Childbirth influences maternal and neonatal physical outcomes and may affect the self-efficacy of each woman. Continuous labor support improves outcomes for both mother and infant (Fortier & Godwin, 2015 ; Hodnett, Gates, Hofmeyr, & Sakala, 2013 ; Steel, Frawley, Adams, & Diezel, 2015). A doula is a companion who provides support and is present continuously with the laboring woman. This support is an effective supplement to the clinical care provided by obstetricians, family physicians, midwives, and labor and delivery (L&D) nurses (Ahlemeyer & Mahon, 2015). Benefits include, but are not limited to shorter labors, more vaginal births, fewer interventions such as the use of medications and forceps, fewer cesareans, newborns who are less likely to have low Apgar scores, shorter hospital stays, higher rates of breastfeeding, and greater satisfaction with the birth experience (Akhavan & Lundgren, 2012 ; Green & Hotelling, 2014 ; Gruber, Cupito, & Dobson, 2013 ; Harris et al., 2012) (Table 1).
Maternal morbidity and mortality rates have risen in the United States over the past 30 years (Centers for Disease Control and Prevention [CDC], 2017a). Since 1987, rates of maternal mortality have increased from 7.2 maternal deaths per 100,000 births to 17.8 maternal deaths per 100,000 live births in 2016 (CDC, 2017b). Incorporation of a doula in the maternity care team may be a way to help alleviate some aspects of the maternal and infant morbidity and mortality crisis and improve patient safety. See Table 2 for a description of the role of the doula.
Doulas have not been integrated into maternity teams in the United States. A doula is only present in approximately 6% of all births in the United States (Declercq Sakala, Corry, Applebaum, & Herrlich, 2014). Support of physiologic birth is a factor in minimizing risk of poor outcomes and increasing safety. A consensus statement from three midwifery organizations in the United States defined normal physiologic childbirth as “spontaneous onset and progression of labor; includes biological and psychological conditions that promote effective labor; results in the vaginal birth of the infant and placenta ...and supports early initiation of breastfeeding” (American College of Nurse-Midwives, Midwives Alliance of North America, & National Association of Certified Professional Midwives, 2012, p. 2). The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG & SMFM, 2014) have a consensus statement on prevention of primary cesarean births that includes promotion of the use of doulas. An ACOG (2017) committee opinion identifies various approaches to promote physiologic labor and limit the number of interventions during labor and birth. One of these approaches is continuous one-to-one support provided by a doula. Doula care should be integrated into obstetric care teams as the physical and emotional support provided by a doula promotes the physiologic process of labor (Everson & Cheyney, 2017 ; Zielinski, Brody, & Low, 2016).
In many clinical settings, doulas remain outside the inner circle of obstetric caregivers. A collaborative program of maternity care that includes physicians, midwives, nurses, and doulas can attain the improved perinatal outcomes associated with a doula. Here we examine literature about overall attitudes of physicians, midwives, and nurses toward doulas in the intrapartum setting.
There is increased appreciation for the benefits of physiologic labor and recognition of the risks associated with unnecessary interventions during labor (Zielinski et al., 2016). The cesarean birth rate in the United States was 31.9% in 2016 (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018). Although this is a slight decrease from the rate of 32.7% in 2015, it is an overall 60% increase from 20.7% in 1996 (Martin et al.). Labor was induced or augmented in 50% of women surveyed in 2011-2012, and rates of interventions such as multiple vaginal exams, intravenous fluids, urinary catheters, artificial rupture of membranes, and episiotomies increased or remained the same (Declercq et al., 2014).
Although doulas have increased in popularity with birthing families, occasional conflicts and an unfavorable attitude toward collaboration persist between obstetrical providers, L&D nurses, and doulas (McLeish & Redshaw, 2018 ; Meadow, 2015 ; Steel et al., 2015). Numerous factors can influence the attitude of other members of the obstetrical team toward doulas including providers' and nurses' own birth experiences (Aschenbrenner, Hanson, Johnson, & Kelber, 2016).
Nurses and Doulas
Doulas typically interact more with the L&D nurse than other members of the obstetrical team due to the number of times the nurse enters the room to assess and care for the laboring woman. This interaction offers opportunities for collaboration between nurses and doulas. Globally and within the United States, issues of interprofessional tension and conflict result between L&D nurses and doulas (Amram et al., 2014). Akhavan and Lundgren (2012) and Steel et al. (2015) suggested the conflict may be due to a lack of knowledge by the L&D nurse of the doula's role and scope of practice. Although L&D nurses have the knowledge and expertise to support women during labor, they also have other nursing responsibilities that require their attention. Therefore, doulas can be an excellent complement to intrapartum nurses. A relationship that is complementary between doulas and L&D nurses can achieve the best and safest outcomes for laboring women (Paterno, Van Zandt, Murphy, & Jordan, 2012).
Midwives and Doulas
Zielinski et al. (2016) identified the distinct supportive roles that obstetrical healthcare providers have in promoting the physiologic birth process. Specifically, midwives have led the way in promoting and supporting physiologic birth in uncomplicated pregnancies. Midwifery offers continuity of care, patient safety, and improves outcomes and mothers' birth experiences, while using fewer interventions (McLeish & Redshaw, 2018). There is a shared understanding between midwives and doulas in their theoretical approaches to offering physical, emotional, and continuous support while simultaneously encouraging patient autonomy. However, Middlemiss (2015) summarized differences in roles of the doula and the midwife and identified potential for conflict if the role of the doula is misunderstood. Some have identified antagonistic attitudes toward doulas that create a challenge to midwives (McLeish & Redshaw) and interprofessional tensions within the dynamics between midwives and doulas (Steel, Frawley, Sibbritt, & Adams, 2013). These include misunderstandings, fear that the doula will usurp the role of the midwife or nurse, and “turf” issues with nurses and midwives (de Carvalho Leite & Higginbottom, 2017 ; Meadow, 2015; Middlemiss).
Physicians and Doulas
A provider's attitude toward physiologic birth may have an impact on the type of interventions used during labor, which in turn may affect the ability to work with others (Zielinski et al., 2016). Steel et al. (2013) reported providers' concerns about the role of the doula including concerns that the doula might interfere with the therapeutic relationship between the patient and the provider, as well as fear that doulas may be offering clinical maternity care outside their scope of practice.
The role of the doula is often unclear to providers and at times there can be increasing incidents of tension between the two professionals (Stevens, Dahlen, Peters, & Jackson, 2011). Although varying levels of support for doulas were described, approximately half of obstetricians and many family physicians had unfavorable attitudes toward doula care (Fortier & Godwin, 2015). Gilliland (2014) reported that physicians have mixed feelings about the presence of a doula, and the attitude becomes less positive with younger obstetricians of both genders.
Better understanding of the role of each member of the maternity care team is needed. Knowledge and understanding lead to a meaningful appreciation and value, which will improve collaboration (Zielinski et al., 2016). A positive attitude of respect and recognition of the contributions of each member of the maternity team, including doulas, will lead to fewer interventions (Fortier & Godwin, 2015).
A scoping review was conducted based on Arksey and O'Malley's (2005) framework to identify attitudes of obstetrical care providers toward doulas.
In October 2017, a search was conducted using PubMed, CINAHL, Scopus, and Google Scholar databases. Search terms included a combination of the following: “physicians' attitudes towards doulas,” “physicians and doulas,” “attitudes towards doulas,” “obstetrical providers and doulas,” “obstetrical providers' attitudes towards doulas,” “care providers and doulas,” “care providers' attitudes and doulas,” “care providers attitudes regarding doulas,” “midwives and doulas,” and “midwives' attitudes towards doulas.” Boolean phrases such as “doula AND relationship AND providers” were used in the search; 1,810 records were returned.
The following limitations were initially applied within each database for articles published in the last 5 years (2012-2017) and in the English language.
Results were expanded to include articles published in the last 10 years (2008-2018) to provide a more exhaustive and comprehensive examination of the literature. Preliminary titles and abstract screens were assessed for inclusion criteria of original research that included attitudes of obstetrical providers specific to physicians and midwives, or nurses' attitudes toward doulas followed by full-text screening. Articles that met the criteria were included.
Search Procedure. The search was updated in December 2017 and again in January 2018. Articles were reviewed by the primary investigator. The second investigator served as a consultant reviewing records for which inclusion was questionable. After elimination of 120 duplicates and 1,631 articles based on an initial title screen, abstracts of 59 articles were reviewed to assess content for appropriateness. Twenty-nine articles were initially excluded as they did not include doulas. Full text was examined for the remaining 30 articles. Twenty-one articles were excluded as they were not original research. Reference lists were hand-searched and yielded examination of nine articles. Further examination using data charting and iterative discussion between the two study team members occurred, resulting in exclusion of six articles. Three articles remained and were considered appropriate for inclusion in this scoping review.
There is limited research about providers' and nurses' attitudes toward and collaboration with doulas (see Table 3 for a summary of the finding of the articles included). All three studies used cross-sectional survey design (Klein et al., 2009 ; Liva, Hall, Klein, & Wong, 2012 ; Roth, Henley, Seacrist, & Morton, 2016). Two were set in Canada exclusively (Klein et al.; Liva et al.) and one was inclusive of nurses and doulas in Canada and the United States (Roth et al.). As only one article included both physicians and midwives (Klein et al.), it is difficult to draw any comparative conclusions.
Klein et al. (2009) used a survey to identify attitudes toward labor and birth. Participants included 549 obstetricians, 897 family physicians, 400 midwives, 545 nurses, and 192 doulas in Canada. Although the study was not specifically about doulas, attitudes toward doulas emerged as one of the nine themes. Overall, midwives were supportive of doulas. Obstetricians were neutral in their attitude toward doulas: half favored doulas and half did not. Family physicians and nurses were overall positive. Areas of similarity among all participants included openness to a team approach.
Liva et al. (2012) conducted a survey with 545 perinatal nurses in Canada to identify attitudes toward birth practices including acceptability of doulas. Factors identified as influential in nurses' attitudes included years of intrapartum experience, choices for personal maternity care, and hospital employment. Liva et al. concluded that nurses' attitudes are influential in care provided in the intrapartum setting. More research is needed on the degree to which workplace exposures and other practices affect intrapartum nurses' attitudes toward doulas.
Roth et al. (2016) surveyed nurses and doulas in the United States and Canada to identify factors that lead to a reciprocal and positive attitude between nurses and doulas. Out of a total of 704 nurses and 1,470 doulas, approximately 225 doulas and 60 nurses were from Canada. Other participants represented various regions in the United States. Factors that were identified as influential for a mutual positive attitude included education and certification, exposure to each other, appreciation for the role, and collaborative behavior. Roth et al. concluded that nurses and doulas desire optimal maternal and neonatal outcomes, and that improved collaboration will assist in meeting this goal.
Attitudes of members of the maternity team toward doulas vary. Factors that influence the differences in the attitude of providers and nurses range from personal exposure to individual preferences. Personal attitudes may have an impact on practice in perhaps a more influential manner than evidence (Klein et al., 2011). More exposure to each other during their education may help in creating improved positive interprofessional attitudes among members of the maternity team (Klein et al.). Physicians, midwives, and nurses are open to a team approach and collaborative care. The role of the doula is a win-win situation for laboring patients and all providers. The doula's provision of continuous presence can empower and support laboring women, as evidenced by improved health outcomes for both the mother and the infant (Hodnett et al., 2013).
Collaborative practice and effective communication yield improved healthcare outcomes (Brown, Lindell, Dolansky, & Garber, 2015). The common goal of a safe and satisfying childbirth experience promoting physiologic birth is the outcome of a collaborative effort from the maternity team of providers, nurses, and doulas (Zielinski et al., 2016). Although effective communication is associated with better outcomes, poor communication can lead to adverse events and sentinel events (Horton et al., 2017 ; Lyndon et al., 2015 ; Streeton et al., 2016).
Policies to acknowledge and include doulas in institutional protocols for care of women in labor are needed. Ideally, criteria for credentials that are mandated and recognized for doulas who work with laboring women should be established. Expansion of insurance coverage for doulas could decrease the out-of-pocket expenses for families and is one strategy gaining national momentum (Zielinski et al., 2016). Social disparities will be addressed and outcomes for women and their infants will improve with doula care through the establishment of national and state policy reform (McDaniels, 2017). Based on benefits of doula care, financial savings are likely with insurance to cover doula care (Chapple, Gilliland, Li, Shier, & Wright, 2013). Lack of coverage and reimbursement are barriers to care that have known clinical benefits to patient safety (Kozhimannil, Hardeman, Attanasio, Blauer-Peterson, & O'Brien, 2013).
More education is needed for all members of the maternity care team to fully understand each other's roles and the importance of collaboration. Interprofessional education may be helpful. Education could lead to clarification of roles, common nomenclature, quality standards, and increased collaboration with a shared understanding and respect for the contributions that each individual healthcare team member offers to the care of the laboring patient and family.
Standardized Education and Certification for Doulas
Standardized education and certification for doulas should be considered. Roth et al. (2016) identified the need for doula certification as a step to recognize doulas as a unified and regulated body. While there are many certifying organizations for doulas, doula practice is unlicensed. Doulas of North America (DONA) is an internationally known organization that educates and certifies doulas. Although DONA is a respected organization, there are other agencies that also offer certification with varying education and competencies. There is no standardized educational program to which doulas are accountable, which leaves varying styles and types of doulas to provide support in ways that may undermine the credibility of the work of the profession as a whole (Roth et al.). National certification would create a unified standard that could make doulas accountable, credible, and respected by other professionals.
In the most recent Cochrane systematic review, Hodnett et al. (2013) concluded that all women in labor should have a doula. Although many are vaguely familiar with the doula, many do not fully understand the role of the doula or the scope of a doula's practice. Research on physicians' and nurses' attitudes toward doulas is limited. Most of the research on these attitudes has been set in Canada. More research is needed on attitudes among physicians, midwives, nurses, and doulas in the United States and how to promote collaboration among these professionals.
Suggested Clinical Implications
- More research is needed about physicians', midwives', and nurses' attitudes toward doulas and how to effectively work together as a maternity team to promote the best outcomes for mothers and babies.
- Education on the role of the doula is necessary for all members of the maternity care team to improve interprofessional collaboration.
- Shared clinical time is recommended as part of the education for obstetrical professionals to have exposure to each role of physician, midwife, nurse, and doula.
- Certification for doulas is recommended to recognize doulas as unified and regulated in practice with provision of advocacy as well as physical, emotional, and informational support.
- Doulas can be included in the institutional obstetrical policies acknowledging them as part of the team to provide support for the laboring woman and family. These policies should include requirements for education and credentialing of doulas and a structured orientation to the maternity unit.
- Coverage by private insurance and government insurance for doula care would be helpful in allowing more women to choose the option of a doula during their childbirth.
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Attitudes of Physicians, Midwives, and Nurses About Doulas: A Scoping Review
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