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 This is preliminary research, it is probably not peer-reviewed (critiqued by other scientists in the field to make sure it is done well), and though we can still gain valuable information from it, keep in mind our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 learn at least one “new” thing at every birth I attend.  One of the best things I have ever done in my development as a doula is keeping a doula journal.  I made sure the journal I choose was pretty so I would enjoy retrieving it to use.  It is smallish so that it is easily portable in my doula bag.  As I enter year 4 as a doula, the benefits of keeping a journal are coming back to me.

So what do I record?  The bare essentials, like first names of mom, dad, and baby.  The date.  The location.  The care provider.  Vaginal or cesarean. Epidural or not.  Then I write down one special memory and one “thing” that I learned. Most entries are one page.  Sometimes there is more than one special memory and more than one thing that I learned.  
 
At the start of each year I also record some of the goals I would like to meet in the coming year.  These are examples of some goals I have already met and some I am still looking forward to:

-Make a webpage.  
-Have a booth at the Farmer’s Market.  
-Blog more.
-Attend Lamaze Training.
-Send in DONA recertification packet in August. 
   
At the end of the year, I do a little recap on the statistics of my birth work.  I can provide these statistics to my clients when they seek reimbursement from their health insurance!

-How many vaginal births versus cesarean births?
-How many epidurals versus no pain meds?
-Which hospitals did I attend the most?

The journal has been a great way to maintain focus on the how, when, where and why of my work in the birth world.  I read my journal two to three times a year.  Time changes perspective on events and often leads to new insights on why things happened the way they did.  The new insight gives me a broader, more complete knowledge base to work from.  So what have I learned?

I always pack extra hair bands in my doula bag, because my clients often get irritated with their hair in their face. Little did I know that one day I would use one to pull back the midwife’s hair (when her hair knot did not work)!  
 
Always bring a fresh change of clothes.  I never know when a birth is going to be a little lonnngggg.  That includes socks. And underwear.  I feel fresher and smell better.   

Some women don’t like to be touched.  Expand my verbal support  toolbag.  
 
Never, ever close my mind  to the suggestions of a nurse or a care provider.  Question them? Yes.  But never dismiss them without respectful consideration.  I have learned many things from nurses, midwives and obstetricians. But, on the other hand, the time to have an in-depth, philosophical conversation on “episiotomy or not to episiotomy” is probably not when my client is pushing (not one of my prouder doula moments).

If a mom gets discouraged during pushing, encourage her to feel the baby’s head.  The amount of energy they find at that moment is amazing.  Learned from a midwife.

At some births, I may never feel like I am in sync with the mom, the dad, the staff, the whatever.  BUT, the most important thing is continuous caring presence. It makes a difference-it really does.  Thank-you cards received months later and chance encounters with past clients in a grocery store have all proved to me that my presence was truly appreciated and positive.  On the other hand, there will be births that are unhappy, but my presence will probably make it easier to bear.    
 
Birth number 4, I decided I was never again going to tell a mom to push.  There are plenty of other people in the room willing to do that.  Instead, I focus on telling her how  well she is doing, wiping her brow, reminding her to take a deep breath for baby, giving her a sip of water.  
 
Some babies come really  fast.  Do I need to say more?  Stealing a phrase from one of my doula  sisters, “Use your spidey sense.”  If a mom seems transitiony or pushy, trust your doula instinct.  

Extended family love updates.  Take a stroll past the waiting room on the way to a bathroom break.  Give them an update.  They may feel uninformed. It is a great time to provide educational support that may lead to them, in turn, providing better support to your client.  
 
Few births are “typical.”  They almost all have something that makes them unique. So, essentially the more you experience, the more likely you are to have the next birth teach you something new. A concept I learned from a lactation consultant.

I want a peanut ball.  My clients like them and not all hospitals have them. Doula work is my passion.  It is an art.  It takes creativity, an open mind, empathy, diplomacy, and a willingness to learn. My journal gives me a chance to rejoice at the special memories and acknowledge the things I learned that will make me a better doula at the next birth, and the next birth, and the birth after that.  Looking forward to recording my next Happy Pushing memory!

I have a notebook.  It is just a basic marble-type composition notebook, except mine has pretty foil flowers and butterflies on it.  I call it My Super Secret Notebook Full of Exciting, Wonderfully Helpful Information.  Or My Super Secret Notebook for short.  Truthfully, I only put the word secret in there to amp up the level of buzz surrounding my notebook -- there really isn't anything secret in there; it's more like my own secret club, I guess, because I am probably the only one who thinks there is value in what is written within the pages.

I use my notebook in a few different ways, which in my mind, all relate to my role and energy as a childbirth educator. 

1.  When I read a book, I always keep my notebook handy.  As I come across meaningful phrases, ideas, or concepts, I copy them down in my notebook, taking care to also record the quoted source and corresponding page number.  A couple quotes from this section:  "Scent memory - rub your nose prior to learning something important that you want to remember" (Smart Moves; Why Learning Is Not All in Your Head, by Carla Hannaford).  And another:  "...living the focused life is not about trying to feel happy all the time....Rather, it's about treating your mind as you would a private garden and being as careful as possible about what you introduce and allow to grow there" (Rapt; Attention and the Focused Life, by Winifred Gallagher). 

2.  I like to keep my notebook around as I watch movies and TV.  If I see something funny that I could relate to a class topic, I make a note of it.  If I see something that is analogous to an idea we discuss in class, I also make a note of it.  As a learning tool, I can introduce a concept in a humorous light which helps springboard a discussion.  Or I can show 40 seconds of what seems to be an unrelated media clip and then flesh out similarities to a particular procedure, intervention, or idea without actually starting the discussion with the boring term or concept.  An example I have in my notebook is a scene from Mission Impossible II.  Tom Cruise is chasing after the heroine/co-star after she refuses to join forces with him against the villain.  They are shown flying around winding cliff roads driving two very fast sports cars.  All of his chasing causes her car to almost drive off a cliff edge.  He jumps out of his car and into hers, pulling her out to safety just before her car takes a nosedive off the precipice.  What does this represent?  An Iatrogenic effect.  Had he not been chasing her, she wouldn't have driven off the cliff; he "saved" her, yet it was he who put her at risk. 

3.  As I am able to attend conferences, workshops, or other classes, childbirth or otherwise, I take notes about things I want to remember, thoughts I have relating to the subject at hand, and even (this may be the secret part!) critques about the presenter or facilitator.  A few good ones I have:  "Lead by following."  "Eye to eye, breath to breath, heart to heart."  "The quietest person in the room is often the one most heard."  Contrasted with:  "What I felt was missing - no intros, no warm-ups, no outlet for embarassment, no explanation of terms, no talk of birth images or films that are watched..." and a big :( to go along with that last list.

Cultivating my notebook has taken years, and it is still a work in progress!  As I mentioned before, it may not hold any value for any other person on the planet but me, and I guess that's what makes it my Super Secret Notebook Full of Exciting, Wonderfully Helpful Information.  I highly suggest, no matter what you do in life, you seek to create one of your own.