Introduction
Normal childbirth is a uniquely personal experience. The childbirth experience is carved in the mother’s heart for a lifetime and is associated with a woman’s entity as a mother. Therefore, all women should have the opportunity to go through a positive pregnancy and childbirth and have a pleasant experience [1, 2]. 
There are numerous ways to improve a mother’s experience of childbirth. Continuous support is one of them. The quality of the support that the expectant mother receives during labor and delivery is a sufficient reason for her experience. There has long been an emphasis on the necessity of support for the mother during delivery and the expectant mother’s companions. However, the possibility of these supports has decreased in hospital deliveries [3]. 
Support during delivery can be provided by any person with whom the expectant mother feels comfortable (family, spouse, friend, or doula) [4]. An accompanying midwife (doula) is a trained person who attends mother during childbirth to support her. From the mother’s point of view, the doula seems like a good listener and understands the mother’s condition. She is a person who promotes the mother’s self-confidence. A doula provides no medical interventions in the delivery room. Her duty is to offer spiritual support, provide counseling, and render assistance for physical and emotional improvement [5]. 
Providing continued support for the expectant mother and correct and appropriate information during labor and delivery result in the mother’s comfort and tranquility and help her to identify the source of pain correctly and consider childbirth as a positive life event [6]. Several studies showed that mothers supported by doulas were happier and more satisfied with their childbirth experience [7, 8, 9]. 
A study by Kazemi Robati et al. showed that the presence of a trained doula could reduce stress and pain during childbirth [10]. The type of support that doulas provide for pregnant women depends on the country’s culture too. Because there are different aspects to the expectant mother’s experience, it is necessary to conduct qualitative studies to enrich the data on this topic [11]. The rate of elective C-section is high in Iran for different reasons, including lack of proper support for the mother during delivery [12]. 
The study of Akbarzadeh et al. in Iran shows that the effect of doula support in labor compared to acupressure use leads to a further reduction of anxiety and improved delivery outcomes [13].
Iranian pregnant women infrequently use the services offered by doulas, which are provided at their expense if they choose to use them. Moreover, doulas’ services are not available in all hospitals. Furthermore, in hospitals where doulas are present, their presence in the ward is limited to the labor process and the beginning of the postpartum period. Thus, there is not much information about the experience and understanding of delivery with the support of a doula [14].
Childbirth is a unique experience for each person, and everyone understands it differently. To deeply understand mothers’ feelings, a qualitative method was chosen [15]. We conducted this study to determine the expectant mothers’ experience and understanding of normal vaginal delivery with the support of a doula in an Iranian setting. The findings of this study can help clarify the various dimensions of the doula role.
Materials and Methods
This research was a qualitative study with a content analysis approach and was conducted in a hospital in Zanjan Province, Iran, where pregnant mothers can choose a doula before going through labor. The participants were selected from Iranian nulliparous or multiparous women aged 18 years and above who gave birth within the last six months. In this way, they could recall and describe their experience of delivery with the support of a doula and were willing to participate in the study. Mothers unable to describe their experience due to fatigue or lack of opportunity did not enter this study. The doula was present on the mother’s bed from the active phase of labor until two hours after delivery. 
The participants were invited to the study using a telephone call. Their contact information was obtained from documentarians and the postpartum admissions office. Data collection lasted for 6 months, from January 2018 to June 2019. The data collection method was an in-depth semi-structured individual interview with postpartum mothers. The participants entered the study after obtaining informed consent and explaining the study objectives if they met the inclusion criteria. Sampling was performed by a purposeful method. The participants were informed about voluntary participation in the study. The interviews with the participants were recorded. The participants were informed and assured of the study objectives and confidentiality of the interview and the results. Then, written informed consent was obtained from them. The study data were collected using in-depth semi-structured individual and face-to-face interviews in one session until data saturation was reached. The interview guide was initially set up. The place and time of the interview were in a room in the postpartum ward. Before each interview, questions were asked about demographic characteristics. The interview started with communicating and gaining the participants’ trust with the question, “How was your experience of giving birth with a doula’s help?” In addition, some exploratory questions were used, such as “what do you mean?” or “please explain more if you can.” 
The mothers were free to express their ideas and opinions using their expressions and words. The researcher used probing questions whenever a deeper understanding of the sentences and concepts stated by the participants was desired. After 13 interviews, the researcher found no new data. For further assurance, three more interviews were conducted. Totally, 16 participants were enrolled in the study. The interview to determine the mothers’ experience and understanding of the support of a doula during labor and delivery started with the question, “what was your experience of delivery with the support of a doula?” and continued with the following probing questions:
Was the doula’s support in your delivery process helpful to you?
How did the doula accompany you in childbirth? Please explain to me. 
How did you feel when she was with you in labor?
What were the pros and cons of this experience for you?
The questions changed as more interviews were conducted and new questions were added to the interview guide. “What were the advantages and disadvantages of doula’s support for your family members?”
The first three interviews were done as pilot interviews. Each interview took about 60-90 minutes. All interviews were recorded with the participant’s permission and listened to carefully, and finally transcribed verbatim for use in the analysis. 
Data analysis was done in parallel with the interviews according to the method proposed by Graneheim and Lundman [16]. After transcribing the interviews, the entire text was read to gain a general understanding of its content. Then, the meaning units and preliminary codes were determined, and similar preliminary codes were classified into broad subcategories. Next, the main categories were generated by discovering the patterns between subcategories. 
Several strategies were applied to improve the study’s validity, including listening to and reading the interviews several times, using the participants’ views, and the external check. For external check, part of the data was presented to participants and researchers that were not involved in the research as external referees to make sure that they also had a similar understanding of the data.
Results
The number of participants was 16. All interviews were conducted in one session, so 16 interviews were obtained. The participants were 18-35 years old (Mean±SD age: 27.5±6.7 years). Three women had a primary school education, 7 had a high school diploma, and 6 had a university education. Four women were employed, and the rest were homemakers. The majority of the women were city dwellers, and only three of them lived in rural areas. 
In general, 101 preliminary codes were extracted. Subcategories were developed through analysis of birth experiences with the support of doulas, which were merged into four main categories: comprehensive support, assisting in materializing the motherhood dream, internal reinforcement, and mother-centered care. The subcategories are presented in Table 1.


Some participants’ statements and their reasoning are shown in the following Table.
Comprehensive support
The participants believed that “support” was one of the most significant roles of doulas. Comprehensive support has two subcategories of mental and physical support.
Physical support: The mothers felt physically calmer with the help of doulas and experienced less pain.
“she told me how to breathe through the pain. My doula performed the exercises and helped me.” said participant number 3.
“The massage and exercises she gave me made me feel less pain.” said participant number 8. 
Mental support: Doulas provided good mental support for the mothers. The mother had a companion and supporter and felt she was not alone.
“When she came in, she told me what would happen. I was prepared, and she did not leave me alone at any stage. When you are in the worst pain, she holds a kind hand in your hand that helps you, does not get tired of your nagging, is not hurt by your screams, and tries to help you.” said participant number 5. 
“My mom was always worried and scared; she could not give me a message and left me whenever I screamed. The presence of the doula made me relieved.” said participant number 6. 
Assisting in materializing the motherhood dream
This category had two subcategories: passing through the darkness and being released from pain and suffering.
Inducing the calm in the mother: Participants said the presence of the doula was like a guide to the mothers that passed them through the dark and horrifying path of delivery.
“I was like traveling to a foreign country, you don’t know any place or their language, but then someone comes to help and show you where you want to go.” said participant number 4. 
“My doula helped me endure the pain of childbirth and have a good experience.” said participant number 5.
Being released from pain and suffering: according to study interviews, the mother forgot her pain with the doula support. 
“For a moment, I thought I was at the gym. I forgot I was there to give birth. I do not mean to say I had no pain, but it was not like my previous delivery. I suffered a lot during my previous childbirth. The doula helped me feel happy after birth.” Said participant number 2.
“My doula helped me pass through the darkness into the light. When my child was born, I liked back and saw that all the pains and screams were gone, and there were only light and sweetness.” said participant number 9. 
Internal reinforcement
According to expectant mothers, perhaps the most important experience with doulas was creating a feeling of internal reinforcement, which had two subcategories: acceptance of pain and self-esteem. 
Acceptance of pain: participants in this study believed that the doulas empowered them to deal with childbirth, accept their experience, and try hard to succeed. 
Self-esteem: according to interviews with participants, the mother developed a belief in her doula support and was saved from concerns about failure, lack of success, and unfamiliarity with the ward or delivery process. 
“I managed to have a vaginal delivery. My doula gave me hope that I could do it; I felt contented and happy.” said participant number 7.
“I can still give birth naturally. This time I am strong. Even I can motivate my sister to choose natural childbirth.” said participant number 11.
“I listened to my doula and had a vaginal delivery, which made me believe in my power. I was always afraid I would be stuck during the delivery process and could not continue.” said participant number 13. 
Mother-centered care
This category had two subcategories: Doula as a different supportive and bidirectional relationship.
Doula as a different supportive: An interesting point that the mothers mentioned was that the doula guided them through the delivery path and helped them have a safe childbirth using her knowledge and expertise. Most of the mothers stated that their other companions could never offer the support provided by the doulas.
“My mom was always worried and scared; she could not give me a message and left me whenever I screamed. The presence of the doula made me relieved.” said participant number 6. 
“They gave me much training, appropriate and timely training, about the exercises and breathing techniques, child care, breastfeeding, etc. I was sure what I was doing was safe for me and the baby.” said participant number 2. 
Bidirectional relationship: The mothers found themselves at the center of attention and care with the support of doulas. They stated that their relationship with their doulas was completely bidirectional, and nothing was forced or imposed on them. 
“My doula listened to me and cared about my opinion. She did not seek to monitor the fetal heart rate as quickly as possible and left. She explained, and I chose. She maintained eye contact with me. She asked me what comforted me.” Said participant number 7. 
“The midwife and the doctors sometimes spoke to me firmly and compulsively, but the doula always asked my preferences,” said participant 8.
Discussion
The present study was conducted to determine the expectant mothers’ experiences of delivery with the support of doulas. The results showed four main categories: comprehensive support, materializing the motherhood dream, internal reinforcement, and mother-centered care. This study found that all mothers received adequate support and were satisfied with the doulas. Massage, breathing techniques, assisting with getting up and sitting, and keeping company during different activities were some examples of physical support provided by doulas.
Delivery is considered a special event in a woman’s life, requiring continuous and individual support and care [17]. As a result of the presence of the doulas, the mothers felt more physically comfortable and experienced less anxiety. The doulas reduced the mothers’ fear of the unknown and guided them toward the limits of pain tolerance, which was childbirth. The mothers were free of pain and fear and saw themselves indebted to the doulas for this freedom. The continued presence of the doulas, as well as their physical contact, assurance, explanations, and guidance, reduced the mothers’ anxiety during delivery [18].
This finding is similar to the results of many studies investigating the role of doulas in the normal vaginal delivery process. According to these studies, the doula’s presence was associated with increased mental and physical tranquility, reduced maternal anxiety, and improved pregnancy outcomes [19, 20]. 
In one study, the mothers even stated that the support was not limited to them, and the doulas also offered relief to their husbands and family members by providing emotional support [4]. According to the Swedish women’s experience of doula support, all mothers’ needs during labor were described as puzzle pieces, with the doula being an essential missing piece. The doula was considered a mainstay and a source of support [21]. Support for the mother is an important step in the delivery care cycle, satisfaction, and the process of care quality. 
The rate of C-section is high in Iran [22]. An effective solution to reduce unnecessary C-sections is to increase satisfaction with normal vaginal delivery by using the services offered by doulas dosing delivery. De Sousa et al. conducted a study in Brazil, which was very similar to Iran, regarding the choice of C-section as the preferred delivery method. They found that the doula’s presence was necessary and considered an excellent strategy for supporting normal delivery and popularizing it [23].
Self-esteem and acceptance of pain were two subcategories of internal reinforcement. The doula empowered the mother to come to terms with delivery, accept this experience, and try hard to accomplish it. Doulas empowered them to deal with childbirth, take their experience, and try hard to succeed. The mother believed it was a physiological process and that “she could handle it.” A woman who was once frightened and restless and was always thinking of a way to undergo a C-section was now calm and peaceful. This point is very important since when an expectant mother accepts that she can take an active part in managing her childbirth, she accepts that normal vaginal delivery will be a good experience for her, like other mothers and that normal vaginal delivery is a possible and viable option. Studies have shown that self-esteem is a very influencing factor in the childbirth experience and the mother’s satisfaction. The mothers that benefit from doula support during delivery have higher self-confidence and are capable of taking better care of themselves and their infants [23]. Some studies have shown that the doula’s presence improves how the mothers feel about themselves and enhances their self-efficiency [24, 25, 26].
Although delivery is a physiological process, it may be associated with severe pain and uncertainty and failure, and the mother may feel lonely and vulnerable during delivery. In this case, the mother’s lack of control over the fear negatively affects maternal and neonatal outcomes [27].
Mother-centered care was another emerged category, which had two subcategories: safe motherhood and bidirectional relationship. The mother experienced a safe delivery with the doula support and was not worried about her and her baby’s life. In general, increasing the participation of mothers in decision-making helps them believe that a correct decision has been made for them and implemented appropriately. Providing a clear explanation about unexpected events improves the mother’s feeling of safety, which has become possible through doulas [28]. Many mothers preferred the presence of a doula, even to their family members, during childbirth. The reason could be the companions’ lack of knowledge about safe delivery, excess concerns about the pregnant woman, tenderheartedness of the companions, tiredness, and boredom, which the doula easily covers.
The expectant mother asked the doula whatever was on her mind, and the doula addressed all mother’s needs with her experience and expertise. When a pregnant woman is aware of what is going to happen, how intense the pain is going to be, and what the labor stages will be, she will believe in her abilities, especially considering that the doulas had diverse experiences and it was easy for them to answer pregnant women’s questions such as “What happens if the labor does not advance?”, “Why don’t they perform a C-section?” and “My water broke; will my baby suffocate?”
The doula’s interaction with the mother has an important effect on maternal and neonatal outcomes, and a good relationship improves the quality of care. The doctors and nurses sometimes left the mothers or did not make an intimate relationship with them and only performed the required procedures. Although the mothers interacted with doulas in all delivery stages, they had the right to know and decide in all processes. 
 A doula has a key role in the care of a pregnant woman. She places the pregnant woman in the center of attention and satisfies her needs. Nothing is forced or imposed on the mother, who makes informed choices. 
According to the present study, all mothers were satisfied with doula support during delivery. The doula’s presence made childbirth a positive and satisfactory experience. The doula guided mothers from fear, pain, and ignorance to happiness and satisfaction. Therefore, the doula’s presence during delivery may have positive effects. Considering the positive results, the services provided by doulas should become widely available to expectant mothers. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Tehran University of Medical Sciences (ethical code: IR.TUMS.FNM.REC.1398.143). 
The researchers assured the mothers about data confidentiality. They informed the mothers of their right to leave the study at any time during the study. The doula was present on the mother’s bed from the active phase of labor until two hours after delivery.

Funding
This study was financial supported by Tehran University of Medical Sciences (98-01-2841626).

Authors' contributions
Conceptualization and supervision: Zahra Behboodi Moghadam; Methodology: Mahsa Khoshnam Rad and Solmaz Heydari Fard; Investigation, writing-original draft, and writing-review & editing: All authors; Data collection: Mahsa Khoshnam Rad and Solmaz Heydari Fard; Data analysis: Mahsa Khoshnam Rad, Solmaz Heydari Fard, and Zahra Behboodi Moghadam; Funding acquisition and resources: Zahra Behboodi Moghadam.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors wish to thank the mothers who participated in the interviews.

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