Midwives’ and doulas’ perspectives of the role of the doula in Australia: A qualitative study
Introduction
‘Doula’ is a Greek derived term for a woman helper who is experienced in providing continuous non-medical physical and emotional support before, during and after birth (Stein et al., 2004, Dundek, 2006, Campbell et al., 2007). The role of the doula is described as focusing on the mother’s comfort and wishes during labour (Papagni and Buckner, 2006), and providing one-to-one continuous support through encouragement, non-medical information and comfort (Hottenstein, 2005). Doulas are unique in that they are employed by women yet have no decision-making responsibilities. They only have one labouring woman that they devote themselves to and they remain with her throughout the whole labour and birth (Stein et al., 2004).
Doulas provide tailored support specific to each woman’s needs by educating and encouraging them to write an informed birth plan, with the aim to facilitate normal births (Simkin and Way, 1998, Koumouitzes-Douvia and Carr, 2006). The World Health Organization (WHO) defines a normal birth as: a spontaneous birth that is low risk throughout the labour and birth; with the infant being born in the vertex position between 37 and 42 weeks of pregnancy; and mother and infant being in a good condition (Ahmed et al., 1997). The Lamaze Institute for Normal Birth adapted from WHO describes six evidence-based practices that promote normal birth. These practices are: labour begins on its own; the labouring mother has continuous labour support; there are no routine interventions; there will be spontaneous pushing in a gravity-neutral or upright position; and there be no separation of mother and infant after birth to encourage bonding and breast feeding (Lamaze International, 2007).
The benefits of doula care include the provision of continuous labour support, reducing women’s stress, provision of multicultural and religious support, support for women’s partners, reduced interventions during birth and increased breast-feeding initiation (Campbell et al., 2006, Dundek, 2006, Hodnett et al., 2007). Doula support can decrease women’s anxiety and the perception of pain, and thereby increase their ability to cope during labour (Murray and McKinney, 2006). A woman can employ a doula who has the same language, cultural and/or religious background, which may provide her with more appropriate and culturally sensitive care. Doulas are not only helpful to the mother but also support partners by acting as role models and by allowing the partner to take breaks (Ballen and Fulcher, 2006, Koumouitzes-Douvia and Carr, 2006). They can also increase breast-feeding initiation and provide continuing breast-feeding support (Langer et al., 1998, Scott et al., 1999, Hodnett et al., 2007, Nommsen-Rivers et al., 2009).
Doulas are relatively new in Australia; nevertheless, demand for them is increasing (Cencighalbulario, 2008). The rise in the use of doulas is thought to be due to increasing dissatisfaction with the current maternity health-care system. Women are generally not provided the continuity of care and emotional support they want within the maternity system; therefore, there are reports that doulas are taking over this care and doing what midwives traditionally used to do or indeed should do (Cencighalbulario, 2008). However, the doula role in Australia is unclear and almost no research has been undertaken into doulas in this country.
There are no standards for doula training in Australia, and they are not obliged to register with any regulating body (Bogossian, 2007). This lack of regulation is a major source of conflict between doulas and health professionals because anyone can be a doula regardless of how much training they have had. Conflict has been reported when midwives do not know how to intervene when they believe the doula is acting inappropriately (Gilliland, 2002). Some midwives say that conflict occurs when doulas work outside their scope of practice and give medical advice (Ballen and Fulcher, 2006). Furthermore, conflict may be present due to midwives feeling uncomfortable because doulas are providing the care they want to provide (Gilliland, 2002). Even though research shows that a midwife can rely on the doula to provide the emotional support for the woman, handing over this support can be difficult because caring is the core of the midwives’ role, and many midwives feel territorial about their role (Hottenstein, 2005, Ballen and Fulcher, 2006, Bianchi, 2006, Buck and Bianchi, 2006). Midwives in Australia are increasingly reporting concern and tension between themselves and the emerging role of the doula.
This research aimed to answer the question: What are midwives’ and doulas’ perspectives of the role of a doula in Australia? Specific purposes and objectives were to: identify midwives’ perceptions of the role of a doula; identify how doulas see their role; provide insight into what contributes to these perceptions; identify the implications of these perceptions; and increase midwives’ understanding of the role of a doula.
Section snippets
Method
A qualitative method was determined to be appropriate for this research because it is a technique used to collect and analyse data in areas where there is little knowledge, and it seeks to answer ‘what’ questions (Green and Thorogood, 2005, Grbich, 2007, Schneider et al., 2007). Focus groups were chosen as a suitable form of data collection in this research because they have been shown to enhance participant retention rates and provide a means of obtaining large amounts of verbal information,
Findings
There were 11 midwives and six doulas involved in the research. The midwives were all female and aged over 31 years; the majority were between 41 and 50 years of age. The midwives had between three and 30+ years of experience; the majority had between 11 and 20 years of experience. The midwives worked in postnatal wards, antenatal wards, childbirth suites, birthing units, midwife clinics, midwifery at home and private practice, and one worked as a clinical midwifery consultant. The midwives had
Discussion
During the study, it became evident that both the participating midwives and doulas believed that the current Australian maternity health-care system is failing women, and that doulas are being employed by women because the broken maternity system does not adequately meet their needs. Previous research also suggests that a large percentage of Australian childbearing women feel that they are given little or no choice in birth (Gamble et al., 2007). Women who birth in hospital feel that they are
Conclusion
This research is the first research undertaken that aims to understand the role of a doula in Australia. Doulas are employed by women to primarily ‘fill the gap’ in, `the broken maternity system’ in Australia. When doulas provide continuity of care, midwives feel that doulas are ‘taking our role’ because they are meant to be ‘with women’. Despite the conflict, both midwives and doulas see the potential for collaboration. The benefits of continuity of care are strongly supported by research, and
Acknowledgements
We would like to thank all the midwives and doulas that participated in this research. Without their willingness to give their time and to discuss their thoughts, this research would not have been accomplished.
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