​​There is often confusion over what a doula is. Many times I have talked with couples nervous about a doula possibly taking over their birth. They are afraid that a doula may guilt them into  a certain type of birthing. To add a little silliness I have illustrated examples below with my subpar Window’s Paint skills. These show the differences between someone that will fight against your birth, a duel-a you could call her, and a doula, or birth support for your choices.

​This may be new to you, but doulas are not just for natural birth. They are for anyone wanting more support for their birth. Doulas are helpful in cesarean births, medicated births, natural births, hospital births, home births, single parent moms, and so much more. Whether you have a plan or not, we are here for you, no light sabers involved. Note: In the odd case that you want light sabers at your birth, we can help you with that. We do not discriminate against nerds; we just won’t use them to stop your choices.
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The next concern often had regarding doulas: "But I want my husband involved. I want him to intuitively know what I need.” If he helped start this baby business, then it totally makes sense to want him right there involved in the birth.

​Can I tell you my secret? We LOVE it when dads are hands-on and involved. It is our biggest goal to facilitate the best connection between you and your partner. We know that dad helps get the oxytocin and birthing hormones going. Some men need a little direction along the way. They are new to this. Our job isn’t to replace dad, it’s to help him help you best. If dad isn’t there this works the same for grandmas and friends. We will not erupt in flames if someone else gives you counter-pressure.
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I met with a doctor today. He was a little on-guard, and he felt the need to explain how he goes out of the way to help his patients. Sadly, too many providers have met some kind of duel-a, or have heard stories of them. All he knew was that I was a doula and he assumed that I had a negative view of him as a doctor.  In reality,  I have yet to meet a provider that did not want the best for mom and baby. Sometimes they have differing opinions on care, and different points of view, but they all care. Doulas are not out to defy anything medically related. We need the medical team so that we can focus on emotional support and comfort for mom and the family.

​Doulas work with mom’s birth team to help her best reach her desires.  Doulas will encourage you to choose a provider that you feel you can trust that you can work with together. They encourage mom to ask questions, find evidence-based information, think over benefits and risks, and if needed, help mom stand up for herself. Our job is not to have a show down with the medical staff. Our job is not to speak for you. Our job is to help you get the information you need to make choices, and to support you as you speak for yourself.
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I am not a duel-a. I am not out to fight or prove anything. I am a doula -- a supporter of women, babies and families.

Becky Hartman serves as a birth, postpartum, and bereavement doula, birth and pregnancy photographer, Benkung belly binder, and energy worker. She has been shaped by her own births, and the realization that education factors into creating an empowering experience. Becky strongly believes women can follow their hearts and they will know the decisions that are right for their situations. She encourages families to learn, explore, develop ideas, and then go with the flow of their birth experience. Becky lives with her family in Clearfield, Utah. ​

My journey to becoming a doula makes plenty of sense in retrospect, but it is a winding journey. I entered college as a pre-veterinary science major, ultimately switched to a Psychology major, hated counseling but fell in love with animal behavior research, and graduated with a BA in Psychology, Biology minor, and Biology Honors. I then entered a PhD program at the University of Nebraska-Lincoln in the Biological Sciences with the intention of becoming a research professor. I actually completed my coursework for a PhD, but cut my research short to graduate with a Masters when I decided a career in academia was no longer what I wanted. After graduation, I became a homemaker and mom when our son was born 5 months later. When he was 10 months old I completed my doula training with DONA International, and attended my first doula birth one month later. Now my husband and I have three children, I am a certified birth doula with DONA International, a Hypnobabies Childbirth Hypno-Doula, co-leader of ICAN of Lincoln (International Cesarean Awareness Network), and have attended more than 55 births. I have a passion for teaching others, empowering women and families to love one another better, birth, birds, and chocolate.
 
I wanted to write a guide to other doulas and to parents-to-be on how to find, read, understand, and use primary research literature. When you have found, read, and understood the research, using the information will be a highly individual decision that only the patient themselves is able to make, based on their intuition, desires, trusted counsel, and circumstances. Yesterday, I discussed how to find and read research papers in Part 1. Here in Part 2, I walk you through a short research article and talk about how to understand the paper, and how to use that information.
 
Here is a short example of how I read a research paper. This article is a short write-up of a conference poster session. This is preliminary research, it is probably not peer-reviewed (critiqued by other scientists in the field to make sure it is done well), and though we can still gain valuable information from it, keep in mind our knowledge can change drastically with more studies, more research, and better analysis. Go read it. Really. It's quick, you'll be back in no time! Here is the paper (if you want to and have the means, print it out and grab a pen!):
 
Afshar, Y; Wang, E; Mei, J; Pisarska, M; and Gregory, K. 279: Higher odds of vaginal deliveries in women who have attended childbirth education class or have a birth plan. American Journal of Obstetrics & Gynecology, 2016;214(1):S162.
 
Since this is such a small write-up, there is no introduction or background section, simply a research objective. Do Child Birth Education classes (CBE) and/or birth plans impact the delivery mode of those women?
 
Let's look at the study design. The authors looked in the past (retrospective) at a group of women all from the same period of time with similar demographic characteristics (cohort study), and give the dates and type of birthing facility. Because birth modes can differ so much between singles and multiples, the authors only looked at singleton births. They also divided the groups into all moms, and just moms having their first birth (nulliparous). Then they divided each group into moms who attended CBE, those who had a birth plan, and those who did both.
 
Understanding statistical analysis is a whole other ball of wax, and there is no way I can explain everything here. What you need to know is when p-values are reported (p=0.01, p>0.1, p<0.0001, etc), the smaller the p-value, the greater the effect of the variable being tested. The p-value is basically the probability that any difference between the groups is due to chance, so if the p-value is small, the difference between the groups is probably due to the different variables. There is a lot more to statistics than just understanding p-values, but there's your crash course in statistics for today.
 
In this study, there were over 14,000 births that were included in the analysis (met inclusion criteria). There were differences between groups of women who did and did not attend CBE and/or have a birth plan. After adjusting for these population differences, the authors found that women who had attended CBE, had a birth plan, or both, had higher odds of a vaginal delivery compared to the group who did none of those, but there was no stronger effect of doing both. This effect was true of first-time moms as well, so the impact of CBE and/or birth plans is the same no matter which birth this is for a woman. In their original poster session, the authors likely included more figures, including their logistic regression analyses, which would help us understand the relationship between the variables and their effects, but it's a simple study and we can understand the basics with the information given here.
 
The authors conclude that attending CBE and/or having a birth plan increase the odds of a vaginal delivery, and they state that further research is needed to understand how this works. In my opinion, given my cursory understanding of this study, I think this conclusion is sound.
 
The questions I have after reading this are:

• Does the type of CBE class and/or birth plan matter?
• It seems like the number of women who had both attended CBE and used a birth plan and those who only wrote a birth plan were very close. Did most of those women who wrote a birth plan also attend a CBE, or is this an incorrect assumption?
• Does the type of class a woman took impact whether or not she writes a birth plan?
• I would have liked to know about how many scheduled and unscheduled (emergency) cesareans were in each group of moms. And the reason for the cesarean?
• How about assisted vaginal delivery (forceps or vacuum) and CBE and/or birth plan?
• I would have liked to see figures of the data, not just the study design, hopefully this research will be published in full soon.

Finally, the authors found a statistically significant difference in delivery mode based on CBE and/or birth plan, and with a relatively small group of women! In human research, 14,000 people is really not much. That's approximately the population of downtown St. Louis, MO. To find a statistically significant effect in a small sample size suggests that either it is due to random chance, or this is a very strong effect. I am excited to see what further research shows in this area!
 
In lengthier research articles, there would be a list of references. For more information on the topic and related topics, this list is where you want to start. In lengthier research articles, there would be a list of references. For more information on this and related topics, including additional studies, this list is where you want to look.

Now, how do you use this information, either for your doula or CBE clients, or for yourself? First, you must understand that research does not, and can not predict your outcome. Research is not a crystal ball, it cannot predict with certainty, in real life, who will and will not experience which outcome. In addition, the facts, found in the scientific literature, are an important piece of any decision-making process. But your intuition, your desires, the availability of options, the counsel of trusted medical caregivers, and many more variables will come together to determine the best decision for you in your circumstances. Science tries to isolate variables, to pinpoint and quantify the exact effect of one thing, which is vital for understanding how one thing affects another. But we do not live in a laboratory. Applying those results to real-life, complicated, individual healthcare decisions is something that only the patient themselves can do.
 
I hope that now you are better equipped to find, read, understand, and use primary research articles. Happy reading!

I must admit, I hate math, and following close behind, is interpreting research. Have you ever noticed, many views are given when it comes to "studies" -- often "data" can be found to support opposing views of the same argument. It's enough to avoid a subject entirely, because who knows what to believe? Not feeling confident in one's ability to understand "the facts" as presented by a study can be a real weakness for a doula (and a parent!). Joyce takes this on in two parts, sharing her knowledge of the subject as she offers a primer on how to read, mark, and question a study, to really look at it critically. 

​My journey to becoming a doula makes plenty of sense in retrospect, but it is a winding journey. I entered college as a pre-veterinary science major, ultimately switched to a Psychology major, hated counseling but fell in love with animal behavior research, and graduated with a BA in Psychology, Biology minor, and Biology Honors. I then entered a PhD program at the University of Nebraska-Lincoln in the Biological Sciences with the intention of becoming a research professor. I actually completed my coursework for a PhD, but cut my research short to graduate with a Masters when I decided a career in academia was no longer what I wanted. After graduation, I became a homemaker and mom when our son was born 5 months later. When he was 10 months old I completed my doula training with DONA International, and attended my first doula birth one month later. Now my husband and I have three children, I am a certified birth doula with DONA International, a Hypnobabies Childbirth Hypno-Doula, co-leader of ICAN of Lincoln (International Cesarean Awareness Network), and have attended more than 55 births. I have a passion for teaching others, empowering women and families to love one another better, birth, birds, and chocolate.

I wanted to write a guide to other doulas and to parents-to-be on how to find, read, understand, and use primary research literature. There are excellent, free resources where the public can read the full text of research studies, although you may need to ask your physician for papers they can only access using their professional subscriptions. Reading and understanding the scientific literature is a learned skill, and I've given a crash course here. Finally, when you have found, read, and understood the research, using the information will be a highly individual decision that only the patient themselves is able to make, based on their intuition, desires, trusted counsel, and circumstances. Today in Part 1, I address how to find and read research papers, and tomorrow in Part 2, I walk you through a short research article, and discuss how to understand the paper and use the information.
 
How do you find research literature? I won't reinvent the wheel here, Understanding Research and Evidence Based Birth are great places to start. If you find a title that you cannot access without a subscription, sometimes you can search the title on Google Scholar, or even just Google, and find the full text for free. If you only have access to the abstract, use caution. The abstract is the very last piece researchers write before submitting their article for publication, and they may accidentally include incorrect information in their haste. Scientists are human too, remember? So, if you cannot read the whole paper, use caution in using that information to make decisions.
 
Once you've found a paper that interests you, how do you know if it's a good one? The best way is to read it and understand it. The research methods will clue you in to the robustness of the research. The gold standard of medical research is a double-blind randomized controlled trial, in which the individuals receiving the treatments, and those collecting the data, do not know what treatment was received, the treatments are randomly assigned to each individual research subject, and there are appropriate controls against which to compare the treatment effects. However, this is really difficult to do, so it is rare. When you read the methods, do you see any holes in the procedure? Anything that could have an alternate explanation? The fewer alternate explanations of the effects, the better the study. If you have found a review article, or a metastudy, this is gold. These are not primary research articles, but rather they summarize an entire field of research. Metastudies actually take the data from multiple similar studies, group them together and reanalyze the data as if it were one huge study, a powerful method. The Cochrane Database of Systematic Reviews is a great place to find these. While the review may be missing pertinent data, and only includes research conducted prior to submission for publication, these types of papers are wonderful sources of good information, when they exist.
 
Those five years of graduate school were largely devoted to training myself to read and understand the primary literature in my field efficiently. While the average science-literate citizen need not undertake this intense training, a guide to research articles is still necessary, as reading research is not the same as reading other materials. This has been covered well and more extensively by others, so I will summarize my advice here.

• Skip the abstract completely.
• Do write in the margins, underline, write questions. Read it once, and then read it again.
• First read the introduction/background section. Look up any words you don't understand before moving on.
• Identify the author's question, what have they identified is missing in the previous information, and what are they going to investigate? This may be explicit, as an "objective" listed in the article, or you may have to search for it in the text.
• Once you understand the question(s) the authors are investigating, read the methods. Do you think this effectively asks the question the authors want to answer?
• Once you understand what the researchers did, look at the tables, graphs, and charts.
• Once you understand those, read the results section.
• Then read the discussion section. Do you understand the author's conclusions? Do they make sense? Can you think of any alternative hypotheses the authors did not address? Do more questions come up for you?

 
Want more? www.understandingresearch.com, www.sciencebuddies.org, and www.violentmetaphors.com have wonderful guides to reading research articles.
 
Join me again tomorrow for Part 2 where we walk through a short article together and learn what to do with the information once you understand it! This is a short, less than one page, write-up of some preliminary research. Here is the paper:

Afshar, Y; Wang, E; Mei, J; Pisarska, M; and Gregory, K. 279: Higher odds of vaginal deliveries in women who have attended childbirth education class or have a birth plan. American Journal of Obstetrics & Gynecology, 2016;214(1):S162.

Go read it, following my instructions as best you can, and come back tomorrow!

​Joyce Dykema, MSc, CD(DONA), HCHD, became a certified birth doula in May 2012. She is also a trained Hypnobabies® Hypno-Doula, and volunteers as  leadership for ICAN of Lincoln, her local chapter of the International Cesarean Awareness Network. Joyce is a woman-focused doula. While passionate about natural birth and what research shows is the best for moms and for babies, the goal she strives for with every client is for women to have empowering and positive births, as the woman defines it. In addition to her doula credentials, she holds a BA in psychology and an MS in biological sciences. She breastfeeds, uses cloth diapers, uses baby sign language, babywears, and homeschools because these choices made sense for her family; she encourages others to explore and find what makes sense for their families. Joyce and her husband have three children, and live in the Lincoln, Nebraska area.

I heard a doctor say once, when presenting a pivotal intervention to the family I was working with, "If you were my wife, this is what I would do." It truly does offer the feeling: "He really cares about me." This is actually a fallacy -- faulty emotional appeal. It isn't based on science, or evidence, or the unique needs of mother and baby. It is simply an opinion said with feeling, and it can be swaying. Maddie McMahon hits the nail on the head here, and she offers sage wisdom to those of us who work with families -- families who may be vulnerable to the words we say and feel with emotion, that may not exactly be the truth.

These are the kinds of things I hear parents saying quite a bit, and they always remind me that being kind is just not enough. Meaning well is just not enough. Smiling and speaking gently is just. not. enough.

​There is a lot of talk in health care about compassion. And so there should be. It should pretty much be a core quality of anyone working in a caring role. Compassion means having a deep understanding and sympathy for another’s suffering. It also means wanting to do something to fix that suffering and take it away.

The problem is, compassion on its own can be a problem. If we believe we can make this all better, if we believe we know better, if we can’t bear to see present or potential future suffering, if even the idea of risk is frightening, then compassion can be dangerous.

Compassion needs to be tempered and balanced with empathy. The ability to enter into another person’s feelings, to see the world through someone else’s eyes. It is this ability that allows us not to get caught up in our own emotions and not get swayed by our own assumptions as to what might be right of wrong for this person. It is empathy which allows us to step outside of ourselves, just a little, and make space to really listen – and more than listen, understand WHY someone might feel the way they do.

So my plea to you wonderful, compassionate practitioners out there, whether you are doctors or midwives or nurses or lay supporters like doulas: Please try not to coerce with your kindness. Is this mother doing as she’s told because you’re so kind and she doesn’t want to upset you, or is she making a fully informed decision? Are you laying YOUR stuff on her or are you truly holding the space while she looks at the benefits and risks of all her options then follows her heart? True kindness and care means trusting that those we care for can make safe, appropriate decisions for themselves, even if we disagree with them.

My New Year resolution this year is to pour a cup of Alongsideyou Tea and strive to listen harder and longer and deeper, whenever I can to everyone I meet and give my empathy muscles a workout.

There is a lot of talk about what your ecological footprint is -- meaning, what impact do you have, because of your lifestyle, on the earth and its resources?  Being in the world of moms and babies as a doula and an educator, I have seen a different footprint we can leave, a Birth Footprint.

Basically, your birth footprint is a combination of your personal experiences, beliefs, biases, and philosophies that could be projected onto other women and families -- instead of the pressure you put on the earth, it's the pressure you put on others.

Here are a couple examples of exerting your birth footprint (and they happen to be mine!):

Giving clients opinions instead of actual facts. We don't try to do this intentionally, but rather, we give anecdata from what we have seen or experienced, versus evidence-based information that comes from reputable sources such as Cochrane Collaboration. 

With my second pregnancy, on my due date, my midwife asked if I would like my membranes stripped.  I was tired of being pregnant (who isn't by 40 weeks, huh?) and I willingly agreed. Nothing happened, not one thing -- I was pregnant for another week. In my mind I equated membrane-stripping with a low-risk intervention, not inclined to do much.

Back when I was certifying I had a client who was offered a membrane-stripping by her practitioner. She agreed, and immediately began contracting every 9 minutes. This was the start of hours of uncomfortable, non-progressing labor.  She went to the hospital after 12 hours with contractions still no closer together or longer in length. She begged her practitioner to allow her to stay the night and he agreed.  The next morning, 24 hours after the membrane-stripping with still no change in contraction pattern or cervical dilation, her practitioner broke her water, offered her an epidural, and began induction procedures.  This mama hadn't slept all night, her epidural wore off three different times, and by six pm, she was offered a cesarean birth -- exhausted, she agreed.   

I had no part in her decision, we had not discussed this topic beforehand; but if she had asked me about membrane-stripping, I might have said, "It's no big deal, it doesn't do anything anyway."  My answer would not have been true! While Cochrane states, "to avoid one formal induction of labour, sweeping of membranes must be performed in eight women," it goes on to mention "sweeping can cause discomfort during the procedure, bleeding, and irregular contractions" -- all of which my client experienced. Her contractions didn't change her cervix, but they did wear her down, diminish her spirit, and factor into the making of decisions she previously wanted to avoid.

Letting personal biases interfere. As we work with different practitioners in the birth world, we get good ideas about who we like, and who we would like to avoid. A woman sought out my doula services, and I was thrilled when she shared her midwives were my midwives. An assumption came from this: I knew these women well, I valued their skills and their style, and I had two of my babies with them in amazing-to-me births -- I guessed my client felt the same. But guess what? I was wrong. My client was having doubts about her connection to the midwives, and while she tried to process her own feelings, I was trying to talk these women up, in the hopes that my client would feel better about her choice to birth with them. 

What I didn't realize was, this chipped away at my ability to be the non-biased sounding board my client deserved. My attempts to smooth the rough feelings my client had were actually setting us up for division, as I was supposed to be on the mom's side, and it seemed like I was on the midwives' side. Before things got to an uncomfortable point, I saw my job wasn't to fix the situation. Instead, I offered communication strategies my client could implement, including role-playing with her so she could practice conversations before her appointments. She had a memorable birth with just the right midwife, and I had a memorable lesson in my client's needs and feelings coming first.

Questions to ask yourself if you are a birth-worker:

1-Do I bring up my own experiences of birth and share them readily with my students or clients?  No doubt having babies is exciting and life-changing.  We do have a need to share our stories, this is human nature.  I have joked  that every woman has to share her birth story 78.4 times before she can move past it to help another woman. If she tries to move into birth work before she is ready, her expectations can be either to help women avoid an experience like she had (if it was less-than-satisfying), or to share a formula that other women should follow to have an experience identical to the one she had. This is the client's experience, let it be shaped by her education, desires, personal beliefs, and choices, and she will come out with an incredible story of her own to share. 

2-Do I encourage her to find her own way? Another trap if you already have children is, when your client is presented with a decision, she asks, "What would you do?" It can be the easy way to just simply answer -- you have experience, you know what you are comfortable with. But that would be taking away this family's experience of facing a tunnel of indecision and coming out the other side with an answer they feel fits for them. In the short run, you can look like a hero with the solution, but in the long run, that doesn't help this family build up their confidence in parenting and making choices for their baby.

3-Do I have strong feelings about choices families make regarding birth and parenting?  I have a close friend who admitted she couldn't work with pregnant or new moms because she can't handle when they make choices she feels are wrong. Instead of trusting parents to make their own educated decisions, she wants to "bully" them into parenting as she does.  For example, she has always co-slept with her babies, and it drove her mad to see parents put their babies in cribs. Instead of offering evidence-based information such as Dr. James McKenna's research, she wanted to jump to scare-tactics to push parents into making their decisions. This is not choice, this is force fueled by strong statements full of fear. We must trust families to make the choices they feel are right for their situations. 

4-Do I include myself as an integral part of their birth story? I admit, it feels good when a family says, "We couldn't have done it without you!" And it would be great if I could really believe that and walk around with that feather in my doula cap. Maybe it's altruistic (more likely, insecurity!), but that doesn't rest well with me. I once read a birth story where the doula went on and on to list all the things she did (10+, all numbered and acknowledged) to make this birth experience amazing for the mom and dad. Did the parents walk away feeling the power of themselves and their baby? Or did they walk away feeling like without their doula, they would not have been equipped with the tools and strength to have their baby? My response in situations like these is the same: "You could have done it without me -- I could not have done it without you."

5-Do I have specific requirements for parents? I had a former doula client who moved states away after the birth of her first baby. She was pregnant again and interviewing doulas. She texted me: "Is it normal for doulas to say they will only take you as a client if you agree to specific things?" The doula they interviewed said, she taking them as clients would be contingent upon them taking "approved" childbirth classes, committing to breastfeeding, and signing a statement to say they would agree to "nighttime gentle parenting." This family already believes in breastfeeding and the family bed, but they weren't prepared to take additional classes. Equally upsetting was, they were prepared to interview the doula, and instead they felt they were the ones being interviewed. "This was not what we were looking for, it kind of goes against the reason we wanted a doula in the first place." After a few more interviews with different doulas, they were able to find one that better fit their family. Of course as doulas we need to take clients we also feel fit our needs, I understand that. The process, though, can still be about the parents while we quietly assess how the fit feels for us, and then act accordingly after the fact if we know we aren't the right doula for this family.

There are many ways we can shape the births of our clients, these are just a few to consider. Doulas, what other ways can we impose our birth footprint on our clients, and how can we best avoid these roadblocks? I would love to hear from you.