A Volunteer Doula Project: could it work here? Seminar Programme TimeAgendaPresenter 9:15 Welcome and Introduction 9:20 Setting the Scene: Doula care,

A Volunteer Doula Project: could it work here? A Volunteer Doula Project: could it work here? Seminar ProgrammeSeminar Programme

TimeTime AgendaAgenda PresenterPresenter

9:159:15 Welcome andWelcome and

IntroductionIntroduction

9:209:20 Setting the Scene: Doula Setting the Scene: Doula care, the evidence basecare, the evidence base

Shauna PowersShauna Powers

9:409:40 The Goodwin Volunteer The Goodwin Volunteer Doula Project, HullDoula Project, Hull

Heather BarnesHeather Barnes

10:1010:10 Volunteering Doula Volunteering Doula Services: A Canadian Services: A Canadian PerspectivePerspective

Shauna PowersShauna Powers

10:3010:30 Coffee BreakCoffee Break

11:0011:00 Question/Answer Panel Question/Answer Panel DiscussionDiscussion

Heather Barnes, Amanda Heather Barnes, Amanda Hunter, Inga Cosway, Hunter, Inga Cosway, Shauna PowersShauna Powers

11:3011:30 Summary and closeSummary and close Shauna PowersShauna Powers

Birth Doulas: Birth Doulas: the evidence basethe evidence base

Shauna Powers, Shauna Powers, RN, BScN, MScRN, BScN, MSc

NHS Lothian Health Promotion ServiceNHS Lothian Health Promotion Service

Support from the StartSupport from the Start

What is a Doula?What is a Doula? A Greek word meaning A Greek word meaning woman caregiverwoman caregiver Now means a trained and experienced labour companion- Now means a trained and experienced labour companion- aa woman woman

whowho mothers a mothermothers a mother She provides emotional comfort, physical support, and assistance in She provides emotional comfort, physical support, and assistance in

obtaining information before, during and after childbirthobtaining information before, during and after childbirth

Why have a Doula?Why have a Doula? Recognizes birth as a key life experienceRecognizes birth as a key life experience Understands the physiology and emotions of birthUnderstands the physiology and emotions of birth Assists in preparing a birth planAssists in preparing a birth plan Stays by the woman’s side throughout labourStays by the woman’s side throughout labour Provides emotional supportProvides emotional support

Dimensions of labour support:Dimensions of labour support:

Emotional SupportEmotional Support – –encouragement, reassurance, encouragement, reassurance, continuous physical presencecontinuous physical presence

Informational SupportInformational Support – –help families gather information help families gather information about their labour, their options, explanations, non-about their labour, their options, explanations, non-medical advicemedical advice

Physical SupportPhysical Support – –comfort measures, positioning, comfort measures, positioning, massage, breathing, pain relief (non pharmaceutical)massage, breathing, pain relief (non pharmaceutical)

““The Case for a Volunteer Doula The Case for a Volunteer Doula Programme in Leith”Programme in Leith”

Commissioned by The Junction: Young People, Health Commissioned by The Junction: Young People, Health and Well-being after need recognizedand Well-being after need recognized

Evidence-based review of Doula and consistent labour Evidence-based review of Doula and consistent labour supportsupport

Review of Goodwin Volunteer Doula Programme (Hull)Review of Goodwin Volunteer Doula Programme (Hull) Recommendations to carry idea forwardRecommendations to carry idea forward

Evidence Base of Doula SupportEvidence Base of Doula Support

Three systematic reviews were consulted.

31 studies examining the effect of consistent physical and emotional support to labouring women.

Most reviews assessed random control trials (RCTs) that compared the physical and emotional outcomes of constant physical emotional support, predominantly provided by a doula, compared with limited or intermittent labour support.

Each systematic review has shown a marked decrease in most obstetric interventions such as caesarean sections, forceps and vacuum delivery, oxytocin induction and use of epidural anaesthesia when consistent care was apart of the labour process

Systematic ReviewsSystematic ReviewsZhang et al’s. (1996) systematic review studied the results of doula

support with young, first-time mothers with an average age of 20, involving 1,349 women. Those with doula support were:

Twice as likely to have a spontaneous delivery as the control group with no doula support.,

spent 2.8 hours less in active labour than the control group felt more satisfied with their birth experience Had an easier time bonding with their infant

Had breastfeeding initiation rates higher than those without doula support.

Systematic ReviewsSystematic Reviews Scott et al (1999), Systematic review that looked at 11 RCTs, involving a total of 4,391

women. These studies examined the outcomes of constant versus intermittent care by either medical professionals, doulas or lay female attendants.

The authors concluded that intermittent care in any form had no significant effects on medical outcomes or interventions.

However with continuous support, medical interventions such as epidural analgesia, oxytocin augmentation, forceps and caesarean section delivery were significantly reduced.

Systematic ReviewSystematic Review Hodnett et al. 2007Hodnett et al. 2007 (Cochrane Review) (Cochrane Review)

Sixteen trials involving 13,391 women Sixteen trials involving 13,391 women Primary comparison: women who had continuous intrapartum Primary comparison: women who had continuous intrapartum

support were likely to have a slightly shorter labour, were more likely support were likely to have a slightly shorter labour, were more likely to have a spontaneous vaginal birth and less likely to have to have a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth intrapartum analgesia or to report dissatisfaction with their childbirth experiences. experiences.

Subgroup analyses: in general, continuous intrapartum support was Subgroup analyses: in general, continuous intrapartum support was associated with greater benefits when the provider was not a associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour and in member of the hospital staff, when it began early in labour and in

settings in which epidural analgesia was not routinely availablesettings in which epidural analgesia was not routinely available..

Individual Studies and Systematic ReviewsIndividual Studies and Systematic Reviews(Powers 2009)(Powers 2009)

Medical InterventionMedical Intervention CitedCited

Decreased Caesarean Section Decreased Caesarean Section RatesRates

McGrath & Kennell, 2008McGrath & Kennell, 2008

Keenan 2000Keenan 2000

Kennell et al. 1999Kennell et al. 1999

Klaus et al. 1986Klaus et al. 1986

Trueba et al. 2000Trueba et al. 2000

Hodnett et al. 2008 (SR)Hodnett et al. 2008 (SR)

Scott et al. (SR)Scott et al. (SR)

Zhang et al. (SR)Zhang et al. (SR)

Decreased need for forceps and Decreased need for forceps and vacuum deliveryvacuum delivery

Kennel et al. 1991Kennel et al. 1991

Hodnett et al. 2008 (SR)Hodnett et al. 2008 (SR)

Scott et al. (SR)Scott et al. (SR)

Zhang et al. (SR)Zhang et al. (SR)

Decreased need for oxytocin Decreased need for oxytocin inductioninduction

Kennel et al. 1991Kennel et al. 1991

Klaus et al. 1986Klaus et al. 1986

Hodnett et al. 2008 (SR)Hodnett et al. 2008 (SR)

Scott et al. (SR)Scott et al. (SR)

Zhang et al. (SR)Zhang et al. (SR)

Decreased need for epidural Decreased need for epidural analgesiaanalgesia

McGrath & Kennell, 2008McGrath & Kennell, 2008

Keenan 2000Keenan 2000

Kennell et al 1991Kennell et al 1991

Hodnett et al. 2008 (SR)Hodnett et al. 2008 (SR)

Scott et al. (SR)Scott et al. (SR)

Zhang et al. (SR)Zhang et al. (SR)

Effect of Doula Care on Psycho-social outcomesEffect of Doula Care on Psycho-social outcomes(Powers, 2009)(Powers, 2009)

OutcomeOutcome CitedCited

Higher self-esteem and less Higher self-esteem and less emotional distressemotional distress

Manning-Orenstein 1998Manning-Orenstein 1998

Trueba et al. 2000Trueba et al. 2000

Scott et al. 1999 (SR)Scott et al. 1999 (SR)

Hoddnett et al. 2008 (SR)Hoddnett et al. 2008 (SR)

Higher rates of exclusive Higher rates of exclusive breastfeeding initiationbreastfeeding initiation

Scott et al. 1999 (SR)Scott et al. 1999 (SR)

Langer et al. 1980Langer et al. 1980

Positive prenatal expectations, Positive prenatal expectations, positive perceptions of their positive perceptions of their infants, support from others and infants, support from others and self-worthself-worth

Campbell et al. 2007 (SR)Campbell et al. 2007 (SR)

Sosa et al. 1980Sosa et al. 1980

Shorter laboursShorter labours Langer et al. 1998Langer et al. 1998

Kennell et al. 1998Kennell et al. 1998

Keenan 2000Keenan 2000

Klaus et al. 1986Klaus et al. 1986

Hodnett et al. 2008 (SR)Hodnett et al. 2008 (SR)

Scott et al. (SR)Scott et al. (SR)

Zhang et al. (SR)Zhang et al. (SR)

LimitationsLimitations

Definition of “Doula” Agreement with “constant care” How doula care is defined has varied (lay support-family/friends,”female

companions”, trained and or certified doulas; usually this difference is not distinguished in systematic reviews.

Cochrane Review: “continuous intrapartum support was associated with greater benefits when continuous intrapartum support was associated with greater benefits when

the provider was not a member of the hospital staff, when it began early in the provider was not a member of the hospital staff, when it began early in labour and in settings in which epidural analgesia was not routinely labour and in settings in which epidural analgesia was not routinely available.”available.”

How much is “Decreased”: Varies widely (10-50%)

Doula UKDoula UK165 surveys were returned from 735 births. All births were in the UK in 2008 165 surveys were returned from 735 births. All births were in the UK in 2008

InterventionIntervention Doula UKDoula UK National National AverageAverage

Caesarean Caesarean Section rateSection rate

15%15% 24.3%24.3%

Epidural Epidural AnaesthesiaAnaesthesia

20%20% 30%30%

InductionsInductions 10%10% 20%20%

Goedkoop V. MIDIRS Midwifery Digest, vol 19, no 2, June 2009, pp Goedkoop V. MIDIRS Midwifery Digest, vol 19, no 2, June 2009, pp 217-218, Available at: 217-218, Available at: http://www.doula.org.uk/content/duk/about/Survey_Results.asphttp://www.doula.org.uk/content/duk/about/Survey_Results.asp

Natural Birth (no Natural Birth (no induction, induction, medicated pain medicated pain relief, augmentation relief, augmentation or instrumental or instrumental deliverydelivery

45%45%

Doula was single Doula was single birth partnerbirth partner

11%11%

Breastfed at birthBreastfed at birth 86%86%

Support from the StartSupport from the Start

Support from the Start:Support from the Start:

Overall, EL fairs better than other areas of the Lothians Overall, EL fairs better than other areas of the Lothians overall, but what about the pockets of deprivation missed overall, but what about the pockets of deprivation missed by these statistics?by these statistics?

How can we help families who are hidden by the How can we help families who are hidden by the statistics?statistics?

Midlothian Breastfeeding Rates at Midlothian Breastfeeding Rates at 6-8 week review6-8 week review

Midlothian, NHS Lothian and Scotland rates 2002-2008Midlothian, NHS Lothian and Scotland rates 2002-2008

Source: Scottish Neighbourhood Statistics website: www.sns.gov.uk,Accessed February 19, 2010

East Lothian Breastfeeding Rates East Lothian Breastfeeding Rates @ 6-8 week review@ 6-8 week review

East Lothian, NHS Lothian and Scottish Rates, 2002-2008

Source: Scottish Neighbourhood Statistics website: www.sns.gov.uk,

Accessed February 12, 2010

Breastfeeding Rates in EL Breastfeeding Rates in EL @6-8 weeks@6-8 weeks

Breastfeeding Rates

64.5

46.8

22.9 22.5

34

0

10

20

30

40

50

60

70

North Berwick East Lothian Wallyford &Whitecraig

Prestopnans Tranent N

Source: Community Health Profile 2004

InequalitiesInequalities The Greater Glasgow and Clyde Inequalities

Sensitive Practice Initiative (2009) Qualitative report examining the

experiences of vulnerable childbearing women.

These women reported feelings of: vulnerability, feeling like an “outsider” and difficulty communicating their wishes.

They expressed a need to become involved in their care and become part of the decision making process as opposed to being recipients of care.

Recommendation: This report advocated services that would respond to their specific and complex needs. It emphasised quality interpersonal communication and relationship building as the way to achieve this.

Green (2008) conducted a qualitative study involving 39 women who

had participated in the Goodwin Volunteer Doula project either as expectant mothers or volunteer doulas.

The expectant mothers highly valued “having someone there” who was on their “side”.

They often reported developing a supportive relationship with their doula and

feelings of personal empowerment.

The report concluded that the programme was a beneficial service to both childbearing women and volunteers doulas and suggests that this program has the potential to complement current maternity services

Thank-you!Thank-you!

Questions???Questions???

ReferencesReferencesDoula UK. 2009. [online] Available at: http://www.doula.org.uk. Accessed February 19, 2010.

Greater Glasgow and Clyde. 2009. Inequalities Sensitive Practice Initiative: Analysis of the Maternity Services User Engagement Survey, Final Report. Dalian House: Glasgow. Available online at: http://www.equalitiesinhealth.org/publications.html

Green, J. 2008. Volunteer Doulas for women in a Sure Start area: What does the service mean to them?. University of Hull: Hull.

Goedkoop V. MIDIRS Midwifery Digest, vol 19, no 2, June 2009, pp 217-218,

Powers, S. 2009. The Case for a Volunteer Doula Project in Leith (Unpublished). Available from author: [email protected]