An Interprofessional Collaboration Between a Community‐Based Doula Organization and Clinical Partners: The Champion Dyad Initiative

Abstract

As access to doula services expands through state Medicaid coverage and specific initiatives aimed at improving maternal health equity, there is a need to build and improve upon relationships between the doula community, hospital leaders, and clinical staff. Previous research and reports suggest rapport‐building, provider education, and forming partnerships between community‐based organizations and hospitals can improve such relationships. However, few interventions or programs incorporating such approaches are described in the literature. This article describes the development and 5 core components of the Champion Dyad Initiative (CDI), a novel program that uses bidirectional feedback between SisterWeb, a community‐based doula organization, and 5 clinical sites (4 hospitals and one birthing center) to ensure pregnant and birthing people receive fair and equitable treatment. We also describe implementation challenges related to documentation, funding, and institutional support. The CDI is a promising model for community‐based doula organizations and health care institutions to develop collaborative partnerships, build respectful doula‐provider relationships, and work toward improving the pregnancy‐related care that Black, Indigenous, and people of color receive in hospital and birth center settings. It is our hope that this innovative initiative can serve as a model that can be adapted for other locales, organizations, and hospitals.

INTRODUCTION

Over the past decade, policy makers and advocates have worked to expand access to doula services to improve maternal health in the United States, ¹ particularly among Black pregnant and birthing people, who are most impacted by adverse outcomes. ² , ³ Pregnant and birthing people in the United States face high rates of maternal mortality compared with other high‐income countries, ⁴ and 1 in 6 women have reported experiencing mistreatment during maternity care in US hospital settings. ⁵ Such mistreatment includes being ignored, shouted at, or scolded by health care providers, and experiencing violations of physical privacy. ⁵ Notably, Black, Hispanic, Asian, Indigenous, and other people of color experience higher rates of mistreatment than their White counterparts ⁵ and face bias, racism, and discrimination in health care settings. ⁶ , ⁷ , ⁸ , ⁹

Doulas provide physical, informational, and emotional support before, during, and after childbirth to pregnant, birthing, and postpartum people. Research suggests that doulas can improve patient experience, promote respectful care in hospitals, and help facilitate communication between clients and clinical staff. ¹⁰ , ¹¹ , ¹² , ¹³ Specifically, in one study, health care providers described how doula presence led them to more consciously consider their approach to care and provider‐patient communication, thereby increasing health care providers’ personal sense of accountability toward patients. ¹² Given the benefits to doula support, there are ongoing efforts to increase access to doula services through a variety of mechanisms, including Medicaid coverage of doula services and community‐based doula programs.

However, doulas still face challenges supporting clients in clinical environments. Physicians, midwives, and nurses have mixed views of doulas, ¹⁴ , ¹⁵ , ¹⁶ and tensions exist between health care professionals and doulas, many of whom are not employed by hospitals. Conflict may stem from lack of role clarity, the perception that doulas obstruct or delay care, and differing attitudes on physiologic birth. ¹¹ , ¹⁵ , ¹⁷ , ¹⁸ The COVID‐19 pandemic also highlighted ways hospital administrators regulate doula entry and deprioritize their importance as support people. ¹⁹ , ²⁰ , ²¹

QUICK POINTS

• ✦Doulas face challenges supporting clients in clinical environments, and some tensions exist between health care professionals and doulas.
• ✦Forming partnerships between community‐based organizations and hospitals may improve relationships between doulas and clinical staff, but few program models are described in the literature.
• ✦The Champion Dyad Initiative (CDI) partners SisterWeb, a community‐based doula organization, with health care providers at 4 hospitals and one birth center in San Francisco to engage in bidirectional feedback about client, doula, and provider experiences and work to integrate doulas into clinical settings.
• ✦Through the CDI, SisterWeb staff and clinical partners have identified ways to repair harm when doula clients report negative experiences during pregnancy‐related care and taken steps to prevent similar issues from happening again.
• ✦Those interested in launching a similar initiative should be mindful of contextual factors that allowed the CDI to materialize, including existing relationships between doulas and health care providers at clinical sites.

As access to doula services expands, there is a need to build and improve upon relationships between the doula community, hospital leaders, and clinical staff. Importantly, doulas and health care providers have described positive experiences working together while supporting pregnant and birthing people. ¹¹ , ¹⁵ , ²² Previous research and reports suggest rapport‐building, provider education, and forming partnerships between community‐based organizations and hospitals can improve relationships between doulas, hospital leaders, and clinical staff. ¹¹ , ¹⁵ , ²³ , ²⁴ However, few program models incorporating such approaches are described in the literature. This article aims to describe the Champion Dyad Initiative (CDI), a novel program that uses bidirectional feedback between a community‐based doula organization and clinical sites to ensure that pregnant and birthing people receive fair and equitable treatment. Challenges to implementing this program, adaptation considerations, and next steps will also be discussed. The CDI has not yet been formally evaluated; therefore, this article focuses on the CDI's development and core components.

ORIGIN OF THE CDI

The CDI is led by SisterWeb, a community‐based doula organization in San Francisco, California that launched in 2018. SisterWeb's mission is to dismantle racist health care systems, strengthen community resilience, and advance economic justice for birthing families and doulas in San Francisco, California. SisterWeb began offering culturally congruent community doula care at no cost to Black, Pacific Islander, and Latinx pregnant and birthing people in 2019 through 3 programs: Kindred Birth Companions for Black clients, M.A.N.A. Pasefika for Pacific Islander clients, and Semilla Sagrada for Latinx clients. As of 2024, SisterWeb only provides doula care to Black clients through Kindred Birth Companions.

Expecting Justice, a collective impact collaborative based in the San Francisco Department of Public Health, was a key partner when SisterWeb launched as an organization. Expecting Justice established the Doula Access Working Group to help inform SisterWeb's programmatic planning and strategic decision‐making. ²⁵ Working group members included community doulas, San Francisco residents, social service providers, and health care providers. ²⁵

The Doula Access Working Group believed advancing community doula care would require partnerships with key stakeholders across San Francisco's health care system who understood the benefits of doula care and were committed to addressing racial inequities in birth. With input from the working group, SisterWeb and Expecting Justice began codeveloping the CDI. Through the CDI, SisterWeb partners with 1 to 2 champions in labor and delivery departments at 4 hospitals and one birth center where SisterWeb clients receive pregnancy‐related care. The CDI creates a space for SisterWeb and site champions to engage in bidirectional feedback about client, doula, and health care provider experiences and work to integrate doulas into clinical settings. Bidirectional feedback is a critical element of the CDI as it allows for SisterWeb staff and site champions to identify successes and opportunities for improvement, which can ultimately lead to improved client and patient experiences.

CDI GOALS AND CORE COMPONENTS

The core components of the CDI, described below, are key to achieving the CDI goals outlined in Table 1. We note that the CDI has evolved since it began in 2019, and although the initiative continues to grow and change, these core components have emerged as foundational building blocks. Figure 1 details the initial implementation steps taken to launch the CDI.

Table 1.

CDI Goals for SisterWeb and Site Partners

Goals
1. Site or hospital health care providers and clinical staff understand the SisterWeb community doula model and refer all eligible patients in a way that respects community and birth workers.
2. Site or hospital health care providers and SisterWeb staff work collaboratively to identify population data related to birth outcomes and increase awareness at each site regarding current inequities and quality improvement needed.
3. SisterWeb doula programs have close working relationships with health care providers and clinical staff, building respect between roles and sharing resources and feedback.
4. With the support of CDI sites, SisterWeb programs effectively and efficiently are able to collect data related to patient and doula experience and communicate data back to hospital sites with a focus on action steps and systemic improvements.
5. Site or hospital health care providers and clinical staff support SisterWeb doulas in their professional journeys with consistent, constructive feedback and opportunities for professional growth and skill building.
6. All SisterWeb doulas deeply understand the value of the CDI and the importance of using and maximizing it as a tool that will help accomplish CDI goals.

Abbreviation: CDI, Champion Dyad Initiative.

Figure 1.

Initial Implementation Steps to Launch the Champion Dyad Initiative

Champion Dyads

In early 2019, SisterWeb and Expecting Justice leveraged their connections, including those developed through the Doula Access Working Group, to recruit champions from 4 hospitals and one birth center in San Francisco to participate in the CDI. Each clinical site has champion health care providers (eg, obstetrician‐gynecologists, midwives, nurses, and patient navigators) who partner with SisterWeb to achieve CDI goals. Champions are passionate about collaborating with doulas, understand SisterWeb's community doula model, believe in SisterWeb's mission, and are committed to practicing antiracism. Ideally, champions hold leadership roles within their departments, allowing them to implement or advocate for transformative change at their sites, and can effectively communicate positive, neutral, and negative feedback to hospital or birth center staff. Champions from each site work in partnership with at least one SisterWeb staff member, forming a Champion Dyad. These dyads are expected to attend standing monthly meetings, participate in community building activities, and maintain open lines of communication, all of which facilitate bidirectional feedback. Site champions voluntarily participate in the CDI and are not compensated by SisterWeb. Similarly, sites do not compensate SisterWeb staff for identifying ways to improve patient experience in clinical settings or improve relationships between clinicians and doulas.

Community Building Activities

When SisterWeb first launched, Champion Dyads focused on preparing clinical staff and SisterWeb staff to work together. Champion Dyads organized site‐specific meet and greets, hospital and birth center tours, and trainings related to community doula care for clinical staff. These community building activities served as a starting point for SisterWeb doulas and health care providers to build close working relationships and establish mutual respect, a key CDI goal.

Meet and Greets

During meet and greets held at clinical sites, SisterWeb doulas and administrative staff presented information about SisterWeb's programs, reviewed eligibility criteria for referrals, and answered questions. Nurses, obstetrician‐gynecologists, certified nurse‐midwives, clinic staff, and some department leaders attended these events.

Hospital and Birth Center Tours

SisterWeb doulas toured all 5 clinical sites to familiarize themselves with the locations where their clients would give birth. Site champions reviewed protocols for arrival to labor and delivery units, including which entrance to use during day and night shifts, security measures, parking, and other logistics. They also showed doulas important, site‐specific features, such as kitchen and cafeteria access, waiting rooms for family members, and where doulas could access supplies, such as birthing balls. Information garnered from these tours helped doulas prepare clients to navigate the hospital or birth center where they would receive care.

SisterWeb‐Led Trainings for Clinical Staff

With input from site champions on useful training topics, SisterWeb staff designed and facilitated multiple trainings for clinical staff at CDI sites. Thus far, training topics have included restoring and repairing the perinatal care relationship, using nonviolent communication to address conflict in the moment, and how to effectively work with doulas. Champion Dyads continue to identify opportunities for SisterWeb staff to facilitate informational sessions and trainings with clinical staff to improve patient care.

Referrals

SisterWeb used its relationships with champions to establish referral processes with clinical sites. Site champions educate colleagues about SisterWeb's services and how to refer patients. They also identify ways to strengthen the referral process and communicate those ideas to SisterWeb's CDI representative.

Communication and Bidirectional Feedback

The CDI uses bidirectional feedback, meaning SisterWeb staff and staff at clinical sites provide and receive feedback about provider, doula, and client experiences. Champion Dyads review feedback during standing monthly meetings but address urgent issues in real time.

Doula and Provider Feedback Forms

SisterWeb doulas are encouraged to fill out an online feedback form after encounters with health care providers. Using the form, doulas can report positive, neutral, or negative experiences with health care providers while supporting clients in clinical settings, such as during childbirth or at prenatal or postpartum appointments. Doulas are asked to include details such as the encounter location, date, and who was involved (ie, client and clinical staff). If doulas or clients experience any harm during these encounters, they can request remediation. Examples of past remediation include health care providers apologizing directly to SisterWeb clients or site champions issuing staff guidance. Health care providers who work at CDI sites are encouraged to fill out a similar online feedback form after encounters with SisterWeb doulas. To prompt health care providers to complete a feedback form, doulas give them a business card that includes a link to the form after each encounter.

SisterWeb CDI representatives review each form submission and discuss feedback with champions during monthly site meetings. However, if feedback requires immediate attention, SisterWeb CDI representatives will contact the site champion.

Monthly CDI Meetings

During monthly meetings for each CDI site, champions meet virtually with SisterWeb staff to discuss referrals and client care coordination, exchange bidirectional feedback, share organizational updates, and identify collaboration opportunities. Champion Dyads also use meeting time to celebrate accomplishments and verbalize appreciation for one another's work. SisterWeb's CDI representatives maintain meeting notes to document progress and action items requiring follow‐up.

When discussing feedback during meetings, Champion Dyads identify actionable steps to address a particular situation and work toward systemic improvements when opportunities arise. For example, if feedback revolves around a client or doula's negative experience, the site champion might initiate a conversation with the provider(s) involved or revisit hospital practices that may be causing harm. Likewise, if a provider shares feedback about an experience with a doula, SisterWeb's doula coordinators will discuss the incident with the doula during weekly reflective supervision meetings. Champion Dyads also discuss feedback regarding CDI processes, such as how to strengthen referral practices and improve feedback forms.

Resolving Urgent Issues

If SisterWeb doulas cannot resolve urgent issues while supporting clients at clinical sites, a SisterWeb staff member can contact site champions via text message or phone. If the champion is unavailable, there are back‐up clinicians to contact.

All‐site CDI Meetings

All‐site CDI meetings, which bring together Champion Dyads from the 5 clinical sites, were originally used to collaboratively develop the initiative. Currently, the CDI uses these biannual meetings to share programmatic data, review and recommit to CDI goals and expectations, discuss successes and challenges around the partnerships, and engage in strategic planning related to the CDI.

Professional Development Opportunities for SisterWeb Doulas

As part of SisterWeb's workforce development program, SisterWeb doulas attend monthly trainings to expand their knowledge and skillset. Champions contribute to this effort by hosting trainings for SisterWeb doulas that contribute to their professional growth. Thus far, training topics have included labor induction protocols, routine prenatal care and screening, and pregnancy loss. Champions have facilitated trainings themselves, co‐facilitated with SisterWeb staff, and recruited colleagues to lead sessions.

IMPLEMENTATION CHALLENGES

Several challenges related to documentation, referrals, capacity, funding, and institutional support have emerged as the CDI has grown and evolved. Regarding documentation, SisterWeb largely relies on data collected through the doula and provider feedback forms to keep track of incidents that require remediation. During the early phases of implementation, many doulas viewed completing the feedback forms after attending births as a burdensome task. This has improved over time through continued training, particularly as SisterWeb leaders have communicated how documentation can contribute to systemic change and improve client and doula experiences. Currently, relatively few health care providers fill out the provider feedback form, which was created in consultation with site champions and shortened after receiving feedback about the form length. Site champions report that health care providers may also view the form as burdensome because of the amount of documentation they are required to complete as part of their job responsibilities. Thus far, when health care providers have an issue with a SisterWeb doula, they tend to report it directly to the site champion. Feedback through any mechanism is useful, but lack of consistent health care provider feedback via the form has made it difficult for SisterWeb to identify opportunities for improvement.

Next, although site champions have communicated that health care providers value knowing if patients who they referred were matched to a SisterWeb doula, SisterWeb is not able to match everyone or communicate when a match has occurred due to its limited capacity. Site champions have reported that this has frustrated some health care providers and disincentivizes them from referring patients to SisterWeb, which is a core component of the CDI. Notably, even when SisterWeb doulas cannot take new clients, the organization asks health care providers to continue referring patients, as tracking referrals and the length of SisterWeb's waitlist helps demonstrate the need for additional funding to provide more doula services.

SisterWeb largely relies on grant funding to provide doula care to communities most likely to experience racism in health care settings. Generally, SisterWeb leaders have struggled to secure sustainable funding for its programs, but specifically funding the CDI has been uniquely challenging. Much of SisterWeb's grant funding goes toward the provision of doula services. The CDI is not directly supported by these grants. Given that the CDI's efforts focus on addressing racism and bias in health care settings, SisterWeb leaders believe hospital administrators should explore cost‐sharing opportunities for maintaining the CDI.

Lastly, in order for the CDI to work effectively, there must be broad institutional support for doula care at clinical sites. SisterWeb has found that even the most dedicated site champions experience difficulties advocating for community doulas if they work at institutions where leaders have not been supportive of doula care.

DISCUSSION

The CDI is a promising model for community‐based doula organizations and health care institutions to develop collaborative partnerships, build respectful doula‐provider relationships, and work toward improving the pregnancy‐related care Black, Indigenous, and people of color receive in hospital and birth center settings. Importantly, findings from our previous work evaluating 2 of SisterWeb's doula programs ²⁶ , ²⁷ suggest bidirectional feedback exchanged through the CDI creates provider‐ and institutional‐level accountability and can facilitate change within hospitals. ¹¹ However, the CDI was not specifically evaluated, and further investigation is needed to explore whether the CDI is a replicable model for system change.

Nevertheless, SisterWeb leaders believe the CDI plays a critical role in their mission to dismantle racist health care systems. Using CDI communication mechanisms, SisterWeb CDI representatives and site champions have identified ways to repair harm when clients report negative experiences during pregnancy‐related care and taken steps to prevent similar issues from happening again. In addition to community building activities, SisterWeb staff report that exchanging bidirectional feedback has also contributed to better collaboration and understanding between health care providers and SisterWeb doulas, as exemplified in Table 2.

Table 2.

Examples of Bidirectional Feedback Exchanged Through the CDI

Feedback	Response to Feedback
During a CDI meeting, Champion Dyads discussed an instance when a Mam‐speaking a SisterWeb client did not consistently have access to an interpreter throughout the client's hospital stay.	The site champion relayed this experience to a hospital leader, who explored alternative interpretation services with more consistent access to Indigenous languages.
A doula filled out a CDI feedback form describing a client's experience with an attending physician and resident physician in the labor and delivery unit. The health care providers did not tell the client that the attending had a supervisory role while the resident was a trainee and that each provider would perform a cervical examination. Instead, after the resident performed a cervical examination, the client was informed that the attending would also need to perform an examination. The client felt extremely uncomfortable.	After a SisterWeb CDI representative and site champion discussed the feedback at a CDI meeting, they asked the doula for more details. The doula could not provide the names of the attending or resident physician but reported that the client consented to a cervical examination 8 times over the course of her hospital stay. An attending and resident performed an examination each time, resulting in a total of 16 examinations. Clinical leadership learned of the incident and acknowledged that it reflected a wider issue that nurses had reported as well. During CDI meetings, the site reported a need for an internal policy aimed at providing more transparency from the beginning of the informed consent process for cervical examinations.

Abbreviation: CDI, Champion Dyad Initiative.

^a

Mam is a Mayan language.

Those interested in launching a similar initiative should be mindful of contextual factors that allowed the CDI to materialize in San Francisco, where reducing inequities in maternal and infant health is a city, county, and state priority. ²⁸ , ²⁹ Launching the CDI required strong partnerships between SisterWeb and clinical sites where SisterWeb clients receive pregnancy‐related care. To establish these partnerships, SisterWeb leaders participated in the Doula Access Working Group organized by Expecting Justice and leveraged long‐standing relationships with key health care providers cultivated over more than 2 decades of collective experience as doulas in San Francisco. These connections with influential health care providers laid the foundation for CDI partnerships at a few clinical sites. Leaders of community‐based doula organizations in other locales may not have existing allies within health systems, which may make it harder to gain buy‐in for similar initiatives.

CONCLUSION

It is encouraging that doula care is increasingly recognized nationally as an important intervention to improve maternal health inequities. However, in order for doulas to most effectively serve clients in clinical settings, health systems must welcome doulas and understand and support their work. It is critically important to focus on establishing mutual respect and understanding between doulas and physicians, midwives, and nurses, which may positively influence patient care. SisterWeb's CDI is a unique and promising model of collaboration and relationship‐building between doulas, hospital leaders, and clinical staff. Next steps include examining whether the CDI has led to systems‐level changes that improve birth equity, such as shifts in clinical policy and protocols. Exploring the perspectives of key stakeholders, including site champions, doulas, and health care system leaders, on this model's potential to improve patient experience is also necessary. The innovative initiative described here can then serve as a template for other locales, organizations, and hospitals who seek to facilitate collaborative working relationships between doulas and care teams as part of a broader strategy to ensure pregnant and birthing people receive fair and equitable treatment in health care settings.

CONFLICT OF INTEREST

Alli Cuentos is a cofounder of SisterWeb San Francisco Community Doula Network, where she currently serves as co‐Executive Director. Alyana Almenar and Gabriella Mace were SisterWeb interns during the article preparation period.