North American Nurses' and Doulas' Views of Each Other

"We Are All There to Make Sure the Baby Comes Out Healthy":: A Qualitative Study of Doulas' and Licensed Providers' Views on Doula Care

Policymakers are exploring ways to expand access to doula care to address persistent inequities in maternal and infant health across the United States. Doulas are non-medical professionals who provide physical, emotional, and informational support to birthing people before, during and after childbirth. Growing evidence supports the role of doulas in improved birth outcomes. Delaware is among several states moving towards Medicaid reimbursement for doula care to serve those most at risk. Objective: To gain an in-depth understanding of key stakeholders' knowledge, attitudes, beliefs and experiences regarding doula training and certification, relationships among providers, and other potential needs related to infrastructure to identify areas of agreement and inform policy change in the state of Delaware. Methods: We conducted focus groups with 11 doulas and key-informant interviews with 12 licensed providers practicing in Delaware, including six nurses, four physicians and two certified nurse midwives. Qualitative data was collected via Zoom (video conferencing) between September 2022 and April 2023. Results: Analysis revealed themes related to training, credentials and competencies of doulas, including cultural competence; logistical, administrative, and financial considerations for policy and practice change; and the whole care team-relationships between doulas and medical partners, and opportunities for growth. Conclusions: Doulas and licensed providers agree on key elements of doula training, the value of certification, the need for financial support, and the importance of relationship-building across the care team. Policy implications: Areas of agreement among stakeholders provide a foundation for state leaders to move forward to ensure the delivery of the most accessible, high quality, and culturally competent doula care for birthing people in Delaware.

Readiness to Implement a Doula-Hospital Partnership Program

OBJECTIVE

To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program.

DESIGN

Survey of obstetric clinicians and leaders before implementation of the doula program.

SETTING/LOCAL PROBLEM

Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality.

PARTICIPANTS

Obstetric clinicians and leaders (N = 48).

INTERVENTION/MEASUREMENTS

We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis.

RESULTS

Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics.

CONCLUSION

Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

'Do we need doulas…?' - Perspectives of maternity care managers on the role of doulas in Poland

AIM

The purpose of this study was to analyse perinatal care managers' perspectives on the role of doulas in Poland and to consider how managers' perspectives might affect the opportunities for doulas to practice in individual hospitals.

DESIGN

This is a qualitative descriptive study.

METHOD

The total of 17 hospitals was selected for the study. Semi-structured interviews were conducted with 11 manager staff members.

RESULTS

Three groups of facilities were identified: '0' (n = 6) - refused to give interviews, 'A' (n = 8) - marginal experience in working with doulas, and 'B' (n = 3) - regular experience in working with doulas. The hospitals from Group A showed indifference towards working with doulas. Group B declared a positive attitude towards such cooperation. Attitudes towards doulas vary among executives and are related to the frequency of doula-assisted births. Our results indicate factors that may influence the attitude of medical staff towards doulas and which may contribute to improve future initiatives meant to facilitate collaboration between midwives and doulas.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the lived experiences of perinatal care managers.

Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies

BACKGROUND

A doula is a person who provides support to women in the perinatal period without providing medical services. During childbirth, the doula becomes a member of the interdisciplinary team. This integrative review aims to analyse the nature of the cooperation between doulas and midwives, its efficiency and challenges and ways of strengthening this cooperation.

METHODS

A structured integrative review of empirical and theoretical studies written in English was conducted. The literature search included MEDLINE, Cochrane, Scopus, ProQuest, Science Direct, Web of Science, and Embase Health Source: Nursing/Academic Edition databases. The analysis included papers published in 1995-2020. Dedicated documents were searched for different combinations of terms and standard logical operators. A manual search of the studies was included for additional references.

RESULTS

Twenty-three articles from 75 full-text records were analysed. Three main themes emerged. (1) doulas are needed to prop up the system (2) barriers in collaboration between midwives and doulas; and (3) how cooperation between midwives and doulas can be strengthened. None of the articles referred directly to the impact of collaboration between midwives and doulas on the quality of perinatal care.

CONCLUSION

This is the first review to analyse the impact of collaboration between midwives and doulas on the quality of perinatal care. Ensuring adequate collaboration between doulas and midwives requires effort from both of these professional groups and the health care system. However, such collaboration is supportive for birthing women and the perinatal care system. Further research in terms of the impact of this collaboration on the quality of perinatal care is needed.

Community-based doulas for migrant and refugee women: a mixed-method systematic review and narrative synthesis

BACKGROUND

Community-based doulas share the same cultural, linguistic, ethnic backgrounds or social experiences as the women they support. Community-based doulas may be able to bridge gaps for migrant and refugee women in maternity settings in high-income countries (HICs). The aim of this review was to explore key stakeholders' perceptions and experiences of community-based doula programmes for migrant and refugee women during labour and birth in HICs, and identify factors affecting implementation and sustainability of such programmes.

METHODS

We conducted a mixed-method systematic review, searching MEDLINE, CINAHL, Web of Science, Embase and grey literature databases from inception to 20th January 2022. Primary qualitative, quantitative and mixed-methods studies focusing on stakeholders' perspectives and experiences of community-based doula support during labour and birth in any HIC and any type of health facility were eligible for inclusion. We used a narrative synthesis approach to analysis and GRADE-CERQual approach to assess confidence in qualitative findings.

RESULTS

Twelve included studies were from four countries (USA, Sweden, England and Australia). There were 26 findings categorised under three domains: (1) community-based doulas' role in increasing capacity of existing maternity services; (2) impact on migrant and refugee women's experiences and health; and (3) factors associated with implementing and sustaining a community-based doula programme.

CONCLUSION

Community-based doula programmes can provide culturally-responsive care to migrant and refugee women in HICs. These findings can inform community-based doula organisations, maternity healthcare services and policymakers. Further exploration of the factors that impact programme implementation, sustainability, strategic partnership potential and possible wider-reaching benefits is needed.

Birth Companions: Teaching Nursing Students to Become Doulas

The benefits of continuous labor support have been repeatedly discussed in the literature and supported by professional obstetric organizations. At the Johns Hopkins University School of Nursing, students are offered the unique opportunity to learn how to be a doula. The Birth Companions program provides nursing students the opportunity to develop knowledge and skills to provide continuous labor support to women of Baltimore and surrounding areas. This faculty-led, student-run program also supports student engagement in service learning, and practice regarding leadership skills and interprofessional collaboration as a student nurse.

Peer doula support training for Black and Indigenous groups in Nova Scotia, Canada: A community-based qualitative study

OBJECTIVES

The objectives of this qualitative study were to explore participant experiences of doula training programs offered by a prisoner health advocacy organization and Indigenous and Black community groups.

DESIGN

This investigation employed a qualitative design. Recruitment was conducted through email. Interviews were conducted in Winter 2020. Data were analyzed using thematic analysis.

SAMPLE

A total of 12 participants were recruited to participate in this study. Six participants identify as Black and six identify as Indigenous. All participants identify as women.

MEASUREMENTS

Qualitative interviews were conducted using a semi-structured interview guide to elicit a breadth of information.

RESULTS

Key themes included training experiences, training improvements and ''bridging the gap''. The training validated participants' experiences of birth and began to address the exclusion of Black and Indigenous people from birth work. However, participants expressed concerns about not being adequately positioned for sustained participation in birth work.

CONCLUSIONS

Participants expressed receiving great value from the training programs. These trainings, which were fully subsidized, removed a financial barrier. However, these trainings do not address the exclusion of Black and Indigenous people from perinatal work or the lack or sustainable support systems for Black and Indigenous communities. This study makes several recommendations for future interventions.

On the Outside Looking In: A Global Doula Response to COVID-19

From around the world, doulas report the impact of new COVID-19 restrictions on their ability to provide continuous emotional, physical, and informational support to pregnant people and their families. In a qualitative survey conducted in March and April 2020, we heard from over 500 doulas in 24 countries. Doulas practicing across the world revealed rapid changes to hospital policies. Even accounting for different public health responses across countries, the doulas in our study pointed to one common theme - their absence at births and the subsequent need to support birthing people virtually. In a follow-up survey and in interviews we conducted in July, we reconnected with doulas from our initial study to track their access to institutional birthing spaces. As countries experienced the effects of "flattening the curve," we found that doulas were still not considered "essential" workers and the majority could not attend births. Our research shows that doulas have ambiguous feelings about the efficacy of virtual support, that they raise concerns about the long-term impact of COVID on their profession and that they are concerned about mistreatment and obstetric violence as birthing people enter hospitals alone.

A Labor Support Workshop to Improve Undergraduate Nursing Students' Understanding of the Importance of High Touch in a High-Tech World

This article presents the development and evaluation of a labor support workshop aimed at providing senior undergraduate nursing students with education on the provision of labor support. In collaboration with a Lamaze educator, a two and half hour interactive educational session was developed. The workshop included both a didactic and a hands-on component which included physical labor support strategies, which could be utilized in the clinical setting. Pre-and postintervention data was collected on students' knowledge and self-efficacy in the provision of labor support, as well as, data on their use of these strategies while in the clinical setting. The labor support workshop was well received by students (4.9/5) and increased their self-reported knowledge (p = <.001) and self-efficacy (p = <.001) in the provision of labor support.

Attitudes of Physicians, Midwives, and Nurses About Doulas: A Scoping Review

INTRODUCTION

Evidence supports numerous positive clinical benefits of doula care. There are varying attitudes among physicians, midwives, and nurses toward support of doulas in a collaborative approach with women in labor. Tension and conflict with use of doulas may occur in some intrapartum settings in the United States.

METHODS

A scoping review of the literature between January 2008 and January 2018 was conducted using PubMed, CINAHL, Google Scholar, and Scopus database to identify specific attitudes of physicians, midwives, and nurses toward doulas; 1,810 records were identified and initially reviewed. Inclusion criteria included original research published in the last 10 years and in the English language. Articles were excluded if the research was not original and if obstetrical providers' or nurses' attitudes toward doulas were not included.

RESULTS

Three records met criteria for inclusion. All used a cross-sectional survey design. Two were set in Canada exclusively and one was inclusive of nurses and doulas in both Canada and the United States. Themes emerged that may explain the influence and variances in attitudes toward doulas and the support they provide to laboring women.

CLINICAL IMPLICATIONS

More research is needed to identify attitudes of members of the maternity care team toward doulas and to better understand implications of their attitudes on working together collaboratively and on patient outcomes.

Doulas in the Operating Room: An Innovative Approach to Supporting Skin-to-Skin Care During Cesarean Birth

INTRODUCTION

Skin-to-skin care (SSC) immediately after birth is recommended for all women and their newborns. Barriers to SSC after cesarean birth lead to delays in initiation of this practice. The purpose of this quality improvement project was to implement an innovative approach with volunteer doulas to support initiation of SSC after cesarean for all clients.

PROCESS

Volunteer doulas in a well-established hospital-based program within an academic health center were trained to provide care during scheduled cesarean births in the operating and recovery rooms. Data on rate and time of SSC and client and nurse satisfaction were collected for a 12-week period.

OUTCOMES

Sixty-six women received doula-supported care in the operating room. All medically stable woman-newborn couplets with complete data (N = 58) initiated SSC in the operating room and were included in the data analysis. Forty-eight women completed a feedback survey after birth. Scores indicated that clients agreed or strongly agreed that the doula was an important part of the birth experience. Feedback from labor and delivery nurses indicated highly positive attitudes about the importance of SSC and the presence of volunteer doulas. All nurses surveyed who had participated in doula care (n = 20) agreed or strongly agreed that they were satisfied with the doulas and that the doulas were prepared for this role.

DISCUSSION

This project demonstrates that volunteer doulas can be prepared to provide supportive care to clients during and immediately after cesarean birth. Doulas can play an integral role in supporting the initiation of SSC after cesarean birth and are perceived as an important member of the maternity health care team by clients and nurses.

Fostering Collegial Collaboration Between Labor Nurses and Doulas

Nurses and doulas do not always have positive views of each other. When labor nurses face challenges in their ability to provide continuous labor support, one might believe that a doula would be welcomed, yet this is not always true. Conflicts can arise between nurses and doulas, often because of overlapping roles. However, an optimal health care system is one for which there is an integrated system that fosters collegial interprofessional collaboration. This commentary explores the role of doulas and the care they provide and describes strategies to promote collegial relationships between nurses and doulas.