III The Birth and Parent Companion Program
IV Evaluation Potential
V References and Resources
--submitted by Brittany Irvine
Mothercraft Ottawa is a non-profit organization that provides services and programming to families with infants and young children. The organization’s name is licensed under the Canadian Mothercraft Society and has been operating since 1944. The organization hosts an Ontario Early Years Centre, childcare programs, breastfeeding support drop-in, childbirth education courses and a very special program that arranges doula support for women and families in need. The official title of the doula support program is The Mothercraft Ottawa Birth and Parent Companion Program. It was established in 1991 to lend support to mothers in need so that they did not have to be alone during labour and delivery. I have been a volunteer doula with the program for two and one-half years.
I am often asked how I became involved with the Birth and Parent Companion Program. I was writing a Master’s thesis on the religious and cultural consequences of pregnancy-related evacuation amongst Inuit women. Historically, and as an effect of colonization, pregnant Inuit women were evacuated south to deliver their babies in hospitals even when their pregnancies were normal. I have been told or read stories about birthing in Inuit societies previous to colonization that explain why and how birth is ritualized in this rich cultural-linguistic tradition. Currently Inuit midwifery in Nunavut and Nunavik is expanding and we are seeing more births take place in Iqaluit, in community birth centres such as the Rankin Inlet Birthing Centre, or with the Inuulitsivik midwifery service and education program. However, Baffin Islanders with high-risk pregnancies still tend to go to prenatal appointments in Ottawa and end up delivering in one of the tertiary care centers there. This is a very small but very important population of women receiving perinatal care in Ontario. Sometimes women evacuated from Baffin Island access doula support through the Birth Companion Program – as they are often here without friends or family and far away from their communities. Evacuated women tend to find temporary housing at the Larga Baffin Residence while in town. They can be in Ottawa weeks before their deliveries. So, I decided to become a volunteer doula with Mothercraft keeping in mind my interest in making a difference and improving the care and support provided to Inuit women delivering far away from home.
I was interviewed to join the Birth and Parent Companion Program by the Doula and Family Support Worker at Mothercraft. After being accepted I completed a forty-hour training course covering topics such as physiology of labour; pain relief during labour and delivery; complications of pregnancy including prematurity; woman abuse in the perinatal period; accessing resources for moms and families; promoting breastfeeding, bonding and attachment; supporting teenage mothers, new Canadians, Aboriginal women, refugee women, women who require a translator to, women with substance misuse issues; homeless women or women living in shelters or shelter-overflow situations; mothers of babies being apprehended by Child and Family Services; mothers who are giving their babies away; and mothers accessing Ottawa’s adolescent obstetrics clinic and associated services.
III The Birth and Parent Companion Program
The Birth and Parent Companion Program supports pregnant women with disabilities and hardships of all kinds. The one common denominator for all women accessing the program is that they are living on a low income. In 2011, 71% of the clients served by the program were on Ontario Works. Another 13% of the clients were receiving Ontario Disability Support Payments. Some program participants have almost unimaginably horrific lives and some have very nice lives, with very little money. Considering the population we support with the program, I always take something when I meet participants – tiny baby clothes and something nice for the mother. Mothercraft has a great donation closet that I sometimes dig through. Donate to us today!
Fifteen women including myself completed the Mothercraft doula training course in the spring of 2011. We all had police record checks to be able to work in the vulnerable sector and at the close of the training we had our pictures taken to be made into identity badges. While working as a volunteer doula in the hospitals or in clinics I wear my identity badge that clearly states that I am a Mothercraft Volunteer Birth Companion. Doulas in Ottawa are very well organized and negotiations between hospital administration and doulas took place in the wake of the SARS outbreak – incidentally, an event that was instrumental in the creation of the Public Health Agency of Canada. It was decided in these negotiations that doulas carrying badges when working or volunteering at the Ottawa Hospital or the Montfort Hospital should be considered part of the care team, rather than visitors. This means that in the event of a disease outbreak or in the event of a caesarean section, a woman’s doula is able to provide continuous support during labour. A professional doula charging for her services is considered a contractual employee of whoever she has signed a contract with.
Women are referred to the Birth and Parent Companion Program by health care providers or Ottawa Public Health, or they find out about it through word of mouth and self-refer. The Doula and Family Support Worker at Mothercraft does an extensive intake interview with the potential client via phone describing the program and asking standard demographic questions (address, phone number, date of birth, expected date of delivery, number of children, marital status, housing status, immigration status, spoken languages, mother tongue), standard obstetrical questions (number of previous pregnancies, miscarriages or abortions, complications in pregnancy or in previous pregnancies, healthcare provider, referred by, intention to breastfeed), and socio-economic questions (income source, level of support, CAS involvement, etc.)
Once it is confirmed that the woman wants a doula, the Doula Support Worker calls one of the doulas from the roster of available volunteers who keep their paperwork up-to-date and asks the volunteer if she is willing to take on a match. If the doula is willing to be matched, she receives the information from the intake and quickly gets in touch with the mom-to-be. Mothercraft’s Doula Support Worker follows up with both the doula and the client to make sure that the relationship has been established. After that point there is a lot of variability in how the volunteer doula and her match communicate. For every match that I have taken on I have made an effort to meet in- person and to chat one-on-one about life in general and about planning for the birth. I have done a lot of texting and calling, and have often gone to the hospital with women who think they are in labour (and they usually are, but just very early labour) but who subsequently are sent home and told to come back. Mothercraft is excellent about reimbursing taxi fare for its volunteer doulas. I have been reimbursed for every taxi receipt I’ve submitted. Usually when things really start to pick up I get a call from my match and I pick her up in a taxi and we go to the hospital together. I stay with her for the duration of the birth and into the early hours of her baby’s life. It is such a neat experience, being at a birth. I follow-up with my matches and usually see them once or twice after the birth. Some I continue to be friends with on Facebook and some I see around the city on occasion. Mothercraft also matches clients to Parent Companions if new moms feel like they could use more support postpartum. Many of my former matches continue to be supported by Mothercraft parent companions. I try to have my matches sign a form indicating the date that we met. The Mothercraft Family Outreach/Doula Support Worker always emails and asks the volunteers to send a quick tally of match communications monthly. Just a quick tally of how many times you've been in contact, e.g., three visits, two texts, one call suffices.
Being a doula is a really amazing experience. What I actually do at a birth varies depending on the situation. More or less, I am just there to be a support person and a friend who knows a little bit about labour and delivery. I had one match who had told me at a prenatal visit that she had had a nightmare about having her baby taken away and then at her delivery her baby was held by a nurse first and was wrapped before being given to her. That mother looked at me and said “Remember I told you about that nightmare I had?” As a doula I get to be the person who understands these things. In my volunteer work through Mothercraft I have been able to see deliveries by maternal-fetal medicine sub-specialists, by general obstetricians, by midwives and by family physicians. I was really thrilled when an obstetrician at the Montfort Hospital said to my match “Oh so you have a doula? That is the best thing you can do for yourself.”
After I assisted at five deliveries as a Mothercraft volunteer I qualified for membership in the Ottawa Valley Doulas. The Ottawa Valley Doulas also issues badges to its members which bestows the same privileges in hospital settings as does the Mothercraft Volunteer Doula badge. Ottawa Valley Doulas members are trained either through the Birth and Parent Companion Program, Doulas of North America (DONA) International or the Childbirth and Postpartum Professional Association (CAPPA). Many doulas practising in Ottawa have qualifications from both Mothercraft and DONA or CAPPA and some are also Certificate Childbirth Educators. Every Ottawa Valley Doulas member signs Standards of Practice and Code of Ethics forms.
IV Evaluation Potential
I would like to see the Birth and Parent Companion Program recognized as a Best Practice on the Canadian Best Practices Portal. The Portal showcases community-based interventions that improve health for specific populations. The Portal’s inclusion criterion gives points for longevity, for recent and thorough evaluations and for proving that an intervention has an identified positive impact. The purpose of the Birth and Parent Companion Program is to “offer support and guidance to women during pregnancy, childbirth, and the transition into parenting.” To evaluate the program we could establish a qualitative study asking women who received support through the program to answer a open-ended questions about what having a doula meant to them. Alternatively, or in addition, a quantitative evaluation focused on the significance of doula support on maternal, birth and neonatal outcomes could supply the information needed. The Cochrane Collaboration recently updated a systematic review titled“Continuous Support for Women during Childbirth” which concludes that “all women should have continuous support during labour.” And also noted that “Continuous support from a person who is present solely to provide support, is not a member of the woman's social network, is experienced in providing labour support, and has at least a modest amount of training, appears to be most beneficial.”
To manage this evaluation, Mothercraft would provide the Better Outcomes Registry and Network (BORN) Ontario with a list of identifying information about the women (names, dates of birth, dates of delivery, site of delivery) who received doula support through the Birth and Parent Companion Program over the last five years, and request a de-identified data set for these women and for controls matched for pre-existing comorbidities and socioeconomic status. Then using that data set we could evaluate whether women receiving our intervention, i.e., having a birth companion during labour, have fewer inductions, fewer epidurals, fewer episiotomies, less use of vacuum and forceps, fewer caesarean sections, and whether babies born from mothers with birth companions have better APGAR scores. There are many things that influence pregnancy and labour, but there is justification to evaluate the dimension of continuous support from trained doulas. In 2011 the Mothercraft Birth and Parent Companion Program supported 203 women. Some of those women were receiving only parent companionship and some were receiving birth companionship but did not call on their doulas to attend at their births. Unfortunately this is a common outcome – it has happened many times that I have provided prenatal supports to a woman but not be invited to her birth. It continues to be disappointing. If we request de-identified information from BORN about the women who had Mothercraft volunteer birth companions attend their births over the last five years this should ensure a large enough sample size for the needs of the study. Another way to measure the effectiveness of the program and of doula support in general would be to add a data field to the BORN Information System under the pain relief category wherein the individual entering data could write Doula – Mothercraft Badge, or Doula – Ottawa Valley Doulas Badge.
When the Executive Director of Mothercraft Ottawa reviewed this article she wrote to me that:
“The E-Bulletin is fantastic! Unfortunately the database that we have to collect data for this program is not very user friendly and therefore some of the data that you would be looking for in the completion of the evaluation may not be there and the information that is there may not be readily accessible. We have recently started collecting important data outside of the database, and are in the process of exploring new database options. Going forward the information you refer to will be readily available but retrospectively it is not.”
So now I know where I need to start to accomplish the task of evaluating this program. I will be looking at the de-identified data of a prospective cohort.
My vision for integrating doulas into Ontario’s maternal child care system begins with measuring the associations I have described above. I would like to see Ottawa-based data incorporated into the next update of the Cochrane systematic review on the subject and I would like to see all pregnant women with the option of continuous one-on-one support during labour.
Please feel free to contact me if you have comments or questions and especially if you know of other programs providing doula support to women. I am available on twitter @britirvinedoula or at firstname.lastname@example.org.
V References and Resources
Hodnett ED, Gates S, Hofmeyr G, Sakala C. “Continuous Support for Women during Childbirth.” Cochrane Collaboration Updated Systematic Review. http://summaries.cochrane.org/CD003766/continuous-support-for-women-duri...
Ottawa Valley Doulas' website is at http://ottawavalleydoulas.webs.com/.
Mothercraft of Ottawa Carleton Birth and Parent Companion Program has a website at http://www.mothercraft.com/prenatal_parent/BPCP.php
and the Mothercraft Annual Report 2011 is available at http://mothercraft.com/about_us/Annual_Report_2011_.pdf.
Doulas of North America (DONA) International website can be found at http://www.dona.org/.
Childbirth and Postpartum Professional Association (CAPPA) website is at http://www.cappa.net/.
Better Outcomes Registry and Network (BORN) Ontario website can be visited at http://www.bornontario.ca/.