DOULA SUPPORT, CHILDBIRTH SATISFACTION, and BREASTFEEDING SELF-EFFICACY AMONG IRANIAN WOMEN a Thesis Presented to the Faculty O

Home , Breastfeeding promotion, Doula

DOULA SUPPORT, CHILDBIRTH SATISFACTION, AND

BREASTFEEDING SELF-EFFICACY AMONG IRANIAN WOMEN

A Thesis

Presented to the faculty of the Department of Graduate and Professional Studies in Education

California State University, Sacramento

Submitted in Partial Satisfaction of The requirements for the degree of

MASTER OF ARTS

Child Development

Nastaran Milani

SPRING 2017

DOULA SUPPORT, CHILDBIRTH SATISFACTION, AND

BREASTFEEDING SELF-EFFICACY AMONG IRANIAN WOMEN

A Thesis

Nastaran Milani

Approved by:

______, Committee Chair Sheri E. Hembree, Ph.D.

______, Second Reader Kristen Alexander, Ph.D.

______Date

Student: Nastaran Milani

I certify that this student has met the requirements for format contained in the University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis.

______, Graduate Coordinator ______Sheri E. Hembree, Ph.D. Date

Department of Graduate and Professional Studies in Education

iii

Abstract of

DOULA SUPPORT, CHILDBIRTH SATISFACTION, AND

BREASTFEEDING SELF-EFFICACY AMONG IRANIAN WOMEN

Nastaran Milani

The current study investigated the association between doula support during labor and delivery and childbirth satisfaction and breastfeeding self-efficacy among Iranian women. Thirty-three Iranian mothers from Davis, Sacramento, San Jose, and Los

Angeles participated in this study. A survey design was employed to collect mothers’ responses to the Mackey Childbirth Satisfaction Rating Scale, to the Breastfeeding

Personal Efficacy Beliefs Scale, and to the Maternal Prenatal Demographic questionnaires. The questionnaires were sent to participants in either English or Farsi (the parent preferred language) by mail along with a letter that provided general information about the purpose and process of the research study and consent form. Correlational analyses were conducted in order to explore the association between receiving emotional support from doulas and the women’s self-reported childbirth satisfaction and breastfeeding self-efficacy. Results indicated that doula support during labor and delivery was significantly associated with childbirth satisfaction and breastfeeding self-efficacy among Iranian women who have been living in California. Future research should include iv larger samples and in-depth interviews to better understand the experience of doula support, and to develop models of doula effectiveness, in order to enhance childbirth satisfaction and breastfeeding self-efficacy among this population.

______, Committee Chair Sheri Hembree, Ph.D.

______Date

ACKNOWLEDGEMENTS

As a new mother who had childbirth experience only twenty days before the start of the academic year and did not have any family members in the U.S., I still had a glimmer of hope in my heart to be a master’s student. I asked God to give me comfort, power, and love to start my study as an international student. I am thankful for God’s assistance and want to dedicate my life to help and empower those in need, especially children and family.

I should like to thank my supervisor, Dr. Sheri Hembree. I appreciate your kindness, support, and guidance throughout my study at Sac State. I would never have been able to reach my dream to get my master’s degree without your help. You enabled me to believe in my abilities and myself as an international student. In the courses I took with you, I realized that you not only care about my academic achievement, but also care about my life here in the U.S. as an international student. I was so relieved to have you as a source of comfort. Moreover, I should like to thank my second reader, Dr. Kristen

Alexander, for her guidance and patience throughout my thesis and my study at Sac State.

I enjoyed taking Theory class with her and learned a lot.

I should also like to express my gratitude to the Child Development Department at Sacramento State University and to all of the staff for helping me as an international student and making my university experience memorable. I owe Dr. Amber Gonzalez a deep debt of gratitude: I took several courses with her in an intellectually stimulating vi environment, and her lovable sense of humor made my late evening classes so pleasurable.

I should like to thank my husband, Navid Saberi-Najafi, for believing in me. He has supported me through every endeavor and hardship I have faced throughout my life and study. Thanks for encouraging me to follow my dream, for staying awake long nights, and for taking good care of our precious daughter, Nahal. She is one of the reasons to live.

I should like to express my gratitude to my parents, Ali Milani and Roshanak

Gharavi, for all their unconditional love, support, and never-ending encouragement throughout my entire life. They both teach me how to build my confidence and self- esteem and to believe in myself. Without their financial and emotional support, I would never have been able to enter graduate school in the first place. Also, thanks to my lovely sister and best friend, Yasaman and my kind brother Mohamad Hasan for their emotional and spiritual support throughout my life. Moreover, thanks to my nephew Taha and my niece Zoha. You were one of the reasons that I selected the Child Development major.

Last but not least, a special thanks to my dearest friends. First, thanks to Lang

Reasenberg who was like a miracle in my life in America. She has always understood and never judged. Her encouragement and support make my personal and academic life much easier. Second, thanks to Mrs. Zahra Rahbar who provided me with moral support. She always reminded me to believe in my skills and abilities; I can never thank God enough for placing her in my life. Finally, thanks to Neda Dolatshahi who was like an angel to

vii me. She helped me with my studies, and she took care of my daughter whenever I had no one to help me.

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TABLE OF CONTENTS

Page

Acknowledgements ...... vi

List of Tables ...... xi

Chapter

1. INTRODUCTION ………………………………………………………………....1

Purpose of the Study ...... 4

Definition of Terms ………………………………………………………….5

Methods ……………………………………………………………………...6

Limitations ………………………………………………………………….7

Organization of the Study …………………………………………………...8

2. REVIEW OF THE LITERATURE ….………………………………………...... 9

Childbirth and Childbirth Support ……………………………..………...... 10

Supporting Positive Childbirth Experience …………………..…………....14

Breastfeeding Self-Efficacy………………………………………..…...... 17

Summary and the Current Study …………………………………..……....24

3. METHOD ……….……………………….…………………………………...... 27

Participants …………………………………………………………...……27

Procedure ……………………………………………………………....…..28

Measures …………………………………………………………..…..…...29

Data Analysis ……………………………………………………..………32

4. RESULTS ……………………………………………………………..……….33

Descriptive Analyses ……………………………………………..………33

Doula Support and Childbirth and Breastfeeding Outcomes ……..…...... 35

5. DISCUSSION ……………………………………………………………..…...39

Limitations …………………………………………………………..……45

Appendix A. Descriptive Letter ………………………………………………….48

Appendix B. Informed Consent ………………………………………………….49

Appendix C. Maternal Prenatal Demographic Questionnaire …………………....50

Appendix D. Mackey Childbirth Satisfaction Rating Scale ……………………...51

Appendix E. Breastfeeding Personal Efficacy Beliefs Intervention ……………...57

References ………………………………………………………………………...61

LIST OF TABLES

Tables Page

1. Means and Standard Deviations for Study Variables ……………………….34

2. Correlations between Childbirth Satisfaction and Breastfeeding Outcomes ..37

3. Comparison between Doula/ No Doula in Childbirth Satisfaction and

Breastfeeding Personal Self-efficacy ...... 38

Chapter 1

INTRODUCTION

The transition to motherhood requires much adaptation and understanding, and it can be one of the most joyful experiences in life. Factors such as satisfaction with childbirth and successful breastfeeding skills can promote mothers’ confidence. Improving childbirth satisfaction and improving breastfeeding confidence are two separate factors that are under the influence of the level of support provided for laboring women.

The support laboring women receive during their childbirth process can substantially influence childbirth outcomes in terms of childbirth experience and breastfeeding success. A doula is one who provides continuous informational, physical, and emotional support for laboring women and one with knowledge about areas such as breastfeeding and the help required for women to cope with pain and stress during childbirth. This targeted approach assists the new mother in the early postpartum period of her life, which is a time of significant transitions.

There is substantial research that has investigated the positive effect of receiving continuous informational, physical, and emotional support from doulas during the childbirth process on childbirth satisfaction and breastfeeding self-efficacy among various cultures. The current study broadens the scope of current scholarship on the effectiveness of doula support and its outcomes, focusing exclusively on Iranian women who have been living in the United States.

Breastfeeding provides psychological and physiological benefits for infants and mothers.

According to the World Health Organization (WHO) (2003), breastfeeding is recommended as the ideal nutrition for infants’ healthy development, as it can promote ideal levels of physical, neurological, and cognitive development. Exclusive breastfeeding—when babies receive only human breast milk and drops or syrups that contain minerals, vitamins, or medication, prescribed by doctors or pediatricians—in early infancy can protect children against acute respiratory 2 infection, which is known as one of the main risk factors of child morbidity (Mihrshahi et al.,

2007). Moreover, the possibility of wheezing, in which children breathe with whistling sounds, and asthma—a condition that produces extra mucus in the bronchi of the lungs, which inflames and narrows the airways, causing difficulty in breathing—can decrease by breastfeeding (Oddy,

De, Sly, & Holt., 2002; Silvers et al., 2012). Furthermore, there is association between breastfeeding and a lower level of child obesity later in life (Ip et al., 2007), and the lack or absence of breastfeeding increases the risk of diabetes in children’s future lives (Patelarou et al.,

2012).

Women who breastfeed their babies can obtain physical and emotional benefits from nursing. For example, breastfeeding can promote secure attachment between mothers and babies

(Mathews, Leerkes, Lovelady, & Labban, 2014) and decrease the risk of post-partum depression

(Borra, Lacovou, & Sevilla, 2015). Moreover, the risk of breast cancer is lower among breastfeeding mothers (Palmer et al., 2014) and women’s history of lactation can influence breast cancer prognosis and survival (Kwan et al., 2015). Also, the chance of diagnosing other types of cancer such as ovarian cancer can significantly decrease by breastfeeding (Feng, Chen, & Shen,

2014). Finally, maternal cardiovascular health can improve by lactation, especially when breastfeeding is continued for 2 years or more (Fagerhaug et al., 2013).

Emotional support that women receive during labor and delivery can encourage them to select or continue breastfeeding. In one study, a woman’s social support, her decision to breastfeed, and her self-confidence in breastfeeding, were the significant components in breastfeeding success (Meedya, Fahy, & Kable, 2010). According to DONA International (2017), continuous informational, physical and emotional support that doulas provide for laboring women enhance women’s successful breastfeeding skills and help mothers to have satisfying and unforgettably positive memories of their childbirth process, contributing to maternal health. A doula’s support contributes to a lower level of childbirth interventions and complications and a 3 higher level of childbirth satisfaction. Moreover, mothers’ confidence in their abilities to impact their own pregnancy outcomes may increase through guidance and encouragement that they receive from doulas during their labor and delivery (Gruber, Cupito, & Dobson, 2013).

The connection between doula support and breastfeeding self-efficacy and childbirth satisfaction is worth exploring. Previous research has shown that successful breastfeeding is a main component that promotes women’s and children’s physical and emotional health. In addition, the physical, informational, and emotional support that laboring women receive from doulas during their childbirth process is associated with a lower risk of childbirth complication and intervention, which ultimately can enhance maternity health.

Although the growing body of literature supports the positive effect of receiving support during labor and delivery for women and children, in Iran, due to cultural, political and religious factors, companionship during labor and delivery is not a routine practice. Further, there is little to no research regarding cultural perspectives associated with childbirth and breastfeeding for Iranian women living in the United States. Therefore, research is needed to identify whether Iranian women obtain advantages from doula support. Identification of these factors might provide avenues for enhancing childbirth outcomes and maternity health for Iranian women.

Understanding how Iranian women can benefit from doula support may positively influence perspectives on doula support. Moreover, due to cultural, political and religious factors in Iran, women give birth without any companion and just have interaction with nurses and midwives; therefore, this study may show that the current policy of Iranian hospitals needs to be revised in order to provide mothers with an emotionally pleasant childbirth experience and with better breastfeeding skills.

Purpose of the Study

The purpose of the current study was to investigate the nature of the relationship between continuous doula support and childbirth satisfaction and breastfeeding self-efficacy for Iranian women who have been living in the United States. In the current study, childbirth satisfaction included Iranian women’s experiences during labor and childbirth, the level of satisfaction of care and support that they received from nurses, medical staff, and their partners during labor and childbirth, the level of satisfaction of their control over themselves and different situations during labor and delivery, and finally, the level of satisfaction of their babies in terms of physical condition and amount of time which passed until they held and breastfed their babies. Also, breastfeeding self-efficacy included Iranian women’s attitudes towards breastfeeding, the level of confidence in breastfeeding their babies in various situations, the level of breastfeeding support, and their future breastfeeding plans. Possible influential factors central to childbirth satisfaction and breastfeeding self-efficacy, such as the mothers’ age and their babies’ age, the mothers’ level of education and their type of delivery (with or without doula support), term pregnancy (early term, full term, late term, and post term), and breastfeeding future plans, were included as possible covariates.

This study addresses three main questions. First, is there a relationship between having continuous doula support and Iranian women’s childbirth satisfaction? Second, is there a relationship between having a continuous doula support and Iranian women’s breastfeeding self-efficacy? And third, do factors such as mothers’ age, babies’ age, education level, type of delivery (with or without doula support), weeks of pregnancy, and breastfeeding future plans, statistically predict Iranian women’s childbirth satisfaction and their self-confidence in breastfeeding? It was hypothesized that Iranian women who had doula support during labor and delivery would display a higher level of childbirth 5 satisfaction and breastfeeding self-efficacy than Iranian women who did not receive this kind of support.

Definition of Terms

For the purpose of clarity, several terms must be defined. A doula refers to one who is trained and experienced in childbirth and provides continuous informational, physical, and emotional support for laboring women. Informational support refers to the doulas’ ability to facilitate women’s communication with their partner, midwife, nurse, and other medical staff, and to encourage them to make their own decisions with respect to available labor-related options by offering basic information about the process of labor. Physical support refers to the doulas’ ability to help mothers to try various positions during labor and delivery, to perform back and pelvic massages to reduce their pain during contraction (e.g., the double hip squeeze), and to offer breathing and relaxation techniques. Finally, emotional support is defined as the doulas’ ability to provide mothers with reassurance and to honor women’s emotions in the process of labor (DONA

International, 2017).

Childbirth satisfaction refers to satisfaction with labor experience, partner’s participation during childbirth, hospital staff, and feeling of personal control. Satisfaction included women’s abilities to manage their pain during contraction, to stay calm, to participate in the decision- making regarding their labor, and to be aware of their labor process (Goodman et al., 2004; Green

& Baston, 2003; Melender, 2006). Breastfeeding self-efficacy refers to mothers’ beliefs about their ability to breastfeed their children (Dennis, 1999).

Methods

In order to explore the association between receiving support from doulas and Iranian women’s childbirth satisfaction and breastfeeding self-efficacy, a correlational survey study was conducted. This study used a quantitative design, and surveys about family demographics and the use of doula, childbirth satisfaction, and breastfeeding self-efficacy, were administered and analyzed to discover associations between doula support and childbirth and breastfeeding outcomes.

Participants

The study sample included 33 Iranian women living in the United States who (a) had one or more babies, (b) had experienced low-risk pregnancies, (c) had their partners and/or family members and/or doula during their childbirth, (d) experienced vaginal delivery in hospital settings, and (e) had given birth to their babies ranging from 2 to 16 weeks. The mothers in the study resided in Davis, Sacramento, San Jose, or Los Angeles. The mean age of the mothers was 2.52 and the mean level of education of the mothers was 4.27.

Participants were recruited from Iranian community centers. Each of the cities of Davis,

Sacramento, San Jose, and Los Angeles had a listserv which included email addresses of a large number of Iranians. I introduced my thesis project and asked those who were interested to send me an email for more details. Those who met all inclusion criteria received the following forms: A descriptive letter that defined general information about the purpose and process of the research study; the informed consent; and questionnaires that included the participant’s demographic information, childbirth satisfaction, and breastfeeding self-efficacy. Precautions were taken to protect confidentiality of participants’ answers, and for their protection no items asked participants to identify their name, and instead, IDs were used. Since the target population for this study were 7

Iranian women, participants received surveys in Farsi and English, depending on their preference.

Measures

Three different forms of questionnaires were completed by the participants. First, the maternal prenatal demographic questionnaires provided general information about the participants, such as their age, babies’ age, level of education, type of delivery, term of pregnancy, and breastfeeding future plans. Second, The Mackey Childbirth Satisfaction Rating Scale is a 40-item scale which indicated mother’s level of satisfaction and dissatisfaction with their childbirth experiences. Third, The Breastfeeding Personal Efficacy Beliefs Intervention is a 27-item scale which assessed mother’s beliefs and abilities to breastfeed their babies.

Limitations

It is important to note the limitations of the current study, and they are listed for those who are interested in conducting future research. One limitation was that the measures employed in this study were self-reported surveys which can be vulnerable to participants’ misreporting or reporting in a manner that they feel is socially desirable. Future research should include other means of self-report such as interviews, as well as the attempt to obtain collaboration from other sources (e.g., doulas, nurses, and medical staff). Another limitation is that this study is retrospective. Participants were asked to recall their childbirth experiences, but memory can be vulnerable to deterioration.

Moreover, since the data were collected all at the same time and are correlational, no conclusions about causality can be drawn. It can only show that there is a relationship between the doula support and childbirth satisfaction and breastfeeding self-efficacy. 8

Regarding cultural perspectives, this study did not represent the cultural factors as it limited participants’ groups by focusing only on Iranian culture. Also, the small sample does not represent all Iranian women and is not inclusive enough to be generalized to a larger population of

Iranians. Although the participants may be reflective of the state of California, they are not a representative sample of other regions of the United States.

Future research should attempt to isolate confounding variables, such as some medical risk factors, the presence of close family members and friends during childbirth, the labor and breastfeeding preparation practices of the women’s prenatal provider, the family history of breastfeeding, and the living environments that yielded positive outcomes.

Organization of the Study

This chapter has provided an introduction to and an overview of the thesis. The next chapter presents a review of the literature and examines the relationship between doula support and childbirth satisfaction and breastfeeding self-efficacy. Chapter 3 provides the explanation regarding the methodology used in this study, and Chapter 4 provides a summary of the results of the study.

Finally, Chapter 5 includes a discussion of the conclusions reached, the limitations of the study, and future research.

Chapter 2

REVIEW OF THE LITERATURE

Receiving emotional support during labor contributes to a lower level of childbirth interventions and complications and a higher level of childbirth satisfaction (Akhavan & Edge,

2012; Hodnett, Gates, Hofmeyr & Sakala, 2012; Winslow, 1998). In addition, breastfeeding protects children against acute respiratory infection and diarrhea, which can ultimately decrease child morbidity and the risk of type I diabetes later in life (Patelarou et al., 2012).

A doula is a professionally trained and experienced person who provides continuous support for laboring mothers. After receiving training and gaining enough experience in childbirth processes, doulas are prepared to provide continuing informational, physical and emotional support for mothers without performing any clinical tasks, such as administering medications and performing vaginal exams (DONA International, 2017).

There is association between having a doula and childbirth satisfaction and successful breastfeeding experiences (Nommsen-Rivers, Mastergeorge, Hansen, Cullum & Dewey, 2009;

Grassley & Sauls, 2012; Campbell, Scott, Klaus, & Falk, 2007). For example, in a study conducted in a multicultural setting, women who received doula support were more likely to report an intention to breastfeed their babies and to breastfeed within 1 hour of delivery (Mottl-

Santiago et al., 2007). Nonetheless, there are no doula programs in hospitals in Iran to provide emotional support during labor and after childbirth. At the age of six months, only 27.7% of the infants in Iran were exclusively breastfed (Olang, Heidarzadeh, Strandvik & Yngve, 2012). The focus of this thesis is to investigate whether the experience and support provided by a doula predicts similar positive outcomes among Iranian women.

Laboring women are under great physical and psychological pressure during childbirth.

Receiving emotional support during labor and delivery may provide a more comfortable 10 atmosphere, ultimately influencing their childbirth satisfaction and breastfeeding self-efficacy.

Although many studies demonstrate the positive effect of receiving emotional support from doulas in the process of childbirth, there is no study that evaluates the effect of the presence of continuous support from doulas on childbirth satisfaction and breastfeeding self-efficacy among Iranian women who have given birth to their babies in the United Sates. The purpose of this thesis is to examine associations between having a doula as a source of emotional support as well as childbirth satisfaction and breastfeeding self-efficacy for Iranian women who have lived in the

United States. The following questions will be addressed: (a) is there a relationship between having a doula for emotional support and Iranian women’s childbirth satisfaction, and (b) is there a relationship between having a doula for emotional support and Iranian women’s breastfeeding self-efficacy? It is hypothesized that Iranian women who had doula support during labor and delivery will display a higher level of childbirth satisfaction and breastfeeding self-efficacy than

Iranian women who had not received this kind of support. The following is a review of relevant literature on doula as a supportive companion, which includes the following foci: Childbirth and childbirth support (childbirth in America and childbirth in Iran), supporting positive childbirth experience (benefits of doula support for childbirth), benefits of breastfeeding (barriers to breastfeeding, supporting breastfeeding, breastfeeding factors for Iranian women, and doula support for breastfeeding).

Childbirth and Childbirth Support

Childbirth in America

In the United States, a major shift from home birth to hospital birth occurred early in the

20th century. Following this transition of births occurring primarily in hospitals, pregnant women were attended primarily by nurses and medical staff rather than by family members. Some 11 practices became common even among low-risk and uncomplicated childbirth. For example, the use of widespread forceps—a surgical instrument which is placed around the baby’s head to help the baby out of the birth canal—began in the 1920s, and anesthesia became common in the 1940s and continuous lumbar epidural anesthesia in the 1960s. Moreover, electronic fetal monitoring was introduced in the early 1970s. Until the late 1960s, fathers were not allowed to be present in hospital labor wards, and laboring women experienced childbirth without their support, and they were just in contact with nurses and the medical staff (Walker, Visger, & Rossie, 2009). These changes meant that laboring women lost the childbirth support they might have received from their friends, family, and community members (McCool & Simeone, 2002).

By the 1970s, the natural childbirth movement emphasized family-centered approaches to care (Hodnett, 1996). Fathers were encouraged to be with their wives during childbirth and play active roles in supporting their partners (Blackshaw, 2009). In the early 1980s, cesarean rates rose rapidly in the U.S, and obtaining assistance from doulas became popular. Mothers selected their close female friends, childbirth instructors, or their friends who were obstetrical nurses, as doulas in order to avoid cesarean surgery (Gilliland, 2002).

The history of childbirth education started when a British physician named Dr. Grantly

Dick-Read produced scholarship in 1932 about the beginning of pregnancy, labor, and delivery studies. In 1944, this was expanded to include how to overcome fear of childbirth and the advantages of normal childbirth. In the 1960s, Elisabeth Bing and Maroriee Karmel established formal childbirth education classes, which were held outside hospitals and provided information regarding birth, relaxation and breathing, and support for women and their partners at the end of their pregnancy; what is more, they established the American Society for Psychoprophylaxis in

Obstetrics which was known as Lamaze International. Methods implemented in Lamaze

International were derived from the scholarship of Dr. Fernand Lamaze’s breathing and relaxation techniques and from Dr. Dick-Read’s natural childbirth techniques. Lamaze’s childbirth education 12 goals focused on promoting normal childbirth, enhancing women’s confidence regarding their abilities to give birth naturally and to enhance women’s level of knowledge and skills regarding the childbirth process (Gutmann, 2001). Childbirth education became popular in the 1960s and

1970s, which helped pregnant women and their partners to cope with their fear and anxiety and to become familiar with their options for childbirth (Leavitt, 2003).

Childbirth in Iran

Over 1,170,000 babies are born in Iran annually and over 95% of these babies are born in hospitals (Akbary, 2005). According to Iranian hospital rules, laboring women usually are not allowed to walk in the labor ward; most of them are given an intravenous line, which is a flexible catheter inserted into a vein of the hand or arm in order to give fluid or drugs to laboring women.

The most common childbirth position which is applied in hospitals is the supine position and episiotomy, which is an incision in the area of the genitals—a common procedure for a first birth.

Also, women with previous caesarean experience are not allowed to have a vaginal delivery for their next deliveries (Torkzahrani, 2008).

The recommendation from the World Health Organization (WHO) (2015) regarding the acceptable rate of caesarean section (CS) is 10-15%, and the rate in Iranian hospitals is much higher than the recommended rate: At public hospitals, the rate of CS is approximately 30-40% and at private hospitals 50-60% (Pour-Reza, 2007). In one meta-analysis, researchers evaluated the deliveries of 74,809 Iranian women. A literature search done from 2000 to 2012 showed that

48% of Iranian women had a caesarean section (CS) (Azami-aghdash, Ghojazadeh, Dehdilani,

Mohammadi, & Asl Amin-Abad, 2014). Another study of 283 laboring women in the northern part of Iran found that approximately 36% of laboring women preferred a CS over a vaginal delivery and mentioned fear of childbirth pain, prevention of deformity and rupture of the genital area, which may result from vaginal delivery. The physicians’ recommendations were the main 13 factor contributing to mothers’ selection of the type of childbirth (Eynsheykh, Shaahmadi,

Taslimi, Emamiureh, & Moeinaldini, 2013). Moreover, insufficient knowledge about the caesarean method, misperception of vaginal delivery (Sehhati Shafai, Kazemi, &Ghojazadeh,

2013), and previous caesarean-section experiences (Azami-Aghdash et al., 2014), were factors associated with selecting the caesarean method among Iranian women.

In Iran, due to cultural and religious factors, companionship during labor and delivery is not a routine practice. Laboring women go through the process of labor and delivery without receiving any emotional support from their husbands, family members, or close friends. Typically, mothers only have interaction with the medical staff during the childbirth process (Torkzahrani,

2008).

However, research indicates that support from others can have benefits for mothers’ childbirth outcomes. For example, Shahshahan, Mehrabian, and Mashoori (2014) studied one- hundred laboring women in Isfahan (a large city located in Iran), evaluating the effect of the presence of personal support on the childbirth process. Laboring women had the opportunity to select their mothers, one of their sisters, or one of their close friends as a source of support during their entire childbirth. They supported laboring women through providing verbal comfort (e.g., reassuring the laboring women) and physical comfort (e.g., offering massages and helping mothers take warm showers). Results showed that those with personal support had a significantly shorter first and second stage of labor, a higher satisfaction score, and a better childbirth outcome

(Shahshahan et al., 2014). The aim of the current study was to evaluate the effect of receiving support from doulas during labor and delivery on childbirth satisfaction and breastfeeding self- efficacy among Iranian women who live in the U.S.

Supporting Positive Childbirth Experience

There are several factors related to positive birth experiences for mothers. Numerous studies have evaluated the factors related to childbirth satisfaction. Satisfaction with labor experience, partner’s participation during childbirth, hospital staff support, and feeling of personal control (women’s abilities to manage their pain during contraction, to stay calm, to participate in the decision-making concerning their labor, and to be informed about their labor process) are all main factors that contribute to women’s childbirth satisfaction (Goodman et al., 2004; Green &

Baston, 2003; Melender, 2006).

Feeling in control during labor is also linked to childbirth satisfaction. Laboring women’s external control refers to their abilities to control what medical staff perform for them during labor and childbirth, and internal control refers to their abilities to control their own behavior during their labors and contractions. Green and Baston (2003) conducted a study on 1146 women in

England. Participants completed the questionnaires in two stages. The first stage was completed when the participants were in the 29th week of their pregnancy, and the second stage was completed 6 weeks after childbirth. Results showed that although feeling in control of what staff did exerted a significant influence on psychological outcomes for laboring women, only 39.5% reported being in control of their staff. Lack of control may lead to negative childbirth outcomes.

In a review of the literature, Lobel and Deluca (2007) found that lack of control, which can result from cesareans, negatively affected women’s childbirth satisfaction, parenting behaviors, postpartum mood, and their perception over their babies and themselves.

Emotional support is also linked to higher rates of satisfaction in the birthing process

(Grassley & Sauls, 2012). For example, Grassley and Sauls (2012) investigated the effect of the

Supportive Needs of Adolescents During Childbirth (SNAC) intervention on mothers’ childbirth satisfaction and breastfeeding success. SNAC offered emotional and practical support for mothers 15 based on their age. Mothers received professional labor support, breastfeeding support before childbirth, breastfeeding support in the first hour after childbirth, and uninterrupted skin-to-skin contact with their babies immediately after childbirth. Results showed that mothers who received the SNAC intervention experienced higher childbirth satisfaction and more likely initiated breastfeeding within the first hour after delivery.

Benefits of Doula Support for Childbirth

A growing body of literature indicates that continuous labor support can be beneficial to mothers and infants and lead to childbirth satisfaction for laboring women (Hodnett, Gates,

Hofmeyr, & Sakala, 2012; Sauls, 2000). For many women in the U.S., professionally trained doulas serve as an important source of that support. According to DONA International (2017), a doula provides continuous informational, physical and emotional support for mothers without performing any clinical tasks. Their goal is to help mothers to have satisfying and unforgettably positive memories of their labor and delivery. Through informational support, doulas offer basic information about the process of labor, which can facilitate women’s communication with their partner, midwife, nurse, and other medical staff, in addition to encouraging them to make their own decisions with respect to available labor-related options. Doulas’ physical support refers to their ability to help women to cope with their pain by offering various positions during different points of their labors, by performing back and pelvic massages to reduce their pain during contraction (e.g., the double hip squeeze), and by offering breathing and relaxation techniques.

Through emotional support, such as offering reassurance and honoring women’s emotions, doulas encourage women to trust their own bodies’ abilities in the childbirth process. Doulas can play a significant role in improving maternity health outcomes (DONA International, 2017).

DONA International was established in 1992 in the United States. Through offering workshops, the organization provides informational and practical courses to its participants who 16 aim to become a doula. The number of doulas receiving certification from 1994 to 2016 exceeds

12,000. Based on the types of training, DONA International offers birth doula certification that focuses primarily on the need of laboring women before, during, and shortly after childbirth, along with postpartum doula certification, which mainly aims to support women and families in their transition to parenthood for as long as several months after childbirth (DONA International, 2017).

The focus of the current study is the birth doula. In the United States, laboring women can have access to the following: doula care through hospital-based programs, in which free doula services are offered; community-based programs, in which doulas and laboring women have the same cultural values, beliefs, and even language; and/or doulas in private practice, in which laboring women hire doulas in advance (DONA International, 2017; Gilliland, 2002).

Although support from nurses plays an important role in childbirth outcomes, doulas may offer different forms of support to laboring mothers. Doulas are more knowledgeable about laboring women’s relationship within their families and their fears, plans, and desires for their childbirth, and nurses know more about medical practices, hospital policies, and laboring women’s medical status. Both doulas and nurses can complement each other through collaborating and appreciating each other’s roles (Gilliland, 2002).

Research indicates that doula support is linked to more positive childbirth experiences for

U.S. women. For example, Winslow (1998) investigated the benefits of continuous doula support during labor. Participants were 412 healthy nulliparous women who ranged in age from 13 to 34 years. They were randomly assigned to the observed group in which they only received routine hospital care, or to the intervention group in which they received continuous support from doulas.

Results indicated that low-income and black, Hispanic, and white women show similar results of positive effects of doula intervention on childbirth satisfaction; 8% of women who received doula support had a shorter duration of labor and a lower cesarean rate in comparison with 18% who did not. It should be noted that 8% of those who received doula support used instrumental delivery 17 devices such as a forceps versus 26% of women who did not, and 8% of women with doulas used epidural anesthesia in comparison to 55% who did not. What is more, 10% of mothers who received doula support had to have their infants stay at the hospital in contradistinction to 24% of mothers who did not receive doula support. Research has confirmed the positive role of doulas in childbirth outcomes. More specifically, there is an association between doula experience and support as well as childbirth satisfaction and breastfeeding self-efficacy. The current study investigated whether positive childbirth outcomes occur for Iranian women who have doulas during their labors and childbirths in comparison to Iranian women who do not have doulas.

Breastfeeding Self-Efficacy

Mothers’ breastfeeding self-efficacy has been considered as one of the most important components of improving breastfeeding outcomes (Meedya et al., 2010). Breastfeeding self- efficacy refers to a mother’s capability to breastfeed her child (Dennis, 1999) and it has influenced the duration and exclusivity of breastfeeding positively (Blyth et al., 2002). One of the important factors that can influence breastfeeding self-efficacy is the level of support women receive regarding their breastfeeding practice (Dennis, 1999).

Benefits of Breastfeeding

Another outcome examined in the current study is the practice of breastfeeding. According to the World Health Organization (WHO) (2003), breastfeeding is recommended, as it is an ideal form of nutrition for infants’ healthy development. Both mothers and infants can benefit from breastfeeding physiologically and psychologically. Based on the United Nations Children’s Fund

(UNICEF) (2004), exclusive breastfeeding from birth to at least six months can decrease infants’ mortality rate. Breast milk can boost infants’ immune systems which protect them from infectious 18 diseases, especially where health resources are insufficient and infectious diseases are common, such as in developing countries in which exclusive breastfeeding can significantly influence infants’ mortality rate.

Furthermore, there are associations between breastfeeding and protecting babies from respiratory infection and asthma. Mihrshahi et al. (2007) found that exclusive breastfeeding keeps them safe from children against acute respiratory infection and diarrhea which can ultimately decrease child morbidity. Oddy, De, Sly, and Holt (2002) found that the cessation of exclusive breastfeeding—when infants receive only human breast milk and drops or syrups that contain minerals, vitamins, or medication prescribed by doctors—before the age of 6 months is a risk factor for wheezing—a condition in which children breathe with whistling sounds in their chest because of the narrowing of their airways. Moreover, they found that the cessation of exclusive breastfeeding before the age of 2 months is a risk factor for respiratory tract infections among children later in their lives. Finally, Silvers et al. (2012) investigated the association between exclusive breastfeeding and protection against asthma. They evaluated infants’ feeding type and duration of exclusive breastfeeding at birth and at 3, 6, and 15 months, and then evaluated the possibility of wheezing and asthma in children 2 to 6 years of age. Results showed that the longer period of exclusive breastfeeding was associated with longer protection against asthma.

Moreover, there is association between breastfeeding and a lower level of obesity and diabetes in children. As an example, Grube, Lippe, Schlaud, and Bretteschneider (2015) collected data from children and adolescents who lived in Germany from the age of 3 to 17 years. The researchers found that there is negative correlation between breastfeeding and the risk of obesity.

Children who received breastfeeding for more than 4 months showed a significant reduction in obesity compared to children who did not receive breastfeeding or had breastfeeding for a shorter duration of time. Another study found that infants who exclusively receive human milk in the first

6 months are less likely to become obese later in life, and the risk of getting acute otitis media is 2 19 times lower than children who receive only formula (Ip et al., 2007). Finally, Patelarou et al.

(2012) argued that based on 28 studies that were conducted between 1974 and 2011, absence or lack of breastfeeding is associated with the increase of the risk of type I diabetes in the future.

A growing body of literature indicates that lactation plays an important role in maternal health after childbirth and in later life. There are psychological benefits for nursing mothers: breastfeeding can promote better secure attachment between mothers and their babies (Mathews,

Leerkes, Lovelady, & Labban, 2014). Moreover, Borra, Lacovou, and Sevilla (2015) found that breastfeeding can decrease the risk of post-partum depression among mothers who did not have any sign of depression during their pregnancies and intended to breastfeed their babies. Also, there are physical benefits of breastfeeding for nursing mothers. Palmer et al. (2014) investigated the relation of parity and lactation to specific subtypes of breast cancer in African-American women.

Based on data from the African-American Breast Cancer Epidemiology and Risk (AMBER)

Consortium, there was an association between lactation and triple-negative breast cancer.

Moreover, according to the Life After Cancer Epidemiology (LACE) study—a study on women who were diagnosed with breast cancer—found that women’s history of lactation could influence breast cancer prognosis and survival (Kwan et al., 2015). Also, the risk of ovarian cancer is also reduced by lactation. A meta-analysis of 19 studies concluded that lactation significantly decreased the risk of ovarian cancer. More specifically, women who breastfeed for 8 to 10 months have a lower chance of being diagnosed with ovarian cancer (Feng, Chen, & Shen, 2014).

Furthermore, there is association between lactation and maternal cardiovascular health: Women who breastfeed for 24 months or longer had a lower mortality rate than women who had never lactated (Fagerhaug et al., 2013).

Barriers to Breastfeeding

There are many factors associated with continued breastfeeding. For example, mothers 20 tend to breastfeed exclusively longer when they report positive maternal attitudes toward breastfeeding, adequate family support, good mother-infant bonding, appropriate suckling technique, and no nipple problems (Cernadas, Noceda, Barrera, Martinez & Garsd, 2003). In one study of low-risk mothers and their newborns, Cernadas et al. (2003) evaluated the reasons for the discontinuation of breastfeeding through telephone interviews. Mothers were interviewed at 1 to 2 days postpartum and then again at 2 and 12 weeks postpartum. The results showed that at week 2, mothers who discontinued breastfeeding reported less confidence in the ability to breastfeed their babies; what is more, early breastfeeding problems and lack of sufficient maternal education were two other reasons for discontinuing breastfeeding after week 2. Other research documents that mothers who must return to school or work are more likely to discontinue breastfeeding their babies at 12 weeks (Taveras, Capra, Braveman, Jensvold, Escobar, & Lieu, 2003), and women who believe that they needed more information about breastfeeding before their delivery, or had experienced breastfeeding difficulties, were less likely to breastfeed their babies exclusively at 6 to

10 weeks postpartum (McLeod, Pullon, & Cookson, 2002).

Across different cultures, women express different reasons for stopping breastfeeding. For instance, Arab women who delivered their babies by C-section and used oral contraceptives after delivery to prevent further pregnancy, were more likely to stop breastfeeding and were less likely to maintain breastfeeding up to 12 months post-partum than those who delivered vaginally and did not use oral contraceptives (Shawky & Abalkhail, 2003). Moreover, Asian mothers report that the main barrier for exclusive breastfeeding was a lack of a supportive environment and a cultural perspective that encourages the start of solid foods or water with infants before the age of 6 months in order to have healthier and stronger babies (Thin, 2003). In another study, African mothers mentioned cultural factors as one of the main barriers to breastfeeding their babies exclusively. Based on their cultural values and beliefs, breastfeeding can manage babies’ thirst but not weight, and mothers are not allowed to have sexual relationships during the breastfeeding 21 period (Kakute et al., 2005). Other factors such as returning to work, not having access to an adequate and a healthy nutrition, not producing enough breast milk, having mental problems, having health problems related to the mother’s breast, having short birth intervals, and perceiving themselves as not attractive because of their breastfeeding practices, were all mentioned by Asian mothers as barriers for breastfeeding practices (Thin, 2003). In the sample of 1323 mothers in the

United States, mothers who stopped breastfeeding or pumping milk were asked to complete a questionnaire in which 32 reasons were offered for stopping breastfeeding. Mothers, through a 4- point Likert scale, specified which of those reasons were not at all important, or very important in their decision to stop breastfeeding. Factors such as self-weaning, in which babies no longer had interest to feed at the breast and had an insufficient supply of breastmilk, are mentioned as reasons for discontinuing breastfeeding their babies at the age of 3 to 8 months. Also, lactational, nutritional, psychosocial, and milk-pumping were reasons for discontinuing breastfeeding within the first and second months of childbirth (Li, Fein, Chen & Grummer-Strawn, 2008).

In Iranian culture, women express the following reasons for stopping breastfeeding:

Physicians’ recommendations, mothers’ attitudes towards the amount of their breast milk, mothers’ mental illness, mothers’ use of medicine, infants’ illness, and return to work. At the age of six months, only 27.7% of the infants of Iranian women were breast-fed exclusively. It should be noted that 54% of Iranian women mentioned that the reason for stopping exclusive breastfeeding was because of physicians’ recommendations. Moreover, receiving sufficient support and encouragement from physicians can significantly contribute to exclusive breastfeeding

(Olang, Heidarzadeh, Strandvik, & Yngve, 2012).

Women’s level of knowledge about breastfeeding and positive emotional support that they receive encourage them to select or continue breastfeeding. For example, Clifford and McIntyre

(2008) argue that breastfeeding is increased when fathers, other family members, and friends have positive attitudes towards breastfeeding and mothers have the skill and knowledge about 22 breastfeeding choices. Moreover, Clifford and McIntyre argue that although health professionals can positively affect breastfeeding support, they may lack the training to provide this kind of support for women.

Supporting Breastfeeding

There is an association between emotional support—before, during, and after childbirth— and longer breastfeeding for mothers across different cultures. Mothers across cultures have noted that the support they receive from their husbands can influence their breastfeeding success (Rêgo,

Souza, Da Silva, Braga, Alves, Leitão, & Cardoso, 2009). In one study, Pisacane, Continisio,

Aldinucci, D'Amora, and Continisio (2005) investigated the role of fathers in breastfeeding promotion. Fathers in the intervention group received instruction in a 40-minute class which mainly focused on the following points: infant feeding, mothers’ concern about an insufficient supply of milk, health problems relating to mothers’ breast, mothers’ return to the workplace, and the prevention and management of problems associated with lactation. Results showed that mothers, whose husbands received instructions, were more likely to breastfeed their babies exclusively until 6 months after their deliveries and more likely to continue to breastfeed until their babies were around 12 months. Similar research supports the link between fathers’ supportive attitudes and practices and knowledge about breastfeeding and more positive breastfeeding outcomes (Datta, Graham, & Wellings, 2012; Haya, Monique, Matilda, Rawan, &

Hibah, 2013; Ku & Chow, 2010; Sherriff & Hall, 2011),

There are other sources for breastfeeding support. For example, one study has shown that most Iraqi women select bottle-feeding over breastfeeding mainly because they do not receive educational and emotional support for breastfeeding from community health care centers, especially before pregnancy and after they return home from the hospital (Madanat, Farrell,

Merrill & Cox, 2007). It should be noted that 51.4% of women with supportive companionship 23 during labor were exclusively breastfeeding their babies in comparison to 29.3% of women who did have such support during their labor (Hofmeyr, Nikodem, Wolman, Chalmers & Kramer,

1991). Similarly, given that mothers who receive support from doulas and other female relatives show higher rates of satisfaction in the birthing process (Campbell et al., 2007; Grassley & Sauls,

2012), there may also be better breastfeeding outcomes.

Breastfeeding Factors for Iranian Women

There are documented positive effects of receiving emotional support and breastfeeding outcomes among Iranian women. For example, Assarian, Moravveji, Ghaffarian, Eslamian, and

Atoof (2014) investigated the association of postpartum maternal mental health with breastfeeding status among Iranian women. Participants consisted of 458 women who were categorized in two groups: unsuccessful breastfeeding mothers whose infants received their mothers’ breast milk and formula, and successful breastfeeding mothers whose infants only received breast milk and liquids containing vitamins or medicines. Based on interviews and questionnaires that were conducted when the infants were younger than one, the researchers found that providing emotional support and following up on mothers’ emotional status, especially for those with depression, significantly contributed to successful breastfeeding among Iranian women. The duration of breastfeeding among Iranian women increased when they received emotional support from their families and community healthcare providers, such as nurses, midwives, and health counselors. Moreover,

Parsa, Masoumi, Parsa, and Parsa (2015) found that mothers who breastfeed their babies have positive views of their own abilities to take care of their babies, preventing childhood illness.

Iranian women’s age, education, level of income, and number of children, were not associated with their breastfeeding decision. Thus, breastfeeding Iranian mothers would likely benefit from educational and emotional support provided by doulas.

Doula Support for Breastfeeding

Doulas can play an important role in enhancing mothers’ breastfeeding skills by helping women to recognize babies’ feeding cues, informing laboring women how to put their babies in the right position for nursing (the baby’s ear, shoulder, and hip should be in alignment), teaching the proper latching technique which can prevent painful breastfeeding (the baby should be latched beyond the nipple, and his/her lips should be flanged), and emphasizing the right sign of true sucking (women should pay attention to an audible sucking pattern). What is more, doulas can encourage those mothers who need extra help for nursing their babies to obtain more guidance from lactation consultants who can help mothers learn the art of breastfeeding (Mallak, 1999).

Doula care can promote initiation and duration of breastfeeding. As an example, Nommse-Rivers,

Mastergeorge, Hansen, Cullum, and Dewey (2009) investigated the role of doulas in breastfeeding success. Their participants consisted of 141 women who were from low-income families and gave birth in California. Results showed that women who received doula care during their labor were more likely to experience breast milk production or initiation of lactation within 72 hours after delivery and continuation of breastfeeding at 6 weeks postpartum. Similarly, Kozhimannil,

Attanasio, Hardeman, and O’Brien (2013) investigated the role of doula-supported birth in breastfeeding initiation among low-income and culturally diverse women. Results showed that women who received culturally appropriate support from their doulas were more likely to initiate breastfeeding compared to women who did not have the support of doulas. The current study investigates whether having a doula during a labor and childbirth positively influences Iranian women’s breastfeeding self-efficacy and childbirth satisfaction.

Summary and the Current Study

Identifying factors that contribute to childbirth satisfaction and breastfeeding success is an 25 important priority for mothers and children. As laboring women are under great pressure physically and mentally during the childbirth process, receiving continuous support from doulas can improve childbirth outcomes in term of childbirth satisfaction and breastfeeding self-efficacy.

Partners, together with nurses and doulas, can play an important role in maximizing mothers’ childbirth satisfaction and breastfeeding self-efficacy (Gale et al., 2001; Gilliland et al.,

2002). The feeling of personal control as well as the satisfaction with labor experience, the partner’s participation during childbirth, and the hospital staff, are all main factors that contribute to women’s childbirth satisfaction (Goodman et al., 2004; Green & Baston, 2003; Melender,

2006). Doula intervention is linked to lower rates of childbirth complication and medical intervention in culturally diverse samples (Winslow, 1998).

Studies show that breastfeeding contributes to physiological and psychological benefits for mothers and infants. There are associations between breastfeeding and a lower level of child morbidity, acute respiratory infection, diarrhea (Mihrshahi et al., 2007), and diabetes (Patelarous et al., 2012). Researchers have found that fathers’ attitudes towards breastfeeding and the level of support they provide for their wives can significantly affect breastfeeding initiation and duration

(Haya et al., 2013; Ku & Chow, 2010; Pisacane et al., 2005), and there is also an association between having a doula as a support person and childbirth satisfaction and successful breastfeeding experiences (Campbell et al., 2007; Grassley & Sauls, 2012; Nommsen-Rivers et al.,

2009).

Since no studies have been conducted in the United States to examine the association between doula support and childbirth satisfaction and breastfeeding self-efficacy among Iranian women, the current study aims to contribute to the understanding of this relationship among

Iranian women who live in the United States. The research questions in the current study focus on the relationships among doula support, childbirth satisfaction, and breastfeeding self-efficacy for

Iranian women. The research questions were addressed through self-report questionnaires (a 26 maternal prenatal demographic questionnaire, the Mackey Childbirth Satisfaction Rating Scale, and The Breastfeeding Personal Efficacy Beliefs Intervention), which were distributed among

Iranian women who had been living in the United States. Correlational analyses were conducted in order to examine the relationships among variables. 27

Chapter 3

METHOD

A correlational descriptive study was conducted in order to explore the association between receiving emotional support from doulas and Iranian women’s childbirth satisfaction and breastfeeding self-efficacy. To address this question, data were collected from a sample of Iranian women and analyzed quantitatively.

Participants

The sample in this study included 33 healthy primigravidas (women who have experienced pregnancy for the first time) and multigravidas (women who have experienced pregnancy two or more times). The participants were Iranian women who had given birth to their babies ranging from 2 to 16 weeks and had been residing in Davis, Sacramento, San Jose, and Los Angeles; they met the following criteria: (a) they had lived in the United States, (b) they had one or more babies,

(c) they had low-risk pregnancies, (d) they had their husband and/or their family members and/or doula present during their labor and childbirth, and (e) they had a vaginal delivery of healthy babies in hospital settings. Of the 33 Iranian women, 42.4% (n= 14) had doula support, and 57.6%

(n= 19) did not have doulas during their labor and delivery. All women in the current sample had fathers present during their labor and delivery.

The Iranian women who participated in this study ranged from 20 to 40 years of age; 9.1%

(n= 3) were 20 to 25 years old, 36.4% (n= 12) 26 to 30, 48.5% (n= 16) 31 to 35, and 6.1 (n= 2) 36 to 40. At the time of the mothers’ participation, their babies’ ages ranged from 2 to 16 weeks:

36.4% (n= 12) of the babies were 9 to 12 weeks of age, 30.3% (n= 10) 5 to 8 weeks, 30.3% (n=

10) 13 to 16 weeks, and only 3% (n= 1) 2 to 4 weeks. The mothers’ level of education ranged 28 from some high-school study to doctoral education. More specifically, 3% (n= 1) of the mothers had some high-school education, 6.1% (n= 2) had a high-school degree or GED, 21.2% (n= 7) had a college degree, 33.3% (n= 11) had a bachelor’s degree, 12.1% (n= 4) had received some graduate-level education, 15.2% (n= 5) had a master’s degree, and 9.1% (n= 3) had a doctoral degree.

The majority of mothers (75.8%) had a full-term pregnancy, delivering their babies between 39 to 40 weeks, 12.1% (n= 4) had an early-term pregnancy, and 12.1% (n= 4) had a late- term pregnancy. The rates of breastfeeding for participants who had stopped breastfeeding before their participation and for those who had just started breastfeeding their babies and anticipated to breastfeed them for a longer duration, were as follows: 9.1% (n= 3) of the participants breastfed for less than 4 weeks, 3% (n= 1) up to 8 weeks, 21.2% (n= 7) up to 4 months, 12.1% (n= 4) up to

5 to 6 months, 15.2% (n= 5) more than 6 months, and 39.4% (n= 13) between 1 to 2 years.

Procedure

Participants were recruited from Iranian community centers in Davis, Sacramento, San

Jose, and Los Angeles. Those who met all inclusion criteria, who were 33 Iranian women, received the following forms: a descriptive letter that included general information about the purpose and process of the research study (see Appendix A); two copies of the informed consent

(see Appendix B)—one copy for the researcher’s record and one copy for the participant’s personal record; and questionnaires that requested the participant’s demographic information and assessed childbirth satisfaction and breastfeeding self-efficacy. The questionnaires were administered as part of a packet distributed directly to parents. No names or other identifying information were attached to the questionnaires. Instead, IDs were used. Completed questionnaires were placed in sealed, addressed, and stamped manila envelopes and mailed directly to the 29 researcher via regular U.S. mail. The informed consent was separated from questionnaires, and all study data were stored in a secure, locked location.

Measures

Since the target population for this study were Iranian women, participants received the forms in Farsi and English. The forms were translated into Farsi by the Persian Language Program

Coordinator at the University of California, Davis and then back-translated to ensure validity. The

Farsi version of MCSRS, which was evaluated by Moudi and Tavousi (2016) and was approved by both as an internally consistent (Cronbach’s alpha = .78) and valid instrument, was used in the current study.

Maternal Demographic Survey

A maternal prenatal demographic questionnaire (Appendix C) provided general information about the participants, such as the mother’s age, baby’s age, mother’s level of education, type of delivery (with doula support and without doula support), term pregnancy (early- term, full-term, late-term, and post-term), and breastfeeding future plans.

Childbirth Satisfaction

The Mackey Childbirth Satisfaction Rating Scale (Appendix D) was used to assess

Childbirth Satisfaction. The questionnaire is a 40-item scale which indicates mothers’ level of satisfaction and dissatisfaction with their childbirth experiences. Questions 1 to 34 were answered using a 5-point Likert-type scale—1 being “very dissatisfied,” and 5 being “very satisfied.”

Questions 35 and 36 were open-ended and asked mothers to name what contributed to their satisfaction and dissatisfaction with their childbirth experiences and then to classify their 30 responses based on the level of importance. Questions 37 and 38 were rated on a 4-point Likert scale and asked about the mothers’ general labor and delivery expectations—1 being “not at all like I expected it to be,” 2 being “very little like I expected it to be,” 3 being “somewhat I expected it to be,” and 4 being “just like I expected it to be.” Finally, questions 39 and 40 measured mothers’ overall labor and delivery experiences through a 4-point Likert-type scale—1 being

“very negative,” 2 being “somewhat negative,” 3 being “somewhat positive,” and 4 being “very positive.”

In combining scores, all ratings were first converted to a consistent 5-point scale. Total scale scores and subscale scores were then created by taking a mean of relevant items. Items were grouped into subscales. First, the experience subscale (6 items) measured overall satisfaction regarding labor and delivery experiences, including “level of comfort” during their labor and delivery, and their labor and delivery “as being primarily [a] positive or primarily negative experience.” Nine items measured satisfaction with the level of care received during their labor and delivery including “the physical care you received” from the nursing and the medical staff,

“the technical knowledge, ability, and competence” of the nursing and medical staff, and “the amount of explanation or information received” from the nursing and the medical staff, during their labor and delivery. Ten items measured the level of support received during labor and delivery, e.g., “husband’s help and support,” “the personal interest and attention” from the nursing and personal staff, “help and support with breathing and relaxation” from the nursing and medical staff, and “sensitivity” of nursing and medical staff towards women’s needs during their labor and delivery. The nine items in the control subscale measured the level of control experienced during their labor and delivery, including items such as “level of participation in decision-making,”

“ability to manage labor contraction,” and control over their “actions” during their labor and delivery. Finally, three items measured women’s satisfaction with their babies in terms of “baby’s physical condition at birth” and the amount of time that passed by before they first fed and held 31 their babies.

Internal consistency of the Childbirth Satisfaction Rating Scale was tested with Cronbach’s alpha, demonstrating high internal consistency (α = .98) for the total scale. Alpha coefficients for subscales were as follows: Control, .93; Support, .95; Care, .95; Experience, .95; and Baby, 0.49.

The Baby subscale was not used in subsequent analyses due to its low internal consistency.

Breastfeeding Efficacy

The Breastfeeding Personal Efficacy Beliefs Intervention (BPEBI)—see Appendix E—is a

27-item scale used to measure women’s breastfeeding personal efficacy beliefs. The first version of this scale contains 25 items, assessing women’s abilities to breastfeed their babies in six categories, which are as follows: social support, breastfeeding challenges and duration, breastfeeding in family and public situations, motivation, and breastfeeding techniques. Two items

(e.g., “receiving support from the baby’s father”) measure the confidence in managing social support for breastfeeding. Four items (e.g., “doing the activities that mother pleases”) assess the level of confidence in managing possible challenges of breastfeeding. Eight items (e.g., beliefs regarding breastfeeding up to 3, 6, and 12 months) measure the level of confidence in managing breastfeeding for longer durations. Furthermore, three other items, which gauge the amount of confidence in managing breastfeeding in different environments, focus upon managing breastfeeding “at the mall,” “with immediate family present,” or “with extended family present.”

Moreover, four items (e.g., “having a pleasant time while breastfeeding”) determine women’s extent of motivation to breastfeed. Finally, four items gauge the confidence women have in putting the techniques of breastfeeding into practice, such as “getting the baby on and off the breast.”

Each item is followed by a visual analogue scale, in which there is a 100-millimeter horizontal line. A 100-millimeter line is divided into three parts: “cannot do (0%),” “might do in 32 the middle of the line (50%),” and “certainly can do (100%).” Participants marked a percentage, starting from 0 % to 100%, and then each marked scale was measured with a ruler. The score near

100% indicated the higher level of breastfeeding confidence, and the one near 0% indicated the lower level of breastfeeding confidence. The alpha coefficient for this scale in previous studies was 0.89 (Cleveland & McCone, 2005). In the current study, items were scored on a 3-point scale as 1 (cannot do), 2 (might do), or 3 (certainly can do), and combined into a single self-efficacy score by taking a mean of the items. The Cronbach’s alpha coefficient demonstrated adequate internal consistency (α = .96) for the total score.

Data Analysis

Data collection began after approval for the study was obtained from California State

University. The data were analyzed using SPSS (version 24). Descriptive analysis (means, SD, and percentages) was conducted to describe the demographic characteristics of the participants and the study variables. The linear correlation coefficient was calculated to measure the direction and strength of the relationship between the group of Iranian women with doula support and without doula support and childbirth satisfaction and breastfeeding self-efficacy. An independent sample t- test with α= .05 as a criterion for significance was conducted to examine whether two groups of

Iranian women (those who had received doula support during their labor and delivery and those who had not) were significantly different in the case of childbirth satisfaction and breastfeeding self-efficacy.

Chapter 4

RESULTS

This chapter outlines the results of this study, which investigates the relations between having doula support and childbirth satisfaction as well as the relations between having doula support and breastfeeding self-efficacy. First, the descriptive results are presented, including the means and standard deviation of the maternal demographic and prenatal information, childbirth satisfaction, and breastfeeding self-efficacy. Correlations examining the relationship between childbirth satisfaction and breastfeeding self-efficacy are also presented. Next, t-test results testing the hypothesis that Iranian women who had doula support during labor and delivery would display a higher level of childbirth satisfaction and breastfeeding self-efficacy compared to Iranian women who did not, are presented.

Descriptive Analyses

Maternal Prenatal Demographics

The sample demographic information was obtained from the responses of the 33 participants who filled out the Maternal Prenatal Demographic Questionnaire (see Appendix C).

These demographic variables were examined for correlations with Childbirth Satisfaction and

Breastfeeding Efficacy. Neither the women’s age (M= 2.52, SD= .75), their child’s age (M= 2.94,

SD= .86), their level of education (M= 4.27, SD=1.50), nor their pregnancy term (M= 2.00, SD=

.50) was associated with the level of childbirth satisfaction and breastfeeding self-efficacy. There were also no differences in childbirth satisfaction or self-efficacy related to child gender.

Childbirth Satisfaction and Breastfeeding Self-Efficacy

Descriptive analyses were conducted with scales and subscales measuring Childbirth

Satisfaction and Breastfeeding Self-efficacy, and breastfeeding practice was reported. Table 1 shows the means and standard deviations for these variables for the entire sample.

Table 1 Means and Standard Deviations for Study Variables (n=33)

Variables M SD

Total Breastfeeding Self-Efficacy 2.20 .62 Total Childbirth Satisfaction 3.45 .73 Experience Subscale 3.31 .90 Care Subscale 3.56 .76 Support Subscale 3.61 .72 Control Subscale 3.24 .65

Correlations between childbirth satisfaction and breastfeeding outcomes were also computed. These correlations are provided in Table 2. Across the board, the scales and subscales for outcome variables were highly correlated. The duration of breastfeeding was significantly and positively associated with breastfeeding self-efficacy (r= .93, p< .001), childbirth satisfaction was significantly and positively associated with breastfeeding self-efficacy (r= .85, p < .001), and the duration of breastfeeding was significantly and positively associated with childbirth satisfaction

(r= .82, p<.001). Moreover, as shown in Table 2, the childbirth subscales (experience, control, care, and support) were highly intercorrelated and correlated with breastfeeding self-efficacy and extent of breastfeeding. 35

Doula Support and Childbirth and Breastfeeding Outcomes

The main hypothesis tested in the study was that doula care during labor and delivery is associated with Iranian women’s childbirth satisfaction and breastfeeding self-efficacy. Table 3 shows the means and standard deviations of breastfeeding and childbirth satisfaction scales for the two groups (doula/no doula), and the results of independent sample t tests.

As shown in Table 3, women with doula support show significantly higher reported levels of breastfeeding practice and self-efficacy as well as childbirth satisfaction than women without this support. Iranian women in the current sample who received doula support during their labor and delivery (M= 7.14, SD= 1.23) had reported significantly longer durations of breastfeeding than women without doula support during the birth of their child (M= 5.68, SD=

2.05), t (31) = 2.35, p = .02. Consistent with the hypothesis, breastfeeding self-efficacy was rated significantly higher in the doula support group (M= 2.02, SD= .65) than no doula group (M= 2.45,

SD= .50), t (31) = 2.04, p = .050.

Similarly, the doula support group showed a significantly higher total childbirth satisfaction (M= 3.84, SD= .61) than those without doula support (M= 3.16, SD= .70), t (31) =

2.88, p = .007. These significant differences were also found in the childbirth satisfaction subscales (Table 3). In comparison to Iranian women who had not received doula care during their labor and delivery, those with doula support reported more positive experiences during childbirth

(t (31) = 2.97 p = .006), and experienced more control during labor and delivery (t

(31) = 2.76, p = .009). In addition, compared to those without doulas, the doula group experienced more satisfaction with care they received from nurses and medical staff during labor and delivery

(t (31) = 2.88, p = .007), and reported feeling more supported during childbirth (t (31) = 2.42, p =

.021). All women in the current sample had fathers present, so it was the doula support in addition 36 to their male partners’ support that was linked to more positive satisfaction with childbirth and more confidence in breastfeeding.

Table 3 Comparison between Doula/No Doula in Childbirth Satisfaction and Breastfeeding Personal Self- Efficacy

No Doula Doula M (SD) M (SD) t p

Duration of Breastfeeding 5.69 (2.05) 7.14 (1.23) 2.35 .025

Breastfeeding Self-Efficacy 2.02 (.65) 2.45 (.50) 2.04 .050

Total Childbirth Satisfaction 3.16 (.70) 3.84 (.61) 2.88 .007

Experience Subscale 2.95 (.90) 3.80 (.64) 2.97 .006

Control Subscale 3.00 (.64) 3.57 (.52) 2.76 .009

Care Subscale 3. 26 (.72) 3.96 (.62) 2.88 .007

Support Subscale 3.36 (.65) 3.94 (.69) 2.42 .021

Chapter 5

DISCUSSION

The purpose of this study was to gain a better understanding of the nature of the relationship between doulas’ continuous informational, physical, and emotional support and childbirth satisfaction, and breastfeeding self-efficacy for Iranian women who had been living in the United States. It was hypothesized that Iranian women who had doula support during labor and delivery would display a higher level of childbirth satisfaction and breastfeeding self-efficacy than

Iranian women who had not received this kind of support. To address this question, survey data were collected and analyzed using correlational analyses examining the association between receiving continuous support from doulas and Iranian women’s childbirth satisfaction and breastfeeding self-efficacy. While none of the demographic variables was associated with childbirth and breastfeeding outcomes, there were significant differences in these outcomes depending on whether a birth doula was present. Iranian women who had a doula experienced higher childbirth satisfaction and breastfeeding efficacy, and they rated themselves as likely to breastfeed longer.

The data showed that in comparison to Iranian women who had not received doula care during their labor and delivery, those with doula support were more likely to be satisfied with their labor and delivery. For example, they had a higher perception of their abilities in managing pain, controlling their emotions, participating in decision-making during labor and delivery, and communicating with doctors and nurses, all of which contributed to a higher level of childbirth satisfaction. Although it cannot be determined conclusively that having a doula was the reason for the greater likelihood of positive birth outcomes, there is association between receiving support from doulas during labor and delivery and satisfaction with childbirth and confidence in breastfeeding. 40

The communication and encouragement from a doula during labor and delivery can empower Iranian mothers to achieve the best birth outcomes. Doulas may boost the empowerment and motivation of Iranian women in order to enable them to experience a positive childbirth and successful breastfeeding outcome. Physical, informational, and emotional support from doulas during labor and delivery can increase the Iranian women’s self-efficacy regarding breastfeeding; they perceived themselves as more capable and more willing for longer durations of breastfeeding in comparison to Iranian women who had not received support from doulas during their childbirth process. These results are consistent with previous research conducted amongst American women.

The presence of a support person was one of the important factors associated with satisfaction with the childbirth experience in previous research (Campbell et al., 2007; Hodnett et al., 2009).

The findings are consistent with those of other researchers who conducted reviews in which the effects of social support on women’s views of their childbirth experience were examined. As an example, Campbell et al. (2007) argued that women who received doula support during labor and delivery more likely reported positive attitudes of themselves and experienced a more positive perception of their labor experiences compared to women who just received routine hospital care.

Continuous labor support can be beneficial to mothers and infants and lead to childbirth satisfaction for laboring women, who experience fewer cesarean deliveries, fewer instrument- assisted deliveries, receive less regional anesthesia, and have higher rates of spontaneous vaginal birth, thereby improving maternal health (Hodnett et al., 2012; Hodnett et al., 2013; Sauls, 2000).

Some of the striking reasons for childbirth dissatisfaction mentioned by Iranian women who lived in the north-western part of Iran were lack of informational, physical, and emotional support during labor and delivery; they complained about the lack of clarification about the process of labor and delivery, as well as a lack of physical comfort during labor and delivery (such as back massages), or emotional support during labor and delivery (such as praise and 41 encouragement) (Naghizadeh, Fathnejad-Kazemi, Ebrahimpour & Eghdampour, 2013). Midwives and other medical staff in Iran typically do not receive training for providing emotional and physical support for laboring women. Moreover, the over- crowdedness of the maternity ward and the existence of other medical responsibilities do not allow midwives to provide continuous support for laboring women during labor and delivery (Torkzahrani, 2008).

As doulas’ roles are mainly focused on providing informational, physical, and emotional support for laboring women, and the results of this study has shown that Iranian women received benefits from doula support in the United States, Iranian hospitals are encouraged to revise their policies and to allow women to have a trained companion in childbirth through their labor and delivery. In Iran, due to cultural, political, and religious factors, companionship during labor and delivery is not a routine practice. Iranian women only have interaction with the medical staff and go through the process of labor and delivery without receiving any emotional support from their husbands, family members, or close friends. The rate of childbirth in Iran is over 1,170,000 annually (Akbary, 2005). The recommendation from the World Health Organization (WHO)

(2015) regarding the acceptable rate of caesarean section (CS) was 10-15%. The rate of cesarean section in Iran is high. According to Azami-aghdash et al. (2014), the rate of cesarean section in

Iran was 48%, which was much higher than the recommended rate announced by the World

Health Organization. The rate of CS was higher in private hospitals than in public hospitals (Pour-

Reza, 2007). One of the main reasons of CS in Iran was fear of childbirth, as mothers perceived the process of a vaginal delivery more painful than a cesarean section (Azami-aghdash et al.,

2014). Doulas, who are trained and experienced, are able to make a difference in mothers’ childbirth experiences through providing continuous informational, physical, and emotional support, lowering women’s anxieties about childbirth. Therefore, doula support might promote normal vaginal delivery among Iranian women through allaying fear and anxiety.

In the United Sates, fathers are allowed to and expected to accompany laboring women 42 during their labor and delivery. They might become anxious about laboring women’s pain and distress during labor and delivery and be less effective as a support person. They might not be able to stay calm and objective due to their emotional bonding to their wives and infants. Fathers’ support behavior during labor and delivery is different from doula support (Dlugosz, 2013). A study of over 420 laboring women showed that couples who received doula support exhibited more satisfying childbirth experiences, and both women and their male partners had positive views towards doula support (McGrath & Kennell, 2008).

Male partners might not be able to fulfill the role of primary labor companions. Results from this study showed that the support provided by fathers does not demonstrate the same positive influence on childbirth satisfaction and breastfeeding self-efficacy. All women in the current sample had fathers present, so it was the doula support in addition to their male partners’ support that was linked to more positive satisfaction with childbirth and more confidence in breastfeeding. Doulas come to a labor with a unique, well-defined role, and their individual and continuous support for laboring women can significantly and positively influence the outcomes of childbirth.

Identifying factors that can help laboring women to initiate and continue breastfeeding is a major priority for maternal and child health. In 1991, Alireza Marandi founded the National

Committee of Breastfeeding Promotion in Iran, which aimed to promote breastfeeding practice in order to enhance maternal and child health and well-being (Marandi, Afzali, & Hossaini, 1993). A study of over 63,071 infants all throughout Iran between 2005 and 2006 found that the exclusive breastfeeding rate at 6 months of age in urban areas was 27% in comparison to 29% in rural areas of Iran (Olang, Farivar, Heidarzadeh, Strandvik, & Yngve, 2009). More recently, according to the

Iran’s Multiple Indicator Demographic and Health Survey (IrMIDHS), in 2010, the rate of exclusive breastfeeding up to 6 months all throughout Iran was 53.1% in total, which was higher in the rural than in the urban areas, and girls were breastfed exclusively more than were boys. 43

Moreover, the researchers recommended sharpening mothers’ level of knowledge about the benefits of exclusive breastfeeding by encouraging mother and baby skin-to-skin contact after birth and by providing lactation consultants, as two effective ways to promote breastfeeding success among Iranian women (Kelishadi et al., 2016). In addition, factors such as insufficient educated personnel, public education, services, and referral systems to follow up on lactation and other maternal problems, might negatively influence breastfeeding outcomes in Iran (Kalantari &

Haghighian-Roudsari, 2013).

Breastfeeding outcomes can be enhanced among Iranian women who receive support from companions with sufficient training and experiences regarding childbirth, and breastfeeding can significantly promote breastfeeding success. However, doulas can play an important role in breastfeeding promotion and support. Doulas can offer guidance to mothers by helping them to recognize babies’ feeding cues, informing laboring women how to put their babies in the right position for nursing, teaching the proper latching techniques, and emphasizing the right sign of true sucking (Mallak, 1999). The findings of the current study show that doula support positively influences breastfeeding self-efficacy among Iranian women, perhaps because doulas improve women’s sense of competence during labor and delivery through providing continuous support which might ultimately improve women’s confidence needed for successful breastfeeding. This finding is supported in the literature among diverse cultures of laboring women. For example, a study of over 11,471 mothers who were from various races, such as Black, White, Hispanic,

Haitian, Asian, and Cape Verdean, showed that the Birth Sister Support who functioned as a doula had better breastfeeding outcomes than mothers without intervention. Mothers were more determined to breastfeed, to initiate breastfeeding shortly after childbirth, and to continue breastfeeding for longer periods of time (Mottl-Santiago et al., 2007). More recent studies showed that 92.7% of African- American women with doula support initiated breastfeeding, compared with 70.3% who did not receive doula support during their labor (Kozhimannil, Attanasio, 44

Hardeman, & O’Brien, 2013). Moreover, it seemed that the positive effect of doula support increased over the years. According to Mottl-Santiago et al. (2007), the intention of breastfeeding for women with Birth Sister Support was 50% in 1999 and then rose to 83% in 2005. Also, breastfeeding initiation for women with support during labor and delivery was 11% in 1999 and then rose to 40% in 2005.

According to the World Health Organization (WHO) (2003), breastfeeding is the ideal form of nutrition for infants’ health, and it protects them against diseases. Moreover, breastfeeding can be emotionally and physiologically useful for mothers and children. Promotion and supportive programs are crucial for the initiation and increased duration of breastfeeding. The positive association between doula support and breastfeeding self-efficacy which has been demonstrated in this study may have a positive influence on Iranian women’s perspective towards receiving informational, physical, and emotional support from doulas and may encourage them to select doulas as one of their companions during their labor and delivery. Moreover, it might convince hospitals in Iran to revise their policies at birthing wards and provide support for laboring women during their labor and delivery in order to enhance childbirth and breastfeeding outcomes.

Laboring women are under great physical and psychological pressure during labor and delivery. Practical advice and companionship from doulas during labor and delivery may provide a more comfortable atmosphere and ultimately influence women’s perception of their childbirth and breastfeeding confidence. With the evolution of technology, medical staff have often paid more attention to hospital equipment and less attention towards the human aspect of patient care, and it might be appropriate to reconsider the role of female companions like doulas in childbirth satisfaction and breastfeeding success.

Limitations

This study yielded several important findings, although it has limitations. One limitation concerns the methods used to collect the data. Although the study utilized several questionnaires in order to evaluate the effect of doula support on childbirth satisfaction and breastfeeding self- efficacy, the measurements applied in this study were mostly self-reported. Despite the fact that this kind of methodology is valid, it may be inaccurate or biased because Iranian women may respond in socially appropriate ways, rating themselves as more competent in breastfeeding and in managing their childbirth process. Moreover, participants may have been aware of expected findings and may have inflated self-reports. Future research should include interviews to allow the participants to express their feelings and explain the information given to them.

Moreover, since the data were collected all at the same time and are correlational, no conclusions about causality can be drawn. The results cannot conclusively show that there is a causal relationship between doula support and childbirth satisfaction and between doula support and breastfeeding self-efficacy. Future research should apply experimental designs in which participants are assigned to different conditions. For example, one group may receive doula support and a second group routine care without doula support in an experiment. Through providing intervention, more definitive conclusions can be drawn.

In addition, as mothers were invited to participate in this study after delivering babies ranging from 2 to 16 weeks, instead of asking them to rate their childbirth experiences at the hospital in the postpartum stage, they had to rely on their memories, which might have influenced their responses. Also, the different range of participants’ child age made it unclear how child age can influence mothers’ decision regarding their future breastfeeding plan. Moreover, as mothers did not choose to participate before their childbirth, those with more satisfying childbirth experiences—than those with less satisfying ones—might have decided to participate. 46

In the current study, Iranian women’s responses towards their breastfeeding self-efficacy and childbirth satisfaction may be biased, as they have different expectations and attitudes towards receiving support from doulas. Regarding cultural perspectives, this study did not investigate directly cultural factors about doula support and childbirth satisfaction and breastfeeding self- efficacy, as it was limited to Iranian culture. Further, although the constitution of Iranian women in this sample is representative of the state of California, it may not be reflective of other regions of the United States. Future research should include a larger population of participants. In addition, the current study has a relatively small sample size, 33 Iranian women. Future research should include a larger sample of Iranian participants in order to ensure that group comparisons are valid and generalizable.

Future research should attempt to isolate confounding variables that may contribute to positive outcomes in this study. Questions to be examined include some medical risk factors, the presence of close family members and friends during childbirth in addition to doulas, family history of breastfeeding, and the labor and breastfeeding preparation practices of the women’s prenatal provider (e.g., lactation consultants).

Measure of anxiety and maternal and newborn bonding can be included in future research studies on the effects of receiving doula support during labor and delivery for Iranian women.

Finally, maternal support from fathers during the childbirth process needs to be examined meticulously.

Appendices

Appendix A

Recruitment Letter

Dear Mothers,

My name is Nastaran Milani, and I am a graduate student in the Child Development Master’s program at California State University, Sacramento. I am inviting you to participate in my master’s thesis research study. This research will attempt to investigate childbirth satisfaction and breastfeeding self-efficacy among Iranian women.

If you decide to participate in this research study, you will be asked to complete three questionnaires. It will take approximately 15-30 minutes to complete them.

The information you provide will be kept confidential. Please send the 3 completed questionnaires along with your signed consent in the stamped addressed envelope and for your personal record you can keep the second copy of the informed consent. Thank you in advance for your help in this survey!

Sincerely, Nastaran Milani

Appendix B

Consent to Participate in Research

You are being invited to participate in the research that is conducted by Nastaran Milani, a graduate student in the Child Development MA program at California State University, Sacramento.

The three attached questionnaires are part of a study designed to explore childbirth satisfaction and breastfeeding self-efficacy among Iranian women.

I am asking you to help with this study by completing three questionnaires: A Demographic Survey, a Childbirth Satisfaction questionnaire, and a Breastfeeding Questionnaire.

I do not anticipate that these questionnaires will present any physical, social or economic risk. There is a possibility that you may feel uncomfortable or upset when you answer a few of the questions. For example, if you had negative experiences regarding your childbirth and/or breastfeeding outcomes, you may feel uncomfortable or upset. If this happens, please be sure to discuss them with the nurse or doctor. You have the right to skip any question you do not wish to answer. It will take approximately 15-30 minutes of your time to complete the questionnaires, and your responses will be contributed to our understanding of childbirth satisfaction and breastfeeding self-efficacy.

Your participation is voluntary and you are free to withdraw from the study any time without any consequences. Your name will not be attached to any of the questionnaires and any personal information will be kept confidential. All signed informed consent forms and questionnaires will be kept in a locked file cabinet, separate from study data.

I am available by email at [email protected] in case you have any concerns or questions, or you may contact my thesis sponsor, Dr. Sheri Hembree at [email protected]. Your signature below indicates your understanding and agreement to participating in this study.

Signature of participant ……………………………………… Date……………………….

Appendix C

Maternal Prenatal Demographic Questionnaire

Mother ID: ………

Please select or write the best response to the following questions:

1. Your age: ……….

2. Your child’s age: ………….

3. Your level of education:

⃝ Some high school ⃝ High school degree or GED ⃝ Some collage ⃝ Bachelor’s degree ⃝ Some graduate level coursework ⃝ Master’s degree ⃝ Doctoral degree 3. Your Delivery type: ⃝ With a doula (experienced women who provide continuous emotional and physical support during labor and childbirth) ⃝ Without a doula 4. Your term pregnancy: ⃝ Early Term: Between 37 weeks 0 days and 38 weeks 6 days ⃝ Full Term: Between 39 weeks 0 days and 40 weeks 6 days ⃝ Late Term: Between 41 weeks 0 days and 41 weeks 6 days ⃝ Postterm: Between 42 weeks 0 days and beyond 5. How long did you breastfeed, or how long do you plan on breastfeeding your baby:

⃝ Less than 4 weeks ⃝ ≤4 weeks ⃝ Up to 5 to 6 weeks ⃝ Up to 6 weeks ⃝ Up to 8 weeks ⃝ Up to 3 to 4 months ⃝ More than 6 months ⃝ Other …………….

Appendix D

MACKEY CHILDBIRTH SATISFACTION RATING SCALE

ID # ______

(Please circle one answer code to the right of each question unless otherwise instructed.) I am interested in your evaluation of your childbirth experience.

For each of the following items listed below, indicate how satisfied or dissatisfied you are with that aspect of your childbirth experience. (Circle one response for each item. You may write in comments about your answer.) neither satisfied very nor very dissatisfied dissatisfied dissatisfied satisfied satisfied

1. Your overall labor experience 1 2 3 4 5 Comments:

2. Your overall delivery experience 1 2 3 4 5 Comments:

3. Your level of participation in decision-making during labor 1 2 3 4 5 Comments:

4. Your level of participating in decision-making during delivery 1 2 3 4 5 Comments:

5. Your ability to manage your 1 2 3 4 5 labor contractions Comments:

6. Your level of comfort during labor 1 2 3 4 5 Comments:

7. Your level of comfort during delivery 1 2 3 4 5 Comments:

neither satisfied very nor very dissatisfied dissatisfied dissatisfied satisfied satisfied

8. The control you had over your emotions during labor 1 2 3 4 5 Comments:

9. The control you had over your emotions during delivery 1 2 3 4 5 Comments:

10. The control you had over your actions during labor 1 2 3 4 5 Comments:

11. The control you had over your actions during delivery 1 2 3 4 5 Comments:

12. Your husband's help and support during labor 1 2 3 4 5 Comments:

13. Your husband's help and support during delivery 1 2 3 4 5 Comments:

14. Your baby's physical Condition at birth 1 2 3 4 5 Comments:

15. The amount of time which Passed before you first held your baby 1 2 3 4 5 Comments:

neither satisfied very nor very dissatisfied dissatisfied dissatisfied satisfied satisfied

16. The amount of time which passed before you first fed your baby 1 2 3 4 5 Comments:

17. The physical care you received from the nursing staff during labor and delivery 1 2 3 4 5 Comments:

18. The physical care you received from the medical staff during labor and delivery 1 2 3 4 5 Comments:

19. The technical knowledge, ability, and competence of the nursing staff in labor and delivery 1 2 3 4 5 Comments:

20. The technical knowledge, ability, and competence of the Medical staff in labor and delivery 1 2 3 4 5 Comments:

21. The amount of explanation or information received from the nursing staff in labor and delivery 1 2 3 4 5 Comments:

neither satisfied very nor very dissatisfied dissatisfied dissatisfied satisfied satisfied

22. The amount of explanation or information received from the medical staff in labor and delivery 1 2 3 4 5 Comments:

23. The personal interest and attention given you by the nursing staff in labor and delivery 1 2 3 4 5 Comments:

24. The personal interest and attention given you by the medical staff in labor and delivery 1 2 3 4 5 Comments:

25. The help and support with breathing and relaxation which you received from the nursing staff in labor and delivery 1 2 3 4 5 Comments:

26. The help and support with breathing and relaxation which you received from the medical staff in labor and delivery 1 2 3 4 5 Comments:

27. The amount of time the nurses spent with you during labor 1 2 3 4 5 Comments:

28. The amount of time the doctors spent with you during labor 1 2 3 4 5 Comments:

29. The attitude of the nurses in labor and delivery 1 2 3 4 5 Comments:

neither satisfied very nor very dissatisfied dissatisfied dissatisfied satisfied satisfied

30. The attitude of the doctors in labor and delivery 1 2 3 4 5 Comments:

31. The nursing staff's sensitivity to your needs during labor and delivery 1 2 3 4 5 Comments:

32. The medical staff's sensitivity to your needs during labor and delivery 1 2 3 4 5 Comments:

33. Overall, the care you received 1 2 3 4 5 during labor and delivery Comments:

34. Overall, how satisfied or dissatisfied are you with your 1 2 3 4 5 childbirth experience? Comments:

35. Name what contributed to your overall satisfaction/dissatisfaction with your childbirth experience. ______

36. Using the items you named in question #35 above, number them in order of importance. Place "1" in front of the item which contributed the most to your satisfaction/dissatisfaction; place "2" in from of the next most important item and so on until you number all of the items.

37. Generally, was your labor experience like what you expected it would be? (Circle one answer code.)

Not at all like I expected it to be 1 Very little like I expected it to be 2 Somewhat like I expected it to be 3 Just like I expected it to be 4

Comments:

38. Generally, was your delivery experience like what you expected it would be? (Circle one answer code.)

Not at all like I expected it to be 1 Very little like I expected it to be 2 Somewhat like I expected it to be 3 Just like I expected it to be 4

Comments:

39. Overall, would you rate our labor as being primarily a positive or primarily a negative experience? (Circle one answer code.) It was very negative 1 It was somewhat negative 2 It was somewhat positive 3 It was very positive 4

Comments:

40. Overall, would you rate your delivery as being primarily a positive or primarily a negative experience? (Circle one answer code.) It was very negative 1 It was somewhat negative 2 It was somewhat positive 3 It was very positive 4

Comments:

THANK YOU!

Appendix E

The Breastfeeding Personal Efficacy Beliefs Intervention ID# For each of the following statements, please choose the answer that best describes how confident you are/were with breastfeeding your new baby. Please make a mark along the line that is closest to how you feel. Note: The following questions apply to mothers who have either stopped breastfeeding or are in the process of breastfeeding.

1. I can improve my baby’s health by breastfeeding I l 0% 50% 100% Cannot Do Might Do Certain Can Do

2. I can get information about breastfeeding if I want it. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

3. I can breastfeed my baby at the mall. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

4. I can breastfeed my baby with extended family present. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

5. I can breastfeed my baby with immediate family members present. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

6. I can pump breast milk at work and save it for my baby. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

7. I can breastfeed my baby through a growth spurt. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

8. I can make enough milk no matter the size of my breast. I l 0% 50% 100% 58

Cannot Do Might Do Certain Can Do

9. I can have an attractive body while I breastfeed. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

10. I can learn to get my baby on and off the breast. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

11. I can make milk that is safe for my baby. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

12. I can eat mostly as I please while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

13. I can get help caring for my baby from others while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

14. I can expect support from my baby’s father for breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can

15. I can improve my baby’s intelligence by breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

16. I can have a pleasant experience while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

17. I can breastfeed my baby during the nighttime. I l 0% 50% 100% 59

Cannot Do Might Do Certain Can Do

18. I can save money by breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

19. I can take most drugs that I need while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

20. I can bond easily with my baby while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

21. I can ease my return to work by breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

22. I can do most activities while breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

23. I can provide all my baby’s food for several months by breastfeeding. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

24. I can breastfeed my baby right after birth. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

25. I can breast feed my baby for three months. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

26. I can breast feed my baby for six months. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

27. I can breast feed my baby for one year. I l 0% 50% 100% Cannot Do Might Do Certain Can Do

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