This cross-sectional study investigates the impact of doula support during childbirth among Brazilian women who previously participated in a health education intervention named the Senses of Birth (SoB).
The senses of birth intervention
The SoB intervention was developed to promote normal birth in Brazil and to reduce medically unnecessary interventions in childbirth. This international grant-funded public educational intervention was implemented in five large population cities in Brazil from 2015 to 2017 to engage the local community and disseminate information regarding evidence-based practices in childbirth . The interactive intervention led participants through the stages of pregnancy, childbirth, and the postpartum period and demonstratedEBPs and valuing the physiology of normal birth . All visitors were invited to walk through a scenario, first as a pregnant woman, and later as a newborn baby. Myths and facts about prenatal health, labor and delivery, and the postpartum period were discussed using theater, sensorial experience, and a video panel discussion .
Data and sample
This paper uses data collected as part of the SoB project research analysis. All women provided written informed consent prior to answering the post-intervention survey and the follow-up survey. All participants were invited to complete a paper-based self-administered structured questionnaire after participation at SoB containing sociodemographic characteristics and questions about perceived knowledge related to normal birth, cesarean sections, and EBPs. All 1,287 pregnant women over the age of 18 years who answered the post-intervention survey were invited to complete an online self-administered structured questionnaire after childbirth.
The follow-up survey included questions related to the most recent labor and childbirth experience, use of the EBPs during childbirth, and memory and influence of the educational intervention on their childbirth experience. Five hundred and fifty-five women answered the follow-up questionnaire (43% of the original sample) between June 2015 and April 2016. Women who did not respond to the survey after three email invites and three phone calls were eliminated.
Use of doula support during childbirth data was collected through a closed-ended question regarding the professional(s) present during childbirth. The answer options were: doula, obstetrician, midwife, obstetric nurse, pediatrician, no health professional present, and others. The participant could choose as many options as applicable. A dichotomous variable to indicate doula support (doula support vs. no doula support) was created.
Sociodemographic characteristics included age (19 to 34 years old vs. ≥ 35 years old), race (white vs. non-white (Black, Asian, and indigenous)), education level (< 12 years, ≥ 12 years), private health insurance (yes, no), and income (very poor, poor, moderate, and wealthy). In Brazil, services rendered through the national public health system (known as the Unified Health System or SUS) are available to all residents and nonresidents without out-of-pocket charges or co-payments41. Some residents (ranging from 22 to 25% of the population) also have additional coverage through private insurance, commonly financed by employers. Income was measured using the monthly family earnings relative to the country minimum wage. The income levels included Very Poor = < 2 minimum wage, Poor = 2 to < 5 minimum wage, Moderate = 5 to < 10 minimum wage, Wealthy ≥ 10 minimum wage One minimum wage at the time of the intervention was approximately R$788.00, which was USD $224.14. Childbirth experience included questions related to pregnancy: first pregnancy (yes vs. no), type of delivery (vaginal vs. cesarean), type of hospital of delivery (SUS- public hospital vs. private hospital) indicating the mode of finance. “SUS” refers to public or non-profit hospitals integrated with the public health system, funded by the government, without any direct payment of patients for any care. “Private” refers to for- profit or non-profit hospitals not funded by the government, healthcare paid by privately-owned health insurance or direct or out of pocket payment by the patients.
The EBPs described in this paper were identified through a review of the literature [15, 32]. They were incorporated into the education provided through SoB and included: midwife care during childbirth (yes vs. no); freedom of mobility during labor (yes vs. no) characterized as the ability to walk, dance, and crouch; position during delivery (lithotomy position vs. no lithotomy position) where non-lithotomy position was characterized as any position other than supine (traditional gynecological position) including kneeling, semi-sitting with support, or sitting upright; and use of non-pharmacological methods for pain relief (yes vs. no), including massage, use of a birth ball, shower, bathtub, electrodes (TENS), music, meditation, and breathing techniques.
Perceived knowledge about normal birth, cesarean section delivery, and EBPs was measured through questions using a Likert scale (1 to 3 – low and 3.01 to 5 high). The different questions were combined using a factor analysis to create a domain knowledge variable for normal birth, cesarean section delivery, and EBPs. The method used for the combined variable has been described in a previous publication.
Chi-Square tests were performed to identify the relationship between doula support during childbirth and type of delivery, sociodemographic characteristics, childbirth information, perceived knowledge, and use of EBPs during labor. Logistic regression analyses were performed to identify association in an adjusted analysis and associations were considered statistically significant with P-value ≤ 0.05. The statistical program IBM SPSS Statistics 24R was used for the data analysis.
Two regression models were constructed to identify association with doula support during childbirth compared to no doula support: Model 1 - all women participating in the study; Model 2 – subsample of women who had vaginal birth. All variables that obtained a p-value equal to or less than 0.20 in the bivariate analysis were included in the logistic regression model. The magnitude of the association in the logistic regression models was evaluated through odds ratio (OR) and their respective confidence intervals at 95%. The quality of the fit of the model was assessed by the Hosmer-Lemeshowe test and the explanatory power of the model was assessed by the Nagelkerke pseudo-R².
This study is part of the research project named “Senses of Birth: Effects of the interactive exhibition in the perception changes on labor and childbirth.“ The Federal University approved the study at Minas Gerais IRB (COEP/UFMG, 934.472) and the University at Albany Institutional Review Board approved the study (Protocol Number: 18-X-209-01). All participants provided written informed consent prior to participation.