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Headline
This study found that volunteer doula services benefited both disadvantaged childbearing women and the doulas themselves. This is the largest independent evaluation of volunteer doula support in the UK.
Abstract
Background:
The research examined an innovative volunteer doula service, established in one city and rolled out to four other sites. The initiative offers support to disadvantaged women with the aim of enhancing well-being and improving the uptake of health services.
Aims:
The project addressed four broad questions: implications for the NHS; health and psychosocial impacts for women; impacts on doulas; and the processes of implementing and sustaining a volunteer doula service for disadvantaged childbearing women.
Design:
A mixed-methods study using interviews, focus groups and questionnaires to obtain primary data from a range of stakeholders. Existing data sets were used to examine clinical and public health outcomes and contributed to a cost–consequence analysis. A realistic evaluation perspective supported investigation of a complex intervention in its real-world context.
Outcomes:
We assessed impacts, perceptions and experiences of women, doulas, midwives and heads of midwifery. Clinical and public health outcomes included epidural use, rates of caesarean section, low birthweight, admission to neonatal unit, smoking and breastfeeding. The costs of running a doula service and cost implications for the NHS were calculated.
Data sources:
Data sources included the service database at the original site; available outcomes were compared against those in reference data sets. Women completed questionnaires and a small number participated in focus groups. Doulas contributed information through focus groups, postal questionnaires and telephone interviews. Staff, commissioners and local champions of doula services provided information through interviews and focus groups. Midwives and heads of midwifery took part in focus groups and telephone interviews respectively.
Results:
Although doula-supported women in the original site used fewer epidurals and generally required fewer caesarean sections than women in reference groups, these differences were not statistically significant. The utility of comparisons is constrained by the absence of parity information from comparison data. For outcomes with a low incidence, data were pooled across years; this included comparisons for low birthweight and admission to neonatal units where no significant differences were observed. Reductions in rates of smoking at birth were not consistently statistically significantly different from available comparators. More doula-supported women initiated breastfeeding and were continuing at 6 weeks. Initiation rates were significantly higher for most years than in reference groups and significantly higher for continued breastfeeding for all years. The majority of women who accepted doula support valued it highly for its continuity and doulas’ availability and flexibility, being listened to by someone who was non-judgemental and having fears allayed, together with building self-esteem. Women also appreciated volunteer doulas for the knowledgeable companionship, relief of isolation and help with accessing services. Nearly all doulas enjoyed the role and felt well prepared by their training and the majority felt well supported. Midwifery staff appreciated volunteer doulas for their commitment and support to women. Doula services’ challenges in implementing and sustaining their services included funding, balancing referrals and volunteer availability, and relationships with other organisations. The costs of providing a doula service varied considerably, with some costs absorbed by host organisations. Some improved clinical outcomes point to potential cost benefits to the NHS although these were less than the per birth costs of the service in the original site.
Conclusions:
This is the largest independent evaluation of volunteer doula support in the UK. Limitations include lower than optimal questionnaire response rates and the relatively small sample size available for outcome measurement. Our findings of positive psychosocial impacts reflect those reported among women in other settings, where women may not have access to midwifery support. Significant improvements in maintaining breastfeeding were particularly striking. Volunteer doulas were highly regarded by women and doula support was accepted by NHS midwives. Doulas enjoyed the role and reported positive impacts for various areas of their lives. Funding was a continuing challenge for doula services.
Funding:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Background, aims and objectives
- Chapter 2. Methods
- Settings
- Sponsorship, ethics and governance
- Advisory group and public involvement mechanisms
- Design
- Literature search
- Data collection from key informants
- Development of Context, Mechanism and Outcome configurations
- To determine the impacts of volunteer doula support on key clinical and public health outcomes for women and their babies
- To determine the impacts on NHS midwives
- What are the health and psychosocial impacts for disadvantaged childbearing women?
- What are the impacts on volunteer doulas?
- What are the processes of implementing and sustaining a volunteer doula service for disadvantaged childbearing women?
- Overview of maximum possible primary data collection
- Data analysis
- Chapter 3. Findings: implications for the NHS
- Chapter 4. Findings: health and psychosocial impacts for women
- Women’s data sources
- Sample characteristics
- Experiences of the doula service
- Characteristics of doula support and doula qualities that women valued and experienced
- Description of the doula intervention
- Support behaviours
- Communication between the woman and the service and the doula
- How is the doula different?
- Understanding the relationship
- Impacts of doula support
- Doulas’ relationship with midwives
- (Dis)satisfaction with the service
- Women who commenced support and did not receive the ‘full service’
- Chapter 5. Findings: impacts on doulas
- Doula questionnaire response
- Training
- Doulas’ perceptions of the service that they provide
- To what extent is the doula role about friendship?
- What does the back-up doula role mean to you?
- What is it about how the doula service works that makes it different?
- Matching issues
- Barriers and challenges
- How the doula service fits and works with other services
- Endings
- Impact on doulas
- Stopping volunteering and summing up the doula experience
- Site Z: case study
- Chapter 6. Findings: implementing and sustaining the service
- Facilitators, challenges and barriers of establishing and sustaining the original volunteer doula service
- Funding for service costs
- Facilitators and barriers to implementation in roll-out sites
- Experiences of the replication package at the roll-out sites
- Summary of variations in use of the replication package
- Chapter 7. Health economics
- Chapter 8. Discussion
- Acknowledgements
- References
- Appendix 1 Ethics approval letter
- Appendix 2 Search strategy
- Appendix 3 Women’s questionnaire supported
- Appendix 4 Women’s questionnaire unsupported
- Appendix 5 Service evaluation documents: use and findings
- Appendix 6 Doula questionnaire: supported women
- Appendix 7 Doula questionnaire: not (yet) supported women
- Appendix 8 Breastfeeding by postcode district
- Appendix 9 Women’s sampling frame and distribution
- Appendix 10 Sample characteristics of women completing questionnaires (n = 166)
- Appendix 11 Average weekly hours doula support by site
- Appendix 12 Combinations of stages supported, presented by site (n = 166)
- Appendix 13 Service managers’ questionnaire
- Appendix 14 Reflections on conducting research on volunteer roles and with third-sector agencies
- List of abbreviations
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 10/1009/24. The contractual start date was in October 2011. The final report began editorial review in August 2013 and was accepted for publication in June 2014. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
none
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