Abstract
Doulas provide individualized support during labor and childbirth. Research has consistently shown that having doulas support increases positive physical and psychological outcomes. Professional medical organizations have begun to recognize the evidence showing the positive effects of doula support. Even though professional organizations recommend doulas to reduce non-medically indicated treatments such as overuse of cesarean delivery, many practitioners uphold their authority to intervene as they see necessary. I utilize interviews with 25 doulas to explore how doulas use scientific evidence to ensure that women receive appropriate care. Results indicate that doulas do not think that many obstetricians follow evidence-based practices; doulas feel compelled to serve as overseers who remind medical staff about the clinical guidelines. In addition, doulas use evidence to prepare mothers to confront providers. I argue that while doulas can help close gaps, obstetric medicine needs to implement evidence-based strategies more systemically to improve care for all women.
This article explores how doulas use evidence-based medicine (EBM) to secure the best care for mothers. Doulas support women during labor and childbirth. They do not provide medical advice or services; their role is purely supportive. Doulas learn much about the science of childbirth and effective care approaches, using their knowledge to implement evidence-based strategies for helping women. Doulas subscribe to a model of care that focuses on limiting the use of interventions in low-risk births that could cause physical or psychological harm. In this way, doulas seek to use evidence to improve the experiences of women giving birth in the United States.
Maternal health in the United States lags behind that of other industrialized nations. Historically, obstetricians (physicians who deliver babies) have overtreated some women, while overlooking needs among others (Taylor 2020). Such inequalities in care and tendencies toward overtreatment persist today. While social, structural, and environmental factors cultivate inequalities in health care policies and practices, organizations can have profound effects on the care that people receive. The United States has a strikingly high maternal mortality rate (Peterson et al. 2019); to address this, in recent years, The American College of Obstetricians and Gynecologists (ACOG 2019) and other professional organizations have started to reassess obstetric medicine and have launched efforts to standardize care.
Professional organizations have begun to recognize that doulas can be instrumental in improving birth outcomes. Research shows that doula-attended births are associated with more positive results. On average, women who have doulas experience shorter labors, less need for pain medication, and they are less likely to have cesarean (surgical) deliveries (ACOG 2014; Bohren et al. 2017). Women who utilize doulas have also reported lower rates of depression (Wolman et al. 1993). While results are largely attributable to labor support, some outcomes may also be credited to doulas’ support for fewer non-medically indicated interventions in birth. Professional organizations now recommend doulas for helping to reduce non-medically indicated treatments like overuse of cesarean section (ACOG 2014).
Doulas can be instrumental in helping women receive the care that they want and require. However, some obstetricians and nurses may be less familiar with what doulas offer and may not see them as necessary for their patients. Doulas must continue to justify their contributions to gain acceptance in labor and delivery rooms so that they can support more women in need. In this article, I look at how doulas use evidence-based medical research to validate their approaches. 1 I use interviews with 25 doulas to explore the following question: How do doulas use scientific evidence to ensure that mothers receive the best care?
Literature Review
Doulas
A doula is a “trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth” (DONA International 2021). Unlike physicians or midwives, doulas do not have medical training and they do not deliver babies; their role is purely supportive (Klaus, Kennell, and Klaus [1993] 2012; Meltzer 2004; Morton and Clift 2014). In most hospital births, the medical staff focus on the healthy delivery of the baby, with less attention toward the emotional care of the mother. Doulas provide continuous support to mothers throughout labor and delivery. Although doulas focus on non-medical care, they provide support for women who have both medicated and unmedicated births, and planned or unplanned cesarean births as well.
Medical research and public health reports have shown substantial benefits from using doulas. Early randomized controlled trials in the 1980s and 1990s revealed that having doulas frequently results in shorter labors, lower epidural use, and lower cesarean rates (Flamm, Berwick, and Kabcenell 1998; Gordon et al. 1999; Hodnett and Abel 1986; Kennell et al. 1991; McGrath and Kennell 2008). Randomized controlled trials, qualitative studies, and case studies from this time as well as more recent studies have found that women who hire doulas also report having higher self-esteem and express feeling more in-control and emotionally supported (Deitrick and Draves 2008; Manning-Orenstein 1998; Pascali-Bonaro and Kroeger 2004; Zhang et al. 1996). Cochrane Library, which compiles data from multiple peer-reviewed and evidence-based studies, continues to publish reviews that find that doulas do not cause harm and offer multiple benefits to mothers (Bohren et al. 2019; Bohren et al. 2017). Finally, the World Health Organization (WHO 2018) and the professional authority on obstetrics in the United States, the ACOG (2014), have come out in support of doulas for improving outcomes. A 2014 report from ACOG championed doulas as an important tool for lowering the cesarean rate in the United States. Numerous sources show that doulas play an important role in positive experiences and outcomes for birthing women.
Although various sources of scientific evidence indicate that doulas are associated with positive birth outcomes, doulas are underutilized in the United States. Surveys of mothers have found that although a majority of women have heard of doulas, fewer have doula-supported births (Declerq et al. 2013; Sakala et al. 2018). One constraint is cost. Research showing the efficacy of doulas has increased efforts by certain states (such as Florida, Minnesota, New Jersey, Oregon, Nebraska, Indiana, and California), insurers (such as Blue Cross Blue Shield), and professional organizations to provide access to doula services (Gourlay 2022; Platt and Kaye 2020; Robles-Fradet 2021). However, many women in the United States do not have access to free doula support and therefore have to hire doulas privately for fees ranging from a few hundred to a few thousand dollars, depending on the doula and the location (Morton and Clift 2014). Adding to cost barriers, although awareness of doulas has increased over time, many women still lack full understanding of the benefits that doulas offer (Sakala et al. 2018). Relatedly, while some women may have awareness and interest, there may not be enough doulas available for all women giving birth (WHO 2018). Access can keep women with interest from benefiting from doula services.
In addition to access barriers, hesitancy from physicians and labor and delivery nurses can impede women’s use of doulas. Doulas were less common in the past, but in recent years, more research has lent greater legitimacy to doula care, leading to increased efforts to implement their services (Robles-Fradet 2021). Even though WHO and ACOG support the use of doulas, “rank-and-file” obstetricians may not fully assume the recommendations of “medical elites” (Armstrong 2002; Freidson 1984). In practice, obstetricians maintain the authority to debate the evidence and recommendations from professional organizations (Timmermans and Berg 2003; Timmermans and Mauck 2005). Despite research from high-level professional authorities about the benefits of doula support, in-hospital physicians and labor and delivery nurses may not fully accept doulas as important members of the birth team (Roth et al. 2016), which can result in women not seeing their necessity. At the same time, everyday practitioners and staff may be hesitant to implement the less medical approaches that doulas promote.
EBM and Obstetric Care
EBM emerged in 1992 as a new “paradigm for medical practice” (Evidence-Based Medicine Working Group 1992:2420). The working group behind this new term criticized clinical decision-making for its reliance on individual experiences and preferences, and argued for reorienting all of medicine to focus on the best and latest research. EBM is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 1996). According to this definition, those who practice EBM use current empirical findings to inform their practices (Knaapen 2013). Physicians typically learn about evidence-based medical guidelines through their professional organizations, which encourage them to practice based on the latest research reports in conjunction with their own best judgment (Sackett et al. 1996). In this way, EBM serves as a standard of best practice for the twenty-first century that applies in assorted contexts.
EBM creates a standard of practice, but EBM is also produced continuously. Newer studies with updated information must be considered alongside existing research and also measured according to existing standards within professions (Timmermans and Epstein 2010; Timmermans and Mauck 2005). While some might assume that EBM standardizes care in a way that closes all debate, allowing for professional and individual input and autonomy produces some fluidity to what evidence dictates. Updating evidence and critically assessing the implications remains important for creating strong standards (Timmermans and Epstein 2010). Effective providers keep up to date on the evidence as well as upcoming directions for research and practice.
Obstetric medicine is a unique medical specialty. It emerged during the nineteenth century in response to economic pressures facing medicine. To create a new medical market, physicians used the fear that many women have about childbirth to reframe it as a “dangerous” process in need of the oversight of a medically trained practitioner instead of a midwife (Starr 1982; Wertz and Wertz [1977] 1989). Important to this reframing was the inherent professional authority of obstetricians to determine the best approaches. From early on, obstetrics has allowed physicians to individualize approaches to treatment of patients rather than strictly adhere to standards. This has led to overtreatment, and especially overuse of cesarean delivery (Morris 2016; Roth and Henley 2012). At the same time, obstetricians have neglected necessary treatment to many “vulnerable” patients (usually poorer women and women of color) whose needs are often overlooked (Lu and Noursi 2021). Due to their advanced education and their exclusive credentials, obstetricians have enjoyed a professional and cultural authority that has allowed them to be the best judges over others’ care, and use their own discretion to deliver babies as they prefer (Epstein and Timmermans 2021). The EBM movement arose to establish standards that would result in the best care for patients (Pope 2003; Timmermans and Berg 2003). However, obstetric medicine has lagged behind other medical specialties in the move to follow evidence-based guidelines (ACOG 2019; Talaulikar and Nagasekar 2012). Despite recent movements to decrease the number of non-medically indicated treatments, obstetrics still lends physicians the autonomy to medically intervene as they see necessary (Reiger and Morton 2012).
At the same time, concern about increases in maternal mortality in recent years has resulted in obstetric medicine adopting more standardized approaches and making greater efforts to track and measure outcomes (ACOG 2019). The United States has an alarmingly high maternal mortality rate for an industrialized nation, and rates are highest among racial minorities (Peterson et al. 2019). In addition, racial disparities in maternal morbidity persist, increasing pressure on hospitals and obstetricians to adopt more standardized methods of care (Debbink et al. 2022; Lu and Noursi 2021). This leads to frequent debates about best practices. Some obstetricians disagree with EBM on different guidelines for preterm labor, induction, and when cesareans are needed, among other issues (Talaulikar and Nagasekar 2012). In addition, obstetrics lacks evidence from unbiased randomized controlled trials in some medical circumstances (Carmichael and Snowden 2019). This results in less evidence to consult in the first place, imparting many decisions to obstetricians. Physicians maintain the authority to determine the best approaches for treating their patients. Despite professional and hospital measures to create evidence-based standards of care to which practitioners must adhere, much of the authority and decision-making still rests in the hands of individual obstetricians.
EBM and Doula Care
Culturally, doulas may not seem like professionals following evidence-based protocols. Many stereotype doulas as “hippies” focused on nature over science (Schiller 2019). In fact, doulas who receive professional training learn much about the evidence-based ways to help women most effectively. Most doulas who become certified do so through DONA International. To get certified through DONA International, doulas must read at least seven books on labor support from a given list, complete a self-assessment of knowledge, submit a certificate of completion for a minimum of 16 hours of formal classroom training, and submit parent and provider evaluations and reflection essays from at least three births that they attended as trainees (DONA International 2021). Certified doulas learn much about the physiology of labor and delivery from the selected books and classroom training that they receive, and especially the researched-backed ways to support women during childbirth (Henley 2015). Doulas learn various methods for providing effective touch, encouragement, and support for individual women. Doulas are more scientifically informed than many realize and they use this information to serve women seeking more empowering birth experiences.
Doulas learn not only the evidence behind their role but also the evidence behind common approaches to labor and delivery care. Part of doula training includes education on the midwifery model of care, an evidence-based ideology in which low-risk births are treated as normal and needing minimal medical oversight (Davis-Floyd et al. 2009). In contrast, the medical model approaches medical treatment as a necessary part of labor and delivery. This approach can be life-saving in some cases, but overreliance on medical interventions like epidural (an injection that numbs pain signals), Pitocin (a hormone that speeds up labor), and cesarean delivery among others can result in avoidable physical complications as well as potential psychological distress (Declerq et al. 2008; DeGroot and Vik 2017; Morris 2016). In contrast, randomized controlled trials have shown that less reliance on medical interventions in labor can reduce needs for cesarean deliveries (Cheng et al. 2014; Gimovsky and Berghella 2016; Zhang et al. 2010). As part of their training, doulas read about the research on different treatments. The Doula Book, a book that most doulas read at least for certification requirements (DONA International 2021), details findings from multiple peer-reviewed scientific publications about the use of various medical approaches (Klaus et al. [1993] 2012). Evidence supports the use of treatments in medically indicated cases; doulas learn about these treatments and when they are needed (Henley 2015). Doulas offer research-backed support in addition to evidence-based perspectives on how to approach labor and delivery in ways that can improve outcomes for women.
Both obstetricians and doulas believe that their approaches are evidence-based even if the practices are oppositional. Part of this may be due to the fact that EBM lends final decisions to physicians. Obstetricians still have authority in the delivery room (Reiger and Morton 2012). Even though the cultural authority of medicine has shifted over time, it remains resilient in that most still inherently trust those dedicated to health care (Epstein and Timmermans 2021). Those who potentially challenge medical authority, either outright or through seeking alternative approaches, may sit on the margins of the birth arena. Research shows that quantification and the use of evidence can legitimate the work of those operating on the peripheries (Porter 1995; Reay 2007). Physicians have a long-standing expertise whereas newer agents of care, such as doulas, are still working to show medical staff that their approaches are legitimate. In this article, I explore how doulas use scientific evidence in their interactions with medical staff and clients to help women receive the most appropriate care.
Data and Method
Data
The data for this study come from a larger project on doulas and alternative knowledge. For this article, I focus on the data from in-depth interviews with 25 doulas from the southwestern United States. I conducted semi-structured interviews using a question guide, but I asked follow-up questions where needed and allowed participants to volunteer additional information. I asked doulas about their background, how they became doulas, how they viewed their role, and about the sources of their views about childbirth. For this study, I focus on responses to questions about the use of scientific evidence in doulas’ marketing and practices. See Appendix A for the interview guide.
I recruited doulas through local organizations, hospital and birth center postings, Web listings, and snowball sampling. I emailed organizations and individuals who might be willing to participate and invited them to partake in a research study on doulas. Participants volunteered to meet me for interviews, thus making the sample non-random. Although the sample is likely to suffer from selection bias, qualitative studies like this aim to understand processes and mechanisms underlying social phenomena rather than to produce highly generalizable results. Rather than attempt to characterize the experiences of the doula population as a whole, this research aims to understand the rationales that doulas have for relying on their knowledge sources and the experiences that doulas have with conveying their information to clients and to medical staff. 2
Obtaining a random sample of doulas would not be feasible because the number of doulas in a given area or in the United States as a whole is hard to calculate. Many doulas are not certified by national/international organizations and are therefore not listed on the Web sites of certifying organizations. In addition, many doulas work independently of any organization, making them difficult to locate in a systematic way. For those who do not publicize themselves and/or have their own Web sites, the only way to find them is through personal referrals, which is how I found four of the doulas in my sample. Overall, given that doula-attended births are uncommon, my sample of 25 doulas likely represents a high proportion of those who serve as doulas.
I used email and phone calls to arrange interviews with doulas during 2013 and 2014. Most interviews took place in-person but some took place virtually or by phone in cases of distance or an interviewee’s preference. We arranged to meet or talk at times convenient for both the researcher and the interviewees. With their signed permission, I audio recorded all interviews. I was able to hire a transcriber using funds awarded from an internal grant. I use pseudonyms for all the respondents discussed in this article. The Institutional Review Board at my university authorized all interview research protocol.
Method
To analyze the interview data, I reviewed the responses to the set of questions that I asked about evidence. I also combed through the transcripts for discussions of evidence that emerged in other parts of the interviews. Doulas used terms such as “evidence,” “evidence-based,” “science,” or “scientific evidence” interchangeably, and thus, I used these key terms to locate relevant discussions in other parts of the interviews. I also read through the full transcripts after searching for these key terms to check that I did not miss any relevant points. I completed this two additional times to ensure consistency.
I noted whether doulas emphasized scientific evidence in their views about doula support, whether they thought that their knowledge legitimated them to medical staff, and whether they emphasized their scientific knowledge in conversations with clients. I noted similar responses before I had completed my interviews and used this as a guide for achieving thematic saturation (Glaser and Strauss 1967). I found common themes that began to emerge within the first 12 interviews with each group, which supports previous research on structured interview methodology (Guest, Bunce, and Johnson 2006). Few new themes emerged after 20 interviews with doulas, and at 25, I found that I had sufficiently captured the ideas that I had set out to explore. Departmental peers at my institution provided guidance and approval for this method of analysis.
Results
“We’re All Science-based”
In Table 1, I provide a summary of the descriptive characteristics for the doulas that I interviewed. (A more detailed Table B1 appears in Appendix B.) The data in the table reveal that the majority of the doulas I interviewed (80 percent) identified as white, which reflects the larger doula population in the United States (Salinas, Salinas, and Kahn 2022). Table 1 also shows that all doulas had some training and that most (80 percent) were certified or in the process of becoming certified. Certification matters for proving that those who have credentials have completed the readings and required training hours (Henley 2015). The doulas in this study highlighted what they read in their training and what they continue to learn in order to remain current in their work.
Descriptive Statistics of Doulas (N = 25).
Doulas I interviewed argued that their beliefs and approaches to labor and delivery were evidence-based, but that obstetricians’ practices were not. Of the doulas I interviewed, 84 percent emphasized that their approaches were “evidence-based.” These doulas argued that their adherence to evidence-based guidelines distinguished them from obstetricians. As I show in this section, the doulas I interviewed were critical of obstetric medicine, arguing that it does not adhere to clinical evidence.
Doula Molly emphasized the evidence behind the services that doulas offer. Before I had asked my first interview question, Molly stated, We’re all science-based. We don’t do anything because “That’s the way it’s always been done.” We do it because there’s solid studies showing that “This is the best way to do it.”
Doulas like Molly believe that they approach patient care based on evidence; in addition, they imply that obstetricians may not practice the latest EBM because obstetrics adheres to long-established methods. Even though doulas and obstetricians have very different roles in labor and delivery (supportive care vs. medical care), doulas like Molly focused on the ideological bases that separated them. Molly argued that doulas’ approaches to labor are based on the latest evidence, whereas physicians’ preferred methods for managing labor follow routine.
Similarly, Ava explained that many physicians attending women in hospitals are more interested in meeting timelines than accommodating individual women, a custom revealed in Wendy Simonds’ (2002) work. According to Ava, As horrible as that sounds, hospitals are businesses. They have to get their rooms clean and ready for the next patient so that they- and not every OB is like that . . . We have some wonderful OBs in our hospital who are completely against starting a woman who is way too early in her labor to put her in Pitocin, knowing that there’s harm for the baby and the mom to do that. [But] there are some that want to be done at a certain time so that their weekends are free. It’s a convenience thing.
Doulas like Ava believe that giving women more time to labor naturally may run counter to the goals of medical practice. In this way, doulas’ preferences for birthing women follow evidence, whereas obstetric practice follows hospital (business) priorities.
Four of the eight doulas I interviewed after the release of an ACOG (2014) article that mentions the importance of doula care specifically discussed this report and how it may help raise awareness of the importance of what doulas do. Gina explained, ACOG just released new guidelines . . . I guess I’ll say that [medical clinicians] they’re just starting to catch on that this might be an important piece of the whole process. The . . . continued support. What you asked is is it important to them. I don’t think they’re even at that point yet . . . a lot of them don’t even know the scope of what we do for people.
Gina argues that while ACOG supports doula services, doulas need to prove themselves to the medical community. The doulas I interviewed explained that the benefits they offer through their personalized support come from scientific studies revealing the best ways to help women have positive birth experiences. Notably, doulas believe that doulas adhere to evidence more than physicians do.
“As a Doula You Walk That Fine Line”
Not only did doulas I interview criticize many obstetricians’ approaches to birth, but they also discussed how they use EBM to ensure that medical clinicians follow the evidence. Raquel, who practiced as a doula for 12 years before becoming a nurse, said that I know that Lamaze . . . are evidence-based. We know that if you tie a woman down to continuous monitoring you are changing the path of labor, you’re not improving the outcome by monitoring the baby continuously . . . all of these things that we know and that regardless, doctors keep on doing. I understand. Now as a nurse I’m also having to watch my license and the doctors, in this litigious society, are working with a gun against their head . . . Evidence-based medicine tells us that it’s okay to do intermittent monitoring, but the practice is totally different.
Raquel explicitly distinguished EBM from the ways that obstetrics is often practiced today. Like many doulas, Raquel approached labor and delivery from a less medicalized perspective; now, as a nurse, she understands that financial concerns influence practice. She oversees the work that medical clinicians do and reminds them about what the evidence says about monitoring labor. Even if somewhat understanding of the reasons behind the practice, doulas like Raquel remain critical of too much medical management of labor and delivery.
Similarly, Bella discussed how obstetrics focuses more on worst-case scenarios over more “normal” deliveries; she believes that this emphasis leads physicians to ignore the evidence on treating typical cases. Bella explained, I’ve heard that some doctors leave school never having seen a natural childbirth, whereas doulas and midwives have seen many . . . I think that if I was a trained doctor I would be looking for a reason for everything, to fix the problem . . . I think the more natural births that doctors experience . . . I think they would be there, too. Right there with the doula, as far as trusting the body.
Bella critiqued the way in which obstetricians approach birth as a problem to be fixed. Instead, she emphasizes that based on her own training in seeing natural births, bodies do not always need interventions. Doula Bella argues that physicians should observe births without medical management, because then they would be more supportive of doulas and what doulas help many low-risk clients to achieve.
Finally, doula Joni discussed how she establishes positive relationships with medical staff so that they accept her and her role in labor and delivery. Joni, like most doulas, said that she has had more interactions with nurses than with physicians. She explained that medical staff, including nurses, have little familiarity with doulas’ expertise; therefore, Joni follows the staff’s lead to keep peace. Joni explained, As a doula you walk that fine line, so even if you know the answer, if the nurse is there you want to defer to the nurse so she has respect for you . . . I’ve started out with nurses who are really brusque and they’ve ended up being nice because [I’ve asked] “Oh, what do you think about this?” or, “How do you do this?” Even if I know the answer, because it makes them feel like they’re important and that they know more than you do.
Joni explained that although doulas are very knowledgeable about evidence-based practices, they have to defer to those in authority because when those in authority say it, then it is true. By establishing positive relationships with the medical staff, Joni gains the respect to lend her own expertise to labor and delivery experiences.
“Arm the Moms”
Doulas I interviewed believed that part of their role was not only to support women but also to use evidence to empower women to challenge medical authorities. Doulas felt that evidence was especially important for empowering women who do not have the authority that physicians do when it comes to making birth decisions. As Molly said, We can arm the moms with this information so when we’re not there they can bring it up with their doctors and they can question “Oh the doctor wants to do this. Why?”
In my interviews, 40 percent of the doulas said that they provide their clients with scientific information up front. On the contrary, 28 percent of doulas said that they direct clients to references if the clients request it. (The remaining doulas did not discuss this.) Doulas like Molly directed clients to sources in order to empower them in their decision-making. They believed that the science might contradict what can be common practice for individual obstetricians and that EBM would be a better way to approach labor and delivery. Similarly, Darlene said, I really push evidence-based birth . . . “Do your research. Question everything.” . . . I think my biggest push would be to do your research. “Don’t take my word for it. Don’t ask me what you should do. I’ll be happy to send you to these resources or people, but don’t just take whatever your care practitioner told you as the gold standard.”
Both Molly and Darlene believe that women should question authority, but should do so with scientific evidence. They argue that most patients conform to what obstetricians direct, which may not be best in all cases. “Evidence Based Birth (2021)” is an independent organization dedicated to making research on childbirth freely available to the public. They publish systematic reviews of randomized controlled trials, observational studies, and case studies, discussing the implications and limitations of the medical research. Doulas like Darlene “arm” mothers with valid scientific research that supports less medical approaches to low-risk births so that mothers can justify their own requests.
The 2014 ACOG report served as an important source of legitimacy for the role of doulas and the care that they provide. Doula Theresa discussed referencing ACOG reports that dictate the latest evidence-based approaches to birth. In her discussion of sources that support doulas’ methods, Theresa said, I try to stick with ACOG.
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I want to stick with things that would be recognized by the medical community and that I can also give good information for . . . I do think it’s important that doctors understand that we’re not out there disregarding the medical community and disregarding science for some experiential thing.
Theresa explained that she reads established sources of information that are both evidence-based and coming from a physician-recognized source. Theresa emphasizes that her recommendations come from a professional authority to justify her approaches. In referencing ACOG to moms, Theresa “arms” them with information that physicians should recognize.
For the 28 percent of doulas I interviewed who direct clients to resources upon request, while they believe that scientific evidence matters for informed decision-making, they argue that women should control the research process. For example, Connie said that I do encourage letting them know what the ACOG says . . . “If your doctor’s trying to do something different, you should be asking why.” I do encourage them to do their research. I don’t necessarily provide studies; I don’t like doing that because I feel like that’s pushing them towards a decision I want them to make. I will tell them where to go to find information . . . but I think, a lot of the times, by the time I see a client . . . they’ve done a lot of research already.
Connie stated that many women seeking doula care are already well-informed. Part of this may be the fact that mothers who seek doulas often have higher levels of education, which results in a greater propensity to conduct health research independently (Song et al. 2012). While “research” includes a broad scope of material ranging from extremely biased “studies” to peer-reviewed clinical research, Connie suggests that clients have much of the same information that she has. Connie believes that women who seek doulas already desire births with fewer non-medically indicated treatments hire doulas. In this way, doulas may hold physicians accountable to EBM through supporting mothers.
Discussion and Conclusion
This study looked at how doulas use scientific evidence to ensure that mothers receive appropriate care. From my interviews, I found that doulas believed that their adherence to evidence distinguished them from obstetricians, whom doulas argue follow a tradition of overuse of medical treatments. Doulas discussed their knowledge on the use of doulas and evidence-based approaches to supporting women. While doulas sense that medical staff see them as primarily interested in mothers’ naturalistic experiences, doulas I interviewed discussed how much they look to scientific evidence for guidance on labor support and practices.
Notably, doulas I interviewed felt compelled to use evidence in order to hold physicians accountable to the guidelines coming from obstetricians’ professional organizations (ACOG) and the medical literature. At the professional organizational level, doulas have gained greater legitimacy in recent years due to the evidence on the efficacy of their role. The professional authorities have also begun to recommend against interventions that are not medically indicated (especially overreliance on cesarean deliveries) and to support taking more of the approaches that doulas have also suggested. At the same time, doulas may still have to prove themselves to everyday obstetricians and nurses who may have less experience with doulas (Roth et al. 2016). The doulas in this study did not think that many medical staff realize how much doulas know, so doulas felt that they have to convey their knowledge while treading carefully in their interactions with obstetricians and nurses. Joni demonstrated how doulas must act somewhat submissively to gain trust. Even though doulas have read about evidence-based research on many labor and delivery topics, they believe that they must walk a “fine line” between displaying their knowledge and submitting to those with authority in the birth room. Doulas need to convince medical staff of their evidence-based knowledge without undermining those in authority.
Relatedly, doulas may be most successful at holding physicians accountable to evidence through supporting mothers. “Arming the moms” with evidence gives doulas the chance to support mothers without directly confronting obstetricians or nurses. Doulas empower mothers to create their own birth goals and learn about and speak up for their desires. Through mothers, doulas have the chance to implement evidence-based methods of care that prioritize individualized support as well as less reliance on medical interventions in low-risk births. Doulas believe that they can legitimate their approaches through supporting mothers to read the evidence and advocate for themselves. Doulas ultimately want to maintain effective relationships with medical staff so that they can work with them as well as the mothers toward positive outcomes.
Despite changes in recent years attempting to standardize treatment to improve outcomes, physicians maintain authority over birth. Doulas must continue to legitimate their roles in order for their work to gain recognition at the levels of everyday medical practice, and leaning on evidence and quantification has historically legitimated the contributions of those on the peripheries (Porter 1995). Even though doulas had championed the evidence behind their work for years, there was little effect until a professional medical organization presented the science. The ACOG (2014) Report revealed that the medical profession has begun to recognize the importance of doulas and their work. When the authority recommends the use of doulas for lowering cesarean rates and improving birth outcomes, doulas have a chance at increasing their legitimacy and being welcomed into medical settings. However, the evidence on the effectiveness of doulas and their approaches has failed to fully reach levels where it could affect practice. Despite efforts to equalize and improve care systemically, individual obstetricians still have authority over most treatment. My research shows that doulas feel obligated to hold individual medical staff accountable to the latest evidence and that doulas must proceed carefully and often indirectly to maintain their newfound legitimacy.
Doulas offer much to women, but recommendations to increase their implementation may reveal an individualistic strategy to addressing systemic issues in maternal health care. As ACOG, WHO, and other authorities legitimate labor support, the burden for reducing cesarean rates and improving maternal mortality and morbidity rates could shift to individual doulas. Studies show that women with low-risk pregnancies who have doula support are less likely to have various medical interventions, including cesarean delivery (Bohren et al. 2019; Bohren et al. 2017; McGrath and Kennell 2008). Cesarean rates among low-risk pregnancies are too high in the United States, but more often occur with low-income women and women of color (Debbink et al. 2022; Kozhimannil et al. 2016; Roth and Henley 2022). Similarly, maternal mortality is more likely with women of color, particularly African American women (Peterson et al. 2019). These patterns reveal systemic problems in maternal health care that individual doulas (including doulas of color) cannot be expected to cure. Shifting the responsibility for outcomes to doulas and potentially to women who “choose” whether or not to hire them may obscure the larger issues plaguing maternal health care.
Focusing on implementing doula support more routinely would not eliminate maternal morbidity and mortality in the United States. While increasing the number of doulas and/or access to doula care could help many individual women, the systemic problems in health care would remain unaddressed. Social, structural, and environmental disparities breed inequalities in maternal health care (Lu and Noursi 2021). Individual doulas cannot fix the larger problems of racism, classism, and gender inequality that pervade health care systems. Doulas recognize biases in these systems and many want to mediate the effects of such biases on patient care (Wint et al. 2019). However, individual doulas cannot undo a whole system built on unequal and unjust care.
Doulas are also limited in how much they can affect care in hospitals and health care organizations. Organizations have the ability to offer better care through concerted efforts at all ranks. Doulas lack the authority to make final decisions about women’s care, and importantly, doulas do not have the medical background required for assessing and implementing the best courses of treatment. Doulas receive basic education in the physiology of birth, but most of their training focuses on how to provide support to individual women. Doulas should not bear responsibility for medical treatments and effects. Medical practitioners and staff, within the context of the maternal health care system, need to evaluate inequalities in treatments among their patients and seek evidence-based guidance on how to improve outcomes. Doulas can add much to birth teams, but the teams all together should focus on following the latest evidence to provide the best care for mothers.
The findings from this research offer an important perspective on doulas’ relationships with evidence-based care, but the study is not without limitations. The views of medical staff who work with doulas would contribute to understanding the knowledge that doulas offer and reveal how staff receive doulas. Also, even though most doulas identify as white (as my sample reflects), uncovering the experiences of more doulas of color would add much to the research, particularly with regard to illuminating inequalities in care. Finally, even though my research approach allowed me to recruit a suitable sample, the lack of random sample procedures limits the generalizability of the results.
This article shines light on doulas’ knowledge and contributions to birth overall. In addition to supporting women during labor and delivery, doulas serve as watchdogs over the actions of medical staff, and they prepare mothers to object to treatments that may not be evidence-based. Professional medical organizations have begun to recognize the importance of labor support for mothers but without more consistent and widespread structural changes to maternal health care, doulas not only serve individual women but also feel compelled to oversee the procedures taking place in birth settings and to hold physicians accountable to evidence. With increased legitimacy comes increased pressure on doulas to mend gaps in care. Doulas have much to offer, but more thorough implementation of evidence-based practices must take place at each level of obstetrics to improve care for all women.
Footnotes
Appendix A
Appendix B
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded through the University of Arizona Confluencenter Fellowship Grant.
