Bahçelievler Public Hospital Doula Project

This project aims to underline the importance of providing one-on-one and continuous support to women that are in the process of labor, in cooperation with the Hand in Hand for Birth Association's volunteer doulas that have completed or in the process of completion of their doula education in order to provide doula support in Bahçelievler Public Hospital.

The Goal of the Project

This project was designed with the cooperation of Hand in Hand for Birth Association and Bahçelievler Public Hospital in order to show the importance of support during childbirth.

The main purpose of this project is to emphasize the positive impact of continuous and one-on-one support during childbirth on the process of labor, satisfaction of the pregnant person; and to show the differences between no support and support that are also anticipated in the studies done by health workers.

During the course of the project, doula support was provided to people with the pregnant person and their doctor’s permission with the purposes of;

•           Increasing the support provided to people that are in the process of labor,

•           Helping with the workload of gynecologists and midwives,

•           Allowing the midwives to see the use of non-medicinal techniques during childbirth, (bu kısmın Türkçe versiyonu “Ebelerin ilaç dışı tekniklerin doğum süresince nasıl kullanılabildiğinin izlenmesi”. Burada ilaç dışı teknikleri kullananlar ebeler mi yoksa doulalar mı tam anlayamadığımız için böyle çevirdik, eğer yanlışsa geri dönüşünüze göre düzeltme yapabiliriz)

•           Allowing the medical doctors and midwives to see the difference between the results of support and no support during childbirth,

•           And increasing the experience of doulas through providing them an environment where they can practice their skills.

This project aims to increase the prevalence of one-on-one support during childbirth through providing training to midwives, and to allow give hanvoice the employment of an adequate number of midwives that are trained in this direction. In addition to these, another purpose of this project is to increase awareness about allowing the entrance of the doula of the pregnant person’s choice into the delivery room. This is especially important as it can help with the recognition of the pregnant person’s right and need to have whomever they wish escort them at childbirth. 

The Eid holidays were chosen to conduct the pilot study as the number of hospital personnel is lower during these times that allows for providing more help. Furthermore, this choice allowed for the volunteer workers to work according to their own schedules so that there were no interruptions in the conduct of the study.

Stakeholders of the Project

Bahçelievler Public Hospital

Hand in Hand for Birth Association

Doulas

Hand in Hand for Birth Association

Hand in Hand for Birth Association is a civil society organization that aims to ensure respect for people giving and witnessing birth, and to conduct their follow-ups without discrimination. Psychologist Neşe Karabekir acts as the chair of the organization that was founded in 2015.

The main purpose of the organization is to conduct trainings and education for families and professionals, to lay out the vital rights associated with childbirth to ensure a desirable birth environment, and to ensure the protection and sustainance of these rights.  

Hand in Hand for Birth Association’s Role in the Study

After agreeing on the terms of the project with Bahçelievler Public Hospital, our association has taken part in identifying the doulas to participate in the study. Furthermore, it has created the framework of the study protocol that is explained further below; and ensured the progress of the study in accordance with this protocol that was signed by all the doulas that participated in the study.  

The Concepts of Doula and Labor Support

In Latin, the word ‘doula’ means a woman servant. As people offering services for childbirth, doulas are trained to help the pregnant person and their family both emotionally and physically in prenatal, labor and postpartum phases. Since doulas provide non-medical support during childbirth unlike health professionals, the word doula instead of birth support member is used from this point onwards to avoid any confusion.

The studies conducted on labor support show that when the person in labor is provided emotional and psychological support;

•           The process of labor is shortened,

•           Satisfaction is higher,

•           The need for pain relief medication is lessened,

•           There is less need for C-section,

•           There is less need for intervention during childbirth.

Birth support for a pregnant person can be provided by someone from their close circle, such as their partner, sibling, or friend; as well as a doula that was specifically trained for providing birth support. The most important quality of a doula is to prioritize the needs of the baby and the person giving birth with a non-judgmental and non-interventionist approach. 

In their trainings, doulas learn about non-medicinal techniques to enable the person in labor to endure contractions in a more relaxed way and provide relief to the person in labor. These techniques include but are not restricted to breathing and massage techniques, effective birthing positions, relaxing aromatherapy, implementation of acupressure points, meditation and imagery techniques, and the active use of water. 

Although doula educations include trainings on Basic Concepts of Childbirth (??), they do not receive standard medical education. Because of this, their job description does not include offering such services, and they do not offer medical advice and/or take responsibility regarding medical and medicinal procedures. As long as there are no medical reasons disabling them from doing so, doulas offer support for childbirth through different methods such as taking walks, breathing and meditation techniques, affirmations, massage and aromatherapy, food, shower, relaxing bath, emotional support for the pregnant person and their partner, and application of active birth techniques. They act as a bridge and communication point between the partner, caretakers and gynecologist of the pregnant person; and they monitor the progress of everyone that witnesses the experience of childbirth. Yet, their prior responsibility of a doula is to consider the needs of the person giving birth on behalf of them so that the person in labor can focus on themselves and their baby, and to offer support to the partner and other caretakers when necessary. The most fundamental duty of a doula is to offer help in protecting the most private and sacred space that the pregnant person needs. They offer emotional support to the parents, and provide support for the parents to have a less challenging transition period. First and foremost, they are respectful towards the privacy of childbirth and the procreator’s body.

One of the limitations to doula practice is about not being involved with the decisions and operations of the doctor and midwives. They do not question or open these decisions to discussion, and they certainly do not contradict them. The doula provides support for the medical personnel through relieving the fears of the person giving birth and calming them. They help with the workload of the midwives. A doula is a trained support partner to the person in labor, they are not healthcare workers. The official status of a doula in the delivery room is equal to a patient companion.

While a person that has received doula training can be someone from the healthsector such as a medical doctor, midwife, nurse, and psychologist; they can also have a background that is irrelevant to the health sector. Their background in healthcare does not allow a doula to take on medical responsibilities and duties. They intentionally stay out of medical operations and the decision making process of these.

The Difference between a Midwife and Doula

A midwife is a person that is a college graduate and is authorized to participate in medical decisions and inspections during childbirth except for surgical and few other operations.The only common point between a doula and a midwife is the support offered to caretakers, and the ability to use non-medicinal techniques during labor. In today’s intensive and busy working conditions, no hospital is able to offer an adequate number of midwives for childbirth. Doulas aim to compensate this gap by offering one-on-one, uninterrupted and unbiased care. It is important for the doula’s practice to be supportive of the health professionals and their work. Even if the doula is a medical doctor or midwife, the scope of their work in the delivery room is limited to doula practices.  

Scientific Findings on Continuous & One-on-One Care in Childbirth

The studies conducted on birth support show that people who receive one-on-one care are 50% less likely to need C-section and surgical intervention; and their satisfaction is higher compared to the condition of no support. Hodnett’s work on 15288 women from 16 countries includes birth support partners with different levels of experience, such as trained birth support partners, family members and friends that have given birth, midwives, and nurses.

The study that uses 22 cases about people receiving continuous, one-on-one care during labor found the following:

1.         Statistically, the number of vaginal delivery was much higher

2.         There was less need for pain relief medication during labor,

3.         There was less complaints filed about unsatisfactory delivery experiences,

4.         The period of labor was shortened by one hour on average,

5.         There was less need for C-section operations,

6.         There was less need for birth intervention and regional (local??) analgesics,

7.         The Apgar scores of the newborn in the first five minutes were higher,

8.         There was no negative impact of birth support according to case reports.

In summary, in addition to having no negative effect on labor; birth support was seen to be highly beneficial.

According to Hodnett’s 2002 study, there are four main factors affecting the level of satisfaction during childbirth:

1.         Personal expectations

2.         The amount of support provided by healthcare workers

3.         The quality of caregiver-patient relationship

4.         Active involvement in the decision-making processes

Age, socio-economic status, ethnicity, childbirth preparation trainings, the physical birth environment, pain, medical interventions, and the continuity of care were seen to be less influential factors than the four main factors outlined above. The provision of one-on-one care can have a positive impact on these four main factors.

Similarly, ACOG 2017 has addressed the issue of intervention and emotional support in low-risk pregnancies in their annual report. The report has referred to the lessened need for birth intervention, and the positive impact of the presence of a doula in addition to the standard midwife-nurse care. The report has also given place to the additional positive effect of the presence of a trained birth companion on the results of childbirth.

Outline of the Research Protocol

1.         The people that provide doula services must carry their certified doula documentation provided by Hand in Hand for Birth Association at all times.

2.         The doula might have a background in healtcare services such as midwifery, gynecologist, nurse etc., as well as a background outside of healthcare. Regardless of their status in healthcare work, the doula does not carry on any medical responsibilities and duties during their doula practice. In this manner, their status is of equal to the companion of the pregnant person.

3.         Doulas will ask for the permission of the pregnant person to be present in the delivery room. If the pregnant person does not consent to it, there will be no doula(s) present in the delivery room.

4.         If the treating doctor does not give permission, the doula won’t be present in the delivery room.

5.         Both the pregnant person and the treating doctor have the right to withdraw their consent for the presence of a doula at any time during labor. If the presence of the doula is found to be interfering with the work of the healthcare professionals, the doula will leave the delivery room when asked. 

6.         Doulas will act in accordance with the rules and regulations of the hospital and the delivery room.

7.         Doulas will comply with the confidentiality of both medical and non-medical procedures during birth, without any time limitations. Doulas are obliged to respect the confidentiality of the information regarding the pregnant person and their family, and cannot shary any of these information except for their supervisors under no circumstances, except for the condition of legal obligation.

8.         As it was stated above, doulas might or might not come from a background in healthcare work. Regardless of their background, the doula is responsible for providing non-medicinal relief techniques for the pregnant person. As they do not have medical responsibilities and duties, they won’t be expected to engage in any medical diagnosis or treatment. As the prior responsibility of the doula is to provide support for the pregnant person and their caregivers, they will be exempt from responsibilities towards other personnel, except for their obligation to act in accordance with the rules and regulations of the hospital and the delivery room.

9.         The treating healthcare personnel won’t be responsible for any problems that may arise which stem from non-medical procedures that were conducted by the doula during the application of the protocol. 

10.       The presence of doulas in the delivery rooms are entirely based on voluntary participation; thus, doulas won’t receive payment for their work.

11.       In the case of medical or non-medical harm that might be encountered by the doula, the hospital administration’s responsibility towards the doula is the same with their responsibility towards any patient relatives. The potential problems that might arise between the doula and pregnant person and/or caregivers are not within the responsibility of the hospital administration.

12.       Hand in Hand for Birth Association is the party to make the decisions on which doulas can participate as volunteers in this project. Bahçelievler Public Hospital will allow the doulas that are chosen by the association to be present in the delivery room. Both the association and the hospital administration reserve the right to withdraw their consent. In such an instance, the hospital administration and Hand in Hand for Birth Association’s president(s)/chair(s) will have a meeting to investigate the situation.

13.       In the deliveries where there is a doula present, doulas will prepare a report that includes some medical and non-medicinal information about the process of labor. These reports will later be used for evaluating the project. The data produced by these reports may later be used for the purposes of scientific research.

Details of the Study

The dates between the 8th and 18th of September, 2016 were chosen for conducting the pilot project, and the doulas that have agreed to the protocol outlined above and chosen by the Hand in Hand for Birth Association started their 12-24 hour shifts.

28 people in total have participated in the study between these dates. The purpose was to be able to provide 7/24 service; and despite some occasional interruptions, this goal was overall achieved.

During the period of the pilot study, there were 31 deliveries in total that was composed of 20 vaginal deliveries, and 11 C-section operations.

Although there were attempts to conduct surveys with doctors and midwives as participants, the response rate turned out to be low because of the heavy workload and lack of assistance/support. Every doula that has participated during the process of labor has prepared reports about each delivery, both regarding their experiences and personal observations. The observations, emotions and opinions of healthcare workers were recorded by MD Semra Özer as much as possible.

The non-medicinal techniques employed by doulas during this pilot project are outlined below.

•           Relaxation with breathing techniques

•           Practices for communicating with the baby

•           Arometherapy

•           Endorphin massage

•           Active birth positions

•           Meditation

•           Acupressure

•           Music

•           Provision of an environment with dim light

Doulalar tarafından pilot çalışmada, ilaç dışı teknikler olarak kullanılanlar şunlardır:

To ensure the continuity of communication, a Whatsapp group was formed that included the doulas that participated in the study, the chair of Hand in Hand for Birth Association Neşe Karabekir, and Bahçelievler Public Hospital Deputy Chief Physician Semra Özer. This enabled us to make sure that all possible questions about the pilot study were answerd and everything went in line with the protocol.

At the end of the pilot study, there was a supervision workshop done with the doulas that allowed them to share the challenges and emotions they have experienced. 

This pilot study hasn’t generated any qualitative data. In addition to the previously mentioned reports prepared by doulas, hospital workers have also provided their observations and feedback; however, the latter was not reported. Except for a treating doctor’s request for one of the doulas to leave the delivery room that stemmed from a misunderstanding about the change of shifts, there were no negative instances that were reported.

As part of the doula visits following the day of the delivery, the patients have provided their written consent forms for video recordings of patient statements to be made where they have shared their strong and intense feelings about their experience.

The working schedule of doulas and treating doctors during the pilot study is presented below.

  Delivery Room Treating Doctor                   Date

GYN & OBS. Volkan Kasımoğulları             08.09.2016 Thursday

GYN & OBS. Soner Düzgüner                       09.09.2016 Friday

GYN & OBS. Adil Barut                                10.09.2016 Saturday

GYN & OBS. Özlem Akgül                            11.09.2016 Sunday

GYN & OBS. Soner Düzgüner                        12.09.2016 Monday

GYN & OBS. Müge Temel                              13.09.2016 Tuesday

GYN & OBS. Volkan Kasımoğulları               14.09.2016 Wednesday

GYN & OBS. Önder Aydın                              15.09.2016 Thursday

GYN & OBS. Müge Temel                              16.09.2016 Friday

GYN & OBS. Adil Barut                                  17.09.2016 Saturday

GYN & OBS. Volkan Kasımoğulları               18.09.2016 Sunday

08.09 Thursday           Morning          Begüm Babacan Aksel            Tülin Nilay Erkut        Tuğçe Bağcı

            Night   Begüm Babacan Aksel            Yansı Subaşı   Feyza Bağlan Eroğlu

09.09

Friday  Morning          Esra Bozkurt   Ece Efe          

            Night   Janin Marazyan           Esra Taşdemir

10.09 Saturday            Morning          Hayriye Erdoğu          Hanife Doğan Yılmaz Esra Taşdemir

            Night   Esra Taşdemir             

11.09

Sunday            Morning          İrem Bilge                   

            Night   Ayça Yılmaz               

12.09

Monday           Morning          Sima İbrahimiye Ölçer                        

            Night   Şeyma Kaplan             

14.09

Wednesday     Morning          Özlem İlbeyli  Elif Işık          

            Night   Özlem İlbeyli  Elif Işık          

15.09

Thursday         Morning          Linet Behar Morhayım            Özge Kotam    Suna Çetin

            Night   Sibel Toledo    Gülperi Tabanlıoğlu   

16.09

Friday  Morning          Hatice Çizmecioğlu     Esra Taşdemir Elif Sultan

            Night   Esra Taşdemir Melek Arslanbenzer