“Alone, I wouldn't have known what to do”:A qualitative study on social supportduring labor and delivery in Mexico
Introduction
Providing psychosocial support during labor and childbirth has been gaining interest, particularly because of its impact on the results of obstetric treatment and on the health of the newborn baby. In various clinical trials carried out in Guatemala, the United States and South Africa, positive effects have been demonstrated when psychosocial assistance was provided by doulas1 to women giving birth. These studies highlight the relationship between psychosocial support and the reduction of various types of medical interventions such as the use of anesthesia, analgesics, cesarean sections and forceps (Sosa and Kennell, 1980; Klaus and Kennell, 1986, Klaus and Kennell, 1992; Keirse and Enkin, 1989; Kennell and Klaus, 1991), and have also found that support during labor accelerates recovery, favors early bonding between mother and child, decreases anxiety and depression during the first six postpartum weeks, and reduces the time spent in labor (Klaus and Kennell, 1992; Hofmeyr and Nikodem, 1991). In the most recent study (South Africa) a positive effect of psychosocial support was also found on the initiation and duration of breastfeeding (Hofmeyr and Nikodem, 1991).
These results led us to conduct a similar intervention in Mexico, which consisted of continuous psychological and physical support to the woman during labor, childbirth and immediately following birth, and was provided by a group of women (doulas) who had been trained as companions for the first-time mothers. In previous studies, the profile of the doula has varied. In some cases, doulas had been women of the community while in others the doula was a person who received specific training (Sosa and Kennell, 1980). For this study, it was decided that those women considered suitable to take part in the study as doulas would be seven retired nurses. However, four young women who participated in the training course and had shown interest in the intervention but were not nurses, also took part. The theoretical and practical training sessions took place in the same hospital during a period of three weeks. With the previous agreement of the hospital authorities, the doulas were incorporated into the labor and delivery rooms and introduced to all the physicians and nurses. Each part of the doulas' responsibilities of accompanying the pregnant women during the process of her labor and delivery was carefully explained to the hospital staff.
This intervention took place within the Mexican social security system in a typical maternity hospital, which routinely provides conventional medical care, has some rooming-in facilities and develops limited activities to promote breastfeeding. At this hospital, there is an average of 400 births a month, of which 40% are first-time births. According to hospital regulations, a woman who has had an uncomplicated delivery is discharged approximately 24 h after giving birth. If the birth is by cesarean section, women remain in the hospital for approximately 72 h.
This was evaluated by means of a randomized clinical trial, a qualitative study, and an assessment of cost-effectiveness. In this paper we focus on the analysis of women's perceptions as the effectiveness of the intervention is discussed elsewhere (Langer et al., 1997).
The study presented here was centered on reconstructing the women's experiences in a personal dimension. The objective was to explore what women felt during labor and childbirth whether they were accompanied by a doula or left alone. The significance of psychosocial support during a woman's first delivery as well as the quality of the relationships established between the woman, the doula and the hospital staff were assessed. The qualitative study included interviews with the women immediately after delivery and with women at home six weeks after childbirth; interviews with doctors, nurses and doulas; and some structured observations about maternity ward interactions between the different actors (doula–woman, woman–hospital personnel, and doula–hospital personnel); however, in this article we are only describing immediate postpartum interviews with women.
Section snippets
Conceptual framework
In Mexico, care provided to women during pregnancy, childbirth and the postpartum period has become increasingly medicalized during the last decade. In effect, care is provided exclusively by doctors and nurses who generally consider labor and childbirth as potentially pathological conditions for which the mother and/or child require specialized and technological care (Chalmers and Wolman, 1993; Cogan and Spinnato, 1988). National statistics show that 85.4% of births take place in hospitals and
Methodology
In order to review women's experiences, perceptions and opinions about the childbirth event, a series of in-depth interviews were conducted with women in the immediate postpartum period. These interviews informed us about women's insights expressed in their own words, their sense of what they had experienced, and their perception of the relationships they established among themselves, the hospital staff and the doulas (Herzlich, 1987; Oakley, 1990; Reyna and Dı́az, 1989; Lincoln and Guba, 1985;
Results
The interviews with both groups of women were divided into four parts. The first part described the women's general hospital experience and their perception of the way they had been treated by the medical staff. The second part described women's experiences and perceptions with respect to medical information, routines and interventions. The third part referred to the labor experience and women's perceptions of themselves during the process. The fourth part collated the opinions of those who
Discussion and conclusions
Qualitative research in public health is an indispensable complement to epidemiological research because it allows the exploration of the subjective dimension of the processes under study and a deeper understanding of them. This knowledge provides an insight into the processes underlying the intervention's effects, and into the barriers and facilitating factors that should be considered for its adoption on a routine basis.
Research on psychosocial support includes dimensions which are very
Acknowledgements
The authors wish to thank Wellstart International for funding and otherwise supporting this project, the hospital authorities and medical personnel for allowing the study to be conducted, and Philomena Linehan and Angela Heimburger for helping with the translation.
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