional support. Having someone who is able to pass on their knowledge and experience is highly supportive

One of the other ways a doula’s knowledge and experience is found to be supportive results from her insight into the process of birth and her level of preparedness. Her role entails educating the mother and father about the medical and hospital procedures, as well as translating medical jargon used by medical practitioners.

“…why it was so good was because she kind of gave you insight into what was happening, what was going to happen…”

Theme three: The relationship

  • The special qualities of the doula
  • Doula as integral and life-saving element
  • ‘Just being there’
  • Reassurance for fathers
  • Recognition and nurturing of couple’s bond
  • Communication – what is said (and the doula’s words of encouragement)
  • Physical comfort
  • Creating a connection (eye contact & touch)
  • Trustworthy and humane
  • Express care and concern
  • Doulas promote, encourage and affirm celebration of birth
  • Feminine qualities
  • Unique and special connection
  • Sharing in a significant life event
  • Guide into the Unknown
  • Trust

Doulas come across as being incredibly special and unique women who really enjoy and take pride in their work. Not a single participant had a negative or even neutral comment to make about their experiences of doulas. Participants described doulas in terms of being an integral and life-saving element that they felt they wouldn’t have coped without.

The doula ‘just being there’ provides assistance to the mother and father. The presence of the doula is also reassuring for fathers, as they seem to benefit from having a companion to share the experience with.

Fathers need to be supported as well, and that it is very important to consider his needs and how best to support and empower him through the process. The doula’s role needs to involve recognition and nurturing of the couple’s bond. By acknowledging and allowing the couple to stay connected, the labouring woman is supported by both her partner and her doula, while the man still feels he has a role to play and thus their union as a couple and as expecting parents is nurtured and supported too.

One of the most vital ingredients in any helpful relationship is communication. Participants made frequent mention of the way in which the doula’s words of encouragement or the things she said helped. Doulas seem to know the right thing to say at the right time, which helps the mother to feel assured and relieved.

Doulas refer to their words of encouragement as offering mothers positive reinforcement, which relaxes them and helps them to believe in themselves.

Doulas provide physical comfort to labouring women. Some of the things that doulas do to help make the labouring woman more comfortable include massage and touch, helping the woman into different positions, breathing techniques, and helping her to eat and go to the toilet.

Another more subtle aspect of doula support is understood by doulas as creating a connection with the mother, which is often done through eye contact or gentle touch. This is considered helpful in that it provides the mother with reassurance of the doula’s presence.

Doulas were contrasted to medical staff in that they were viewed as more trustworthy and humane. The ways in which the doula communicates with her clients expresses care and concern. Doulas do not patholologize pregnany and birth but actually celebrate birth, which encourages and affirms.

There was reference made to the benefit of the doula’s feminine qualities. The usefulness of women being able to tap into their feminine power and strength through the support of another woman. There is a unique and special connection that is formed between women and that this connection aids and facilitates a successful and positive birth experience.

When describing their experiences of doula support, participants referred to the relationship between doula and client as special and unique due to the particular kind of sharing that goes on during birth. The doula participants also communicated their recognition that birth is a particularly important and momentous event in a woman’s life.

One of the resounding and most acknowledged aspect of the relationship that is helpful and meaningful, as communicated by participants, is the notion of trust. It is through trust that the doula is able to act as a guide to the unknown and it is through trust that she is able to connect with the women she supports.

Conclusion

There is in fact a very close fit between what the participants put forth as the most notable aspects of doula support and what is articulated in the literature.

Some interesting insights into the more subtle and complex features of the doula/client relationship were established.

These findings help to position the work of doulas within its socio-historical context.

Birth is a highly significant event in a woman’s life. Not only is it a physical journey, an experience nobody can truly prepare you for; but it is an emotional and spiritual journey as well.

The particular hormones that are at play combine to place women in an altered state of consciousness, one that is essential yet not completely understood by modern medicine. And through this radical experience, the labouring woman is transformed.

There is clearly something unique about birth that engenders female bonding, where women require the strength, support and wisdom of other more experienced women.

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