Implementation barriers to incorporating a community-based doula program to improve birth outcomes for Black patients in an academic medical center

Abstract

There are significant racial disparities in maternal health and birth outcomes in the United States that disproportionately affect Black individuals. Incorporating community-based doula programs into hospital settings may be an effective intervention to reduce these disparities. However, little research has examined potential barriers and identified strategies to optimize implementation of a community-based doula program in an academic hospital setting. This study used in-depth interviews with clinicians and nurses (n=19) and focus groups with doulas (n=11) to identify multi-level barriers to implementing a doula program for Black pregnant patients in a single academic hospital setting in Milwaukee, WI. Data were analyzed using thematic analysis, and we developed four themes that highlight potential implementation barriers: 1) doulas’ advocacy efforts were met with resistance from the healthcare team; 2) there was a lack of trust and established relationships between doulas, clinicians, and nurses; 3) there was a hierarchy of knowledge within medical settings that diminished the value of doulas’ expertise; and 4) system-level barriers prevented sustained integration of doula programs. Despite the promise of community-based doula programs, significant investment and resources are needed to support implementation and ensure sustainability.

Non-Hispanic Black (hereafter referred to as Black) women in the United States face disproportionately poor maternal and child health outcomes [1]. Maternal mortality rates are nearly three times higher for Black women as compared to white women [1]. This disparity holds true even when controlling for maternal comorbidities and education level [2], [3]. Furthermore, the majority of maternal deaths are preventable, as determined by state review committees [4]. There are also significant racial disparities in birth outcomes [5]. The infant mortality rate for Black babies is 10.9 per 1,000 live births, compared to 4.5 for white babies [6], and the preterm birth rate is 52% higher for Black (13.8%) than white (9%) women [7]. Black infants are almost four times as likely to die from complications related to low birthweight as white infants [8]. Numerous factors have been implicated in these disparities in maternal health and birth outcomes, including racism [9], [10], [11], environmental factors [7], [12], discriminatory practices [13], and stress [14], [15]. Notably, multiple comprehensive literature reviews have documented the relationship between individual- and structural-level racism and maternal and adverse birth outcomes [16], [17], [18]. For example, structural racism, measured by state-level racial inequities in unemployment and incarceration, is associated with increased odds of adverse maternal health outcomes during childbirth for Black women [19]. Additionally, individual experiences of discrimination and population-level income and racialized residential segregation are associated with shorter gestation, an important predictor of infant health and mortality [20].

Community-based doulas are promising partners in efforts to reduce racial disparities in birth outcomes and maternal health experiences [21], particularly since they work in, and are frequently members of, medically underserved and historically marginalized communities [22], [23]. Doula services can include physical, emotional, and informational support to patients and families during the prenatal period, during birth, and postpartum, to reduce racial inequities in maternal health outcomes [24]. In addition to providing care throughout pregnancy and the postpartum period, many community-based doulas provide additional services to fill gaps in social services and health care by providing support around needed social determinants of health such as housing and food access [25], [26]. Community-based doula programs reduce the odds of preterm birth and having a low-birthweight baby by reducing stress and providing social-emotional support [27]. For example, the By My Side doula program in New York City used a matched cohort design to demonstrate how patients who used a doula had lower odds of preterm birth and low birthweight after accounting for factors such as BMI, gestational diabetes, and gestational hypertension [27]. Birthing people who receive doula support also have lower odds of cesarean delivery and lower odds of postpartum depression and anxiety [28], attributable to improved patient-provider communication, buffering stress, and increased advocacy and empowerment [27]. Specifically, in one study of pregnant patients with high-risk conditions, those who received doula care showed a 58% reduction in the odds of a cesarean delivery compared to patients with similar pregnancy complications who did not receive doula care [28]. Doula care is also cost-effective; it has been found to reduce overall costs by avoiding unnecessary medical procedures and the potential resulting complications, reducing NICU admissions, and promoting breastfeeding [29], [30], [31].

Community-based doulas may be particularly beneficial at helping Black pregnant individuals navigate fragmented and biased maternal health systems. Black individuals have long been subjected to mistreatment during labor and delivery, including the dismissing and downplaying of their birthing preferences and concerns [32]. Black individuals have reported negative interactions with clinicians, mistreatment during maternity care, and greater dissatisfaction with birthing experiences compared with white patients [32], [33]. Having a doula has improved patients’ ability to communicate concerns and have them heard during birth [34], [35], and feel as though they receive respectful care during labor and delivery [36]. Doulas have similarly been found to facilitate culturally sensitive care, informed decision-making, and clear communication with medical staff [27]. Doulas can fill gaps in fragmented maternal health systems and try to minimize racial bias and the effects of institutional racism on birth outcomes [27], [34].

Despite these benefits, prior implementation research has shown that barriers in the clinical setting can limit the impact of doulas [27]. For example, hospital policies and management practices can limit the scope of a doula’s practice and inhibit the doula from providing the type of advocacy and support that could improve health outcomes [27]. In addition, to improve collaboration on the labor floor, there needs to be greater mutual understanding and appreciation among nurses, clinicians, and doulas for each other’s roles and expertise. Strengthening these relationships can foster better teamwork and ultimately enhance patient care during labor and delivery [37], [38], [39].

Little research has examined the implementation barriers to integrating community-based doulas into clinical settings from the perspective of clinicians and doulas. This qualitative study aims to fill that gap. The objective of the study was to conduct in-depth interviews with physicians and nurses and focus groups with doulas to identify multi-level barriers to implementing a doula program for Black pregnant patients in a single academic hospital setting. The overarching goal of this study is to develop a doula program to be implemented in the hospital with the goal of improving birth outcomes for Black patients. The study is being co-led by the academic hospital team and a community-based doula program. The data collected here were intended to help capture the current challenges faced by clinicians, nurses, and doulas in the setting and discuss potential barriers to implementing a larger-scale doula program.

Methods

This study is a community-academic partnership between an academic medical setting and a Black birthing-focused nonprofit organization that hires and trains doulas and supports Black birthing patients through prenatal care, labor and delivery, and the postpartum period. From February-April 2024, we conducted in-depth interviews with 12 obstetric clinicians, including OBGYN physicians, certified nurse-midwives, and OB-anesthesiologists, one perinatal psychologist, and six birth center nurses, in a single academic medical setting in Milwaukee, WI. In addition, we conducted two focus groups with a total of 11 community-based doulas employed by our partner community organization. Community-based doulas participated in focus groups, rather than interviews, as recommended by the community partner to facilitate a broader conversation around shared experiences. The community-based doulas who participated in this study had doula certification from Health Connect One, an evidence-based training program. Clinicians and nurses were recruited via direct email outreach to all labor and delivery nurses and physicians at the study site. We continued enrollment until we achieved theoretical sufficiency [40], wherein we had the depth of data needed to understand the challenges to and opportunities around implementing a doula program for Black pregnant individuals. Theoretical sufficiency was determined through regular study team debriefing, discussions of data patterns, and identification of broad themes. Focus groups were held in person, and interviews were held in person or via Zoom. Given the low-risk nature of the study, written consent was waived; all participants provided verbal consent prior to participation. Following the completion of the interview or focus group, participants received a $50 gift card. All study protocols were reviewed and approved by the Institutional Review Board at the Medical College of Wisconsin.

The interview and focus group guides were semi-structured and developed collaboratively by the study team based, which included clinicians, researchers, and community leaders, on lived and professional experiences (e.g., experiences working with community-based doulas, professional experience as an obstetrician, or personal life experiences) and informed by prior research on doulas and birth outcomes. The interview guide content covered several domains, including experiences working with doulas in labor and delivery, benefits and challenges to collaborating with doulas, best practices and preferences for integrating doulas into patient care, and feedback about establishing a formal doula program in the hospital. The focus group guide covered similar domains, including experiences working in labor and delivery, benefits and challenges of providing doula care in hospital settings, and feedback about establishing a formal partnership with a community-based doula program in the hospital. The semi-structured nature of the interviews allowed the facilitator to follow the preferences of the participants and go in unanticipated directions. Given the focus of this analysis on implementation barriers, the study focused solely on the experiences of clinicians, nurses, and doulas. Patient perspectives, while critical in this broader discussion, are outside the scope of this narrow analysis.

Data analysis

Audio files were transcribed verbatim, checked for accuracy, and uploaded into MAXQDA qualitative analysis software. We used a team-based approach [41], [42] to coding, wherein study team members collaboratively reviewed transcripts, discussed potential codes and code definitions, and created a single, agreed upon codebook through a process of consensus. The codebook included inductive codes identified from the interviews and focus groups. Three team members applied the codebook to all transcripts and used analytic memoing [42] to capture semantic and latent concepts in the data and develop candidate themes.

All interviews were double coded by separate team members to enhance coding reliability. Data were then analyzed using thematic analysis [43] to examine patterns within the data, develop descriptive and interpretive accounts of the data, and develop themes that reflected participants’ experiences with and perceptions of doulas and doulas’ experiences in hospital settings. Themes were further developed through ongoing engagement with the full data corpus, memoing, team discussions, and refinement. We finalized four major themes and identified data excerpts that exemplified these themes. These data are presented below.

Results

Although this analysis focuses on the barriers to implementation and challenges to integrating community doulas into an academic hospital setting, overall, clinicians and nurses had positive perceptions of doulas and expressed enthusiasm about creating a stronger healthcare team that includes doulas. As one clinician stated, “Overwhelmingly, I think it’s positive having an additional person there whose purpose is to be a support for the patient, to help the patient navigate a healthcare setting, to navigate stress, and to be an advocate for them.” (P04, Clinician). That said, we identified several barriers to implementing a community-based doula program in an academic hospital setting. Our results are organized around the following themes: 1) doulas’ advocacy efforts were met with resistance from the healthcare team; 2) there was a lack of trust and established relationships between doulas, clinicians, and nurses; 3) there was a hierarchy of knowledge within medical settings that diminished the value of doulas’ expertise; and 4) system-level barriers prevented sustained integration of doula programs. To protect the confidentiality of all participants in this small, single-site study, there are no demographic data associated with any study participants. With each quote, we include a participant ID to differentiate participants and the role of the individual (e.g., Nurse).

1. Doulas’ advocacy efforts were met with resistance from the healthcare team

One of the primary roles of doulas, as described by the doulas in this study, was to advocate for patients and encourage and support self-advocacy during labor and delivery. One doula explained:

At the end of the day, as we say to the client, you are being serviced at this facility. You can, you have the right to, to ask questions and to say no. You don’t have to say yes to everything you see just because they have a medical badge. Like, it doesn’t work that way.

(P13; Doula)

This was echoed by another doula:

We advocate with them and behind them to support them and push them and say, “You know, you can talk to your doctor. If you don’t know what to say, we can advocate for you so we can communicate this effectively.” … we let them know, “You have a voice. We can help empower and educate you. We can help train you so you feel like you’re able to do it. You’re able to speak up.” Some of the doula clients say they don’t know what to say to the doctor. They don’t know how to communicate effectively. They don’t feel like they can say something. Because in their upbringing, some of them, they’ve been taught what the doctor says goes.

(P22; Doula)

Doulas explained how they both acted as facilitators of clear communication, cutting through medical jargon and encouraging direct communication between doctors and patients, and worked to empower patients to speak up and be part of decision-making during birth.

However, doulas who were more outspoken and encouraging of their patients to question interventions and ask questions, were subsequently described as being “difficult” and “obstructionist” by members of the healthcare team. The differing opinions within the team were further complicated by the fact that, as several interviewees explained, the doula often had a stronger relationship with the patient than other members of the team. In many ways, this was described as a benefit of doulas; they had created a bond with the patient and had a trusted relationship that did not exist between the patient and the nurse or clinician. However, this also created tension when physicians and doulas expressed differing opinions. One OB explained:

• P01, Clinician: I’ve also had situations where the doula can be obstructive to the healthcare team in helping make what are like the safest decisions for the patient.

• Interviewer: Tell me what you mean by that, “the doula being obstructive to the healthcare team.”

• P01: I think sometimes the doula will have a little bit of medical information based on their experiences on labor and delivery with other women. And so, then they will say things like, “Well, you don’t need to have an epidural right now,” or, “You don’t need a C-section,” even if we’re recommending that… I sometimes feel like we end up being adversaries when it comes to making sure that the baby is healthy and that the mom is healthy. And I think sometimes what’s hard is it feels like the doula will make a stronger personal connection with the patient. And so, then they are going to trust the doula and not the medical team to make safe decisions. I can totally see why that is, but I will say that, like, sometimes as a physician, it’s really hard to be like, “Look, this is what we’re recommending for your safety. And yes, you don’t have to do any of this, but, like, I’m not recommending this because I’m just bored or, like, I have my shift ending soon. Like, you know, I’m doing this because I really do think it’s in the best interest of you and your baby.” The doula will sometimes be so focused on an unanesthetized vaginal delivery that they lose sight of the safe delivery.

In general, clinicians supported doulas and recognized the benefits and importance of having an additional support person as a member of the healthcare team. Yet, they also acknowledged a tension between the doula and clinical healthcare team that many clinicians felt inhibited care. Clinicians expressed simultaneous understanding and frustration over the trust and strong relationship patients had with doulas, recognizing the potential power for promoting healthy birth outcomes. Yet, as the excerpts above illustrate, when the doula and clinical team were not in agreement, this created tension, and patients were often put in the middle.

A related challenge was a perceived tension between medical recommendations, patient preferences, and recommendations coming from doulas. Nurses and clinicians explained that their medical decisions were rooted in evidence-based medicine, relying on their formal education and expertise as healthcare providers. This, some explained, often stood in contrast to what patients wanted and what their doulas advocated for. As a result, some nurses and clinicians described feeling as though doulas were operating outside of their scope when they discussed medical decisions and preferences with patients.

We, as healthcare professionals, understand the science behind why things happen, and we are trained to read fetal monitor strips to know when a baby is not tolerating the labor experience well or there’s concern with oxygenation. And so, when things like that came to be or we were concerned for infection or labor’s not progressing, we know from a science perspective the risks of some things and of not doing some things medically and with intervention. So, I would try to explain the why we would want to place an internal fetal monitor or the why we would need to change position. And the doula would sometimes fight fiercely as an advocate for the woman. And I felt like at times I was kind of ganged up on based on the vibe in the room, the mom, the woman in labor, the support person, the doula, all wanting this more natural birth experience. And in the moment, we’re really trying to provide intervention for baby’s safety and mom’s… So, it was sometimes playing this very delicate dance to meet what mom really wanted, what the doula was hoping to achieve, and yet what we could see might be needed as medical intervention at times because they’re not fully trained in the way that we are as a nursing or care team.

(P25, Nurse)

There was an assumption among many nurses and physicians in this study that doulas did not know or understand the importance of certain medical interventions (e.g., fetal monitoring), were unaware of risks or the realities of a situation, or did not “understand the science.” Physicians and nurses expressed frustration over doulas who voiced opinions or advocated for things that differed from those being suggested by the clinical healthcare team. Most frequently, these challenges were evident in decision-making around interventions during birth. There was an overwhelming assumption that patients with doulas wanted low-intervention births and that some doulas were willing to advocate for low-intervention births, even when it was not in the best interest of the patient or baby.

We’ve had doulas with very strong opinions about different things, and that interferes with our care and things that nurses need to get done at the bedside. I’ve had experiences with doulas where I need to turn a patient for heart tone reasons; my heart tones are not looking great, and I need to turn a patient quickly. And the doula interrupts and says, “Well, can we do this or X, Y, and Z,” or, “We need to hold off. The patient’s not ready for this.” And it’s like, “Well, no, we have to do it quickly ‘cause the baby is in distress.” So sometimes doulas interfere with a little of the interventions that we need to do quickly, or they will offer their opinion on different things. Our doctors would recommend something, and sometimes that is not what the doula thinks should be recommended… This is not all doulas, but I feel like some doulas are very opinionated on, like, low intervention births. I feel like it kind of puts the patient in a tough spot when you have a doula as your bedside provider, but then you have a medical provider that’s also offering an opinion.

(P29, Nurse)

Doulas who did advocate for their patients in ways that did not align with the nursing staff or clinician were frequently described in interviews as “difficult,” uneducated or inexperienced on issues related to birth. As one nurse explained about her relationship with doulas, “I think it really depends on how much they’re agreeing with the kind of planning care that the hospital is recommending.” (P24, Nurse) That is, things generally went “well” if the doula was agreeable and supporting the decisions of the clinician and nursing team.

2. There was a lack of trust and established relationships among doulas, clinicians, and nurses

One of the factors that contributed to some of the tension described above was the lack of an established, trusted relationship between doulas and the physician and nurses with whom they worked. The physicians and nurses often met doulas for the first time in the delivery room, which typically meant there was not time to discuss and establish boundaries or roles or build a trusted, professional relationship.

I don’t feel like they’re always introduced, and I walk in the room and I just, you know, see that they have doula written on their badge or something, so I just know that they’re the doula. But I don’t think the conversations are as open in labor and delivery. I don’t think that there’s a dialogue, honestly, a great dialogue between the provider and the doula.

(P10; Clinician)

Many doulas felt similarly and described a lack of relationship and trust with clinicians. As one doula stated, “You don’t see me as valuable. You don’t see me as part of the health team, but I am part of your team.” (P22; Doula)

In contrast, clinicians who had an established relationship with a doula explained the benefits of that relationship:

I’ve only had the experience of meeting the doula within the visit beforehand, and then you know, seeing them at delivery. And I feel like I’ve been able to establish a good enough rapport just in those types of encounters. I have a list of doulas that I can refer people to, these are people that I know… I have a relationship with them already. I feel like that relationship piece is key between the physician and the doula ‘cause I feel like you form a relationship with them, you get more experience with how they are with patients, you have a better idea of what to expect on the labor and delivery unit with your patients and them.

(P07; Clinician)

Several nurses similarly mentioned wanting an opportunity to get to know the doulas who supported their patients:

Most impactful, I think, would be meeting these doulas, and then they can teach us and show us, like, “This is what we do for our patients during labor and X, Y, Z.” I’m a big fan of in-person meeting, face-to-face. I know that’s not always easy to plan, though. “This is what we do at the bedside. This is how we can support you in your role as a nurse.” I think that would be great too. Just some education beforehand, um, of how they can help us, ‘cause I think there is just that stigma that doulas just get in the way, where, no, they actually can be really helpful, and it’s nice to have them at the bedside.

(P29; Nurse)

As these interviewees pointed out, establishing a relationship between the healthcare team and the doula can increase trust and help educate nurses and clinicians about the role and benefits of doulas, which can be critical in building a supportive team for patients. Physicians and nurses welcomed the opportunity to learn more about doulas and the roles they can play, while simultaneously wanting to help educate doulas about medical interventions and how they made decisions.

Related to, and potentially as a result of, the lack of relationships, participants also described an underlying mistrust between doulas and clinicians. Throughout the study, participants explained there was often tension between doulas and the clinical healthcare team, frustration around lack of role clarity, and skepticism around doulas’ knowledge and expertise and clinicians’ intentions. This resulted in mistrust on both sides.

I would love to have some joint education between doula programs and healthcare staff so we can understand each other better and trust each other and realize that we are all there for the same goal… I think that the idea of a doula program is phenomenal, especially if we can try to smooth out some of this, inappropriately present tension between doulas and healthcare teams that sometimes I see.

(P04; Clinician)

The “inappropriately present tension between doulas and healthcare teams” was something several individuals alluded to in our interviews. Throughout the interviews, clinicians and nurses described a bias against doulas and patients who used doulas, often suggesting they lacked an understanding of medical decisions. Similarly, some doulas expressed frustration with clinicians who seemed to push for interventions and whose decisions were seemingly driven by time constraints, rather than what was best for the patient.

The community-based doulas we interviewed shared prior experiences that eroded trust between themselves and nursing staff and clinicians. For some doulas, the “tension” described above was partially fueled by perceived mistreatment and devaluing of their role by clinical staff. For example, one community-based doula described a delivery where the nurse was going to call her when the patient was dilated to 6cm, which was the policy for when she could come to the hospital according to the doula organization she worked for.

The nurses told me they have my number. They told me they’re gonna call. And they won’t call. … they still don’t want me in that space. You know, most of the nurses that I’m talking with, they’re Caucasian. They don’t want me in that space. And, you know, we’re there, we’re in that space, because our babies are dying. People of color, their babies are dying, and the women are dying in childbirth. I’m here to help so I can give that woman and that baby a better outcome for you. How dare you not call me? I’m part of her health team.

(P22; Doula)

Community-based doulas passionately described how they were regularly excluded from decision-making, ignored by clinicians in the delivery room, and mistreated by clinical staff. One clinician echoed these sentiments and explained how doulas could be the target of microaggressions and mistreatment from hospital staff:

I feel like doulas understand what their role is in advocating for patients who are oftentimes experiencing these things and don’t really know how to address the bias that they’re experiencing from healthcare providers … I see it play out all the time where, you know, comments are made by staff or providers. Microaggressions or just, you know, some of those implicit biases that come out as people are caring for patients.

(P07; Clinician)

As a result of their own mistreatment from hospital staff, community-based doulas expressed their own mistrust of clinicians and the healthcare system. Although nearly all participants in this study recognized the potential for doulas to bridge a gap between Black women and hospital systems that have historically mistreated them, the mistreatment of doulas and bias against doulas was a barrier to allowing doulas to fulfill this role.

3. There was a hierarchy of knowledge within medical settings that diminished the value of doulas’ expertise

A third barrier identified in the interviews was a lack of appreciation for doulas’ expertise and experience. Clinicians and nurses interviewed in this study were aware that some doulas had formal certifications and years of experience, while others did not. Yet, during labor and delivery, they were often meeting a doula for the first time and did not know the doula’s background and training. Furthermore, clinicians often believed that doulas, including those with certifications, could offer emotional support, but lacked sufficient training to be informed advocates for their patients saying, “I would say there’s a lack of medical knowledge on their part” (P009) and describing doulas as “very opinionated” (P29) and “not fully trained.” (P25) Nurses and clinicians believed that most doulas had limited maternal and child health expertise and that their role should be limited to providing emotional support to patients during labor. One clinician explained:

I’m just gonna be really honest with a lot of the things I’m gonna say here. Doulas can really vary in their past healthcare experience. I think that sometimes you will have a doula that does not have a lot of medical knowledge and yet is trying to sort of portray or give medical advice to the patient. And I think that that can lead to a lot of tension between the healthcare team and the doula in reality. And unfortunately, sometimes that patient gets put in the middle.

(P04; Clinician)

This perceived “lack of medical knowledge” often resulted in frustration among clinicians when doulas expressed their opinions about interventions, positioning, and other clinical decision-making. In contrast, doulas explained how their experiences, training, and expertise were not often valued in the healthcare team.

The biggest challenge, I think, in this whole work and why we do the work is because you have medical providers who feel like they know more because they have a certain training. But at the end of the day, the clients just want to be seen and heard and want to feel like they can make decisions in their life when it comes to something so important like labor. ‘Cause at the end of the day they know their body.

(P13; Doula)

Many community-based doulas felt as though their expertise and experience were not valued in the delivery room, and certainly not as valued as clinicians’. As the doula above explained, this hierarchy of knowledge, and her desire to help clients feel heard and seen, was part of her reasoning for being a community-based doula.

Other community-based doulas shared examples of times when they felt their role as doulas was diminished and their expertise dismissed. One doula shared:

I had one where a nurse, she would not allow me to change positions with the mommy. And any time I made a change while she was out of the room, she would come back in and say, “You need to run this by me before you change positions with her next.” But my mommy would be like, “This is uncomfortable. I’m not feeling this.” So I’m not gonna want you to be uncomfortable … it was passive-aggressive, “I know better. I’m here, you’re there.” And I was just like, “That’s not how we operate? And I’ve been the one doing all this work and preparation and practice with this mommy. Not you. We just found you out today.” Like, “We don’t know you. We’ve got this rapport. We’ve got this trust. We’ve got this familiarity. This is what we’ve been working on. You step back.” That’s what I wanted to say.

(P14, Doula)

The tension between some nurses and doulas was partly rooted in the protectiveness doulas felt for their patients, with whom they had established trust and created relationships. The patient and doula had established themselves as a team that was often portrayed as having to fight back against a harmful healthcare system. Despite having more formal education and training, clinicians often lacked the trust, relationships, and lived experience that many doulas shared with patients. The lived experiences of community-based doulas, particularly Black doulas, were critical in bridging the gaps between the medical team and the patient, yet that expertise was not as readily acknowledged or valued. One clinician acknowledged this:

I mean, how do you change centuries of oppression and patriarchal medicine? I do think something like this doula program could go a long way, right? Having doulas who are members of the community to be a bridge between our community and our hospital. You know, that can go a long way. Having people who say, like, “Look, I have been a mom. I’ve breastfed. I know how hard it is.” And having it be people in our community as opposed to me saying that to patients could go a long way.

(P01; Clinician)

4. System-level barriers prevented sustained implementation of doula programs

Finally, numerous policy and system-level barriers inhibited meaningful collaboration with community doulas. Community-based doulas, nurses and clinicians explained that one of the primary barriers to a sustainable community-based doula partnership in a hospital setting was the perceived lack of buy-in among hospital administrators and leadership. One participant explained, “You need a champion for it. You need to have someone whose heart is in it, and who wants the program to succeed and, and is interested in this kind of work.” (P10; Clinician) Similarly, another participant stated:

It’s the hospital system and leadership that just doesn’t understand the value or what [doulas] would bring to their patients. And so, it’s not at all a priority to try to get to know these doulas and their work… I think those are two of the major challenges: not having the leadership support from the top to really push initiatives forward, and then not having hospital system structure support to further develop their program.

(P07; Clinician)

Study participants recognized that hospital buy-in and the value of such programs were essential to the integration of doulas and the sustainability of such programs.

Hospital-level policies also served to limit the potential impact of doulas. The most commonly described barriers were visitor and support-person policies. Interviewees described how, since doulas were not hospital employees and did not have employee privileges, they had to comply with the security and visitor policies.

One of the things recently is our visitor policy and dealing with security and coming in. The doulas are concerned that they’re being treated like visitors, which, essentially, I mean, they are. Like they’re not employed by [the hospital], so. Um, but they just don’t like that they have to go through the whole security process like everyone else does.

(P26; Nurse)

The problem with such policies, some argued, was that this process created a further separation between the community-based doula and the healthcare team and upheld a hierarchy among those on the team. Some felt these policies demonstrated a lack of commitment to community-based doula partnerships.

Hospital policy also dictated that only one support person was allowed into the operating room (OR) during cesarean delivery. Individuals explained that for many patients, having an unplanned cesarean delivery was stressful and did not align with the patient’s birth plan. As such, many participants thought it would be helpful to allow both a partner or family member and a doula be with the patient in the OR during cesarean delivery. Similarly, there was a policy in place that no support persons (including doulas) could be present during the placement of an epidural. One nurse explained her frustration with these policies.

They’re only allowed one support person back in the OR with them. So, we usually have it be the dad, so he can be present for birth. I have a lot of feelings about our anesthetic guest policies. Like, even when we’re doing an epidural, no support people are allowed in the room, which is ridiculous…. How helpful would it be to have a doula doing breathing techniques or just talking to them! Even during the epidural, my job is to monitor baby. And some patients are challenging to monitor the baby when they’re in that position for an epidural, and I’m focused on that, or I’m listening to anesthesia in case they need things. So, I can’t give the patient, unfortunately, 100% of my attention ‘cause I’m doing five other tasks during the epidural. And, like, how helpful would a doula be in that situation to be the sole emotional support there focusing on that? And additionally, in a C-section, I mean, there’s just so much emotional distress around that decision and situation. And how hard is it to plop one more chair there next to her head? I just feel like that’s a policy that should be looked at. It doesn’t make sense in my brain.

(P27; Nurse)

Although several clinicians explained these policies, namely, patient safety, many also recognized there was room for revisiting these policies and thinking more comprehensively about how doulas should be considered in light of such policies. As the nurse above explained, the doula could be an important part of the team during some of the most challenging or stressful times of labor and delivery for a patient (i.e., epidural placement and cesarean delivery), and yet were excluded on the basis of hospital policy.

Finally, another challenge individuals described was the needed financial support from the hospital system to create a sustainable community-based doula partnership program. One individual explained:

I also think that if there is some financial support for having doulas on the hospital team or a service within the hospital that’s supported financially, I think that that also adds to the success of some of these initiatives.

(P07; Clinician)

In the narrative below, another clinician described the importance of financial support in order to demonstrate value and support for doula programs, particularly when partnering with community-based doula programs.

We are looking to engage with community partners who oftentimes are working very hard to keep their doors open and keep the lights on if they have actual office space because the work that they do is not compensated in the same way that the work that I do is compensated. And so when we reach out and ask for their assistance, it is always challenging to bridge some of those differences and to have some of those conversations.… There’s a lot of selflessness. There’s a lot of work that they do without compensation and without acknowledgment of the effort it takes… So I think it can become a situation where we’re asking a lot without really understanding the challenge and the effort that’s going on behind the scenes to make those asks possible.

(P08; Clinician)

This participant highlighted numerous challenges, including the inequities in compensation between doulas and other clinical staff and the unrecognized and under-appreciated effort and time required by doulas. Several individuals suggested that in order to truly implement a successful doula program, doulas need to be fairly compensated, and the program needs to be financially backed by the hospital system.

Discussion

In this qualitative study, we sought to ascertain and characterize the barriers to implementing a collaborative program between community-based doulas and an academic hospital-based labor and delivery birth center. Through in-depth interviews with clinicians and nurses and focus groups with community-based doulas, we were able to identify key barriers that must be addressed to realize the full potential of community-based doulas in improving birth equity and launching the program successfully.

The primary barrier identified in this study was the lack of an established, trusted relationship between community-based doulas and the clinical team. Doulas, clinicians, and nurses often met for the first time in the delivery room, which limited opportunities for establishing boundaries, clarifying roles, and building professional and personal connections. As a result, there was a lack of trust among the team and frustration and confusion around the scope of doulas’ roles. One of the key sources of tension described in this study was the advocacy role of community-based doulas, which clinicians often perceived as overstepping, adversarial, and occasionally in contrast to what was being recommended by the healthcare team. However, the need for advocacy and questioning of healthcare decisions during labor and delivery cannot be discounted, as one of the reasons for disproportionately higher rates of Black maternal mortality is the downplaying or ignoring of symptoms [44]. Community-based doulas in this study described encouraging their patients to ask questions and speak out strongly for what they wanted, and they criticized physicians and nurses who they perceived to be motivated by time pressures and hospital policies. The lack of established relationships created tension and mistrust between nurses and clinicians and the patient’s doula. This finding demonstrates a need for interprofessional education and relationship-building among all members of the labor and delivery team to delineate roles, understand the importance of collaboration, recognize the advantages that each party brings to the table, and increase collaboration with shared respect and understanding [45].

Related, our results also highlighted the role of trust among the labor and delivery team. Community-based doulas can help bridge the trust divide between patients and healthcare systems, but doing so necessitates building a foundation of trust between community-based doulas and the nurses, physicians, and healthcare systems. This is particularly relevant for Black community-based doulas, who may have lived experiences that contribute to their own medical mistrust. Furthermore, as one community-based doula in this study stated, many Black doulas are motivated to do this work by the significant racial inequities in maternal and birth outcomes. Understanding the realities of racism in the healthcare system and the effects of racism on birth outcomes for Black people may increase their skepticism about the healthcare system and cautiousness in trusting clinicians. Racial concordance between community-based doulas and patients can be useful in helping to overcome mistrust between Black patients and health care systems and clinicians [46]. However, this can only be effective if community-based doulas trust the clinicians they are working with and the systems they are working in.

This study also highlights the importance of considering the role and legitimacy of alternative knowledge in medical settings, where expertise and authority is largely found among clinicians. Many community-based doulas obtain their expertise through lived and professional experience as Black women and doulas, rather than any formal education channels [47]. As others have argued [47], even without formal training or certification, doulas may have alternative expertise and lived experience that can complement medical providers’ knowledge to support women in labor and delivery.

That said, certification and training can also increase respect and legitimacy of community-based doulas’ roles among clinicians, nurses, and even hospital systems [47]. Community-based doulas have also been found to believe that certification can create a standard that could help increase the willingness of clinicians to welcome doula care as a legitimate part of labor and delivery [47]. In hospital settings, community-based doulas lack the privilege, legitimacy, and formal expertise of clinicians and nurses and must work to build relationships and obtain their trust and buy-in [48]. Simultaneously, clinicians must work to welcome community-based doulas as trusted and valued members of the healthcare team, acknowledging community-based doulas’ experience and expertise to gain their trust. Despite some concerns expressed by clinicians and nurses about doulas “overstepping” their roles, prior research with doulas have shown that doulas generally desire to be part of the birth team and advocate for their patients, yet do not seek to take on clinical duties [49].

This study highlights several opportunities for intervention. First, hospital policies and management practices can influence the role and scope of community-based doulas and potentially limit the effectiveness of community-based doula care. People in positions of power who can champion doula partnerships and generate stable funding sources to establish and sustain community-based doula partnerships. Second, policies, such as visitor policies and policies that limit support persons during cesarean deliveries or epidural placement, can inhibit community-based doulas’ scope of work and limit what they can advocate for. Such policies should be reviewed within the context of community-based doula care to identify opportunities for change. Third, we echo others’ calls for a racially diverse doula workforce, as a white doula workforce may not be able to adequately meet the needs of or understand the experiences of Black birthing people [35], [50], [51]. Racial concordance between patients and community-based doulas can foster trust between the patient and doula and help assuage mistrust of institutions and medical teams [34], [46]. Furthermore, research has found a particular benefit of Black doulas who are mothers or have shared experiences around childbirth or challenges related to pregnancy and birth [51]. Similarly, there is an urgent need for more diversity in clinical teams, namely, more Black clinicians and nurses, which could go a long way in building trust and improving outcomes.

Finally, this study highlights the challenges that exist given the lack of national standards for doula certification and training, which serves as a barrier to implementing large-scale, well-supported doula programs [52]. Standardized and comprehensive training may help increase the effectiveness of doulas and provide clarity and legitimacy of their role for providers and nursing staff [25], [47]. Importantly, the community-based doulas who participated in this study had all received certification from Health Connect One, an evidence-based training program. On the other hand, these benefits must be balanced against increased cost for maintenance of certification, time commitment, standardization in training that currently does not exist, and lack of reimbursement by insurance in many of the states [53].

There are limitations to note. First, nurses and clinicians were asked to speak about their perceptions of and experiences with doulas in general, and thus were not necessarily speaking about interactions with the community-based doulas who participated in focus groups for this study. Additionally, nurses and clinicians rarely made the distinction between community-based doulas and other doula programs (e.g., private doulas), and typically did not know the type of doula a patient was working with or what their individual training or experience was unless they had an established relationship. Finally, this study reflects experiences of individuals at a single academic-medical center and from a single community-based doula organization. As such, the experiences described here may uniquely reflect the context and environment of this specific academic medical center.

While overcoming the identified barriers will be essential to the implementation of this clinician-doula collaborative program, larger system-level changes are also needed. For example, as other scholars have pointed out, there must be work done to dismantle racist US health system policies and structures and improve billing and reimbursement for doula services [54]. This work will also require developing a robust, collaborative education and implementation model that ensures equity between all partners and recognizes and demonstrates the true value of doula programs. Ultimately, integrating doulas, particularly Black community-based doulas, into labor and delivery care may help mitigate some of the effects of racism on disparities in birth outcomes [27], [46]. Yet, significant work must be done at the institutional-level to ensure such programs are developed and integrated appropriately.

Citation diversity statement:

Researchers have highlighted the racial, ethnic, and gender inequities in citation practices in numerous academic fields [56], [57], [58], [59], [60], such that papers authored by women and racial and ethnic minorities are under cited relative to the number of those papers in the field. Accordingly, during our writing process, we interrogated the literature we read and cited, and aimed to cite research that reflects the diversity of the field in thought, method, and gender, race, and ethnicity of authors. Although this approach is insufficient for addressing these biases, we aim to raise awareness and encourage other scholars to examine their citation decisions.