Original Article | J Adv Med Biomed Res. 2020; 28(131): 316-322
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
Journal of Advances in Medical and Biomedical Research | ISSN:2676-6264
Effects of the Presence of the Doula on Pregnant Women's Anxiety and Pain
During Delivery: A Randomized Controlled Trial
Atefeh Kazemi Robati1 , Behnaz Molaei 1* , Nima Motamed2 ,
Robabeh Hatami1 , Hamideh Gholami1 , Anita Ahmadi Birjandi3 , Mina Esmkhani4
1. Dept. of Obstetrics and Gynecology, Zanjan University of Medical Sciences, Zanjan, Iran
2. Dept. of Social Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
3. Zanjan University of Medical Sciences, Zanjan, Iran
4. Dept. of Midwifery, Faculty of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
Article Info
ABSTRACT
10.30699/jambs.28.131.296
Background & Objective: Doulas can ease labor and delivery in a
hospital);however, in Iran, few studies have been conducted on this topic because
of the cultural and structural boundaries. Therefore, this study aimed to evaluate the
impact of a doula’s presence on anxiety and pain in pregnant women during the
delivery process.
Materials & Methods: This randomized clinical trial was conducted on 80 pregnant
women referred to Ayatollah Musavi Hospital (Zanjan, Iran) in 2016. For women in
the intervention group, the doula provided emotional and physical support. The
mothers' pain severity and anxiety were measured by using a visual analog scale
(VAS) and Spielberger questionnaire, respectively. Categorical and continuous
variables were compared using chi-square and t tests, respectively.
Results: We found that a higher proportion of patients had experienced mild anxiety
about entering the postpartum period (47.5% vs 15%) and exiting it (80% vs 40%;
P<0.05) compared to the control group. Also, the mean VAS score was significantly
higher in the control group at 4-5 cm (86.5±11.39 vs 78.62±14.0; P=0.007) and 7-8
cm of cervical dilatation (99.0±4.41 vs 95.0±8.47; P=0.01) stages.
Conclusion: The presence of a trained doula during labor can ease the mental
consequences of delivery and decrease women's anxiety and pain during labor.
Keywords: Doulas, Labor, Emotions, Anxiety, Pain
Received: 2019/11/23;
Accepted: 2020/06/12;
Published Online: 01 Oct 2020
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Corresponding Information:
Behnaz Molaei,
Dept. of Obstetrics and Gynecology,
Zanjan University of Medical Sciences,
Zanjan, Iran
E-Mail:
molaei@zums.ac.ir
Copyright © 2020, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License which permits
copy and redistribution of the material just in noncommercial usages with proper citation.
Introduction
The process of delivering a baby could be desirable or
anxious and painful for the pregnant mother (1).
Occasionally, to reduce this stress, pregnant women
choose Caesarean section over natural birth (2). In
Ostovar et al.'s study, the key factors making women
prefer Caesarean section were stress, concern, and pain
associated with natural delivery (3). Thus, it is important
to pay attention to pregnant women’s concern and pain
and attempt to alleviate them (4).
There are different approaches to reduce the pressures
and pain of delivery (5). Some of these approaches
include relaxation methods, hydrotherapy, Lamaze
technique, emotional support, accompaniment of the
father in the delivery room, and presence of a mobile
midwife with the pregnant woman (6, 7). Emotional
support in the delivery room could be provided by the
nurse or physician, midwife, friends, relatives, family
members, father, or trained women (doulas) (8). The key
objective of this emotional support is to diminish the
mother’s anxiety and pain during delivery. The World
Health Organization (WHO) has also suggested that the
pregnant woman should be attended by somebody she
trusts and feels comfortable with (9).
The results of Salehi et al.'s study on 84 pregnant
women indicated that the level of anxiety in a woman
with accompaniments (doulas) and trained husbands
Atefeh Kazemi Robati et al. 317
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
was significantly lower than that of the other groups (6).
Also, the results of another study showed that the
presence and support of pregnant women's family during
delivery would reduce pain and concern and increase the
physical and mental health of the mothers as well as the
sense of well-being (10).
Still, the question remains whether the presence of
doulas through pregnancy has any effect on the
delivery's outcomes. Previous studies have shown that
training pregnant women and clarifying their roles
during delivery, as well as the manner of providing
support, would enhance the outcomes of delivery (11).
Studies have shown that doulas can ease labor and
delivery in ahospital; however, in Iran, few studies
have been conducted on thistopic because of the
cultural and structural boundaries.Therefore,this study
aimed to evaluate the impact of a doula’s presence
onanxiety and pain in pregnant women during the
delivery process.
Materials and Methods
Study Design
This randomized clinical trial was conducted on 80
pregnant women referred to the Ayatollah Musavi
Hospital (Zanjan, Iran) in 2016. We randomly assigned
the patients into the doula support (n=40) and control
groups (n=40). Balanced block randomization (block
size=4) was performed to allocate the patients to the
mentioned groups.
Eligibility Criteria
We included patients with the following criteria: age
18-40 years, gestational age > 37 weeks, lack of obvious
chromosomal abnormalities and fetal anomalies, normal
AFI: Amniotic Fluid Index ,the full phrase is correct (5-
24 cm), normal BioPhysical Profile (BPP) (8-10), fetal
cephalic presentation, single pregnancy, and education
level of at least middle school. The mothers'
disagreement to participation, presence of underlying
diseases, intrauterine fetal death (IUFD), any signs of
fetal distress, clear fetal abnormalities, placenta previa,
placental abruption, suffering from any physical or
mental disorder, and receiving any kind of medication
were considered as the exclusion criteria.
Study Procedure
For women in the intervention group, the doula
provided emotional support (use of encouraging phrases
about the nature of labor pain, effect of pain intensity on
the progress of labor, touching and massaging the
mothers' back, answering mothers' questions about the
progress and success of delivery, providing essential
education during labor (how to breathe, correct
positioning in different stages), and physical support
(helping the mothers to change their position,
accompanying the mother, need to move out of bed).
The women in the control group (without doula support)
only received routine care. The doula was a midwife
with a master's degree or a bachelor's degree trained in
physiological delivery. The time spent in the maternity
ward was from the time of admission and the start of the
active phase to delivery and the postpartum period.
Separate labor rooms were chosen for each patient, or
the beds were screened to prevent contamination
between the doula groups.
Measurement Tool
We used a visual analog scale (VAS) at the time of
presentation to the maternity unit for recording pain
severity. VAS was employed at cervical dilatations of <
4 cm, 4-5 cm, 7-8 cm, and 9-10 cm, with 0 representing
no pain and 10 representing the worst possible pain.
Mothers' anxiety was measured using the Spielberger
questionnaire. This instrument contains 20 items for
measuring trait anxiety and 20 for measuring state
anxiety. Each item is scored from 1 to 4, and patients
with greater anxiety receive a higher score. At least a
sixth-grade reading level is necessary to complete this
questionnaire. The reliability of this questionnaire was
previously confirmed in Iran (12).
The Spielberger questionnaire was completed by the
mothers in each stage. Since the trait anxiety is not
affected by the situation and is considered as the basic
anxiety, the scale was completed only once at the
beginning of the study by the participants of both groups.
However, the state anxiety scale was completed in four
stages: at 4-5 cm and 7-8 cm cervical dilations, first hour
after the delivery, and at the end of the admission. VAS
was also used at the time of 4-5 cm, 7-8 cm, and 9-1 cm
cervical dilations, as well as the beginning of the
entrance to the post-room and time of departure from the
labor room.
Data Analysis
Qualitative data were presented with frequency and
percentage, and quantitative data were shown with
mean±SD. Categorical and continuous variables were
compared using chi-square and t tests, respectively. All
the analyses were performed in SPSS 23 (SPSS Inc.,
Chicago, Ill., USA), and a P-value < 0.05 was considered
as significant.
Results
First, 93 cases were enrolled, and then nine people
were excluded later (Figure 1). Therefore, statistical
analyses were performed on 80 cases (40 control
subjects and 40 intervention cases).
Table 1 presents the demographic characteristics of
both groups. The results revealed a significant
difference between the two groups in terms of parity,
Vaginal Delivery (NVD), and education (P<0.05).
However, the mean age difference between the two
groups was not statistically significant (31.3±3.9 years
in the doula group vs 31.3±4.2 years in the control
group; P=0.22)
318 Effects of the Presence of the Doula on Pregnant Women's
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
Figure 1. Flow diagram of the study
Table 1. Demographic characteristics of the two groups
Variable
Control group
N (%)
Doula group
N (%)
P-value
Parity
0
0
2 (5.0)
0.004
1
11 (27.5)
24 (60)
2
15 (37.5)
7 (17.5)
3
9 (22.5)
7 (17.5)
4
4 (10.0)
0
5
1 (2.5)
0
NVD
0
0
2 (5.0)
0.007
1
12 (30.0)
26 (65.0)
2
16 (40.0)
7 (17.5)
3
7 (17.5)
5 (12.5)
4
4 (10.0)
0
5
1 (2.5)
0
Level of
education
Below high-school diploma
4 (10.0)
3 (7.5)
0.002
High-school diploma
28 (70.0)
14 (35.0)
Academic
8 (20.0)
23 (57.5)
Independent t tests showed no significant difference
in the trait anxiety and state anxiety (4-5) and
dilatation of the cervix between the two groups
(P>0.05). However, there was a significant difference
in the state anxiety (7-8) and dilatation of the cervix
(P=0.046), state anxiety in the postpartum period
(P<0.001), and state anxiety at the exit of the
postpartum period (P=0.028) (Table 2).
Atefeh Kazemi Robati et al. 319
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
Table 2. Characteristics of included studies in the meta-analysis
Variable
Control group
Doula group
P-value
Trait anxiety
40.43 ±9.83
38.43±11.52
0.41
State anxiety (4-5) and dilatation of the cervix
52.33±11.81
49.63±12.86
0.33
State anxiety (7-8) and dilatation of the cervix
58.75±9.71
52.98±15.22
0.046
State anxiety in the postpartum period
43.8±13.44
33.4±11.44
<0.001
State anxiety at the exit of postpartum
33.5±7.67
28.6±11.65
0.028
There was no significant difference between the
two groups regarding trait anxiety and state anxiety at
4-5 cm and 7-8 cm cervical dilatations (Table 3).
Nevertheless, patients in the doula group experienced
a higher proportion of mild anxiety about entering the
postpartum period (47.5% vs 15%) and exiting it
(80% vs 40%) compared to the control group.
Table 3. Comparison of the levels of anxiety in different phases of delivery in the two groups
Variable
Control group
N (%)
Doula group
N (%)
P-
value
Trait anxiety
Mild anxiety
7 (17.5)
11 (27.5)
0.19
Middle-low anxiety
18 (45.0)
18 (45.0)
Middle-high anxiety
10 (25.0)
8 (20.0)
Relatively severe anxiety
4 (10.0)
0
Severe anxiety
1 (2.5)
3 (7.5)
Very severe anxiety
0
0
State anxiety in the 4-5
(cm) cervical dilatation
Mild anxiety
2 (5.0)
3 (7.5)
0.53
Middle-low anxiety
6 (15.0)
10 (25.0)
Middle-high anxiety
8 (20.0)
10 (25.0)
Relatively severe anxiety
19 (47.5)
12 (30.0)
Severe anxiety
5 (12.5)
4 (10.0)
Very severe anxiety
0
1 (2.5)
State anxiety in the 7-8
(cm) cervical dilatation
Mild anxiety
1 (2.5)
3 (7.5)
0.22
Middle-low anxiety
3 (7.5)
9 (22.5)
Middle-high anxiety
4 (10.0)
4 (10.0)
Relatively severe anxiety
21 (52.5)
15 (37.5)
Severe anxiety
10 (25.0)
6 (15.0)
Very severe anxiety
1 (2.5)
3 (7.5)
State anxiety in entering to
postpartum
Mild anxiety
6 (15.0)
19 (47.5)
0.002
Middle-low anxiety
13 (2.5)
16 (40.0)
Middle-high anxiety
13 (32.5)
3 (7.5)
Relatively severe anxiety
3 (7.5)
1 (2.5)
Severe anxiety
5 (12.5)
1 (2.5)
Very severe anxiety
0
0
State anxiety in the exit of
postpartum
Mild anxiety
16 (40.0)
32 (80.0)
0.001
Middle-low anxiety
19 (47.5)
6 (15.0)
Middle-high anxiety
5 (12.5)
0
Relatively severe anxiety
0
1 (2.5)
Severe anxiety
0
0
Very severe anxiety
0
1 (2.5)
320 Effects of the Presence of the Doula on Pregnant Women's
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
There was a significant difference in the state anxiety
about entering the postpartum period (P=0.002) and exiting
it (P=0.001).
Table 4 shows the mean pain score in different phases of
delivery in the two studied groups. The mean VAS score
was significantly higher in the control group at 4-5 cm
(86.5±11.39 vs 78.62±14.0; P=0.007) and 7-8 cm cervical
dilatations (99.0±4.41 vs 95.0±8.47; P=0.01) stages.
Table 4. Comparison of the mean pain score in different phases of delivery in the two groups
Variable
Control group
Doula group
P-value
At the beginning of the study
42.12±15.93
39.75±17.01
0.52
Cervical dilatation: 4-5 cm
86.5±11.39
78.62±14.0
0.007
Cervical dilatation: 7-8 cm
99.0±4.41
95.0±8.47
0.01
Postpartum
7.63±5.77
7.0±7.66
0.68
Exit of postpartum
0.67±2.15
1.1±2.63
0.43
Discussion
This randomized clinical trial was conducted to
evaluate the effect of a doula's presence near pregnant
women during labor on the psychological outcomes of
delivery. The results revealed that the score of anxiety
was reduced in the doula group compared to the control
group, a difference that could be attributed to the
presence of the doula. This indicates that doulas were
informed about the labor process, which reduced
mothers’ anxiety, an effect not shown in the control
group.
Also, the findings of other studies, which assessed
the effect of the presence of accompaniment on
anxiety, were consistent with the results of this study.
Our results indicated that the anxiety score
significantly differed between the two groups during
and after delivery (6, 13). Further, the findings of
another study concerning state anxiety at the time of
admission were consistent with our results (10).
The results of Heaman's study showed that the mean
score of anxiety during the first hours after delivery had
no significant change among the groups (14); in this
study, doulas receive training before delivery and were
only physically existent with the mothers. However, in
the present study, doulas played a vital role in labor and
delivered physical and emotional support to the
mothers. Thus, the doulas had an active role in
decreasing pregnant women's anxiety about delivery
consequences.
Another finding was that the score of pain was
reduced in the doula group compared to the control
group. This indicates that training doulas for the
process of labor and delivery can reduce mothers’ pain.
The presence of doulas increases women's self-
confidence and supports them in adjusting to the pain
(15). The results were similar to the findings of
previous studies (16, 17). Ip et al. believe that
intervention is effective in boosting pregnant women's
self-efficacy for reducing their pain (18). The results of
Melzak et al.'s study showed that intervention for
pregnant women could emotionally decrease labor pain
by 30% (19). This could be due to the changes in
women's views and developing a positive attitude to
labor. Being well educated in childbirth can make
pregnant women feel comfortable and tolerate pain
well (20).
The results of this study should be considered in light
of its limitations. First, the results might have been
affected by the pregnant women and their doulas'
cultural and structural limitations. Moreover,
differences in personnel's attitude and behavior to
pregnant women in labor, as well as the different
characteristics of parity, education, and NVD between
the two groups, could have confounded the findings.
Conclusion
Generally, it is concluded that the presence of a
trained doula by pregnant women's side during labor
can improve the mental outcomes of delivery and
decrease the women's anxiety and pain. It is suggested
that the study should be replicated with a larger sample
and in different health centers of Iran. It is also
recommended that maternity centers should implement
this low-cost and proper intervention during the
delivery process.
Acknowledgements
This study was supported by the Zanjan University
of Medical Sciences (ZUMS). We gratefully
acknowledge the kind support of the participants for
their precious collaboration, as well as the staff of
Ayatollah Musavi Hospital.
Availability of Data and Materials
The datasets used and/or analyzed in the present
study are available; the corresponding author could
answer any reasonable requests.
Atefeh Kazemi Robati et al. 321
Volume 28, November & December 2020 Journal of Advances in Medical and Biomedical Research
Ethical Approval and Consent to
Participate
After the managers read the informed consent, the
researchers explained the purpose of the study and
informed the participants of their rights. Participation
in this study was voluntarily and the participants could
discontinue this when they were not interested in
cooperating for any reason. Ethical approval for the
study was obtained from the Institutional Review
Board of Zanjan University of Medical Sciences
according to the Declaration of Helsinki. This study
was approved by the Ethical Committee of Zanjan
University of Medical Sciences (reference number:
zums.rec.1395.278).
Funding and support
This research resulted from an independent research
without receiving any financial support.
Conflict of Interests
The authors reported no conflict of interest.
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How to Cite This Article:
Kazemi Robati A, Molaei B, Motamed N, Hatami R, Gholami H, Ahmadi Birjandi A et al . Effects of the Presence
of the Doula on Pregnant Women's Anxiety and Pain During Delivery: A Randomized Controlled Trial. J Adv
Med Biomed Res. 2020; 28 (131) :316-322
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