Comprehension on doula’s work at a maternity in Jequitinhonha Valley – MG

Objectives: to analyze the understanding of puerperae, doulas and the care team about the presence of a doula during the pregnant women’s parturition process. Methods: this is a qualitative study, using semi-structured interviews as a data collection instrument. The saturation criterion was used to limit the sample and proceed to the Content Analysis. Results: 19 participants were interviewed, 10 were the health team, 5 were doulas and 4 were puerperae. After the analysis, three categories were identified: the doula’s presence during the pregnant women’s labor and their meaning, the doula’s follow up during the pregnant women’s labor and its improvements, the influence of doulagem in the academic formation. The presence of doulas brought to the parturient security, support, humanization and follow-up on childbirth process. The team brought comfort and tranquility.The doulas scored benefits for academic training. Conclusions: it was possible to recognize doula as part of the humanized care, to provide subsidies for a reflection of her work, and to reveal the influence of the practice of doulagem for academic formation of doulas at university.


Introduction
In recent years, women's healthcare has been advancing with the insertion of humanized care programs, such as the strategy of the Ministry of Health called Rede Cegonha (The Stork Network), which aims to integrate health professionals and empower women as users. 1 The entry of doulas into the childbirth scenario has been showing in the literature as a team/pregnant link, favoring the parturient's protagonism and corroborating with a humanized and welcoming care. 2 The Ministry of Health defines doula as an accompanying person, with or without specific training, who provides constant support for pregnant woman and her companion during the labor, not requiring any technical training in the health area. 3 The Doula's role is to clarify the parturient regarding the labor evolution, to advise the most comfortable positions during contractions, to use non-pharmacological methods for pain relief, promote breathing and relaxation techniques, provide physical contact and offer psychological support. 3,4 The doula's social and physical support during labor also shows a reduction in costs. 5 An international survey showed that women who received support from doulas had lower rates of preterm and cesarean delivery. 5 In addition, they represent a costeffective economy, since a cesarean section is more expensive than a normal childbirth. 6 The insertion of the doula in the hospital environment at a maternity in this study was one of the strategies developed by the care team in partnership with a local Higher Education Institution (Instituição de Ensino Superior -IES), aiming to draw better ways to humanize care for women during the parturition process.
Considering that the presence of a doula aims to achieve humanization care for woman during her baby's birth. The objective of this study was to analyze the comprehension of the people involved at the moment of the pregnant women's parturition regarding to the insertion of a doula in that context.

Methods
This is a qualitative descriptive study carried out at a maternity hospital in Vale do Jequitinhonha, in Minas Gerais, which was submitted and approved by the Ethics and Research Committee under the protocol number 1104982 and CAAE number 42859515.6.0000.5108.
The hospital is a philanthropic entity of macro-regional reference, with public service as the Public Health System (SUS) and some private healthcare agreements. A project to insert doulas, in a pioneering character in the region, has been implemented at this institution.
In the city where this present study was carried out, the doulas' focus on voluntary hospital care during labor, childbirth, and breastfeeding. The acting team is composed of academics from different undergraduate courses in the health sciences area of a Higher Education Institution (Instituição de Ensino Superior-IES). Prior to work as doulas, they underwent a training course, part of an IES extension project.
Data were collected from July to September of 2015. Nineteen semi-structured interviews were carried out to produce the empirical data, 10 were of the maternity care team, 5 were academic doulas of the undergraduate course of a teaching institution active in the scenario of study, and 04 were puerperae who received the follow-up on doulas.
In order to define the number of interviewed subjects, data saturation was used to stop the inclusion of new participants. Once the collected data showed redundancy, according to the researchers, it was considered that there already was an understanding of the phenomenon investigated. 7 The interview process was formulated with questions previously elaborated in order to reach the objective of this study.
The puerperae, who agreed to participate in the research, were chosen based on the inclusion criteria: being admitted to the maternity hospital between 24h and 72h after the birth of their child and received a doula to accompany them during their labor. There were no restrictions on being primiparous or multiparous, adolescents (if under aged, the guardian responsible allowed them to participate in the research) or adult, illiterate or literate. There was no distinction of race, religion and type of hospitalization (SUS, with a health plan or private).
The team directly involved in maternity care was composed of four nurses, fourteen nursing technicians, six obstetricians, four pediatricians and one social worker, totalizing twenty-nine professionals. To participate in the study, professionals of the maternity were selected if had experienced at least a pregnant woman's labor with a doula's presence.
In the doula's team, they had members who were undergraduate of schools in Nursing, PhysioTherapy, and Nutrition. Regarding to the inclusion criterion, it was defined to be active in the scenario of study.
The analysis content was used, based on Bardin's thematic analys through recording and transcription of the interviews, pre-analysis with superficial reading and initial organization of the material; reading with depth and exploration; data coding; data processing and interpretation. 8 In order to categorize the results, letters and numbers were attributed to the excerpts from the present statements. The letter E represented the category of team members, the letter D the doulas' category, and the letter P the puerperas' category.

Results
Nineteen participants were interviewed, four of them were puerperae, ten health professionals (three obstetricians, three nurses and four nursing technicians), and five doulas.
Based on the analysis of the interviews, it was possible to understand the following categories: 1.Doula's presence during the pregnant women's labor and their meaning; 2. Follow-up of the doula during pregnant women's labor and their improvements; 3. The influence of doula's work in an academic training

Doula's presence during the pregnant women's labor and their meaning
In the interviews we could see a close relationship between the accompanying of doulas and the meaning on the reception, accompany, support and humanization, as follows: "So a doula comes to do the work with more humanization, security, comfort, showing affection to the pregnant woman and also to the family" (E8).
"For me, a doula's work means to be able to help the pregnant woman do whatever she wants to do, to give some support. this is a humanization."(D2).
It was observed that the presence of a doula at pre-partum, offers comfort to the team, having a person all the time beside the pregnant women, guiding them regarding to the non-pharmacological activities for pain relief and that, in case of any intercurrence, the doula would be a link between the team and the pregnant woman.
"What I realize there is a kind of tranquility for the pregnant women because they have a person who is accompa-nying them all the time and this is a tranquility for the team. You know there's someone you can go there periodically and that, in case of any problem, he/she will be calling you and everything else "(E1).
"In fact, the team, no matter how much she is aware about the labor, she does not have enough time to accompany the whole labor" (E5).

Follow-up of the doula during the pregnant women's labor and their improvement
In the interviews with the puerperae, it can be observed that all of them denied the need of improvement in this aspect.
"Until then, everything was excellent for me. I do not see the need of any improvement "P3).
"In my opinion, it was great, more than I expected. I did not notice that anything was missing "(P4).
However, the team members and doulas reported a lack of physical and human resources, as detailed in the following statements: "The physical and material issues. There is only one ball, There is no bathtub nor a proper stool for childbirth "(D3).
"I think it's really a space problem. Very crowded"(E7).
It stands out in doulas' reports the lack of appreciation of their work on behalf of the members of the hospital. The fact that the doulas in the scenario of study are voluntary and mostly composed of undergraduate students was seen as a disadvantage since it impairs attendance and periodicity in relation to the prioritization of academic activities.
"I think they could have doulas more often. They help.
The negative point is when there is no doula "(E1).
"Regarding to doulas, they are more assiduity and they should come more often. Because I did the course, but I could not practice due to the lack of time "(E6).

The influence of the doula's work in the academic formation
This category arose because doulas are academic students and come to uncover factors linked to health education. There is a shortage of information on the academic background of doulas regarding to publications in this area, because doulas do not belong as students, but to a more experienced women who often is remembered as a mother figure.
In the reports, doulas brought reflections on the course and the influence of acting as a doula for academic formation. Playing the role of a doula was fundamental to narrow the relationship between the theory lived in the dependencies of the educational institution and in one of the scenarios of practice. It may be noted that the doula course, performed by volunteers, was seen as a tool to further minimize this complexity, strengthening the praxis of humanization in academic formation.

Discussion
During the interviews, it was noticed that 12 out of the 19 interviewees did not know about doula's work and functions before witnessing a doula in the maternity ward. This result has revealed that it is new and little is discussed about the topic in this region.
A study conducted in Florida demonstrates the presence of a doula in normal deliveries as an action already implemented, unlike some Brazilian realities. 9 In addition, it revealed that pregnant women accompanied by this category presented a perception of a significant reduction of pain and fears of labor. 9 The presence of a companion, whether it is a family member, a doula, a friend, or even a professional who accompanies the woman in the prepartum and in childbirth, significantly reduces the parturient's suffering of pain and the use of unnecessary procedures. 2 Brazilian Law number 11,108, on April 8, 2005, regulates the right to have the presence of companions during labor, childbirth and immediate postpartum, within the SUS. Thus, involving the family member during labor may be an excellent strategy for performing non-pharmacological activities for pain relief, where the lack of human resources of care teams in the maternity is a reality. 10 Humanization is a characteristic that, according to the interviewees, all professionals should have when dealing with their patients. Investing in this issue in care, especially in the field of education and vocational professional, is becoming increasingly necessary. 11 According to Silva et al., 11 to reflect on humanized care is to think, above all, of women's right to have freedom of choice, integral health practices on mother/child binomial, respect the user's rights, value popular knowledge and in the amplitude of therapeutic modalities that can be associated with conventional care.
Another result observed in the interviews was the lack of physical and human resources. This study corroborates Silva et al., 11 identifying that many doulas point out as the main obstacle in their practice, the deficiency in the structure of hospitals to carry out their activities, which results in the invisibility of their work.
The maternity in this study has shower and ball in reduced number in relation to the demand of attendances for the work of the care team and the doulas during the practices of pain relief in a nonpharmacological form. The maternity has an average of one hundred and twenty childbirths per month, and in several days it is notorious more than three women in labor at the same time.
It is worth mentioning that the lack of these materials makes it impossible to develop some kind of activities directed for labor, thus performing other ways to relieve pain such as walking, music therapy, changing positions, breathing or even stillness and silence according to each link established.
The doulas' reports showed a feeling of devaluation of their work by hospital members. This fact was also observed in other studies, where the difficulties evidenced in the field of action are related to the professionals and parturients' lack of knowledge, resulting in the devaluation of the work performed by them. 10,11 Studies in the cities of Fortaleza (CE) and Campinas (SP) have concluded that much needs to be done so that doulas' role is recognized and vali-dated in different segments of society. Their presence is restricted in maternities, even if they work voluntarily or hired by the parturient. 12 Despite the perceived devaluation of doulas, the work teams want them to be present at all times during maternity care, emphasizing the essential strategy for linking and security.
Another finding was the practice of the doula as a promising field of work for academic students. Living this experience can be considered as a pedagogical strategy, which will allow us to experience humanization during childbirth, adopting active methodologies and proposing curricular reformulations.
According to Freitas et al., 13 the teaching activities in health have had a deficient formation directed to the practice training. Professors associate this deficiency by reporting difficulties in the spaces of formation that do not involve all the necessary discussion to the fundamental teaching of knowledge and favoring the teaching-learning process in health. 13 The creation of humanized teaching-learning spaces is complex and determined by numerous factors that involve the technical-assistance and pedagogical model. 13,14 Perceptions of humanization, mostly, are limited to the symptom concept, especially in times of impotence faced with the sufferings arising from the dominance of the social or even from technicalism. 14 Considering the limitation of the study as the fact of the interviews were carried out only with the academic doulas, since it was the team acting at the moment of the research. This design allowed an understanding particularity in this region. On the other hand, it is understood that the report of nonacademic doulas could reveal different data.

Final considerations
The proposed objective of this study was reached because, through the reports, it is possible to analyze the understanding of the puerperae, the doulas and the care team about the presence of a doula during labor in the maternity hospital in Vale do Jequitinhonha, Minas Gerais. Also, it was possible to identify the influence of a doula's work for the formation of academic doulas.
Doula's work revealed meanings inherent in a humanized and welcoming care, thus providing a way for maternity care teams, together with managers and other ones involved in the processes of assisting pregnant women, to reflect on the relevance of the presence of doulas in those scenarios. It can be seen that in some maternity hospitals, such as the Hospital Sofia Feldman in Belo Horizonte -MG, the doula is already part of the hospital staff, and is paid for her work institutionally.
In summary, it was possible with this study to recognize doula as part of the humanized care provided for pregnant women in labor, childbirth and postpartum, in addition, providing subsidies to reflect on their work.
For the academic formation, the practice of a doula was notorious and exerted great influence. It is revealing that this practice can be seen as a teaching strategy, in which the objective is to work the content of humanization in the training course in health teaching.
Humanization goes beyond scientific and technological knowledge. It permeates empirical knowledge, as well as professional, social, familiar and individual experiences. It is a grouping of human characteristics that will notably influence the quality of care provided to families during the birth process.

Author's contribution
Lima PO and Miranda JL participated in the elaboration and the study design, methodology, data collecting interpretation, data analysis, writing and reviewed the article. Pinheiro MLP performed the writing and reviewed the article. Almeida HF contributed with the writing, reviewing and the formato the article. Guedes HM accompanied the data analysis, the writing and the review of the article. All the authors approved the final version of the manuscript.