Why The Doula Research We Need Doesn’t Exist: Part II – Medical Politics and Practices

Nov 6, 2017 by

DSC03787As a young woman, I naively thought that the evidence was so overwhelming that we’d steadily see doula research in major medical journals. Nursing and medical students working on research degrees would pair with their professors and community members to answer these pressing questions. The fact that our answers could impact future generations would provide enough incentive. We could stop women’s bodies from being permanently damaged by outmoded obstetric practices and facilitate trust and communication between client and caregiver. We could help mothers and babies have the best possible connection from the very beginning. We could increase physician and nurse sense of connection to patients and colleagues thus positively impacting their mental health outcomes. Doulas do this by offering two commodities that are scarce in the hospital system: time and a listening ear.

I am no longer young. Anyone wanting to study doulas from a medical perspective has been shushed or shut down – that’s my only explanation. They’ve been quietly steered to other topics that would be more acceptable to medical or nursing professors serving on the approval or review board committees. While there are plenty of theses and dissertations on doula topics, very few of them actually add to our understanding of doula support. They are almost exclusively from the social sciences not a medical field. Most focus on the way labor support is experienced by parents or doulas because that aspect is accessible.

My conclusion is there are few doula research studies because of obstacles from medical politics and outmoded beliefs which I explore here. Part III will cover difficulty in research approvals, funding and publishing access; and the feminist political agenda of the U.S. women’s movement.

Politics and Power:

  • Doulas represent the laboring person. They don’t want to maintain the system as it is, they exist to disrupt the system from offering impersonal care. Their very existence demands that the hospital see the patient as an individual, with their own particular needs. Anyone who has a vested interest in maintaining the status quo will actively resist any research on birth doula support.
  • Doulas are unpredictable. Because they make a stand for the primacy of their client’s interests, no one is quite sure what they will do. Ask for the squatting bar? Even wanting a spontaneous labor to take as long as it needs to rather than following a predictable timeline is heresy in some labor and delivery units. Doulas actually interrupt physicians from doing interventions so they can be discussed with the patient first.
  • Doulas disrupt the power imbalance in the labor room. Doulas insist that power be shared with the laboring person (patient) and that medical careproviders discuss benefits, risks, and alternatives. Doulas assist their clients to develop a collaborative relationship with their doctors, even when that is not the wish of the physician. Many doctors are used to making autocratic decisions and not having their opinions questioned. They do not see the benefit to the patient or to themselves, even though it leads to charting of the conversation that benefits the physician if there is need for a review or inquiry.
  • Doulas empower women. Current western society is still built on the premise that women are not equal to men. These patriarchal beliefs are woven into our majority culture along with white supremacy, colonialism, and racism. Anytime an oppressed group exceeds their allotted power in the system, the fear grows that it will spread to other groups. The existing system sees sharing power as a loss rather than a gain. Since doulas are basically disruptive to the status quo they cannot be empowered in any way including research funding or internal review board project approvals.
  • There’s no clear way for hospitals or medical systems to make money exploiting doula support. Although there’s a lot of controversy about the unpredictability of maternity care billing here and here, as a general rule the current system pays more money for a birth when more interventions are used. Since doulas have been shown to reduce the need or use of those interventions, and doulas cost money, there’s no financial incentive to explore labor support. Until the billing and funding systems change there will remain no financial reason to explore doula care except for Medicaid patients.
  • The only medical systems that employ doulas do so because it solves their other problems not because it primarily benefits women or babies. That’s why these systems haven’t published on positive obstetrical outcomes, because there aren’t many. In my own observations, these programs only exist when they help the hospital to attract customers or when the doulas solve other problems in the labor and delivery unit. They don’t exist to get better outcomes, lower complications from interventions, or empower patients in the medical system.

Outmoded Beliefs:

Our medical systems don’t value individual people very much. This is ironic because our medical system is supposed to help people, but when it comes to how obstetrics is practiced people are damaged as well as helped. This is true for physicians, midwives, and nurses as much as it is doulas and patients. No one personally benefits from our current system of labor and delivery care. Only the system itself does. We have to remember that the hospital system of obstetric care was founded on several beliefs:

  • Babies don’t feel pain or remember what happens to them so whatever you do to them doesn’t matter.
  • Women’s bodies are mechanical in nature, so treating the body as a machine with technical difficulties is the right approach. The fact that there is a person inside the body influencing how the body functions was not a part of that original thinking.
  • Physicians function best when divorced from their own lives and feelings and practice in a vacuum, focusing solely on the mechanics of the body and objective data.
  • Nurses are there to be the physician’s hands and eyes, not to have a voice or their own unique knowledge and contributions.
  • A mechanized system of medical care delivery, based on a factory model, provides the best results for the majority of people and the system itself.

We can see how toxic each of these beliefs are. Yet they are still present in how labor and delivery units are designed and how people do their jobs. Acting as if those beliefs are wrong is heresy! Yet that is exactly what doulas do. So no wonder no one wants to pay money or spend time to do research on birth doulas unless they are also invested in changing the way medicine is practiced. Think about it. The changes that many wish to see in the way obstetrics or hospital midwifery is performed challenge one or more of those founding beliefs. My cynical side says that they have no reason to worry as it takes 17 years for the best evidence to actually become medical practice.

In Part III of this series, I’ll explore the obstacles inherent in the research process.  Part IV covers how the lack of any kind of childbirth rights agenda from U.S. mainstream feminist organizations affects doula studies.  Part I covers the doula research I thought we’d have in the 37 years since the first doula study was published.

 

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine104(12), 510–520. http://doi.org/10.1258/jrsm.2011.110180

Free SlideShare Presentation on Why It Takes 17 years  (See Slide 7):  https://www.slideshare.net/iHT2/health-it-summit-san-diego-2015-panel-research-evidence-and-clinical-realities

3 Comments

  1. Jacqueline Levine

    I’ve asked that question too, and continue to do so at every workshop. There have been some studies on why the profession resists the use of best-evidence care…which is what doula care assuredly is, and there is some good research, ignored, as I note here:

    Why Do OBs and Policymakers of Maternity Care Resist Changing Their Protocols to Reflect Best-Evidence Scientific Practices for Childbearing Women? Why Aren’t They Advocates for Doula Care?
    Doula care is a proven best-evidence care intervention, and OBs and other caregivers should hardly need urging to be some of the loudest voices advocating for the presence of the doula as a necessary part of optimal maternity care. Do docs and clinicians really need prodding to be willing and eager to advocate for evidence-based care for their patients? Even medical journals have announced the efficacy of having a doula with a birthing woman. The journal Clinical Obstetrics and Gynecology (Volume 44, Number 4, pp 692–703© 2001, Lippincott Williams & Wilkins, Inc.) gave doula care an official imprimatur, as far back as 2001, via publication of that thorough, in-depth study.

    So what’s holding docs and other clinicians back from jumping in as strong supporters for legitimizing the use of this best-evidence tool with its proven beneficial effects? How many have heard of a doc who explained the benefits of doula care to patients or urged them to find a way to make doula care part of their plans for birth?
    What are the reasons that best-evidence, optimal maternity care is hard to come by? Is it simply the unwillingness of caregivers to change the way they do what they’ve always done? Here’s one result of that kind of question asked of OBs… why docs won’t adopt new best-evidence methods or protocols that are proven to be better for their patients:
    Abstract: In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Concerning comments from this survey included “obstetrics requires manual dexterity more than science”, “evidence-based medicine ignores clinical experience”, and that following guidelines could result in “erosion of physician autonomy”. These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education. Olatunbosun OA, Eduoard L, Pierson RA. Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med. J. 316, 365–366 (1998).
    And this from an AMA journal: the title of the article says it best:
    “The Difference between Science and Technology in Birth: Obstetrics seems to be particularly resistant to making evidence-based changes to common practice, perhaps because of the emotional climate surrounding pregnant women and babies. Aron C. Sousa, MD, and Alice Dreger, PhD September 2013, Volume 15, Number 9: 786-790.”
    So it’s the “emotional climate” that makes it difficult for docs to advocate for and adhere to best-evidence care? It’s not just a patient’s right to be fully informed about their care and to accept or refuse that care in an informed way: it’s a patient’s right to be offered and treated with only best-evidence care and nothing less. If you asked a birthing momma if she’s paying for less than optimal care or whether she’s paying for best-evidence care for herself and her baby, we all know what the answer would be.
    Jackie Levine LCCE,FACCE CD(DONA)CLC,BA

    • Amy Gilliland

      Thank you for participating in this discussion so thoroughly, Jackie Levine. I appreciate you bringing your voice to the table and making additional points! Just what I was hoping for – Amy G.

  2. This has been my exact question over the years. Doulas face the same problems that many alternative practitioners face. It’s very hard to disrupt status quo. With a strong movement to back away conflict within the doula community itself currently, I am worried that this will continue to be a problem for doula research.

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  1. Doula Research Part III – Barriers To Approvals, Funding And Publishing Access | Doulaing The Doula - […] barriers that are unique to publishing doula research examining obstetrical or neonatal outcomes. Part II covered the medical politics…

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