Oral History: experience of doulas in the care of women

Abstracts

OBJETIVO: Mostrar a possibilidade de utilização da História Oral como referencial metodológico para compreender o significado da experiência das doulas durante o processo de parto e nascimento em uma maternidade pública. MÉTODOS: Estudo qualitativo, realizado em uma maternidade pública municipal na cidade do Recife-Pernambuco, na qual o programa encontra-se institucionalizado há quatro anos. O instrumento de investigação utilizado foi a entrevista junto a nove doulas, analisada segundo a história oral temática. RESULTADOS: Emergiram dois eixos temáticos que trazem a experiência das doulas no cuidado à mulher: um caminho para a humanização e acolhendo e criando vínculos. CONCLUSÃO: Os discursos revelaram que as doulas oferecem um cuidado que envolve uma escuta ativa, alicerçada em atitudes de respeito, acolhimento, conhecimento técnico e amor.

Saúde da mulher; Parto humanizado; Acompanhantes de pacientes

ORIGINAL ARTICLE

Oral History: experience of doulas in the care of women^*

Historia Oral: la experiencia de las doulas en el cuidado a la mujer

Karla Romana Ferreira de Souza^I; Maria Djair Dias^II

^IMaster in Nursing. Assistant Professor, Nursing Department, Federal University of Pernambuco - UFPE - Recife (PE), Brazil

^IIPhD in Nursing. IVAdjunct Professor at the Department of Public Health Nursing. Professor of the Graduate Nursing Course, Federal University of Paraíba - UFPB, João Pessoa (PB), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To show the possibility of using oral history as a methodological reference for understanding the meaning of the experience of doulas during labor and birth in a maternity.

METHODS: This is a qualitative study conducted at a municipal public maternity hospital in the city of Recife, in Pernambuco state, where the program has been institutionalized for four years. The research instrument used was the interview with nine doulas, analyzed according to the oral history.

RESULTS: Two main themes emerged that show the experience of the doulas in caring for women: a way to humanize and welcoming and creating links.

CONCLUSION: The speeches revealed that doulas provide care that contains an active listening based on attitudes of respect, foster care, technical knowledge and love.

Keywords: Woman health; Humanized childbirth; Patient escort service

RESUMEN

OBJETIVO: Mostrar la posibilidad de utilizar la Historia Oral como referencia metodológica para comprender el significado de la experiencia de las doulas durante el proceso de parto y nacimiento en una maternidad pública.

MÉTODOS: Se trata de un estudio cualitativo, realizado en una maternidad pública municipal en la ciudad de Recife, en Pernambuco, en la cual el programa se encuentra institucionalizado hace cuatro años. El instrumento de investigación utilizado fue la entrevista junto a nueve doulas, analizada según la historia oral temática.

RESULTADOS: Surgieron dos ejes temáticos que muestran la experiencia de las doulas en el cuidado a la mujer: un camino para la humanización y acogiendo y creando vínculos.

CONCLUSIÓN: Los discursos revelaron que las doulas ofrecen un cuidado que contiene un escuchar activo, basada en actitudes de respeto, acogimiento, conocimiento técnico y amor.

Descriptores: Salud de la mujer; Parto humanizado; Acompañantes de pacientes

INTRODUCTION

The events involving the process of parturition and birth in the hospital setting mark a danger atmosphere, suffering, dissatisfaction, frustration and violence, making it difficult for women and their families to turn that experience into something positive, rewarding and healthy.

However, to meet this need, it was enacted the Law no. 10 241 on March 17, 1999 which, in its paragraph XVI, ensure the presence of the companion in prenatal and at the parturition⁽¹⁾. Finally, on April 7, 2005, the Law no. 11.108 amends the Act No. 8080 of September 19, 1990, which ordered the health services of the Health System and the network itself or private, allow the presence of a companion with the mother during the parturition process, birth and the immediate postpartum period⁽²⁾. The woman in this important phase of her life; may be accompanied not only by their partner or anyone she trusts, but also by a doula⁽³⁾.

The support offered by the mother's companion and the doula are complementary. When this person shares an emotional bond is more difficult to remain calm and oblivious to the discomfort felt by women. At this time, a careful and experienced doula can calmly help this woman to deal with her parturition, teaching her how to be comfortably relaxed. It also represents a reassuring presence to chaperone. A doula offers a different level of support the person who is closely related to the woman in the process of parturition and birth⁽⁴⁾. The word "doula" comes from the Greek for "woman who serves." Worldwide this name applies to women who give emotional and physical support to other women before, during and after parturition. In Brazil, it came to be contemplated calling them as cummers, because in most cases, who held the post of doula were the cummers, willing to help their godchildren's mother during parturition and birth. This name was not adopted because it could cause confusion⁽⁵⁾. About that support an author⁽⁶⁾ states that "in our culture easily identify the role of doula. Traditionally, whenever a woman has children, other women, who generally are already mothers, help the new mother to play her role. These women are mothers, grandmothers, sisters, mothers-in-law, neighbors and friends".

"A doula can be seen as a mother figure in which the future mother find support throughout the parturition process"⁽⁷⁾. The same author says has been in the 70s that this word of Greek origin appeared as the presence of a companion at the parturition and birth moment. However, the word doula was rescued, first by Dana Raphael, an American anthropologist studious of the breastfeeding practice, to refer to an experienced parturition companion who provides the woman, her husband or partner both emotional and physical support during the whole process of parturition and birth including postpartum⁽⁴⁾.

The World Health Organization, in the Normal Maternity Care: A Practical Guide⁽⁸⁾, refers to a doula as a service provider that receives a basic training in parturition and who is familiar with a wide variety of care procedures. It provides emotional support, measures to provide maternal comfort, physical contact, explanations about what is happening during the process of parturition and birth, a friendly constant presence. The Ministry of Health in its publication, Parturition, Abortion and Puerperium - Humane Assistance to Women⁽³⁾, defines doula as a trained companion that in addition to emotional support, should provide information about the entire course of the process of parturition and birth, explaining her of interventions and procedures, so that she can participate in decisions about the conduct to be taken at this time.

During the parturition, the doula acts as an interface between the healthcare team and the couple. She speaks in a language accessible about techniques, hospital procedures and reduces the potential coldness of the team at one of the most vulnerable moments of women's lives. She helps the mother to find more comfortable positions for parturition and birth process, shows more efficient forms of natural breathing and proposes measures that might relieve the pain, such as baths, back rubs, relaxation and when holding the mother's hand, gives her confidence and affection⁽⁹⁾.

The presence of the doula for woman care in situations of parturition means pain relief, support, courage, love and peace. It develops an active listening, learn to be more receptive, and let the woman talk when she needs, communicating through the touch, attitudes, look, and most importantly, through care. Thus, it promotes self-confidence, boosts self-esteem of women by making her believe in her ability. For this, the doula is molded to the moment being fully integrated with the feelings of the mother and respecting the wishes of each woman. This climate of openness and respect represents safety and courage to the mother⁽¹⁰⁾.

Given the important role of doulas in the women care during the process of parturition and birth in the hospital context, the question is: Can such research be possible having the Oral History as a methodological way?

Given this purpose we developed the following questions: why did these women become doulas? Which practices did doulas develop in caring for women during the parturition and birth processes in the hospital context?

To answer these questions was defined as objective to show the possibility of use of Oral History (HO) as methodological framework for understanding the meaning of doulas' experience during parturition and birth processes in a public hospital. Considering that the HO is a type of research that comprises the narrative of the set of individual experiences, their propositions and truths, allowing display the version of facts, according to their world view, being sovereign to reveal or conceal cases, situations and identities.

The HO is a systemic process of using testimonials, poured from oral to written, to be collected as testimonies, examine social processes, facilitating studies of identity and cultural memory⁽¹¹⁾. It also offers the possibility to understand phenomena from the perspective of the individual inserted into its life context and reality⁽¹²⁾.

METHODS

The methodology used in this research was thematic oral history, one of the HO's modalities. There are three types of HO, depending on the content that will be worked in the interviews. Therefore, it is classified by Meihy⁽¹¹⁾ in Life Oral History, Oral Tradition and Thematic Oral History. The Life HO is the story of the whole experience of a person; Oral Tradition works with the permanence of myths and the worldview of communities that have filtered values by mental structures, ensured by references to the remote past and Thematic HO whose commitment is to clarify the speaker's opinion about some defined event.

This research is part of the perspective of thematic oral history, since it is a specific topic with a commitment to reveal the doulas' experiences in caring for women in parturition and birth processes.

The HO considers the witness as a collaborator, free to speak about his personal experience and participate in the process. It allowed the doulas reporting their experiences, contributing to the humanization of care.

The venue for research was in a municipal public hospital located in Recife - Pernambuco, which serves a large population living in Recife and the metropolitan area. It is considered a medium and low risk; a pioneer in the humanized service to women, holding the IV Professor Galba Araujo vand found and considered a Baby Friendly Hospital.

The collection of empirical material occurred in the maternity ward in the period from April to June 2007. The project was presented in advance to collaborators, explaining the purpose of the study and the empirical data that would be collected through interviews by means of recorded interviews with advance interviewees' authorization. It was reinforced the importance of participating in the study and the possibility of quitting in the process. The study project was approved by the Ethics Committee in Research form the State Secretary of Health of Pernambuco.

To construct the oral document, the HO method recommends a series of sequenced procedures from the project designing, definition of the interviewees, collection of the empirical data using the interview technique, followed by phases of transcription, textualization, transcreation, conference and discussion of the material produced.

The interviewed women who participated in the study were selected from the colony and network training. The colony is defined according to broad elements that mark the cultural identity of the group to be studied, related to the study topic. The network is a subdivision of the colony with the aim of establishing parameters to decide on who should and should not be interviewed⁽¹¹⁾.

In this research, the colony was established of doulas and the network by those who agreed to participate in the study. The maternity counted on 11 volunteers doulas, however, this process involved only nine contributors, since two did not participate due to the program remoteness for personal matters.

The interviews were conducted at the maternity, when respondents were on duty in a reserved environment, as the doulas' hall, in order to there is privacy and maintain a closer relationship and trust. Thus, they could freely expose and express their feelings without being interrupted.

To start the interview recording, it is recommended to record the identification data: name of, collaborator's name, time, place and date of the meeting. The collaborator must be informed about the conference, the material produced in the interviews and being assured her that the publication will only be performed with her permission through the Assignment Letter, which Meihy⁽¹¹⁾ considers a key document to define the interview use and the publication of the final text produced, and signing of the consent form. This author⁽¹¹⁾ suggests that the oral history projects are guided by cohort questions, defined as guiding questions that run through all the interviews and must be related to the group analyzed. In this study, the interview was developed from two cohort questions, which were: How did you become a doula? How do you take care of women during the parturition and birth processes?

EMPIRICAL TREATMENT OF MATERIAL

After the interviews, the oral report has been turned into text to make it available to the public. Thus, the steps of transcription, textualization, transcreation and conference of the final text were necessary⁽¹¹⁾.

Transcription: it involves listening to the recorded material in a faithful manner to the events, including the cohort questions.

Textualization: is the next step, where cohort questions are deleted, fusing with the text to get a narrative character. This phase allows the researcher to extract the vital tone of the interview, subject with expressive force to guide the reader, and represents its moral synthesis, being placed in the title form in each narrative.

Transcreation: the last phase of transcription, in which the text is rebuilt in its fullness; with ordination of testmonials in paragraphs, removing or adding words or phrases, according to the observations and notes in the field notebook.

In this study, the conference occurred individually, when doulas were on duty at the hospital. That moment served to deepen some themes. There was no negotiation and the text was approved in full, being corrected some words that were not understood during the transcripts.

For ethical reasons, it was chosen to use fictitious names for anonymity. Names of angels were selected by doulas, once some women assisted by them consider them as true angels in their lives. After performing the steps of empirical material processing, it was taken for each respondent to conference and elaboration of interest issues to the study.

The material was subjected to repeated readings to identify the most significant points directly related to the doulas' experience in the care of women in parturition and birth processes, which generated the most central themes of the study. The strong expressions used to build the vital tone of interviews, which is considered an axis guiding reading, guiding the discussion and understanding through a dialogue established by authors that make up the theoretical research.

RESULTS

In view of the interpretative approach adopted in this study, the evaluation of the empirical material allowed to know the reasons that led women to become doulas in a municipal public hospital in Recife -Pernambuco and learn about their activities in the context of care of health women in the hospital environment.

After reporting of stories on the doulas' care were identified two thematic axis that led to the discussion through a dialogue with the literature.

In the Thematic axis - A road to humanization; it is possible to identify the causes that led women to become doulas. Feelings such as: the desire to help, feel useful and do something to promote the well has been the motivation of most contributors, as evidenced in the following speech: "(...) I became because I like helping (...)" (Angel Ratziel).

The welfare-type motivation expressed in the desire to help others, perceived as someone lacking in affection, of material goods, information and knowledge is responsible for mobilizing the concepts of needs and utility. Therefore, the reasons that drive the desire to help can be diverse, however the greatest interest and concern is with the "other"⁽¹³⁾.

The life histories of some collaborators have shown people with solidarity practices, activities that moved them to the Program, which it realized in the following statement: "(...) I became a doula because of my life experience (. ..), people called me to go to maternity and I was talking and stroking her hair (...)" (Angel Uriel).

This report brings fragments of life histories of some contributors, where the attitude of care had been part of their relations with the world and people. "The care is part of the human essence, it is not just an isolated act, it represents an attitude of occupation, respect, concern, responsibility and affective involvement"⁽¹⁴⁾.

Stories of attachment loss, difficulties in life, identification of the "other" as representative of itself, were responsible for the willingness of collaborators to help, resulting in positive feelings in their lives, such as overcoming injuries, problems, and to feel complete and accomplished. The following statements strengths this affirmation:"(...) when I was having my son my mother could not get into the maternity (...) there was only the medical staff and nursing assistants, and I was feeling alone ... Thus, I was traumatized and do not want to have more children (...)" (Gabriel )."(...) since I was going through a difficult time in my life, I agreed to be doula (...)" ( Angel Zedekiel). "(...) once I have no children, I help women to have their little babies (...)" (Angel Uriel).

These testimonials portray experience marked by lack of care experienced by collaborators at some time of their lives, like loneliness, difficulties and the pursuit of personal fulfillment, which transformed their suffering into a source of power, assuming a therapeutic place for self-help in the search for an emotional return. Therefore, each time the doula takes care of women, she is taking care of herself and thus diminishing her suffering, confirming the statement "what we do to the others we are doing to ourselves"⁽¹⁵⁾ .

In general, the desire to help expressed by welfare, humanitarian and personnel motivations was responsible for doulas developing their work. Thus, the desire has the power to transform, to unite, to give life a meaning, reaching humans significantly.

Humanize the assistance to parturition and neonatal care is to give conditions for the natural movement of life to flow with sovereignty. In the speech below is possible to identify that the emotional support provided by doulas can best lead the process of parturition and birth. "(...) I try to help to make them stronger and feel emotionally relieved (...)" (Angel Zedekiel).

The reception and linking formation are part of the humanization strategy which is essential in caring. The humanized care evidenced in the richness of interactions in the dialogues that doulas establish with mothers is strongly marked by emotional and physical support that they offer, as expressed the testimonials of the angels Zedekiel and Ratziel.

Thus, doulas act as social support that can be understood as emotional, physical and information resources that individuals receive through social relations⁽¹⁶⁾. "(...) I try to help to make them stronger and feel emotionally relieved (...)" (Angel Zedekiel). "(...) I talk to them much, guiding, placing them in the horse, the ball, squatting on the bed and giving them massage (...)" (Angel Ratziel).

It can be seen in the speeches of such collaborators an availability and involvement with mothers to help them to find potential to endure the discomforts of parturition and birth process. Their care empower women, giving them courage and hope. In that space of trust and security, favored by listening and accountability, having the dialogue as a technique of gathering that promotes the construction of bond and commitment, doulas use the relational spaces as therapeutic environment, introducing the physical care, such as use of the horse, ball, encouraging walking, performing messages, attitudes that facilitate the birth and relieve pain. From this perspective doulas provide a new possibility for the woman to experience the birth experience in a positive way. In the second main theme, Welcoming and creating links, doulas recognize that parturition is an important moment in women's lives. Sensations experienced during childbirth will remain forever in the construction of their memories, whether positive or negative, so the need for emotional support, as can be observed in the following speech: "(...) the moment of childbirth is very important, so it must be surrounded by caring, understanding and much patience (...)" (Angel Metatron).

Childbirth is an important step of pregnancy and childbirth, coated with feelings that raise care and attention in order to ease tensions present in this phase. Currently, studies show the influence of emotional factors in childbirth, such as anxiety and fear that contribute to a prolonged parturition⁽¹⁷⁾.

However, the doula's presence calms, gives security and confidence for women during childbirth⁽¹⁸⁾. In a study on support during parturition, the authors⁽¹⁹⁾ concluded that the support provided by doulas reduced the rate of cesarean sections, use of oxytocin, decreased the time of parturition and birth process, the use analgesia/medications for pain relief and increased maternal satisfaction with the birth experience.

A full understanding of women as a bio-psycho and social being enables to identify a particular situation, as the parturition process, from a comprehensive vision and understanding of its context. In this sense, the angel Kamael says: "(...) when I see a woman in parturition process, my first step is to see if she is well, if she already took a bath and it she is calm (...)" ( Angel Kamael).

This statement expresses the approach way used by doulas. To address means "to approach" someone, "to treat"⁽²⁰⁾. This attitude implies being with someone and it is in this sense that the doula, approaching the woman in the process of parturition and birth, comes to watch her and through the dialogue established, creates emotional ties that allow to know their needs to accommodate and assist the mother in full, taking into account their physical, emotional and socio-cultural needs. Thus, the doula sees the woman in its entirety, as a bio-psycho and social being.

In this conception, it is not possible only to take care of physical symptoms, it is also necessary to consider the emotions that influence the progress of parturition and birth.

Studies⁽²¹⁾ concluded that the activities undertaken by doulas provided better obstetrical results and contributed to the emotional welfare of women."(...) We want to approach to relieve their pain (...)" (Gabriel).

In this speech it is realized that doulas develop their activities in order to lessen the discomforts of the mother. The pain involved in childbirth have physical and mental components, so the woman with fear blocks oxytocin, the hormone responsible for the progress of parturition and birth, while the protected woman releases it, improving the evolution of childbirth⁽¹⁰⁾.

Thus, the work of doulas is developed with a view to accommodate the mother and her discomfort, creating a bond that contributes to an experience of the process of parturition and birth in a positive and enjoyable ways.

This welcoming attitude that doulas develop in the pre-birth through the active listening and production of bond is perceived in the speech of the angel Raphael. To welcome⁽²⁰⁾ means to wrap or accept, host, serve, receive, take into consideration. Thus, welcome means "to pay attention to," "worry about"; "care of". Thus, they use the host as a technique for meeting and the dialogue as the main mean of communication. The conversation is the main activity of care⁽²²⁾. Therefore, it is in the conversation that doulas meet women's needs to satisfy them. "(...) I try to convey comfort to them, sometimes they are crying and when I start talking they stop crying, get calmer and with quieter heart (...)" (Angel Raphael).

The attitude reported by the angel Raphael, depicts the bond formation established by the relations and interactions, reducing fear, diminishing suffering and calming the women in the childbirth situation. For the Ministry of Health in its manual of parturition, abortion and puerperium⁽³⁾, the doula is defined as a person capable of offering emotional support to the mother during the different stages of the process of parturition and birth. The Health Municipal Secretary of Recife assigned doulas the role of welcoming and assisting mothers before, during and after childbirth⁽²³⁾.

DISCUSSION

The results described in this paper indicate that the Program of Voluntary Community Doulas is a fragmentation of care, an arrangement of solidarity which constitutes is support networks. They act by the direct interference of population, civil society organizations and weave practical care strategies whose main the objective is to provide emotional support, increasing women's autonomy on the experience of the process of parturition and birth.

It is noteworthy that doulas contribute to the promotion of creation and establishment of links, providing care that focuses on active listening, based on attitudes of respect, care, expertise and love. Knowing the collaborators experience in caring for women in the process of parturition and birth is to recognize that in their life histories there are desire and pleasure to help others. The relationships that these women have with the world and people are of compassion, solidarity, care, concern and caring. Actually, care attitudes.

The main characteristic of this group is that they have interests in common and are driven by ties of solidarity. The feeling of being able to help and be helpful to people reveals a altruistic human being and concerned about his neighbor. Altruism leads to socialization, participation, competence of living together, dialogue and inclusion⁽²⁴⁾.

The result of this interaction is a mutual growth between the caregiver and the cared for⁽²⁵⁾. Thus, caution is initiated by us, with our concern for others and their welfare. Therefore, the caring means to practice living, respect and solidarity. The person who takes care of something or someone always feels affected by the other. Therefore, when caring for someone we are also taking care of ourselves.

Care relationships that doulas provide to the mother, create an environment of trust and safety. In general, care in a holistic approach during the birth process, in addition to transform the environment, it harmonizes relations, sensitizes humans and provides energy to help mothers to find potential to endure the discomforts of parturition and birth process.

Dessa maneira, empoderam a mulher, dando-lhe coragem e esperança, além de se sentirem valorizadas e respeitadas. Thus, empower women, giving them courage and hope, and making them feel valued and respected.

FINAL CONSIDERATIONS

For this study, the methodological choice offered valuable contributions on the possibility of understanding the meaning of doulas' experience in the care of women during the process of parturition and birth in the hospital context.

The Oral History told by the nine maternity collaborators enabled this research, in a qualitative approach, which allowed these collaborators the opportunity and freedom to tell their story, their experiences, using their universe of meanings.

Their actions are concentrated in the period which precedes the time of preparation for the birth, when women go through moments of difficulty, insecurity, anxiety, discomfort and pain. However, it is important to be discussed with health professionals, the possibility of their participation also at birth, whereas the bond built between mother and doula must be respected, since they can establish an intimate trustful and deep relationship with women in a special moment in their lives.

The care developed by doulas during parturition and birth process needs to be understood as a possibility for meeting, interaction and dialogue with the other in the universe care of its daily practice. This relationship enables a qualified hearing, a different look and a careful touch, allowing women to express their anxieties, fears and sufferings. From this perspective, the care is not just an act but an attitude which means welcome, respect for different life histories. Therefore, doulas' activities aim to promote the mother's emotional welfare, helping her to face the discomforts of parturition and birth process, reducing fear, tension and pain and, consequently, increasing the possibility of childbirth to be a positive experience for the woman and her family.

Although many health professionals do not have a vision of all subjects, the findings of this study demonstrate that doulas' practice puts the woman as the center of the process of parturition and birth. Thus, this practice contributes to a reflection in search of new meanings in relations of the process of humanized care.

Therefore, thinking of humanization involves a relationship between subjects of a process that creates and strengthens bonds. Thus, opportunities as the Voluntary Community Doula Program, initiative responsible for a careful warm, dignified and supportive; need to be expanded and extended to different regions of the country since it is an action that brings benefits to women, family and community, making with the process of parturition and birth occurs in an environment of harmony and satisfaction.

However, when all those involved in caring for women during parturition and birth process realize the importance of establishing a partnership with doulas, women will certainly have a real chance to make this moment a positive and humanized experience. From this perspective, doulas can help with this experiment.

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• 24. Mariotti H. O viver: introdução. In: São Paulo (Cidade). Prefeitura do Município de São Paulo. Secretaria Municipal de Saúde. Acolhimento: o pensar, o fazer, o viver. São Paulo: Secretaria Municipal de Saúde; 2002. p. 118.
• 25. Waldow VR. O cuidado na saúde: as relações entre o eu, o outro e o cosmos. Petrópolis: Vozes; 2004.

*

Pesquisa realizada em uma maternidade pública municipal, situada na cidade do Recife (PE), Brasil.

Publication Dates

• Publication in this collection
  27 Sept 2010
• Date of issue
  2010