How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

One of the neglected areas of research on doulas is their impact on physicians. Studies have shown that physicians have mixed feelings about the presence of birth doulas with younger obstetricians of both genders having the least positive attitudes (1). Commenting on this study, Klein stated:

“Perhaps most concerning, the obstetricians in the younger group were less favorable to birth plans, less likely to acknowledge the importance of the woman’s role in her own birth experience, and more likely to view cesarean surgery as “just another way to have a baby”. (2)

Klein has also stated that there is diversity among the attitudes of both obstetricians and family physicians. At least 20% had attitudes similar to midwives and doulas regarding childbirth – especially experienced and older physicians. Even though our philosophies of birth may differ that does not mean that the presence of a doula is detrimental to physicians. In my estimation there are nine benefits that a professional doula can provide for physicians. In order of relevance, these include ensuring informed consent, observing detailed progression of labor; assisting the physician to know the patient; increasing patient satisfaction with the birth experience; fewer interventions; higher percentage of fees collected; informed refusal; early labor monitoring; and mitigating socially awkward situations.

1. Increasing informed consent. When the doula encourages patient discussion with her physician about an intervention, the doula is increasing the level of disclosure. Information about risks, benefits, and alternatives is given until the patient makes a decision. When this happens, patients are able to give explicit informed consent for the procedure, which benefits the physician. It is no secret that obstetrical care providers are one of the most likely to be sued for malpractice (3). Any time discussion of a procedure can be documented, it is positive for the physician. Informed consent strengthens the physician’s position in case of a lawsuit even if it cannot protect him or her from its occurrence.

However, this discussion does not always fit smoothly into the course of a labor. As Morton explains, the doula can drive an “interactional wedge” between the patient and the physician (4). This occurs when the physician is going to conduct a procedure where the mother had not explicitly given consent. As the doula has been trained to act and engaged by the mother to do, she informs the mother of the physician’s actions before they are completed. The physician’s activity is interrupted and must interact with the patient about the procedure. If the doula were not there, this interaction would likely have proceeded without interruption or discussion between the patient and physician.

In the moment the medical care provider (MCP) may not care for the doula or the interruption to what the MCP perceives as giving good care. It is possible the MCP perceives that there is no need for discussion or consent because it has already been given when signing the “consent for vaginal delivery” form. But there can be a difference between what a physician perceives as informed consent and what a patient perceives as informed consent. When the doula knows the patient’s concerns, she or he is able to facilitate communication around those areas where the patient wants more information and more involvement in decision making. However, this interaction can be awkward and resented by the physicians – even though it is ultimately to their benefit.

2. Getting to know the patient as an individual: The majority of the time in a busy hospital the attending physician has never met the mother. Even if a recent pregnancy appointment occurred, it is quite likely that the physician has seen dozens of women since this mother’s last visit. When a doula is present, the medical care providers are urged to individualize their care for this patient. Doulas do this in subtle ways: we encourage mothers and their partners to say what they want to their nurse, to remind the doctor of their priorities, and to write a brief birth plan for their hospital record. Our very presence is a huge reminder that these parents have thought about their birth and have taken action to see that their needs are met. Evidence suggests that both patients and physicians may be unprepared for these conversations or be uncertain how to proceed (1). In these instances the presence of a doula may be valuable to both.

When providers know the mother, they are able to shift their care in a way that is aligning with this patient’s priorities – while still acting in their comfort zone. The doula is also able to explain the physician’s concerns in language familiar to the laboring mother. Without the doula, the physician has a harder time satisfying the needs of the patient and ensuring that their experience is a positive one. Once again, this depends on the physician’s style. Doctors who like to treat all patients similarly may be irritated by requests to individualize care. MCP’s who place a high priority on connecting with their patients will recognize how much easier that is when a doula is present.

3. Increasing patient satisfaction. Three of the most important factors influencing patient satisfaction during labor are the quality of the caregiver-patient relationship, involvement in decision making, and amount of support from caregivers (5). These factors are more influential than age, socioeconomic status, ethnicity, childbirth preparation, physical birth environment, pain, immobility, medical interventions, and continuity of care. Patients who feel higher levels of satisfaction are less likely to sue (6). Several studies show that continuous support by a trained doula helps to increase overall satisfaction with the birth experience (7). When the doula increases communication with the physician, assists with informed consent for interventions, and provides effective labor support, mother’s satisfaction with the birth is increased. The intervention of the doula may carryover into increased satisfaction with the physician and possibly fewer lawsuits.

4. Observing progression of labor. Undoubtedly, physicians and nurses see more labors and births than a professional doula. However, observation of those labors is intermittent. Doulas have the opportunity to be with women for the entire labor. We see the progression of labor more clearly and are attuned to subtle changes in the woman’s behavior and contraction pattern. When a physician asks the doula about the mother’s labor, the doula is able to report detailed changes. With my observations and the physician’s expertise, it is then possible to forecast more accurately. MCP’s need to make decisions about doing a cesarean on another patient, going to the clinic, or seeing their child’s recital. Physicians often do not realize that the doula is a source of information about the patient that is beneficial to their decision making.

5. Lower intervention rates and healthier outcomes: The recent Cochrane Collaboration review of over 15,000 mothers in 22 studies confirmed that mothers with a trained doula are less likely to have certain interventions (7). Thus, the complications that may occur as a result of their use do not happen. Of course, the practice style of the physician and hospital policies are influential factors that have more impact than the doula’s presence (7). However, the fewer interventions that are used, the healthier the outcomes are for both mother and child.

6. Increased profit with a standard reimbursement rate: Mothers who have doulas are less likely to use pharmacological methods of pain relief and receive fewer interventions (6). When the physician receives a preset reimbursement rate for a delivery, there may be more profit when fewer interventions are used (8,9). The same is true for hospitals that are billed and reimbursed separately from physician fees. This is only a benefit when charges are not itemized or reimbursement is an underpayment of the actual cost.

7. Informed refusal. When patients are uncooperative, the doula can be blamed for their behavior. However, it is more likely that mothers and fathers with defensive attitudes hire doulas (10). Doulas are just not influential enough to change lifelong preferences about physicians or hospitals. (This also assumes that doulas are against hospital birth – which is not true.) Those patterns of behavior and beliefs are set long before doula services have begun. The professional doula’s role is to support the mother in her decisions even if it is not what the physician or midwife would want. Because the doula is not encouraging the patient to be compliant, the doula can be seen as part of the problem.

Informed refusal is a part of informed consent and the right of every patient. However, it can appear that the patient is personally distrustful of the physician or that their actions show a lack of care for their child. Misunderstandings often occur because this is an emotionally charged event for both patient and doctor. Sometimes the doula is highly skilled at negotiating the communication so that both parties understand one another even though they disagree. No matter when it occurs, informed refusal is a risk for both doctor and patient. The doctor is being asked to practice in a way that is less than preferred and the patient may experience a drop in the physician’s good feelings towards her. The benefit for the physician to having a doula present is to facilitate communication and to realize there is a person close to the patient who can understand the physician’s legitimate concerns.

8. Early labor monitoring. When the professional doula is at home with the laboring mother, she is able to provide reassurance. Mothers may choose to stay at home until active labor is established rather than arriving too early by hospital standards.  With the new recognition of active labor commencing at 6 centimeters, early labor monitoring becomes even more important.  Because of her level of skill the professional doula is also capable of recognizing overt signs of an impending delivery or emergency that family members may miss. The doula can recommend calling the triage center for advice or emergency services when imminent help is required. The doula’s skilled observation provides an additional level of safety for the patient that may benefit the physician.

9. Mitigate socially awkward situations: Physicians are often required to get to know several patients in rapid succession. Labor often includes meeting and interacting with extended family. Not all patients or providers are socially skilled and not all situations are easy for people to get along. While the doula, nurse, midwife and physician are all professionals, influences of family structure, language, culture, exhaustion, and personality converge to create a number of challenging and awkward social situations. When the doula knows the family and the mother’s desires, she can head off or smooth over interpersonal problems for the physician. Simply introducing everyone properly may defuse tension.

Relationships between doulas and physicians can be tricky. The doula’s presence indicates a desire on the part of the patient to be involved in decision making and to receive individualized care. The doula is the only professional on the birth team who is not beholden to the physician or the hospital, but to the patient. However, this part of the doula’s role – to increase communication, understanding, and respect between physician and patient is a benefit to the doctor. Doulas increase patient satisfaction rates in a multitude of ways, which is also a benefit to physicians. When doctors understand how professional doulas benefit them and utilize their expertise, they can make the birth less stressful for all concerned.

NOTE:  Originally I wrote this post as an opinion piece for a journal.  But the feedback I got was that it was more opinion than research so it was more suited to a blog.  It’s 1400 words, which is too long for a blog post but I didn’t want to omit anything I felt was relevant.   With the release of ACOG’s statement last week, I thought it was a good time to publish this essay. 

1.  Klein, M.C., Liston, R., Fraser, W.D., Baradaran, N., Hearps, S. J., Tonkinson, J., Kaczorowsky, J., Brant, R. Attitudes of the New Generation of Canadian Obstetricians: How do they differ from their predecessors? Birth 2011;38:129-139.

2.  Klein, M.C. Many women and providers are unprepared for an evidence- based, educated conversation about birth. J Perinat Edu 2011; 20:185-187.

3.  Jena, A.B., Seabury, S., Lakdawalla, D., Chandra, A. Malpractice Risk According to Physician Specialty New Engl J Med 2011; 629-636

4. Morton, C., Clift, E. Birth Ambassadors, Praeclarus Press 2014; 4:210

5.  Hodnett, E.D. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160-72

6.  Stelfox, H.T., Gandhi, T.K., Orav, E.J., Gustafson M.L. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med, 2005; 118:126-133.

7. Hodnett, E.D., Gates, S., Hofmeyr, G.J. & Sakala, C. Continuous support for women during childbirth. Cochrane Database of Syst Rev 2013

8. Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E. An economic model of the benefits of professional doula labor support in Wisconsin births. WMJ 2013;112:58-64.

9.  Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health 2013; 103:e1-9

10. Gilliland, A.L. Nurses, doulas, and childbirth educators: Working together for common goals. J Perinat Edu 1998;7:18-24.

11.  Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

For a downloadble pdf copy of this post, click here:  How Professional Birth Doulas Benefit Doctors

 

read more

The Art of Labor Sitting

Jul 22, 2013 by

Labor sitting is the process of being present with a mother when she is laboring and does not require your direct attention, but needs your attentiveness.  In other words, labor is going well but there really is nothing for the doula to do but step to the outer circle and wait.  Common situations for labor sitting are early labor, the first few hours of an induction, when mother is resting with an epidural, or taking turns with another member of the birth team.

Good labor sitting means that the doula seems occupied but interruptable.  The mother does not feel pressured by your presence to be further along in labor or to be doing anything different than what she is doing.  At the same time she can feel your presence, knowing you are available if she should need you.  Often, labor sitting takes place in the same room with the mother.  Effective labor sitting is an active, not passive process.  It may seem we are sitting on the couch working on a little project.  But a good doula is much more aware of what is going on than it seems!

So how do you strike this balance?  Over the years, through trial and error – doing it wrong and by accident doing it right and then repeating it – I have found my way to effective labor sitting.  I do needlepoint.  If I am reading a book or looking at the screen on my phone, I seem occupied by what I’m doing.  My attention is focused on the book or my phone.  Someone might feel they were interrupting me if they spoke to me.  If I am just sitting there, people may feel bad because I’m just sitting in the chair not doing anything.  They might feel badly or pressured because my skills weren’t being used yet.  If I am sitting on the couch doing needlepoint*, my mind is in the room with them, yet I am happily occupied.

One time a father called me saying he and his wife were getting ready to go to the hospital.  They weren’t packed yet so he was rushing around the house.  Her contractions were 4-5 minutes apart with no bloody show.  Mom was relaxing in the bathtub and coping well.  Through our conversation I got the idea that Dad was anxious.  I surmised he wanted to go to the hospital because it would relieve his anxiety.  As we’ve all learned from TV when you go to the hospital the baby comes out.  While this is an irrational belief, it is the way our culture has trained us.

I offered to come over and help.  When I arrived, Mom had just gotten out of the tub and gave me a big smile.  My doula assessment of the labor was that it was not time to go to the hospital.  I asked her preference and she said she wasn’t ready to go (she is the decider, not me).  We talked a bit and I went to sit on the couch and got out my needlepoint.  I didn’t say anything but after a while Dad seemed to calm down.  We chatted and his furious pace of grabbing household items and putting them in the pile slowed down.  He began to pay more attention to Mom.  The message he got from my behavior was:  “Amy’s calm so there must not be any rush.”  When mom had a contraction I would stop and breathe with her, looking at her from across the room.  This visual regard is also a part of effective labor support – if she were to look at me she would see that I was watchful and available.  In due time we went to the hospital; they were both calm and made the decision they were ready.

Another time labor sitting skills come in handy is at the beginning of an induction.  There are many anxieties to soothe and many decisions that are made in those first few hours that have repercussions later.  If I am present I am able to remind them of their choices, make sure their questions are answered, and calm them down.  I create an atmosphere in the room to make it their space.  I can increase the level of connection between my client and the nurse, resident physician, and attending physician.  If I am not there, those things often do not happen.  This is another time to discuss methods of induction and parent’s concerns.  It is often easier to advocate for using the shower or tub, or having a slower, gradual Pitocin drip before any interventions are administered.  Parents may be able to get approval for a plan to go home under certain conditions.  What I have found most often is that a mother may bring up these things and then the medical care providers (MCP) explain to her why they won’t do it that way.  But in the long run, my client has explored her options to the extent she wanted to.  Plus, the MCP and my client have talked and understand each other’s concerns and preferences.  The nurse has heard the mother and she may make more suitable labor support or intervention suggestions.

Of course a discussion about options is fifteen minutes out of three hours of labor sitting.  Even if none of these discussions happen, there are still other fears and plans that are on their minds and choices to be made.  I have never found NOT being there at the beginning of an induction to gain my clients or me anything.  Sometimes with a Pitocin induction, parents want me to leave for a while.  That’s fine and we agree to check in verbally – not with a text – every hour or two.  If they want privacy with a misoprostol induction, I stay immediately outside the room or return every 15-20 minutes.  Those intense contractions can hit without warning and the partner or nurse may not be able to contact me.

Labor sitting is a creative art.  It requires an understanding of the people involved, a perception of possible futures, and an empathetic, compassionate presence.  It is not a passive process – you are not waiting for something to happen and then responding to it.  Instead, you are influencing the present moment.  You are there, caring, mindful, and available.  People take their cues from your behavior and from your presence.  Because of active compassionate labor sitting, labor often unfolds differently.

*Some doulas embroider or crochet something for the baby or make a lace cap out of a handkerchief.  Knitting needles may click which bothers some mothers.

 

 

read more

Hard Research: Birth Doulas Save Insurers and Hospitals Money

Jul 17, 2013 by

I am absolutely THRILLED to beWMJcovergin my new blog with my latest journal article, published in the Wisconsin Medical Journal.  In this collaboration, our team estimated the immediate cost savings per delivery with in-hospital professional doula support in Wisconsin.  This article strives to fill the gap regarding the financial impact of doula care based on the assumption that certain interventions and procedures would be avoided due to the doula’s presence.  We actually quantified how much money is saved when a birth doula is present to attend a low risk laboring mother.  To download a pdf copy, click An Economic Model of the Benefits of Professional Doula Labor Support in Wisconsin Births.

BOTTOM LINE:  There is an estimated $29 million savings if every low-risk birth was attended in-hospital by a professional doula in Wisconsin in 2010.   A professional doula providing only in-hospital labor support would yield an estimated cost-savings of $424.14 per delivery or $530.89 per low-risk delivery.  That does not include paying the doula for her services.  So, if the doula is paid $300, the cost-savings would be $230.89 for a low risk delivery.  This is due solely to the doula’s emotional and physical support at an advanced beginner level, not any advocacy she may do or advanced level skills she may acquire over time.  I can state that with confidence because the doula studies we gathered our statistics from used primarily inexperienced doulas.

COMMENTS: Of course there is no way to estimate the financial cost of improved emotional well-being for mothers and fathers. Hopefully this study will inspire others to do more doula research on those outcomes.  Early drafts included an estimate on the impact of labor doula care on breastfeeding.  But we didn’t have any hard data on the influence of doula labor support on breastfeeding rates (in other words, no randomized trials).

This is a conservative estimate of cost savings, it is likely that other (minor) procedures would also be avoided.  Hospitals often find labor and delivery to be income generating departments. They also expect future business from the families they treat.  For this reason private hospitals are often not interested in doulas to lower the number of epidurals and cesareans.  On the other hand, public hospitals that serve low income patients are interested in lowering their health care costs because the reimbursement rate can be so low.  Insurance companies and PPO/HMO’s are more interested in lowering health care costs than hospitals.  Private hospitals that have paid doula programs are usually located in cities where mothers have the choice of several hospitals to birth.  The doula program can give them a marketing edge.

Keep in mind, there are many influences on epidural and cesarean rates beyond the doula’s care.  Many of them are outside the scope of what we can influence by our presence and labor support skills.

This article does not mention the mechanism why doula care has such an impact.  For my perspective, you’ll need to read my dissertation or attend one of my presentations on the Attachment Needs of the Laboring Mother!  (All are on my main website.)

HOW TO USE THIS RESEARCH:

  1. If you are writing a grant or asking for funding for your doula program, it may increase the legitimacy of your application.  Even if cost savings is not the main reason for the program, having the data can provide a broader context for the value of birth doula support.
  2. This article increases the power and value of doula care.  The services we provide are not just “nice”.  They make a quantifiable difference in the quality of health care received by mothers.
  3. If you have a doula program or are trying to start one in your community, this provides more evidence why professional doula labor support is a significant and positive addition to your community.
  4. This article provides financial data on the relationship between what a doula is paid and cost savings.  We deserve a living wage for what we do.
  5. Are you billing an insurance company for your services?  Include this article with your denial appeal.  This could be especially helpful if your client avoided one or more of the procedures listed in the article.
  6. As a companion to other doula studies that show increased patient satisfaction, lower incidence of postpartum depression, decreased perception of pain, and higher breastfeeding rates, this completes the circle.  “Look, they save money too!”  Let’s hope lots more doula programs receive funding in the next few years.
  7. As a birth activist, are you trying to get doula services reimbursed by an insurance company?  Are you trying to get doula services offered by your HMO or PPO?  This article could be what turns the tides.  The formulas are now available in the article.  With your state or region’s statistics, you can compile your own statistics.  Find a graduate student with statistical expertise and ask for assistance.  (Heck, they’d probably think it was fun – or you can co-author your own report and they can list it on their vitae.)

Please let me know how you’ve used this article and how it impacted you.  Thanks!

 

 

read more

Doulas and Informed Consent

Jul 17, 2013 by

One of our primary functions is to empower the mother and her partner to ask questions.  Many of us feel that a nudging, “Do you have any questions about that?” should get our clients more information in the labor room.  Often I can tell them what they need to know, but I don’t consider that to be my role.  It also defeats one of my main unstated purposes:  to increase communication and trust between patient and medical care provider (MCP).  The more I assist information to flow from the doctor, nurse or midwife towards my client, the more improved their relationship will be.  Mother and her partner or family member can also evaluate their MCP and whether their approaches match.  If I do the talking, those important processes don’t take place.  I know what I know so I can tell whether they are getting the information they need.

What if the mother and her family aren’t getting the information she needs?  What if an important piece is missing?  Then I ask.  Depending on the situation, a direct or indirect approach may be best.  Direct approach:  “Is timing an issue with this procedure?  Some other physicians at this hospital had mentioned that to me before?”  I recommend never mentioning that you read something somewhere – it can be interpreted that you are trying to one up the MCP – bad move!  But stating that you heard it from a MCP with equal status or that you observed it at another hospital works better.   The direct approach works best when you sincerely act curious.  You need to be really present with the thought – “Why is it being recommended this way?

If you have another agenda or predominant emotion it is likely that your subliminal behavior will reveal that and be interpreted negatively– often on an unconscious level.  So the direct approach needs to be used attentively by the doula.  Your client also gets the message from your question that there are different approaches – which the MCP may not care for.

The indirect approach can also be referred to as the Dumb Doula approach.  “Isn’t there something about…um, well…the timing, is it called, with this procedure?”   You are asking a leading question in a non-threatening voice.  This strategy is designed to solicit information from the nurse, physician or midwife without challenging them or their authority.  To be honest, I use this approach most often.  It’s been the most effective at meeting my client’s needs over the years.  Now the Dumb Doula approach is not without controversy.  It certainly doesn’t add to our professional reputation or appeal!  “Those doulas might know how to rub a back, but you’d think they’d have learned some more technical stuff by now.”  Additionally, some doulas may think it is manipulative, that we aren’t being authentic.  To me, crafting communication strategies to maximize effectiveness is what I do all over my life: with my family, my students, in mentoring situations.

Some physicians and midwives are happy to answer questions until their patient is comfortable with the recommended treatment or another decision has been reached.  Others seem to feel that asking questions is equal to challenging their authority.  They may seem brusque or annoyed.  Often it is a clash of health care philosophies.  Your client is likely to be wanted to be treated as an individual and to cooperatively make decisions with the doctor or midwife (who is likely a stranger).  However the MCP is likely to see him or herself as the knowledgeable authority whose role it is to make medical decisions.  In addition, they will have to answer not only to the patient, but their colleagues, the hospital administrator, their liability insurance company, and maybe a judge and jury.  So doing what your client wants rather their preference can be a loaded proposition for a physician or midwife.

Having said that, doulas prompting clients to ask questions and receiving answers actually helps informed consent.  When mothers and their partners receive more complete information regarding procedures and intervention, this actually helps the MCP if an action is called into question.  It also decreases the likelihood of a complaint or lawsuit.  Both patient satisfaction studies in public health journals and birth satisfaction studies in nursing and midwifery journals give the same conclusion.  Involved decision making and more complete information from MCPs leads to greater satisfaction, better long term outcomes, and fewer legal actions against physicians.

As doulas our prompts to get more information for our clients is a win/win for physicians and their patients.  The more moms know before something is done, the more satisfied they can be afterward – both immediately and weeks and months afterward.  I just wish more physicians and nurses understood that.

read more