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D ISSERTATION ON

“ASSESS THE EFFECTIVEN ESS OF FEM ALE BIRTH COM PAN ION IN TERMS OF M ATERN AL

AND N EON ATAL OUTCOM E AMON G THE PARTUR IEN TS AT SELECTED HOSPITALS IN

CHENN AI.”

MSC ( NURSI NG) DEGREE EXAMI NATI ON BRANCH- III

OBSTETRI CS AND GYNAECOLOGI CAL NURSI NG COLLEGE OF NURSI NG

MADRAS MEDI CAL COLLEGE, CHENNAI - 3

A Disse rtatio n Sub mitted To

THE TAMILN AD U D R. M.G.R. MED IC AL UN IVERS ITY, C HENN AI-600 032.

In Pa rtial F ul fill me nt o f t he R equi re me nt s fo r

THE DEGREE OF MASTER OF SCI ENCE I N NURSI NG

APR- 2012

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ASSESS THE EFFECTIVEN ESS OF FEM ALE BIRTH COM PAN ION IN TERMS OF M ATERN AL AND

N EON ATAL OUTCOM E AM ON G THE PARTUR IEN TS AT SELECTED HOSPITALS IN

CHENN AI.

Approved by the D iss ert at ion committee on ……….………

Clini cal S pe ciality Gui de ………….………

MRS . L.ALPHO NS A MAS C HREN AS M.S c (N), Lect urer ,College of Nurs ing ,

M adras M edical College,Chennai-3.

Me dical Expe rt ……….………

D R. M.MO HAN AMBAL M.D.D .G.O.,

D irector, I.O .G.G overnment H ospit al for Women and Children, Egmore,Chennai-8.

Me dical Expe rt ……….………

D R.RAJAKUMARI S UND AR, M.D .D.G.O., D irector, CSI K aly ani M ult i Sp eciality Hospit al, M ylapore, Chennai.

S tatisti cal Gui de ……….………

Mr.A.VENGATES AN , M.S c., M.Phil, P.G.D.C .A, Ph .D., Lect urer in St atistics ,

D epartment of Stat ist ics, M adras M edical College, Chennai-03.

A di sse rtatio n sub mitted to

THE TAMILN AD U D R. M.G.R. MED IC AL UN IVERS ITY, C HENN AI i n partial ful fill me nt o f t he requi re me nt for the

DEGREE OF MASTER OF SCI ENCE I N NURSI NG

APRI L 2012

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CERTIFICATE

This is t o cert ify that this diss ert at ion tit led, “ ASS ESS THE EFFEC TIVEN ES S OF FEMALE BIRTH COMPAN IO N IN TERMS OF MATERN AL AND N EON ATAL O UTCO ME AMON G THE PARTURIEN TS AT S ELECTED HOS PITALS IN C HENN AI” is a bonafide work done by M rs.D .KA RO LIN E, College of N urs ing, M adras M edical College, Chenna-3, submitt ed to The Tamilnadu Dr. M .G.R. M edical U nivers ity, Chennai in partial fulfillment of the univers ity rules and regulat ions tow ards the aw ard of t he degree of M ast er of Science in Nurs ing.

Branch III, O bst etrics and Gynaecological N urs ing under the guidance and s upervis ion during academic period from 2010-2012.

D r.Ms .R.LAKS HMI,Msc(N ).,Ph.D P rincipal,

College of Nurs ing, M adras M edical College, Chennai-3.

D r.V. KAN AGAS ABAI, MD D ean, M adras M edical College, Chennai-3.

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ACKN OWLED GEM EN T

THE LORD IS MY SHEPHERD; I SHALL NOT WANT.

There are s everal hands and hearts behind t his work. T his final shape of concret e cannot be achieved w ithout on optimal insp irat ion during the cours e of t he study, for which I would like t o expres s my heartful gratit ude.

F irst I w ould like to t hank almighty GOD for his abundant grace, bles sings, w is dom, knowledge, guidance, strengt h and uncondit ional love s how ered on me to complet e t his st udy w it hout any interruption.

M y s incere t hanks to Dr.R.KAN AGAS ABAI MD ,D EAN,Madras Me dical C ollege, Chenn ai for providing necess ary facilit ies and extending s upport to conduct this study.

M y great pleasure and privileges t o express my gratit ude t o our resp ected madam Ms .D r.R.LAKS HMI M.S c,(N), Ph .D ., PRINC IPAL, college of nurs ing, M adras M edical College, Chennai for her s upport, const ant encouragement and valuable s uggest ions t o comp let e this study.

M y s incere thanks t o our res earch guide Mrs. D r.K.Men ak a M.S c (N),PhD, Re ade r in Nu rsing ,College of Nurs ing, M adras M edical College, Chennai for her support, guidance and encouragement for t he s uccess ful complet ion of the study

I am grat eful t o our clinical sp eciality guide Mrs .L.Al phonsa Mas ch ren as M.S c(N ), Le ctu rer, College of N urs ing, M adras M edical College, Chennai for her constant source of inspiration and guidance throughout the study.

My sincere t hanks to Mrs .R.S aroja M.S c (N), Le ctu rer, College of N urs ing, M adras M edical College, Chennai for her s upport and guidance during the study.

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5 M y earnest grat itude to Mrs.D r.V.Ku mari M.S c (N ), PhD, Le ctu rer,College of N ursing M adras M edical College,Chennai for her s upport guidance and encouragement during the study.

It is my p leasure and privilege to express my deep s ens e of grat itude to Mrs .D r.N .Gayath ri Pri ya PhD , Le ctu rer ,,Sri.Ramachandra college of N urs ing, Sri.Ramachandra Univers ity, Porur and Mrs.I.S aafreen aMS c(N ,) Le ctu rer,M .S.A .J college of N urs ing, Thambuchetty Street ,Chennai for validat ing t he tool of this study.

M y s incere thanks t o D r.M.Mohanambal , MD DGO , Di rector, I.O.G and H ospit al for Women and Children, Egmore for providing necess ary facilities and ext ending support t o conduct t his st udy.

M y sincere t hanks t o D r. Rajaku mari S un dar, MDD GO, Dire ctor, CSI Kaly ani M ulti speciality H ospit al, M ylapore for providing necess ary facilities and ext ending support t o conduct t his st udy.

M y s incere t hanks to D r. Prema, MDD GO, Chief Profess or, CSI K alyani M ult i speciality Hosp ital M ylapore for providing guidance and s upport to conduct t his study and also I thank t he entire team in t he labour w ard for t heir kind co-operat ion..

M y s incere t hanks to Mrs .Jan cy Ravi, MS c (N ), Prin ci pal , School of N urs ing, CSI K alyani M ult i Speciality H ospit al, M ylapore for providing necess ary facilit ies and ext ending s upport to conduct this study.

I ext end my s incere t hanks t o Mr.A.Ven gatesan MS c., MPhil., P.G.D.C .A, Ph.D ., Lecturer in St atist ics for his valuable s uggestions in the analysis and pres entat ion of the dat a.

I ext end my thanks t o Mr. Ravi ,B.,A B.L.I S c., Librarian, college of N urs ing , M adras M edical College, Chennai for his co-operat ion and ext ending neces sary library facilities throughout the study.

I w is h to express my sincere t hanks to Mrs.D .Mary Th ara, English T eacher, for her t imely help in editing.

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6 A special t hanks t o friend M rs.C.Sus eela M Sc (N ), Nurs ing T utor, Thanjavur, for her cooperation and moral s upport during the study period.

I have no w ords to pen... affect ion and insp irat ion given by my hus band Re v. D r.V.Cale b Pri thi vi raj D .D ., and my everloving son M ast er C .Abishe gam S amuel , my parents Mr.D.D han araj, and Mrs.J.Mary Bru ce, and my Sisters Mrs .D.Ros aline Kal a, N urs ing Sup erint endent Mrs.D .Jose phine Geetha BPEd , Mrs .D.Chith ra Mercy Celine BS c, BEd and my only brot her Mr.D.Hi be rts Jeyaraj M.A,M.Ed, and in laws for their unending love, care, sp ecial prayers and s upport t hroughout w hat is inevit ably a continuing but excit ing exp erience.

I als o acknow ledge and appreciat e t he willingnes s of the parturients to participat e in t he st udy.

I ext end my t hanks to all t hos e w ho have been direct ly or indirect ly ass ociat ed w ith my study at various levels but not ment ioned in this acknow ledgement.

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TABLE OF CON TEN TS

Ch apter C onten ts Page

N o

I IN TROD UC TION 1

1.1 N eed for the study 5

1.2 St atement of t he problem 7

1.3 O bject ives 8

1.4 Operat ional definit ions 8

1.5 As sumptions 8

1.6 Hypothes is 8

1.7 D elimit at ions 9

II REVIEW OF LIT ERATURE

2,1Lit erature relat ed to the support p ers on’s presence 10 2.2Lit erature relat ed to the female birt h comp anion

in terms of maternal out come

12

2.3 Literature related t o t he female birt h comp anion int erms of neonatal outcome

18

2.4 Conceptual framework 22

III RESEACH M ETHODO LOG Y

3.1 Research methodology 26

3.2 Research approach and des ign 26

3.3 Research variables 26

3.4 Sett ing of t he st udy 27

3.5 P opulat ion 27

3.6 Sample siz e 27

3.7 Sampling technique 28

3.8 Sample criteria 28

3.9 Tool 29

3.10D es cription of t he Tool 29

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Ch apter C onten ts Page

N o

3.11 Scoring Technique 30

3.12 Test ing of the tool 32

3.13 P ilot st udy 32

3.14 Dat a collect ion procedure 33

3.15 Ehtical cons iderat ions 33

3.16 Dat a analysis and int erpret at ion 34 3.17 Schemat ic repres ent ation of study des ign 35

IV DATA ANA LYSIS AND INT ERPRETATIO N 36

V D ISCU SSION 68

VI SUM M ARY, CON CLU SION, IM P LICATION S AN D RECOMM EN DATION S

6.1 Summary 74

6.2 M ajor findings of the st udy 75

6.3 Conclus ions 78

6.4 Imp licat ion 79

6.5 Recommendat ion 80

6.6 Limit at ion 80

REFERENCES AP PENDICES

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LIST OF TABLES

Table.

N o Ti tle Page

N o

1. Research Design 26

2. D emographic charecteristics of t he parturients wit h companion and w ithout comp anion.

37

3. O bstet ric variables of the p art urients w ith companion and w ithout companion.

40 4. M at ernal out come among t he parturients w ith female

birth companion

41 5. N eonatal outcome among the p art urients w it h female

birth companion

43 6. M at ernal Out come among the part urients w ithout female

birth companion

44 7. N eonatal outcome among the p art urients w ithout female

birth companion

46 8. Comparison of mat ernal out come among the parturients

w ith and w ithout female

47 9. Comparison of neonatal outcome among parturients w ith

and w it hout female birth companion.

50 10. As sociat ion betw een age and maternal outcome of

parturients w it h female birth companion

51 11. As sociat ion betw een gravidity and mat ernal outcome of

parturients w it h female birth companion.

53 12. As sociat ion betw een the type of delivery and maternal

out come of p arturients w ith female birt h comp anion.

54 13. As sociat ion betw een age and neonat al out come of

parturients w it h female birth companion.

56 14. As sociat ion betw een gravidity and neonat al out come of

parturients w ith female birth companion.

57 15. As sociat ion betw een Type of delivery and neonatal

out come of parturients w ith female birt h comp anion.

58

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LIST OF FIGUR ES

FIGURE

NO CON TEN T

1. Conceptual frame w ork bas ed on M odified Sist er Callist a Roy’s A dapt ation M odel

2. Schemat ic repres entat ion of res earch des ign of the study 3. Comparison of the mat ernal outcome

4. Comparison of the neonat al out come

5. As sociat ion betw een age and maternal outcome 6 As sociat ion betw een gravidity and mat ernal out come 7. As sociat ion betw een type of delivery and mat ernal out come 8. As sociat ion betw een age and neonatal outcome

9. As sociat ion betw een gravidity and neonat al out come

10 As sociat ion betw een type of delivery and neonat al out come 11 Sat isfact ion of the p arturients w ith female birt h comp anion

during labour

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LIST OF APPEND ICES

APPEN D IX TITLE

I Lett er s eeking permis sion to conduct study in the CSI K alyani M ulti Speciality H ospit al,M ylapore.

II Lett er s eeking permis sion to conduct study in the I.O .G H ospit al for w omen and chilren,Egmore.

III List of exp ert opinion IV Cons ent form

V D emographic profile English VI T amil trans lat ion

VII Certificat e of approval by the Ethical Committ ee

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LIST OF ABBR EVIATIONS

S .NO ABBREVIATIONS

1 I.O .G - Inst itut e of Obst etrics and Gynaecology 2 F BC-F emale birt h comp anion

3 AN Check up-A ntenatal check up 4 e-journals-Electronic journals

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ABSTR ACT

Labour is an anxious period regarding pain, t he duration of t he labour and breast feeding .F ear of coming acros s the anxiety is one of t he event w hich t akes p lace for w omen during labour. In anot her asp ect labour is an happiest exp ect at ion along w ith the s evere anxiety stat e regarding t he arrival of the baby. Every w omen enjoys t he mot her hood and loves to breast feed the baby which is one of t he roles of the ideal mot her.

The aim of t he study is to ass ess the effect iveness of female birth companion in t erms of mat ernal and neonat al out come among t he parturients.

Quantitative approach and experimental design. Two group quasi experimental (post test only control group) research design was adopted in this study .The study was conducted at selected hospitals in Chennai. The selected hospitals include Institute of Obstetrics and Gynaecology Hospital for Women and Children, Egmore and CSI Kalyani M ulti Speciality Hospital, Mylapore. 40 parturients without female birth companion for control group and 40 parturients low risk women and with female birth companion were selected for experimental group. The female birth companion’s presence is the experiment in the experimental group. The sampling technique was convenient sampling technique. The tool used for the study was Structured Interview Schedule and Observational Check List.

This study assessed the effectiveness of female birth companion in terms of maternal and neonatal outcome. There was a significant association between certain demographic variables like age, type of delivery and gravidity related to the maternal and neonatal outcome. When the female birth companions are allowed during labour, 82% of the parturients had 100% positive satisfaction. This study also assessed that there is reduction in the level of anxiety and pain along with the shorter duration of labour including less operative deliveries and less use of oxytocics and analgesics.

The study revealed that the female birt h companion’s pres ence during labour reduces t he labour duration, reduces the p ain and anxiety level and also has spont aneous vaginal delivery, init iates early breast feeding w ith increas ed ap gar s core for t he neonat es.

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CHAPTER - I IN TR OD UCTION

“ Th e history of h um an being f or th e nin e m on th s p roceedin g this birth would, p robably be f ar more in teresting an d contain greater m om en t.”

- Samuel T aylor Coloridge.

As illustrat ed in t he Bible, t he G od has created women to bear p ain during labour in Genes is .From then onw ards t he w omen exp erience p ain w hich is excruciat ing and indeed unbearable. In order to ensure a s afe labour, s upport plays a major role. Labour support is “ mothering the mother” .The t erm Doula is a Greek w ord that is “ Women caregiver of another w omen”.

Supportive care involves t he cont inuous p hysical pres ence of a caregiver. It also encompass es t he following elements : physical support (comfort meas ures such as mass ages , touch, cool or hot compres ses, etc.);

emot ional support (encouragement , reassurance); informational support (instructions , information, and advice); and advocacy (relaying t he woman's or couple's w is hes to other t eam members, acting on the w oman's behalf) (Hodnett and Osborn, 1989b; M c N iven et al., 1992; H odnett, 1996, 1998).

A support ive environment is als o crit ical. H ere, an emphas is is placed on privacy, quiet, and a minimal number of intrusions. Creating and maint aining a s upportive environment for birth requires a mult idis ciplinary approach involving all care providers and input from cons umers ; mutual goals can t hen be ident ified, implement ed, and monitored (P hillips, 1994; Hodnett, 1998).

A D oula acts as a companion t o women before ,during and to the less er ext ent after labour. Unlike a M idwife ,s he does not provide ,obstet ric care (deliver babies ) but rather offers continuous and individual emot ional and physical s upport.(i.e. F ather and p art ners pres ence). Since labour is an anxious p eriod regarding the anxiety, p ain, the durat ion of the labour,breast feeding and fear of coming across the anxiety. In another asp ect Labour is an

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15 happiest exp ect at ion along w ith the s evere anxiety stat e regarding t he arrival of t he baby.

One report on Gulateman women found that the women laboured in the presence of the supportive companion called the Doula,had much lower complication rather than the women who laboured alone (Sosa et al (1980)The report states that the presence of the support person reduces the mothers anxiety thus reducing the secretion of the stress hormones called Cetacholamines. These cetacholamines are believed to impair the uterine flow which may result in the disruption of labour and can contribute to fetal distress. Every woman should be allowed to choose her primary source of social support during labour - be it be her partner, friends, or family members. These choices should be respected. However, a professional should also be involved to provide supportive care. Research has shown that the support of the woman in labour by someone of her own choosing is not a substitute for the support provided by a trained midwife or doula(whose only responsibility is care to the woman). The support by a trained midwife or doula results in positive outcomes (Hodnett, 1998).

The effects of one-to-one supportive care to a woman in labour have been well researched and documented in the literature (Health Canada, Canadian Institute of Child Health, 1995). The advantages of trained, supportive lay companions providing one-on-one care to a woman in labour are several: lower cesarean birth rates;

decreased use of oxytocin; decreased use of epidural anesthesia; decreased use of analgesia or anesthesia; improved Apgar scores; fewer operative vaginal births; fewer admissions to neonatal intensive care units; and longer breastfeeding durations (Wolman et al., 1993).

Ot her randomiz ed trials have shown t hat women who w ere accompanied by partners and ass igned a midwife during labour received less ep idural anesthes ia, analges ia, and general anesthes ia; had few er ep is iotomies; and had a great er s ens e of control during labour compared w ith w omen p ermitted accompaniment by p art ners but not ass igned midw ives (Breart et al., 1992). In environments where nurs es are able to spend t ime at the beds ide, as demonstrat ed in the int ermitt ent aus cultat ion trial, beneficial out comes have als o been obs erved (Gagnon et al ., 1997).

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BACKGROUND OF THE STUDY

In most cultures women are att ended by ot her w omen during labor and birth. Female relat ives or friends and a familiar midw ife w ho also plays a sp iritual role, a guardian of the threshold betw een w omb and t he w orld.

M other may have special pray ers , s eeks spirit ual support to empow er her. In M alaysia, South India and s ome p arts of the rural South Italy and G reece the use of image of an flow er opening to help a w omen focus on op ening her baby in order to give birth in Unit ed St ates of America.

The ass istance is sought of a friend or family members who is invit ed to p resent during labour and birth .Thos e trained birth companions st ay throughout labour and provide emotional s upport ,through t heir cont inuous pres ence, reassurance ,prais e and measures t o improve the comfort of the mot her, phys ical s upport measures such as backrubbing ,holding her hands and exp lanat ion w hat is going on during labour and then delivery.

Pascal et al (2004) conducted a study in which the doula provides a continuous one to one caring presence throughout the labour and birth of the women she is attending .This is a beneficial form of the care. In several low and middle income countries like South Africa, Zimbabwe, Tanzania and China the better birth initiative promotes the labour companionships as a core element of care for improving maternal and infant health .The risk factors include delay in breast feeding, delayed labor ,post partum haemorrhage, maternal fever, asphyxia neonatorum and fetal compromise ie., Infant mortality.

Support provided during labour and delivery by t he profes sional health care workers,non medical female attendents and trained women doulas ass igned t o t his task has been evaluat ed in cont rolled st udies .D at a suggest that the effects of support are associated w ith the reduction in the diss atis fact ion or negat ive perception of women t ow ards giving birt h in the use of anest hesia /analges ia ,and in the frequency of instrumental vaginal delivery (forceps and vaccum extract ion )and Caes arean sect ion .

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17 The World Health Organisation recommends that the parturient should be accompanied by people she trusts and with whom she feels at ease ,possibly her partner ,a friend or a doula nurse or midwife .However the effects of the support provided by the presence of the women’s chosen companion on her satisfaction .On the events of labour a delivery and on perinatal results have not yet been fully evaluated in controlled studies .The usefulness of support and the type of support provided by family members ,a partner or by friends of a women have only been evaluated in observational studies .

It is important to recognise and understand the influence of such support not only because of its effects on obstetrical and perinatal events but also on the positive attitude towards the birth experience itself. Although, since 2005,following some initial isolated state initiatives ,it is guaranteed by National Law to all Brazilian women to have a companion of her choice present during labour, it is not respected by many services and providers. Evidence- based data available on the effects of the presence of a companion of the women’s choice during the birth process ,especially in developing countries this study was developed to evaluate the influence of this support provider on the satisfaction of the parturient with labour and delivery and on perinatal and breast feeding outcomes in the twelve hours following delivery.

Recent mat ernal mort ality rat e in India has declined from 254 to 212 per one lakh live birt hs . Every y ear about 78,000 mothers die in child birth and from comp licat ion of pregnancy in India according t o Unit ed Nat ions Int ernat ional Childrens Emergency Fund –2009 (U NICEF).

The mat ernal mort ality rate currently in India is 212 deaths per one lakh and in Tamilnadu t he mat ernal mort ality rat e is 97 per one lakh according t o the sources .

Current st at ist ics in India reveals the dat a of neonat al mortality rate as 36 deaths per 1000 live births and 34 deaths per 1000 live births in T amil N adu in t he y ear 2009 (est.,).In order t o reduce the N eonat al mortality rat e, G overnment of India has established many nat ional p rogrammes . The World H ealth Organis at ion promot es labour companionship as a core element of care for improving t he maternal and infant health (WHO 2002).The regional plan

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18 of act ion for maternal and neonatal health care includes t he monitoring of mat ernal and fetal w ell being and the presence of a companion to provide s upport during labour and delivery as one of t he int ervent ions to improve the neonat al healt h. A trained birth comp anion cont ribut es to reduced t ens ion and short en labour, increas e t he mothers feelings of control, decreas e int ervent ions and caesareans , and also enhance the p art ners p art icip ations to imp rove t he outcome for t he new born,facilit ate p arent /infant bonding ,decreas e postpart um depress ion and increas e posit ive feelings about the birth exp erience.

NEED FOR THE STUDY

The mot her who exp erience pain during labour and child birt h is in need of the s upport p ers on may be a husband, doula, grand p arent s ist ers or any female relat ives including friends .T he cult ural, s ocial, psychological aspect of support varies from st ate to stat e nat ion to nat ion .P artners pres ence during labour supports the mother phys ically, and emot ionally. The support persons pres ence physically and psychologically helps t he mother t o feel comfortable. Support pers ons p resence provide an environment similar t o the home environment co-operation and confidence during the p eriod of straining and there by delay in labour process is reduced .T he s upport p ers ons pres ence ,guidance and exp erience in labour ass ist the mot her to cope up w ith the st res s and t ens ion and t here by t he breast feeding initiat ion is als o induced early. F emale birth attendant as a companion can play a major role than the male companion in providing ass ist ance regarding the caring of women’s health and in breast feeding. Women w ho received s uch s upport exhibit ed s horter period of labour, less p ain medicat ion and required few er medical procedure .There w ere als o reduced rat es of caesarean s ections. It also help ed to p romote breast feeding and decreas e post partum depres sion (T he H indu 23r d, M ay 2004).

Odella Maria B rugge mann e t al .,(2004 ) in t he st udy the evidence of s upport during labour and delivery provided by a health profess ionals ,lay w omen ,and doulas on mat ernal and neonatal out comes by randomiz ed clinical t rials , analys is and systemic reviews A t otal of 212 w omen w ho are

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19 primi parous s upport w omen w ere enrolled betw een F ebruary 2004 , and M arch 2005 .105 w omen w ere allotted to the support group and 107in which there w as no support.T he w omen in the support group w ere more s atisfied w ith labour (median 88.0vs 76.0) p<0.0001) and delivery (median 91.4 vs 77.1 ,p<0.0001).During labour p at ient s at isfact ion w as ass ociat ed w ith the pres ence of a birth comp anion (RR8.06:95%CI :4.84-13.43),w ith care received( RR1.11:95%CI 1.01-1.22) and w ith medical guidance (RR 1.14 95%CI 1.01-1.28).D uring delivery s at is fact ion w as associat ed wit h the pres ence of a birth companion (RR 5.57, 95%CI 3.70-8.38),w ith care received (RR 1.11 95%CI 1.01-1.22) and w ith vaginal delivery (RR 1.33 95%CI 1.02- 174).T he only fact or that w as s ignificant ly low er in the support ive group w as the occurance of meconium st ained amniotic fluid (RR 0.51 95%CI 0.28- 0.94).There was no st at ist ically s ignificant difference betw een t he tw o groups w ith resp ect to any of the other variables .

Vija yalaxmi (2005 ) conduct ed an exp eriment al st udy t o det ermine the effects of s ocial s upport on labour among the primigravida mothers at s elect ed hosp itals at Trichy .St ructured teaching given t o female relat ives w ho w ould be w ith t he primi gravid mothers during labor .The social support act ivities and t he behavioural respons e of the w omen during labour w as collected us ing the obs ervat ional checklist and out come w as meas ured by out comes measurement s cale which show ed s ignificant ass ociat ion betw een the social support and outcome of the labour in experiment al and control group. St udies have show n that allow ing the w omen t o be comforted, reass ured and praised during childbirth has many benefits including the follow ing i.e. s horter labour, less pain medicat ion, decreas ed rat es of caesarean s ect ion ,increas ed s atis faction and birt hing exp erience ,less postpartum depress ion and early initiat ion of breast feeding.

RC H II (Rep roductiv e a nd C hild Healt h II) 2001, has recorded one birt h companion to support the women in labour in all the Hosp itals in T amilN adu . In 2001,Law w as p ass ed by government decreas ing t hat all w omen have the right t o ave comp anions hip during labour .Birt h companion s hip programme permits s upport p ers on to be by t he s ide of the part urient

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20 during labour.(GO No .213 He alth an d Family Wel fare D td 02.07.2004) .A lmost all t he government cent ers , deliveries are conducted w ith birth companion. Hence, the invest igator planned t o conduct t his study in private mat ernity centers , where us ually the birth comp anions are not allowed during labour.

In the int erest of t he women undergoing labour w ith st ress and anxiety during labour and child birt h, the invest igator w ith more clinical exp erience in tert iary care cent ers have decided t o t ake up the study to as sess the effect iveness of female birth companion in t erms of mat ernal and neonatal out come among the parturients at s elect ed hospit als in Chennai.H ence, the investigator planned t o conduct this study in privat e mat ernity cent ers ,where usually birt h comp anions are not allow ed during labour .

PROBLEM STATEMENT

As sess t he effectiveness of female birth companion in t erms of mat ernal and fet al outcome among t he parturients at select ed hospit als in Chennai.

OBJECTI VES OF THE STUDY

1) To ass ess the effect ivenes s of maternal and neonat al out come among the part urients w ith female birth companion.

2) To ass ess the effect iveness of maternal and neonat al outcome among the part urients w ithout female birth companion .

3) To comp are the effect iveness of mat ernal and neonat al out come among the part urients w ith and w ithout the female birt h comp anion.

4) To ass ociat e the major findings w ith the sp ecific demographic variables.

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21

OPERATI ONAL DEFI NI TION

E ffect ive ne ss refers to cons equences or res ults of s upport pers ons pres ence in t erms of pain perception ,durat ion of labour,initiat ion of breast feeding ,ap gar s core,us e of analges ics ,oxyt ocics ,ass ist ed deliveries .

Fe male Bi rth compa nio n refers t o support pers ons pres ence by the s ide of the p art urient during labour and child birt h.(may be sister, mother, mot her-in law,friend ,any female relative w ho had undergone labour exp erience and whom s he prefers .)

Mate rnal o utco me refers to t he res ults in t he p erception of pain,durat ion of labour, anxiety,us e of analges ics and oxyt ocics , ass ist ed delivery and vacuum extract ion.

Neo natal o utco me refers to the results in the init iat ion of breast feeding and Ap gar s core.

Pa rt urie nts refers to w omen who delivered during t he study p eriod in the labour w ards of the s elect ed hospit als in Chennai.

Sele cted ho spital s refers t o Inst itut e of O bstet rics and Gynaecology H ospit al for Women and Children ,Egmore and CSI K alyani M ult i Sp eciality H ospit al, Mylapore.

HYPOTHESIS

There w ill be s ignificant relat ions hip betw een the parturients w ith female birth companion and mat ernal and neonat al out come.

ASSUMPTI ON

Reduct ion in the pain percept ion.

Reduct ion in the anxiety.

Shorter duration of labour.

Less us e of oxyt ocics and analges ics.

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22 Reduct ion in the ass ist ed forceps delivery ,and vaccum extraction.

N eonatal ap gar score for 5 minut e more than s ix.

Early init iation of breast feeding, among the p art urients w ith female birth companion.

DELI MI TATI ONS

1) The study is limited to a p eriod of 4 w eeks .

2) The st udy is limit ed only to w omen w ho are in labour at Instit ute of O bstet rics and Gynaecology for Women and Children, Egmore and CSI K alyani M ult i speciality H ospit al, Mylapore.

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23

CHAPTER –II

R EVIEW OF LITER ATUR E

Review of t he literature is an ongoing process and it covers t he ent ire planning st age. A good res earch is alw ays support ed by its evidence and review of lit erat ure serves as a means of s upport.

THE REVI EW OF LI TERATURE OF THIS STUDY HAS BEEN GI VEN AS :-

The lit erat ure relat ed to the support person’s pres ence

The literature relat ed t o the female birth comp anions pres ence in t erms of mat ernal out come.

T he lit erat ure related to the female birth comp anions pres ence in t erms of the neonat al out come.

THE LI TERATUR E RELATED TO THE SUPPORT PERSON’S PRESENCE

Ma ria B rugg ema nn et a l., (2004 ) in t he study the evidence of a s upport during labour and delivery provided by a health p rofes s ionals ,lay w omen, and doulas on mat ernal and neonatal out comes by randomiz ed clinical trials , O della analys is and systemic reviews . A tot al of 212 women w ho are primip arous p ort w omen w ere enrolled between F ebruary 2004 , and M arch 2005. O ne hundred and five w omens reports w ere allotted to the s upport group and 107in which there w as no s upport. T he w omen in the s upport group w ere more s atis fied w ith labour (median 88.0vs 76.0) p<0.0001) and delivery (median 91.4 vs 77.1, p< 0.0001).During labour pat ient s at isfact ion w as associated w ith the pres ence of a birt h companion (RR8.06:95%CI:4.84-13.43), w ith care received (RR1.11:95%CI 1.01-1.22) and w ith medical guidance (RR 1.14 95%CI 1.01-1.28). During delivery ,sat is fact ion w as ass ociat ed wit h the pres ence of a birt h companion (RR 5.57, 95%CI 3.70-8.38),w ith care received (RR 1.11 95%CI 1.01-1.22) and w ith vaginal delivery (RR 1.33 95%CI 1.02-174).T he only factor t hat w as s ignificant ly low er in the s upport ive group w as the occurance of meconium

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24 st ained amniotic fluid (RR 0.51 95%CI 0.28-0.94).T here w as no st at istically s ignificant difference betw een the two groups wit h resp ect t o any of the ot her variables .

D oulas provide informat ion about labour progress and exp lain procedures and events. T hey advocat e for the w omens right to part icip ate act ively in the management of her labour .Thes e forms of caring help to reduce t he w omens level of anxiety and fear and make her more confident calm and reduce the stress respons e t hat could inhibit the progress of labour Kay ne Gre ullic h et al ., (2000 ).

Ka nnan P (2000 ) conducted a st udy t o the benefit of mass age therapy and us e of a doula during t he labour and childbirth in one t o one care and touch .Support during labour as examined w ith respect to t he partner ,nurs es ,nurs e midw ives and doulas Res ults s how ed s ignificant obstet ric outcomes .

Scott E D et al , (1999 ) review ed the evidence regarding the effect iveness of continuous s upport provided by a t rained lay w omen (doula) during child birth on obstet rical and postpartum out comes .Twelve individual randomiz ed t rials have comp ared obst etrical and postpartum out comes betw een t he doula s upported women and women w ho did not receive doula s upport during child birth. Emotional and physical support s ignificant ly s hortens labour and decreas es the need for caesarean s ection ,forceps ,vacuum ext ract ion, oxytocin augument ation and analges ia .8 of t he 12 trials report ed early or late .Psychos ocial benefit of doula s upport. Early benefit includes reduct ion in the st ate anxiety s cores posit ive feelings about child birth exp erience, increased rates of breast feeding init iat ion .The results of thes e 12 trials strongly suggests the Doula s upport is an es sent ial component of child birth.

C .Modi B e et al, (1999 ) conduct ed a study t o det ermine the effect iveness of t he pres ence of the female relat ive as a labour companion on labour out comes w ith proport ion of w omen in the 109 primigravidas . In uncomplicat ed spont aneous labour w ho w ere randomnly dist ributed into a control group who laboured w ithout family members pres ence and an

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25 exp eriment al group who had a female relat ive w it h them during labour.Results s how ed that s ignificant ly more mothers in t he exp erimental group had a spont aneous vaginal delivery ,les s intrap artum analges ia, less oxytocin, few er amniotomies to augument labour ,fewer vacuum ext ract ions and few er caes arean s ection than in t he control group .T he pres ence in the labour of a female relat ive w as s how n to be ass ociat ed w it h t he few er int ervent ions and a higher frequency of normal delivery compared wit h the out comes of thos e w it hout the family member s upport.

Research at univers ity of T exas H oust on H ealt h s cience Cent er and Case West ern Res erve Univers ity s how s t hat t he w omen s upported by a doula or exp erienced female labour companion during birth w ere more likely to int eract pos itively w ith their children after birt h. M others and doula support lat er vis it ed by res earchers w ere more likely t o hold their babies in a nurt uring w ay and look into the babies eyes t han w ere mothers w ithout doula s upport during delivery.(S cien ce Ne ws May 2 n d (1998).

THE LI TERATUR E RELATED TO THE SUPPORT PERSON’S PRESENCE I N TERMS OF MATERNAL OUTCOME

Cat he ri ne R ubwe za (2006) in new vis ion U gandas leading w ebs ite ,a birth companion eas es labour .A st udy by Klaus and Kennel K laus (1993) conducted at different studies and found that the labour s upport had the follow ing benefits .It reduces the over all caes arean rat es by 50%,length of labour w as strengthened by 25%,reduced us e of pain killers by 60%,reduced oxytocin by 40%,reduced forceps delivery by40%,mot hers have a more pos it ive breast feeding exp eriences, cope bett er w ith the stress of handling a new born, bond fast er w ith their babies (Sci ence news dail y Ma y 2nd 1998 ). Vija yalaxmi (2005 ) conduct ed an exp eriment al st udy t o det ermine the effects of social support on labour among t he primigravida mothers at s elect ed hosp itals at Trichy. St ructured teaching given t o female relat ives w ho w ould be w ith the primi gravid mothers during labour. The s ocial support act ivities and t he behavioural respons e of the w omen during labour w as

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26 collected us ing the obs ervational checklist and out come w as measured by out comes meas urement s cale w hich s howed s ignificant as sociation betw een the social support and outcome of the labour in experiment al and control group.

Women who received s uch s upport exhibit ed short er period of labour ,les s pain medication and required fewer medical procedure .T here w ere also reduced rat es of caesarean s ect ions.It als o help ed to p romot e breast feeding and decreas e post part um depres sion . The Hi nd u -23rd ,Ma y, (2004 )

Ma ria B rugg ema nn et a l., (2004 ) in t he study the evidence of a s upport during labour and delivery provided by a health p rofes s ionals ,lay w omen, and doulas on mat ernal and neonatal out comes by randomiz ed clinical trials, mean analysis and syst emic review s .A tot al of 212 women w ho are primiparous support w omen w ere enrolled betw een february 2004 , and M arch 2005 .105 womens reports w ere allotted t o the support group and 107in which there w as no s upport.The women in t he s upport group w ere more s at isfied w ith labour (median 88.0vs 76.0)p< 0.0001) and delivery (median 91.4 vs 77.1 ,p<0.0001).During labour pat ient s atis faction w as ass ociat ed w ith the pres ence of a birt h comp anion (RR8.06:95%CI :4.84-13.43),w ith care received (RR1.11:95%CI 1.01-1.22) and w ith medical guidance (RR 1.14 95%CI 1.01-1.28).During delivery ,s at is fact ion w as associat ed w ith the pres ence of a birth companion (RR 5.57, 95%CI 3.70-8.38),w ith care received (RR 1.11 95% CI 1.01-1.22) and w ith vaginal delivery (RR 1.33 95%CI 1.02-174).The only factor t hat w as s ignificant ly lower in the support ive group w as the occurance of meconium stained amniot ic fluid (RR 0.51 95%CI 0.28-0.94).T here was no st at ist ically s ignificant difference betw een t he two groups w it h resp ect to any of the other variables.

Po tomac ma ssag e trai ni ng i nstitute USA (2003) collect ed evidence indicat ing a lower epidural rat e and caes arean s ect ion as w ell as s horter labour t ime for pregnant women who receive mass age by their support person.

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27 A me rica n Acad emy o f Phy sicia n (2003 ) s uggested that the doulas attended p arturients have labour as s horter,babies are healthier and they breast fed more early .F urt her more w omen exp erience great er s atis faction w ith the birt h exp erience and an enhanced relations hip w ith their part ner .

Hodnet et al .,(2003 ) in his studyCont inuous s upportive care t hat begins early in labour ss ignificantly reduces t he caesarean birt h rat e,duration of labour ,us e of oxyt ocin,and forceps or vacuum ext ractor and reques ite for ep idural anaesthes ia.Thes e reduct ions are great est w hen the care giver focus es s olely on labour support and is not p art of the st aff of the labour unit .

Mo sallam M et al, (2003 ) conduct ed a study on womens attit udes towards psychos ocial s upport in labour in U nit ed Arab Emirit es.

A cons equt ive Samp le of 400 mothers w ith s ingleton normal pregnancies delivered vaginally during 2 months w as interview ed postpartum about their exp erience and s atis faction w ith s upport ive care during labor using st ructured quest ionnaire .Birt h att endant cont inuous ly accompanied 237 (59.3%)p art icipants including mother59.5%,sister (31.2%),friend( 7.2%),other family members (1.3%)or husband (0.8%).Preference in the no companion group (n=16,40.7%)w as healt h profes sional (56.4%),mot her(25.8%),Sist er (16.6%)or hus band (1.2%). Labour w as s ignificant ly s horter (P< 0.0001) w ith less need for analges ia (P< 0.0001), oxytocin augumentat ion (P< 0.0001)and the neonat al int ens ive care (P= 0.03)in the companion group. Rates of instrument al delivery, epis iotomy, and perineal t ear were s imilar in both groups. T hree hundred and fifty subjects (87.5%)felt that psychological s upport during child birth is es sent ial best provided by non profess ional attendant(companion group) or midw ife /obstetrician (no companion group) 59.3 % and 19.7%of mothers respect ively reported les s s at isfact ion and negat ive feelings about their perinatal experience t hat w as more frequent in the no-comp anion group (P= 0.001 ,P< 0.0001 resp ect ively ).

Sauls JD (2002 ) conduct ed a quantit at ive research st udy related to the effect of labour support on birth and fetal out comes during childbirt h.

Research provided powerful evidence of improved outcomes for mot hers and

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28 babies when mot hers w ere s upported in labour. T hes e out comes include low er rat es of analges ia and us e of anaesthes ia, lower op erat ive birt h rates ,short er labour, few er newborns w ith 5-minut e Ap gar s core les s than 7,increas ed mat ernal sat is fact ion w ith t he birthing process and much more.

E rick son.C .We st mann (2002 ) evaluat ed the psychological fact ors of labour p ain among 35 mothers during the child birth. Psychological fact ors have been implicated in p ain exp erience during child birt h which can have both short and long term cons equences of t he mothers health and her relat ionship w ith her infant. T hes e dat a rep licat e previous res earch has demonst rat ed the significant impact on anxiety ,s ens it ivity on t he p ain responding in their areas and ext ended knowledge in this lit erature to demonst rat e the import ant role that anxity s ens it ivity among women and their exp erience of labour pain.

Kay ne Greullic h et al ., (2000 ) Doulas provide informat ion about labour progress and exp lain procedures and events .They advocate for the w omen’s right to p art icip ate act ively in the management of her labour .Thes e forms of caring help to reduce the womens level of anxiety and fear and make her more confident , calm and reduce the stress response t hat could inhibit the progres s of labour.

Ka nnan P (2000 ) conducted a st udy t o the benefit of mass age therapy and us e of a doula during t he labour and childbirth in one t o one care and touch .Support during labour as examined w ith respect to t he partner ,nurs es ,nurs e midw ives and doulas res ults s how ed s ignificant obstet ric outcomes .

Medl end er HL (2000 ), in the st udy compared 481 pregnant women.It w as developed on the bas is of s emi struct ured int erviews .Results of the respondents w ere 78% express ed fear relat ed to p regnancy and child birth or both .Specific fears concerned child birth, the childs and the mothers w ell being, family life and caes arean s ect ion. So it is import ant for perinat al health care givers to p ay special attention to primiparous and multi p arous w ith negat ive exp erience of earlier pregnancies.

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29 C .Modi Be et al (1999 ) conduct ed a study to determine the effect iveness of t he pres ence of the female relat ive as a labour companion on labour out comes w ith proport ion of w omen in the 109 primigravidas .In uncomplicat ed spont aneous labour w ho w ere randomnly dist ributed into a control group who laboured w ithout family member’s pres ence and an exp eriment al group who had a female relat ive w it h them during labour.Results s how ed that s ignificant ly more mothers in t he exp erimental group had a spont aneous vaginal delivery ,les s intrap artum analges ia ,less oxytocin, few er amniotomies to augment labour ,few er vacuum ext ract ions and few er caes arean s ection than in t he control group .T he pres ence in the labour of a female relat ive w as s how n to be ass ociat ed w it h t he few er int ervent ions and a higher frequency of normal delivery compared wit h the out comes of thos e w it hout the family member s upport.

Scott ED et al (1999 ) review ed the evidence regarding the effect iveness of continuous s upport provided by a t rained lay w omen (doula) during child birth on obst etrical and postpart um out comes .Tw elve individual randomiz ed t rials have comp ared obst etrical and postpartum out comes betw een t he doula s upported women and women w ho did not receive doula s upport during child birth. Emotional and physical support s ignificant ly s hortens labour and decreas es the need for caesarean s ection, forceps , vacuum ext ract ion, oxytocin augumentat ion and analges ia .Eight of the 12 t rials reported early or late . Early benefit includes reduct ion in t he st ate anxiety s cores pos it ive feelings about child birt h exp erience, increas ed rat es of breast feeding initiat ion .Later postpartum benefits included improved s elf est eem ,exclus ive breast feeding .T he res ults of t hes e 12 trials st rongly s uggests t hat the Doula s upport is an ess ential component of child birt h .

La nge r et al ,(1998) p erformed an exp erimental st udy on the effects of psychological s upport during the labour,,delivery and the immediate post parum period provided by a female birt h companion .Social support by a doula provided to women in the int ervent ion group ,While t he w omen in the control group received rout ine care.724 women w ith a s ingle fet al ,no previous vaginal delivery,<6cm of cervical dilat ation ,and no indicat ions for

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30 an caes arean s ect ion w ere randomnly as signed to be accomp anied by a doula ,or t o receive rout ine care.. M ore women in the int ervent ion group perceived a higher degree of control over the delivery exp erience, and t he delivery durat ion of labour w as short er than in the cont rol group (4.56 hours vs 5.58 hours :RR1.07 CI (95%)= 1.52-0.51.)The result had s how n that the psycho s ocial support by doulas had a pos it ive effect on the breast feeding and durat ion of labour.

Ca mpe ro et al (1998 ) conduct ed a qualit ative study t o evaluat e the effects of the provis ion of psychos ocial s upport t o first t ime mot hers during labour ,child birth and in t he immediate postpartum period in a social s ecurity hosp ital in M exico city.T he interview s how ed that the women accomplis hed by “ doula” had a more pos it ive child birth exp erience .724 women w ith no previous delivery and no indicat ions for caes arean s ection delivery w ere randomnly ass igned to be accompanied by t he doula (n= 361 )or to receive rout ine care (n= 363 ).T he frequency of exclusive breast feeding one month aft er birt h w as s ignificant ly higher in t he intervention group than the control group (12%vs 7%) (RR1.64 :95%)Confidence Interval (CI)1.O1-2.64 However the programme did not achieve a s ignificant effect on breast feeding (37%and 36%respect ively ).The durat ion of labour w as short er in the intervention group than t he cont rol group 4.56 vs 5.58 hours :RR1,07 :955CI -1.56 - 0.51).A significantly large proport ion of w omen in the int ervent ion group than the control group perceived a high level o1.14:95%CI,1.03-1.27) control over labour(79.8% vs 77.1%: RR1.14 :95%CI1.03-1.27).

Zha ng J et al (1995 ) conducted a met a analysis to evaluate continuous labour support from labour attendant for primiparous mot hers .T he study results revealed that continuous labour s upport by a labour attendant s hort ens the durat ion of labour,by2.8 hours (95% confidence int ervalCI2.2-3.4)doubles spont aneous vaginal birth relat ive risk RR2.01,95%CI1.5-2.7)and halves the frequency of oxyt ocin us e (RR 0.44 , 95%CI0.4-0.7)forceps us e (RR 0.46 ,95%CI0.3-0.7)and caes arean delivery rat e RR 0.54 ,95%CI0.4-0.7).Women wit h labour support als o report ed higher s at isfact ion and a bett er postpartum cours e.

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31

THE LI TERATUR E RELATED TO THE SUPPORT PERSON’S PRESENCE I N TERMS OF NEONATAL OUTCOME

Imran O Ma rhaso n –B ello (2009 ) conduct ed a study on s ocial report during childbirth as a catalyst for easy breasts feeding initiat ion for first t ime .N igerian mot hers of t he tot al of 84 had companions during labour w hile 115 did not have a companion. T he median t ime to breast feeding init iation was s ignificant ly short er in thos e w ith comp anions comp ared to the controls.(15vs 54 minut es :P< 0.01). T he cumulat ive s urvival analysis indicat ed all in t he treat ment group had init iat ed breast feeding by 26 mts w hile among the control group none had commenced at 30 minutes , post delivery wit h some as late as 12 hours. A ft er Cox Regress ion A nalys is w as used to adjust for poss ible confounder, the out come st ill show ed a s ignificant haz ard rat io207.8(95%CI49.2),878.0:P ,0.01)among women w ho w ere s upported by a comp anion.

Cat he ri ne R ubwe za (2006) in new vis ion U gandas leading w ebs ite ,a birth companion eases labor .A study by K laus and K ennel Klaus (1993) conducted at different studies and found that the labour s upport had the follow ing benefits .It reduces the over all caes arean rat es by 50%,length of labour w as strengthened by 25%,reduced us e of pain killers by 60%,reduced oxytocin by 40%,reduced forceps delivery by40%,mot hers have a more pos it ive breast feeding exp eriences, cope bett er w ith the stress of handling a new born,bond fast er w ith t heir babies .

La urie A Nomssen Riv re s et al .,(2005 )in his study D oula Care ,early breast feeding out comes and breast feeding st atus at 6 w eeks post partum among low income primi parous examined the associations betw een doula care durat ion .Res ults show t hat the labour of a non inst rument al labour vaginal delivery and t o exp erience ons et of lactogenes is w ithin 72 hours .Postp artum t imely ons et of lactogenes is over all 68% of women receiving st andard care were breast feeding at 6 w eeks .iIn the subs et w ith a p renatal st res sor (n=63).The doula care group w as more t han tw ice as likely to be breast feeding at 6 w eeks (89%vs St andard care ,40%).Breast feeding at 6

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32 w eeks also w as ass ociat ed s ignificant ly w ith t he t imely ons et of lactogenes is and mat ernal report that the infant “sucked w ell”at 3 rd day. T herefore doula care w as associat ed wit h the improved child birt h out comes and t imely onset of lactogenes is .Bot h directly and as mediat ed by t imely ons et of lactogenes is, doula care was als o ass ociat ed wit h higher breast feeding p revalence at 6 w eeks .

Women w ho received s uch support exhibit ed s horter p eriod of labour, less pain medication and required few er medical procedure .There w ere also reduced rat es of caesarean s ect ions.It als o help ed to p romot e breast feeding and decreas e post part um depres sion (The Hi ndu -23rd May 2004 ).

A me rica n Acad emy o f Phy sicia n (2003 ) s uggested that the doulas attended p arturients have labour as s horter, babies are healthier and they breast fed more early. F urther more, more w omen exp erience great er s at isfact ion w ith t he birth exp erience and an enhanced relat ions hip w it h their partner.

B ruce A Ma yor et al (2003 ) in his study social support by doulas during labour and t he early postpartum p eriod,in a South African study,a s ignificant ly great er proportion of women support ed by doulas w ere breast feeding 6 weeks aft er delivery t han were controls (51%vs 29%).

Sauls JD (2002 ) conduct ed a quantit at ive research st udy related to the effect of labour support on birth and fetal out comes during chIldbirth .Res earch provided pow erful evidence of improved out comes for mothers and babies when mot hers w ere s upported in labour .T hes e out comes include low er rat es of analges ia and us e of anaesthes ia ,lower op erat ive birt h rates ,short er labour,fewer new borns w ith 5-minute Ap gar s core less than 7,increas ed mat ernal sat is fact ion w ith t he birthing process and much more.

Ca mpe ro et al (1998 ) conduct ed a qualit ative study t o evaluat e the effects of the provis ion of psychos ocial s upport t o first t ime mot hers during labour ,child birth and in t he immediate postpartum period in a social s ecurity hosp ital in M exico city.The st udy focus es on t he experience of the mot hers

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33 w ho received psychos ocial support from a doula and comp ares t hem w ith the exp erience of t hose women w ho gave birt h follow ing t he normal hosp ital rout ine .T he int erview show ed t hat the w omen accomplis hed by “ doula “ had a more pos it ive child birth exp erience .724 women w ith no previous delivery and no indicat ions for caes arean s ection delivery w ere randomnly ass igned to be accompanied by the doula (n= 361 )or to receive rout ine care (n=363 ).The frequencyof exclus ive breast feeding one month aft er birth w as s ignificant ly higher in the int ervent ion group than t he control group (12%vs 7%:relat ive risk (RR1.64 :95%Confidence Interval (CI)1.O1-2.64 However the programme did not achieve a s ignificant effect on breast feeding (37%and 36%respect ively ).The durat ion of labour w as short er in the intervention group than t he cont rol group 4.56 vs 5.58 hours :RR1,07 :955CI -1.56 - 0.51).A significantly large proport ion of w omen in the int ervent ion group than the control group perceived a high level o1.14:95%CI,1.03-1.27) control over labor(79.8%vs77.1%:RR1.14 :95%CI1.03-1.27).

La nge r et al (1998 ) p erformed an exp eriment al st udy in M exican P ublic H ospit al. Social support by a doula p rovided t o w omen in the int ervent ion group while the w omen in t he control group received rout ine care.724 w omen w ith a s ingle fet al ,no previous vaginal delivery,< 6cm of cervical dilatat ion ,and no indicat ions for an caesarean s ection w ere randomnly as signed to be accomp anied by a doula ,or to receive routine care.

The frequency of exclusive breast feeding one month after birth w as s ignificant ly higher in t he int ervent ion group (RR1.64:I-C:1.01-2.64),as w ere the behaviours t hat promote breast feeding. M ore w omen in t he intervention group perceived a higher degree of cont rol over t he delivery exp erience, and the delivery duration of labour was s horter t han in t he control group (4.56 hours vs 5.58 hours : RR1.07 CI (95%)=1.52-0.51.).The res ult had show n t hat frequency of exclusive breast feeding one month after birth was s ignificant ly higher in t he int ervent ion group .The study conducted t hat the psycho s ocial s upport by doulas had a p os itive effect on the breast feeding and durat ion of labor .

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34 Ca mpe ro et al (1998 ) conducted st udy on the exp erience of the mot hers who received psychos ocial support from a doula and compares t hem w ith t he exp erience of t hos e w omen w ho gave birth follow ing the normal hosp ital routine .The interview s howed that the women accomplis hed by

“doula “ had a more p os itive child birt h exp erience .724 women w ith no previous delivery and no indicat ions for caes arean s ection delivery w ere randomnly ass igned to be accompanied by t he doula (n= 361 )or to receive rout ine care (n=363 ).The frequencyof exclus ive breast feeding one month aft er birt h w as s ignificant ly higher in t he intervention group than the control group (12%vs 7%:relat ive ris k (RR1.64 :95%Confidence Int erval (CI)1.O 1- 2.64)

(35)

35

2.4 CON CEPTUAL FR AM E WOR K OF THE STUD Y

MODI FI ED SI STER CALLISTA ROY’ S ADAPTATI ON MODEL

Conceptual frame work serves as a spring board for t heory development. The Conceptual frame work for res earch study pres ent ed the measurement on which the purposes of the propos al study w as bas ed . Conceptual frame w orkprovides t he prospect ive form of which the investigator views the problem. The st udy w as des igned t o ass esss the effect iveness of female birth companion in t erms of mat ernal and neonatal out come among the part urients at s elected hosp itals .

The st udy w as based on the concept t hat ident ifies the adaptat ion of the parturient in the pres ence of support p ers on and in the abs ence of s upport person. T he investigator adopted t he M odified Sist er Callist a Roys adapt ation .T his model w as publis hed first in the y ear 1963.

SYSTEMS

Ge ne ral Informatio n

React w ith ot her syst ems in the environment, react as w hole, dys funct ion in one component affects the ent ire system. Have boundaries and are flexible and open to p ermit int eraction wit h ot her systems . Employ a feed back cycle of input , through put and output.

Inp ut

Support person –female birth companions pres ence Sti mul i

A nxiety, labour p ain. P hysiological changes ,lack of support system, inadequat e know ledge regarding breast feeding ,Lack of know ledge regarding the labour process .

(36)

36

THROUGHPUT

A ccording to the t heorist throughput refers t o the process used by the syst em to convert raw mat erials or energy from the environment into products that are us able by t he syst em its elf or by t he environment .In this active phas e the female birt h companion’s p res ence provides comfort and support t hrough specific care (N utrit ion care ,back rubbing, helps in w alking,and ass ist in breast feeding ).

OUTP UT

Reduct ion in t he anxiety, p ain p erception ,and less forceps ass ist ed deliveries, vaccum deliveries , increas ed ap gar s core, early init iation of breast feeding, spont aneous delivery, and relaxation w ith comfort .

REGULA TOR

It consists of input, int ernal proces ses and output.Input st imuli come from the external environment or from w ithin the p ers on .Int ernal process- including the chemical, neural, and environment ,t rans mit the st imuli caus ing the output, a physiologic process .

COGNATOR

The cognat or subsystem cons ists of input, int ernal process es and output. T his controls the internal process ess relat ed t o higher brain funct ion,such as p erception,informat ion process ing.,judgement and emotion.

ADAPTIVE MODES

A .Phy siologi c F unctio n

It involves the pain perception, relaxation and comfort.

B .Sel f co ncept

Refers to the p leas ant face and confidence

(37)

37 C .Role fun ction

Involves female birth companion.

D.Inte rdepe nde nc e

Involves a persons relat ionship w ith s ignificant ot hers and support syst ems. ie. condusive environment, s at isfact ion of parturients, nurs e-pat ient relat ionship.

(38)

38

(39)

39

CHAPTER -3 M ETHOD OLOGY

3.1 REASEARCH METHODOLOGY

Research met hodology is t he most import ant part of research study w hich enables t o form blue print of the res earch undert aken. Res earch met hodology involves the systemat ic procedure by which the res earcher st arts from t he time of init ial identificat ion of the problem to find its final conclus ion.

3.2 RESEARCH APPROACH AND DESI GN

Q uant itat ive approach and exp eriment al des ign. T wo group quas i exp eriment al (post t est only control group) res earch des ign w as adopted in this study .T he res earcher had 2 groups, experiment al and control group.

Tab le -1: Post te st o nly co ntro l g ro up

Be fore x Afte r R x O1 --- X

R x O

2 --- C

3.3 RESEARCH VARIABLES

Variables are concepts at different levels of abstract ion that are concisely defined t o promot e their measurement of manipulat ion w it hin a st udy.

Influencing variables like age, religion, occup ation, type of delivery, gravidity.

D ependent variables like the mat ernal outcome of the labour s uch as pain perception, anxiety level, and durat ion of labor including the neonatal out come ie.,Ap gar s core and initiat ion of breast feeding.

(40)

40 Indep endent variables are rout ine int ervent ion in labour and female birth companion.

Ext raneous variables like H ospit al s ettings , including t he t reat ment given during labour.

3.4 SETTI NG OF THE STUDY

The study w as done in the I.O.G .Hospit al for Women and Children, Egmore and in the CSI K aly ani M ulti Sp eciality Hospit al ,M ylapore.

I.O .G.H ospit al for Women and Children is the largest and oldest M at ernity Inst itut ion in As ia. T his is an tertiary cent er and gets most of its pat ients usually as reference from ot her government mat ernity centres .It is a centre w ith w ell equipped facilit ies and s killed st aff t o manage all emergency s ituat ions . Being a 770 bedded hospit al, it has about 120 beds exclus ively for gy naecological condit ions. T here are around14,285 deliveries at I.O .G.H ospit al for Women and Children for t he year 2010-2011.The CSI K alyani M ulti Sp eciality Hospit al is the sp eciality hospit al which is run by the C.S.I D iocese of M adras .There w ere around 100 and above labour cas es per mont h including the caes arean s ect ion and instrument al deliveries every month w ithout t he birth companion during labour .

3.5 POPULATI ON

P art urients w ith birth companion in the labour ward at the I.O .G.H ospit al for Women and Children, Egmore.

P art urients w ithout birth companion in t he labour ward at t he CSI K alyani M ult i Speciality H ospit al, Mylapore.

3.6 SAMPLE SI ZE

F orty parturients w ithout female birth companion for control group and forty p art urients low ris k w omen w ith female birth companion w ere s elect ed for exp eriment al group.

(41)

41

3.7 SAMPLI NG TECHNI QUE

The samp ling t echnique used for this st udy is non-probability convenience s ampling met hod. P er day there are around 20 -25 cas es delivered in IOG Hosp ital for Women and Children, Egmore and at CSI K alyani M ult i Sp eciality H ospit al, M ylapore, t here are around 6-8 cas es p er day. The investigat or used convenient s amp ling t echnique due t o non- availability of t he s amples at CSI M ult i Sp eciality H ospit al,M ylapore .The investigator s elect ed samp les from the labour w ards of both t he hospit als.The s ampling s iz e was 40 s amples at IO G H ospit al for Women and Children, Egmore and 40 samp les at t he CSI K aly ani M ult i Sp eciality H ospit al,M ylapore.T he experimental group w ere provided w ith birth companion at IOG Hospit al for Women and Children, Egmore and birth companion w as not provided at K alyani G eneral H ospit al, M ylapore. Both the primi mothers and mult i parous mothers are included as t he s ample.

Convenient s ampling technique w as us ed in the study.

3.8 SAMPLI NG CRI TERIA

Inclusio n cri teria

1) N ulliparous

2) Singleton pregnancy 3) Vert ex pres ent at ion 4) Low ris k pregnancy

5) M others who are w illing to have delivery w ith the birt h companion at IOG H ospit al for Women and Children, Egmore.

6) M others who are w illing to have delivery w ith out the birth companion at the CSI Kaly ani M ult i Sp eciality Hosp ital, M ylapore .

7) Thos e companions w ho had underw ent class es in the antenatal outpat ient department and w illing t o st ay w ith the p art urients .

References

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