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 in Child Development by Nastaran Milani SPRING 2017 DOULA SUPPORT, CHILDBIRTH SATISFACTION, AND BREASTFEEDING SELF-EFFICACY AMONG IRANIAN WOMEN A Thesis by Nastaran Milani Approved by: __________________________________, Committee Chair Sheri E. Hembree, Ph.D. __________________________________, Second Reader Kristen Alexander, Ph.D. _______________________ Date ii 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 by 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 v 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. viii 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 ix 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 x 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 xi 1 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