Doula Research Part III – Barriers To Approvals, Funding And Publishing Access

Nov 29, 2017 by

Untitled designMost people don’t know much about the research process or how difficult and time consuming it can be to publish in a peer reviewed journal. This essay exposes the barriers that are unique to publishing doula research examining obstetrical or neonatal outcomes. Part II covered the medical politics and power dynamics that negatively influence doula research projects, while Part I listed fourteen research questions that have not been answered in the 35 years since the first doula study. To conduct a doula study similar to the ones I listed in Part I, there are four to six different groups who will need to approve of the project. But first, the whole study has to be planned out in advance – and that’s before anyone ever gets paid for doing that work. So barrier number one is having the economic independence to spend the time planning a detailed doula study without any idea whether it might be funded or approved.

Graduate Student Researchers

Graduate students are more likely to pursue a doula study than a professor at a university. I judge this by the number of published theses and dissertations on doula topics. If a graduate student’s goal is an academic career, their thesis and dissertation need to be intriguing to future employers. Plus they want to hire people who have received grant money. So one’s choice of topic influences one’s employability.  That might lead people away from a doula study because you want to choose a topic that looks appealing to funders for the long term.

Graduate students have the added burden of having to pay tuition while they are waiting for project approvals. Most of the time a student can’t propose a project until after all of their classes are completed. Tuition needs to be paid to keep their student status while the project is being approved. As you can see this is often an insurmountable financial barrier. One recent graduate who wanted to study doulas and breastfeeding outcomes confided to me that her committee steered her away from anything medical because it would take about a year to get the approvals and cost additional tuition (typically US $10,000).

Some graduate students develop small projects nested inside the larger research study of an established university professor. But to my knowledge only one person, Katy Kozhimannil, is consistently publishing doula studies. So they are not attracting graduate students to work on their projects or develop expertise on the subject. While not exactly a barrier, this factor definitely influences why there have been few researchers pursuing doula support studies.

Funding

How might one fund a doula study? The first option is grant funding by the National Institutes of Health, which is based on what they determine to be health care priorities. In years past there’s been specific funding priorities for research on opioids or obesity and their effects on pregnant women and babies. These priorities eventually show up as a publication trend in research journals. Less money is “unspecified” so a doula project would be competing with other proposal topics like infant sleep, breastfeeding, and long-term effects of third degree lacerations. NIH grant funding has several cycles per year and the applications are slightly different depending on the priority. So part of the research question and hypotheses might be changed to fit the funding criteria.

A second option is to apply for private foundation grants like those from the March of Dimes, Kellogg Foundation, or Robert Wood Johnson Foundation. Once again the project will need to fit their funding priorities. Each of these organizations has funded doula studies or programs in the past (see pdf below). The budget will need to be precise and include compensation for the researcher, study director, doulas, study participants and cover any project expenses (rent, paper, and so forth).

Lastly, some smaller studies are funded by multiple small grants from local funding sources who are interested in a specific outcome. For example, if a specific population of people is targeted, there may be funds from an organization to see if breastfeeding initiation increases when doulas support this group. That might not be the main point of the study but by including this outcome you can receive financing. So funding sources influence the research proposal and design too.

Planning The Study and IRB Approvals

When planning a study, most people might think a detailed outline would be sufficient at this stage. Actually, every decision is made during this early planning stage down to the smallest detail. The first task is to read everything already published and summarize it in a literature review. Then all the decisions about research methods are made including hypotheses, data collection methods, sample size and recruitment, analysis methods, and statistical power. This research plan or proposal includes the small details that are needed to implement the project such as participant recruitment letters and emails, interview locations, and compensation. This is a good time to ask for input from the people whose cooperation will be needed to conduct the study, such as physicians, nurses and other hospital staff. Funding possibilities and journal requirements also influence the study’s design. Coming up with a plan that meets research goals, funding priorities, and is amenable to the facility and staff where the researcher will be conducting the study is imperative to its success.

A graduate student would make changes to their proposal until the three to five members of their committee approved it. After that they are in the same position as a university faculty or staff researcher, and the plan would be submitted to the Internal Review Board (IRB) of the college. They examine the proposal for its impact on the human participants in the study. They also examine funding sources for possible conflicts of interest.

If researchers are collaborating from different universities, the project needs to be approved by each university’s IRB. At any point the review board can request changes that they feel improve the project. Each request often takes another week to ten days to address and may require significant changes to the proposal.

Once the university approves the project it is time to formally approach the hospitals to support the study. The proposal now needs to go before the hospital’s IRB, which has different priorities and concerns than the university’s review board. Hopefully the researcher has connections with the hospital staff and administration who are open to the changes that conducting a doula study within its walls will bring. The project will also require permission from the physician head of obstetrics, the director of nursing for the labor and delivery unit, and other affected departments. But since it’s already been approved by two IRB’s, no changes to the proposal can be made at this stage. By this time a year may have gone by. Remember, no one has been paid yet.

What Journals Will Publish Your Doula Study?

Along with applying for funding and IRB approvals, a researcher is also considering which journals will publish their doula research study. This is really difficult, much more so than with other perinatal topics. Doula research has no journal home. The Journal of Perinatal Education has published more doula studies than any other journal, however the theme of perinatal education needs to be relevant in the study. Midwifery has been inclusive by publishing doula studies from across the globe, including mine. But it is a very competitive journal. Nursing journals such as MCN or JOGNN reject studies that do not have clinical implications for the ways nurses practice. Many of the doula studies I’d like to see won’t have those clinical implications as a main finding, making nursing journals a poor prospect. Physician journals have similar standards for providing strong clinical implications for the practice of physicians and desiring physician authors.

On top of that, no profession pays attention to findings published in another profession’s journal. This tendency to isolate research findings to a specific profession is called “silo-ing”. Like corn stored in a barn silo, knowledge is kept separate and locked away. This practice is named as one of the main barriers by perinatal health care quality improvement organizations to applying evidence based practices in a timely manner.

While there are many lesser journals and open source ones available, that will not help a doula study to be spread widely unless the journal is peer reviewed AND included in respected databases. I’ve been personally facing this dilemma for years. I have a completed study on the experiences of hospital-based doulas from four different programs but no clear place to submit it. It has few clinical implications for nurses or physicians, but plenty for administrators of doula programs and other doula researchers. But what journal would welcome this piece? One of the main reasons I started this blog was to publish many of the smaller research findings in my doula studies. I’ve been able to disseminate them in an informal way and reach the people who find them useful.

Savvy researchers know the journals they want to submit to when they are in the planning process and will create hypotheses and a research design that they know will appeal to the reviewers for that journal. Even though reviewers are anonymous and change depending on the subject matter of the submitted article, the journal’s previous publications and criteria for inclusion make their priorities known. Without a research “home” for doula studies, this part of the process is more difficult. What Birth publishes is different from the Journal of Midwifery and Women’s Health.

Multiple challenges inherent to the process of conducting a doula study have led (in part) to a dearth of research. Along with the political pitfalls of challenging the status quo in how perinatal care is practiced, and lack of a political agenda that reflects the entire spectrum of how women live in their bodies, there is a trifecta of influences keeping any new knowledge contained. The real tragedy is that without the research exploring the possible greater impacts of doula support we don’t know what other positive effects we are missing.

Related Content: Sustainable-Funding-for-Doula-Programs-A-Study_for-web  For more information, please visit Health Connect One.

Coming Soon: Part IV: Being Let Down By The U.S. Women’s Movements and Moving Forward

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It’s Your Turn to Make Doula History

Apr 3, 2017 by

AmyConf1993

Amy Gilliland, Madison Area Birth Assistants booth, Oct 1993, Madison Women’s Expo

Lately I’ve thought a lot about what’s left after someone is gone – and who tells their story. It has made me really think about who is going to write the story of our movement. Traditionally history is written by people after events have happened, after the world has already changed. It’s written by people who have the power to write and disseminate information – which is why so many of our perceptions of history are distorted.

What about us? What about our history? Who will write the story of birth and postpartum doulas across North America and the rest of the world? Who will point out the indigenous women who never abandoned each other under the pressures of western medicine? Who will write about the women in the seventies and eighties who said, “I will go with you and I won’t leave you”? Who will write about how we took care of each other when our own families would not support us in breastfeeding or avoiding another cesarean?

The battleground of the doula revolution was not on a national stage. It was quiet, in every labor room across the planet, where one woman held another’s hand and said, “You can do this, I believe in you.” We made a stand for another person’s mental and emotional wellbeing in a system that had little room for it. We protected the space. We stood by her side when she said, “No.” We agitated the system with a smile on our faces. We kept doing it, over and over again, for years, until eventually those in power could no longer ignore us or their own research.

That’s the big story. But what about the little stories? What about the doulas in Pueblo, and Springfield, and West Bend? How did birth change there because of the presence of those early doulas? All of our communities have little stories. Each weaves a thread into the tapestry of our great big story of doulas changing birth in the world. Where are those stories?

Who came before you, person reading my blog? And what was birth like in your town? The time has come for you to seek out retired doulas and nurses and midwives and find out.

You see, if we don’t write our own stories, someone else will tell a tale that serves their own purposes. Or they will be forgotten, seen as not being important. Much of women’s daily lives has been unimportant to historians. But doula history is significant. If any one movement will be singled out as creating change in our system of birth, it is going to be birth doulas. Mostly we’ve been like dripping water, slowly eroding rock, getting the system to change. Lots of drips lead to pitting a foundation, causing it to change in response or else collapse. So while we may not be at most births, we don’t have to be. Our impact continues to grow. We aren’t done yet.

What is your community’s story of change?

Starting in the 1990’s I was the Archivist for Doulas of North America (DONA). Doulas sent me articles from their hometown newspapers. Back then it was a rare occurrence. While we might have wanted to change birth, what we really wanted to do was make sure women didn’t lose their power while having their babies. We couldn’t do that for everyone, so we just focused on the family in front of us. We hoped that over time the value of what we did would show.

Our strategy (if you can call it that) worked. Nowadays there are tens of thousands of trained doulas, and many cities have well established doula communities. ACOG recognizes the value of birth doulas. That means to me that it’s an excellent time to look backwards.

That sounds good to me, you say. But what are you suggesting I DO?

  1. Have fun! Talking about this history of birth in your town can be really fun. Most people like to reminisce and are excited that their memories are important.
  2. Investigate! If you don’t know who came before you, start asking. More experienced doulas may be able to remember a name or two. But don’t stop there. Ask the nursing unit director, the lactation consultant in her sixties, and your local midwives. Childbirth educators often last for decades and may be very knowledgeable about past trends. If everyone is young, ask who they’ve heard about being important in years past. Sometimes the only people who are remembered are the ones people didn’t like, but they don’t want to admit it! That’s fine. One name will lead to another. Look for old newspaper articles in the online archive. Most articles will reference older ones, sometimes going back ten years or more.
  3. If you can’t find a specific person, ask retired perinatal professionals about birth trends. Hospitals were remodeled, attitudes towards induction, breech birth, VBAC, episiotomy, cesarean birth, and having family members present have all changed dramatically in the course of my career.
  4. Interview alone or have a party! Sometimes a celebration is in order. In fact I think we need more parties in our lives that celebrate our accomplishments, especially when it comes to birth. Instead of interviewing one person, you could lead a group of people to reminisce. That might be more enjoyable for everyone.
  5. Ask questions that encourage explanations and depth about events. Here are some OralHistoryTips (pdf doc) I compiled to help you.
  6. Create a timeline of the order of events and include anything that might be relevant. This will likely lead to more interesting questions and observations. If you like mystery novels, this is your project! It’s a discovery of how your community moved from where things were in 1980 to where they are today.
  7. Record your interview and make sure your participant has a microphone near their face to avoid recording background noise. Many smartphones can do this well.  There are apps that can transcribe your interview into written form as long as there is no background noise. You may end up with a really interesting podcast, or a local historical society or oral history project may want your recordings for their files.

Then what?  If you complete your local project, I will publish it on a web site devoted to doula history that is available for everyone to read, including students of history to use in their papers.

This project is about more than you. It’s about those who came before but also for those who will come after. You may not know what they will look like or how they will interpret doulaing for their generation, but our history is important for them to know. And if you don’t record it, probably no one will.

 

Resources:

Christine Morton covers much of the big history of doulas in her book, Birth Ambassadors: Doulas and The Re-Emergence of Women Supported Birth in America. It’s our most extensive resource. Since I lived that history, what struck me the most was what wasn’t in there – including all of our small struggles in our own communities. It’s our responsibility to build on Dr. Morton’s achievement and share our stories to build a more comprehensive history.

Along with Mothering magazine, in the 1980’s and 1990’s many of us eagerly read The Compleat Mother, a quarterly newsprint periodical that espoused a radical wholistic philosophy of empowering women through childbirth.  It was more raw and less polished than Mothering. It did not shy away from exposing the patriarchal philosophy entrenched in the medical system and the feminist power available to us when we took charge of our bodies.  Famous Midwife Gloria LeMay wrote “Remembering Catherine Young”, founder of The Compleat MotherRemembering Catherine Young, 21 July 1952 – 11 September 2001

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Fewer Blogs but More Amy

Dec 30, 2015 by

AmySmile2This year has been about serving you, committed birth and postpartum doulas, in a different way. I’ve written fewer blogs, but posts on higher impact topics like essential oils and universal certification. When I’m not blogging, it’s because I’m writing something else. This year alone I’ve had two book chapters published, one podcast, three videos, developed four new continuing education sessions, and one peer-reviewed journal article, all relevant to what YOU do. I also wrote a 350 page memoir, but that was a personal project!  Several of these resources are FREE. I’m committed to improving our profession and your experience of being a doula.

Round The Circle: Advice for New Doulas includes a chapter on the results of my research on Doulaing Friends and Family Members. Basically, it turns out well when what the laboring person expected to happen and what really happened are close to one another. If the birth or postpartum doesn’t turn out as expected, the relationship between the doula and friend or family member will change dramatically, and usually not for the good. Want more?  [Link to Amazon]

Doulas and Intimate Labor is an academic book published this month by Demeter Press. Edited by Andrea Castaneva and Julie Johnson Searcy, my chapter covers my scholarly work on Doulas as Facilitators of Transformation and Grief. As doulas we are present as the woman becomes a mother and must surrender her old self in order to become her new self (this research was done on cisgendered women). Change implies grief, which is one of the unacknowledged journeys of postpartum. In addition, this chapter covers doula’s experiences when the partner dies during pregnancy, and when the baby dies before birth (fetal demise), at birth, or in the immediate postpartum period. I’ve also turned this topic into a successful continuing education session. [Link to Amazon]

Why Do People Attend Doula Trainings? is an original solo research project. I collected data in 2010 and 2014, asking over 400 people why they were taking a doula training (before the workshop). Surprisingly, many people taking a training are not there to become doulas, but because they want a general education about birth! This topic is also a successful continuing education session. The full article is forthcoming in a 2016 issue of the Journal of Perinatal Education!

Sexuality and Birth Video and Podcast – In October, I had the opportunity to be interviewed by Penny Simkin on Sexuality, Birth and Postpartum. This eight minute video is going through approval to be recommended by Lamaze as a resource for parents and professionals. I’m thrilled that this free video, which gets at the sexual and emotional needs of people becoming parents, primarily connection and pleasure.  [Sexuality After Childbirth Youtube video]

Amy Neuhadel, of The Cord in Sweden, also interviewed me on sexuality and birth. We’ve gotten great feedback on how helpful this TEN minute interview has been for parents and for educators.  [Intimacy and Pleasure In Your Birthing Year Link]

Giving Fathers What They Really Need In Birth  – This YouTube interview conducted by Penny Simkin gave me the opportunity to summarize the research on men and fathers (male cisgendered perspective).  You’ve loved my conference sessions on this topic, so here’s a short resource you can use as a discussion starter in your classes, small groups, or just for yourself!  [The Role of Fathers YouTube video link]

Giving Birth, the birth video that I executive produced with director Suzanne Arms (it really is her baby) is now finally available on Amazon Instant Video!  It took me a year, but its now up!  Suzanne Arms sells it on DVD through her site.

Northwest Doula Conference presentation covering The Top Eight Challenges of the Birth and Postpartum Doula Professions. After two hours of listening to me and what I think, I got a standing ovation. And that’s after getting people to commit to making behavior changes to meet those challenges, not just passively listen and go on their way! I had multiple requests to turn this address into a podcast, but I’d really love to give it again live at another conference and record that. Anyone interested?

New workshop content – this year I wrote several new sessions for continuing education. Hospital Based Doulas: What’s The Difference? is based on multiple waves of research interviews with this HB doulas around the United States; Doulas as Facilitators of Transformation and Grief focuses on how to be this significant person in our client’s lives, as they shift into parenthood, face the possibility of loss, and experience grief as part of the transition into a different phase of adult life. It also gives us space to breathe as we recognize our shared responsibility for the emotional well being of our selves and each other as doing doula work changes who we are as human beings.

Communication Skills for Birth Professionals is a skill building workshop where you learn by doing – you leave with skills you didn’t have when you walked in the door! It is available in two, three, and four hour formats. Two hours focuses on listening; the third hour focuses on preparing yourself to communicate successfully; and the fourth hour adds conflict resolution skills focusing on typical situations that birth and postpartum doulas face. These sessions are not formulas, telling you what to say. They teach you how to think about a situation, so you can be authentically yourself in all of your encounters.

PTSD: How It Affects Childbirth And How To Improve Your Outcomes is the latest addition to my catalogue, which came my way because of requests from physicians and nurse groups. Yay! What most doctors and nurses don’t learn in school is how to show they care. They don’t learn the physical and emotional skills that communicate their internal feeling of caring for a patient on a personal level. In fact, for many professionals their educational experience is to have the emotional center pummeled away in order to follow good practices in medical care.  The ‘cure’ for preventing childbirth to make existing PTSD worse is authentic human connection.

If that isn’t enough for you, I also wrote a 350 page memoir of the experience of taking care of my terminally ill mother, who was misdiagnosed for the first half of her illness. Tentatively titled The Summer of Mimi, I hope to complete the second and third drafts in 2016. This was a personal goal of mine, but as I can’t stop being a doula all over my life, its has juice in it for all doulas too.

2016 promises more content and more projects!

As always, please subscribe!  [Box is on the lower left.]  Thank you for your support!

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