Doula und kontinuierliche Geburtsbegleitung in Wissenschaft und Forschung

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Companion of choice during labour and childbirth for improved quality of care

"Who can act as a companion during labour and childbirth?

The companion can be any person chosen by the woman to provide her with continuous support during labour and childbirth. This may be someone from the woman’s family or social network, such as her spouse/partner, a female friend or relative, a community member (such as a female community leader, health worker or traditional birth attendant) or a doula (i.e. a woman who has specialty training in labour support but is not part of the healthcare facility’s professional staff ).

A Cochrane systematic review concluded that all types of labour companions are effective, but that the benefits of support are highest when it is offered by individuals who are not part of the facility’s professional staff . The potential functions of the companion of choice should be clearly stated at the facility level, and should be agreed upon between the woman, her companion and health-care providers. It may be beneficial for the facility to offer orientation sessions for the companion before the delivery on his or her role in supporting the woman during labour and childbirth.

Barriers to implementation Despite clear evidence and the growing emphasis on respectful maternity care, many health-care facilities still do not permit women to have a companion of choice during labour and childbirth. Several barriers have been identified.

These include: 

-the absence of national or institutional policies allowing women to have a companion of choice during labour and childbirth;

-the physical infrastructure of health-care facilities, which limits privacy and contributes to overcrowding in the labour ward and difficulties in maintaining hygiene standards;

-limited knowledge among health-care providers and managers about the benefits of labour companionship;

-negative attitudes of health-care providers towards labour companionship. The way forward Simple measures can be taken to address concerns about labour companionship.

A clear first step is for health-care facilities to establish supportive policies that allow and encourage women to have companions during labour and childbirth. Secondly, facilities should provide women with information and the means to make informed decisions in this regard, ideally during antenatal care visits, so each woman has sufficient time to prepare. For these interventions to be effective, it is important to respect women’s rights to privacy and confidentially at the facility. This may necessitate physical modifications to the space provided for labour and delivery at the facility.

When implemented, the programmes for ensuring that each woman in labour has the support of her companion of choice (if she wants one) should be evaluated in order to share successes and address any persisting barriers with administrators and health-care providers at the facility. For implementation to be successful, it is crucial that health-care providers understand the benefits and potential caveats of labour companionship, as well as the importance of supporting pregnant women to decide whether they want a labour and childbirth companion, whom to choose and what role they want the companion to play on their behalf. A participatory approach is key to introducing labour companionship policies at the health-care facility.

By establishing a committee comprising representatives of health-care providers, facility managers and women themselves (i.e. advocates or members of women’s organizations), concerns from all sides can be considered and solutions can be identified that work for everyone.

Professional organizations – such as international and national associations of obstetricians and midwives – can also play important roles during all phases of implementation of labour companionship programmes, and they can be critical for the sustainability of the practice at the facility level. Incorporating training on the issue of labour and childbirth companionship, and on the importance of respecting women’s autonomy in making decisions during labour and childbirth, into pre- and in-service training for health-care providers and managers could be one effective route towards achieving and sustaining this change. If it is presented as part of WHO/RHR/16.10 © World Health Organization 2016 

 

Safe Prevention of the Primary Cesarean Delivery

ACOG – The American College of Obstetricians and Gynecologists, 3/2014

„Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery (111). Given that there are no associated measurable harms, this resource is probably underutilized.“

Cochrane Review 7/2017 – update: Continuous Support for women during childbirth


„Continuous support in labour may improve a number of outcomes for both mother and baby, and no adverse outcomes have been identified. Continuous support from a person who is present solely to provide support, is not a member of the woman’s own network, is experienced in providing labour support, and has at least a modest amount of training (such as a doula), appears beneficial. In comparison with having no companion during labour, support from a chosen family member or friend appears to increase women’s satisfaction with their experience. Future research should explore how continuous support can be best provided in different contexts.“

Intrapartum Care: Care of Healthy Women and Their Babies During ChildbirthCare throughout labour

NICE Clinical Guidelines, No. 190. National Collaborating Centre for Women’s and Children’s Health (UK). London: National Institute for Health and Care Excellence (UK); 2014 Dec.

„There is evidence to suggest that women with one-to-one care throughout their labour are significantly less likely to have caesarean section or instrumental vaginal birth, will be more satisfied and will have a positive experience of childbirth. This impact becomes more apparent when non-professional staff members, rather than professional staff members, care for them. The non-professional person providing one-to-one care in labour within these studies varied in their level of training, background and in the context of care. There is little evidence on perinatal mortality and the long-term wellbeing of women and their children. There is also a lack of high-level evidence to suggest that support by partners, other family members or friends affects clinical outcomes.“

The Evidence for Doulas
March 27, 2013 by Rebecca Dekker

„Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and C-sections. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth.“

Doula–a new concept in obstetrics

Thomassen P , Lundwall M , Wiger E , Wollin L , Uvnäs-Moberg K Lakartidningen, Dec 2003

“ We wanted to study the effect of extra emotional support in the form of a non-professional woman (doula) before and during delivery. About 200 primiparae were invited to participate in a prospective study which intended to assess differences in delivery outcome between women with and without a doula. Fifty-four declined to participate, 55 had a delivery with doula and 46 were controls. Lower rate of emergency caesarean sections in the doula-group was noted. The parents as well as the staff, became to regard the doula as a valuable support during delivery.

A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates.

McGrath SK1, Kennell JH.

The results showed a substantial improvement in outcomes for women who had both a birth partner and a doula, compared to having a birth partner alone. The Cesarean rate for these first-time mothers was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. The women who had their labor medically induced experienced an even more striking decrease in the Cesarean rate with a doula—the Cesarean rate with labor inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula. Also, fewer women in the doula group required an epidural (64.7%) compared to those without a doula (76%). Research has shown that the most positive birth experiences for fathers were ones where they had continuous support by a doula or a midwife. In the McGrath and Kennell study, the women and their partners who had a doula overwhelmingly rated the support of their doula as positive—with 93% rating their experience with the doula as very positive, and 7% as positive. In other studies, fathers have said that when they had labor support from a midwife or doula, things were explained to them, their questions were answered, their labor support efforts were guided and effective, and they could take breaks from the emotional intensity of the labor without abandoning their laboring partner (Johansson, 2015).

Impact of Doulas on Healthy Birth Outcomes

Kenneth J. Gruber, PhD,* Susan H. Cupito, MA,* and Christina F. Dobson, MEd*,2013

„CONCLUSION:  Doulas can empower women to achieve the best birth outcomes possible, and all outcomes—for births, infants, and mothers—seem to be affected more positively if support is provided by a doula in addition to the medical personnel. The doula focuses on individualized support before, during, and after birth; whereas nurses often are attending to several women in labor and responsible for many clinical and administrative tasks besides direct labor support. Research indicates that the expectation of nurse support by expectant women may be far greater than what is actually provided (Tumblin & Simkin, 2001). Hospitals could address this disparity by including a system of doula support.“

The doula: an essential ingredient of childbirth rediscovered   

MH Klaus, JH Kennell, 1997

Abstract: Eleven randomized control trials examined whether additional support by a trained lay person (called a doula), student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, will affect obstetrical and neonatal outcomes. The women were healthy primigravidas at term. Meta-analysis of these studies showed a reduction in the duration of labor, the use of medications for pain relief, operative vaginal delivery, and in many studies a reduction in caesarian deliveries. At 6 weeks after delivery in one study a greater proportion of doula-supported women were breastfeeding, reported greater self-esteem, less depression, a higher regard for their babies and their ability to care for them compared to the control mothers. Observations during labor showed that fathers remained farther away from mothers than doulas, talked and touched less. When the doula was present with the couple during labor the father offered more personal support. The father-to-be’s presence during labor and delivery is important to the mother and father, but it is the presence of the doula that results in significant benefits in outcome.

After praise and encouragement: emotional support strategies used by birth doulas in the USA and Canada.

Gilliland AL 2011

OBJECTIVE: to describe in detail the emotional support techniques employed by birth doulas during labour.

DESIGN: grounded theory methodology was utilised in collecting and analysing interviews given by doulas and mothers who had doula care. By using both informants, a clearer picture of what constitutes emotional support by doulas emerged.

PARTICIPANTS: 10 mothers from three different states in the Midwestern USA and 30 doulas from 10 different states and two Canadian provinces were interviewed. Two doulas worked in hospital-based programmes whereas the others had independent practices. Doulas usually attended births in hospitals where medical attendants spent little focused time with the mother.

FINDINGS: nine different strategies were distinguished. Four strategies (reassurance, encouragement, praise, explaining) were similar to those attributed to nurses in published research. Five were original and described as only being used by doulas (mirroring, acceptance, reinforcing, reframing, debriefing).

CONCLUSIONS: emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour.

IMPLICATIONS FOR PRACTICE: the doula’s role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive ‚doula effect‘ on obstetric and neonatal outcomes in certain settings.

How Birth Doulas Help Clients Adapt to Changes in Circumstances, Clinical Care, and Client Preferences During Labor

Natalie Lea Amram, BSc, Michael C. Klein, MD, CCFP, FAAP (Neonatal–Perinatal), FCFP, ABFP, FCPS, Heidi Mok, RM, MSc, Penny Simkin, PT, Kathie Lindstrom, CD(DONA), BDT(DONA), LCCE, FACCE, and Jalana Grant, CD(DONA), BDT(DONA), LCCE

"This study demonstrates that DONA-trained doulas are using many techniques to assist couples to integrate changes in the birth process that deviate from the client’s plan. DONA doulas appear to be acting in accordance with their standards of practice. This study shows that there are almost inevitable conflicts that evolve from the intrinsic role overlap between care providers and doulas. Whether and how these conflicts will or will not be actualized is another area for study. When doulas provide their clients with information, this can be perceived as in conflict with the role of care providers. For optimum care and outcome, it is essential that all players accept and respect each other’s unique roles. To achieve this, education of all health-care professionals is necessary so that the doula’s role and scope of practice is clearly understood."

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers‘ wellbeing in a Mexican public hospital: a randomised clinical trial.

Langer A1, Campero L, Garcia C, Reynoso S.

CONCLUSIONS: Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies.

Comparison of the Effects of Using Physiological Methods and Accompanying a Doula in Deliveries on Nulliparous Women’s Anxiety and Pain: A Case Study in Iran

Ravangard, Ramin PhD; Basiri, Aliye MSc; Sajjadnia, Zahra PhD; Shokrpour, Nasrin PhD

The Health Care Manager: October/December 2017 – Volume 36 – Issue 4 – p 372–379

„Childbirth is a great moment in a woman’s life and is inevitably influenced by emotional, social, and psychological stress. This study aimed to assess the anxiety and pain level of nulliparous women giving birth using physiological methods (without doula support) during labor and those women supported by a doula at Towhid Hospital of Jam, Bushehr, Iran in 2015. In this interventional study, 150 women were randomly assigned to either an intervention (with doula support) or a control group (with no doula support). The intrapartum, postpartum, and hidden anxiety levels were measured using Spielberger standard questionnaire used for assessing anxiety. The labor pain rate was evaluated using McGill questionnaire. Results showed that the average rate of obvious anxiety during labor was 57.76 ± 9.57 in physiological delivery (without doula) and 48.04 ± 9.61 in doula-supported delivery. The difference between mean scores of obvious anxiety during labor was significant. The mean anxiety of the control group (who did not receive doula support) was higher (P = .000). Also, the difference between the mean labor pain scores of the 2 groups was statistically significant. The results of the study showed that doula’s presence has positive significant effects on labor pain and anxiety reduction; also, doula-supported mothers reported considerably lower pain and anxiety compared with those experiencing physiological delivery (without doula). Thus, the increased use of doula in hospitals all over the country is recommended.“

How Doulas Have A Huge, Positive Impact On C-Section Rates
August 29, 2014 by Catherine Pearson

„What our study showed is that [lower odds of a C-section] don’t come with wanting a doula; it’s having a doula that is actually associated with important and substantial risk reductions.“

 
 

Doulas Do It Better
March 15, 2013 by Kevin Charles Redmon

„[…] women who were provided a doula’s “continuous support” during childbirth experienced shorter labors, fewer Caesarians, and were less likely to require the use of instruments—forceps, vacuums—or epidural drugs. „Continuous support during labour has clinically meaningful benefits for women and infants and no known harm,” the review concluded. “All women should have support throughout labour and birth.”

The Essential Ingredient: Doula

Documentary produced by DONA International in 2010 featuring commentary by all of DONA International’s esteemed founders and some of its celebrated past presidents speaking on the origin and rationale of doula support.