- Email: [email protected]
Effects of providing hospital-based doulas in health maintenance organizations
follow-up. Women for whom the study mammogram was their initial one were more influenced by a false-positive mammogram than their counterparts who had received prior mammograms. Researchers noted, however. a higher rate of false positivity in the initial mammogram group and hypothesized that radiologists might be more conservative in their interpretation in the absence of comparison views. Study limitations noted by the researchers included the homogeneity of the study population in terms of race and economic status as well as the lack of examination of the effects of false-positive mammograms on general techniques for breast cancer screening. Commentag The psychological effects of screening tests on health care decisions often elude analysis in quantitative or qualitative health research. Current trends toward prcvention screening for reproductive cancers has led researchers to ask if anxiety could impact negatively on a woman’s decision to seek recommended follow-up. The cost-cffcctivcness of unnecessary procedures raises further questions on this issue. As noted by Fletcher (1999) in an editorial 011 the Burman study (l), cart providers are dealing with the epidemiologic fact that mammography yields close to a 10% false-positivity ram. Mammography as a diagnostic and screening tool has steadily improved and risen in popularity since its beginnings in the 1950s (2). It is one of three key components of breast cancer prevention, which include self-breast examination and primary care provider examination. Diet modification, increased physical excrcisc, safer sex behaviors, smoking cessation, and stress reduction arc other factors targctcd in a cancer prevention/wellness model for women. Burman ct al have quantitatively analyzed the cffcct OII subsequent screening produced by false-positive mammogram results for a predominantly white, middle class llM0 population. It is a relief to note that authors found little evidence that anxiety in the face of falsepositive results or complacency in the face of truenegative results adversely affected participants’ screening activities. The authors noted limitations on gcncralizability with their study cohort with populations retfccting different racial and economic backgrounds. Puturc studies reflective of women’s economic and racial diversity would bc wclcomcd and arc needed. A further limitation of the study is the difficulty of analyzing what other components of the cancer screening program affected WOITVX’S decisions to pursue appropriam folfow-up. Although the authors analyzed the effect of primary care phyrsician referral on compliance with breast cancer screening, the type of education or selfbreast t;xanunation teaching covered by cam providers
was not included for study analysis. Were these women performing self-breast examinations? Were they given educational materials and demonstrations by their care providers‘? Were the other components of breast cancer prevention factored into the analysis or part of the screening program‘? Did women, simply by enrolling or being referred to a breast cancer screening program, change their health behaviors? Did the fact that the mammograms *were covcrcd by their HMO effect compliance? Finally, although the authors cite the enhancing factors of measuring observed versus self-reported behavior of screening activities, measuring compliance in this instance does not provide information on women’s anxiety as it affects their health care decisions. Further studies would necessitate talking to women and getting their self-reports on anxiety as it impacted their screening decisions. Studying what, if any, impact public health campaigns on breast cancer prevention have had is also needed. Rurman and her research colleagues have produced an important study. Examining health behaviors and listcning to women’s reported decision-making processes will only enhance future research on this subject. RIIFERENCES
2. IAWCSM. I .intlscy K. Dr. Susan I .OVC’Sbreast hook. Reading (MA): Atldison-Wellcslev. IWO.
Efkts of providing hospital-based doulas in health maintenance organizations. Gordon NP, et al. Obstct Gynccol 1999;93:422-6. Reviewed by: Karen Barr, (:xu, Nurse-Midwife, Alivio Medical Center, Chicago II.,. Synopsis A doula is a woman trained to provide physical and emotional support to laboring and birthing women. This study sought to document the effects of doula care in labor for a population not previously studied. Previous studies, which are addressed in this article. studied young, low-.incomc primigravidas. Thcsc studies demonstrated a decrease in operative (caesarean and forceps) delivcrics, oxytocin use, use of pain medication, and long labor. One study correlated improved coping, quicker bonding, and less postpartum depression with doula support in labor. This study investigated privately insured (HMO) women who were planning birth in one of three Northern California hospitals. The sample drew from nulliparous women over IX years old who were cxpccting an
uncomplicated vaginal birth and who arrived at the hospital with cervical dilation of 5 cm or less. Within 30 minutes of admission, the women were randomized to receive doula care (232 women) or to receive routine care (246 women). The doula was called lo report to the hospital after randomization. At 4 to 6 weeks postpartum, a telephone interview was conducted by a single, blinded intcrvicwer. The interviews addressed the birth cxpcricnce. the presence of others during labor, brcastfceding, and standardized measures of self-esteem and depression. The investigation revealed that women who rcccived doula cart wcrc less likely to use cpidural anesthesia. The difference was significant in only two of the three investigation sites. No significant differences were found in the rates of caesarean birth, use of oxytocin, analgesia, or the decision to breastfccd. Doula presence correlated with differences in certain psychological outcomes. Women who received doula care were found to have increased positive feelings about the birth expericncc. Women reported having coped very well with labor, and they reported a positive effect on their feelings as women and their perception of theil bodies’ physical strength and pcrformancc. There was no significant difference in reports of labor being difficult versus easy, how labor compared with their cxpcctations, their feelings of self-worth, postpartum depression? or their belief in their mothering capabilities. Ninety-six percent of the women believed that the doulas helped them to achieve the birth experiences they dcsircd, and thcsc women would be interested in doula care for future births. Sixty-six percent of the women who did not rcccivc doula care stated they would bc intcrcsted in doula care for future births. In their discussion, the authors hypothesized that the unaffcctcd rates of operative deliveries and the barely significant impact on cpidural use may be attributable to inconsistencies in the doula’s training and/or cxpcrience: or the delay in the doula’s arrival to the hospital. They spcculatcd that doula intervention may not have been
188
.lourmd
achieved early enough to influence labor events or a woman’s decision regarding cpiclural use. A small sample size and subsequent decrease in power was also recognized as a possible limitation of this study. Commentary Birth attendants who have worked with doulas and women who have been cared for by doulas know that they arc important members of the labor team in their ability to provide physical and emotional support to the laboring woman. Although studies have found beneficial effects of doula cart on concrete measurements such as operative delivery rates and the use of analgesia. this study did not. Traditionally, such measurements have held high value because they are measurable, are asso-ciated with morbidity and mortality, and reprcscnt potential cost savings to institutions and payers. These concerns arc important to midwives as they strive to provide safe and effective woman-centcrcd cart while utilizing resources wisely. Perhaps further study could produce such tangible evidence by expanding the sample size and eliminating some of the confounding variables identified by the authors. Despite these limitations, this study directs the rcadcr’s attention toward the less tangible bcncfits of doula care, benefits that are important to midwives and women alike. This study is a reminder that it is good for women to feel strong, satisfied, and enthusiastic about birth and to believe that a caregiver supported them in rcaliLing their birth plans. Of further note, it is very interesting to set that in this study, doula presence did not correlate with a change in the perceived case or difficulty of labor but rather perceived coping abilities and the quality of the birth cxperiencc. As an ever-growing reliance on medication and machinery infects many of our birth places and practices, the doula can provide the human care and contact that is often missing. The findings of this study complement the findings of previous studies, together demonstrating the multidimensional benefits of doula support for the laboring woman.
of Midwifery
& Women’s
Health
0 Vol. 45, No. 2, March/April
2000
was not included for study analysis. Were these women performing self-breast examinations? Were they given educational materials and demonstrations by their care providers‘? Were the other components of breast cancer prevention factored into the analysis or part of the screening program‘? Did women, simply by enrolling or being referred to a breast cancer screening program, change their health behaviors? Did the fact that the mammograms *were covcrcd by their HMO effect compliance? Finally, although the authors cite the enhancing factors of measuring observed versus self-reported behavior of screening activities, measuring compliance in this instance does not provide information on women’s anxiety as it affects their health care decisions. Further studies would necessitate talking to women and getting their self-reports on anxiety as it impacted their screening decisions. Studying what, if any, impact public health campaigns on breast cancer prevention have had is also needed. Rurman and her research colleagues have produced an important study. Examining health behaviors and listcning to women’s reported decision-making processes will only enhance future research on this subject. RIIFERENCES
2. IAWCSM. I .intlscy K. Dr. Susan I .OVC’Sbreast hook. Reading (MA): Atldison-Wellcslev. IWO.
Efkts of providing hospital-based doulas in health maintenance organizations. Gordon NP, et al. Obstct Gynccol 1999;93:422-6. Reviewed by: Karen Barr, (:xu, Nurse-Midwife, Alivio Medical Center, Chicago II.,. Synopsis A doula is a woman trained to provide physical and emotional support to laboring and birthing women. This study sought to document the effects of doula care in labor for a population not previously studied. Previous studies, which are addressed in this article. studied young, low-.incomc primigravidas. Thcsc studies demonstrated a decrease in operative (caesarean and forceps) delivcrics, oxytocin use, use of pain medication, and long labor. One study correlated improved coping, quicker bonding, and less postpartum depression with doula support in labor. This study investigated privately insured (HMO) women who were planning birth in one of three Northern California hospitals. The sample drew from nulliparous women over IX years old who were cxpccting an
uncomplicated vaginal birth and who arrived at the hospital with cervical dilation of 5 cm or less. Within 30 minutes of admission, the women were randomized to receive doula care (232 women) or to receive routine care (246 women). The doula was called lo report to the hospital after randomization. At 4 to 6 weeks postpartum, a telephone interview was conducted by a single, blinded intcrvicwer. The interviews addressed the birth cxpcricnce. the presence of others during labor, brcastfceding, and standardized measures of self-esteem and depression. The investigation revealed that women who rcccived doula cart wcrc less likely to use cpidural anesthesia. The difference was significant in only two of the three investigation sites. No significant differences were found in the rates of caesarean birth, use of oxytocin, analgesia, or the decision to breastfccd. Doula presence correlated with differences in certain psychological outcomes. Women who received doula care were found to have increased positive feelings about the birth expericncc. Women reported having coped very well with labor, and they reported a positive effect on their feelings as women and their perception of theil bodies’ physical strength and pcrformancc. There was no significant difference in reports of labor being difficult versus easy, how labor compared with their cxpcctations, their feelings of self-worth, postpartum depression? or their belief in their mothering capabilities. Ninety-six percent of the women believed that the doulas helped them to achieve the birth experiences they dcsircd, and thcsc women would be interested in doula care for future births. Sixty-six percent of the women who did not rcccivc doula care stated they would bc intcrcsted in doula care for future births. In their discussion, the authors hypothesized that the unaffcctcd rates of operative deliveries and the barely significant impact on cpidural use may be attributable to inconsistencies in the doula’s training and/or cxpcrience: or the delay in the doula’s arrival to the hospital. They spcculatcd that doula intervention may not have been
188
.lourmd
achieved early enough to influence labor events or a woman’s decision regarding cpiclural use. A small sample size and subsequent decrease in power was also recognized as a possible limitation of this study. Commentary Birth attendants who have worked with doulas and women who have been cared for by doulas know that they arc important members of the labor team in their ability to provide physical and emotional support to the laboring woman. Although studies have found beneficial effects of doula cart on concrete measurements such as operative delivery rates and the use of analgesia. this study did not. Traditionally, such measurements have held high value because they are measurable, are asso-ciated with morbidity and mortality, and reprcscnt potential cost savings to institutions and payers. These concerns arc important to midwives as they strive to provide safe and effective woman-centcrcd cart while utilizing resources wisely. Perhaps further study could produce such tangible evidence by expanding the sample size and eliminating some of the confounding variables identified by the authors. Despite these limitations, this study directs the rcadcr’s attention toward the less tangible bcncfits of doula care, benefits that are important to midwives and women alike. This study is a reminder that it is good for women to feel strong, satisfied, and enthusiastic about birth and to believe that a caregiver supported them in rcaliLing their birth plans. Of further note, it is very interesting to set that in this study, doula presence did not correlate with a change in the perceived case or difficulty of labor but rather perceived coping abilities and the quality of the birth cxperiencc. As an ever-growing reliance on medication and machinery infects many of our birth places and practices, the doula can provide the human care and contact that is often missing. The findings of this study complement the findings of previous studies, together demonstrating the multidimensional benefits of doula support for the laboring woman.
of Midwifery
& Women’s
Health
0 Vol. 45, No. 2, March/April
2000