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The system can change: a feasibility study of a doula-clinician collaborative at a large tertiary hospital in the United States

Implementation Science Communications volume 5, Article number: 144 (2024) Cite this article

Abstract

Background

Doulas, non-clinical professionals who provide support throughout the perinatal period, can positively impact patient experiences and clinical outcomes during birth. Doulas often support hospital-based births without being employed by the hospital system, resulting in varied relationships with hospitals and clinicians. Systems-level changes are needed to maximize collaboration between hospitals and doulas to ensure facilitation of, and not barriers to, doula support. We implemented and evaluated a new program, called the "Supportive Birth Collaborative,” to maximize effectiveness of doula support in hospital settings.

Methods

We conducted a single-site feasibility study of the use of implementation mapping to make systemic changes to clinician-doula collaboration for labor and delivery. Implementation mapping consisted of five steps: developing a collaborative of program implementers and knowledge holders, conducting a needs assessment, developing a logic model, applying implementation strategies, and evaluating changes in outcomes. To evaluate change, process data were collected throughout, and implementation outcomes were measured in 2022 and again after one year of implementation via online surveys to all clinicians who provided labor and delivery care. Descriptive statistics were calculated and change over time was analyzed in Stata using log-binomial regression models with clustering to account for respondents who completed both surveys.

Results

The “Supportive Birth Collaborative” (SBC) was founded in November 2021. The first meeting included 19 people, who were obstetricians, anesthesiologists, nurses, doulas, students, social workers, administrators, researchers, and individuals who had given birth at the study hospital. From 2022–2023, the SBC adopted 11 implementation strategies and piloted or fully implemented 10 of them. Implementation strategies ranged from making training dynamic, to changes in the physical environment, to changes in formal policy. In 2022, 104 clinicians participated in the survey; 97 participated in 2023. There was significant improvement in clinician-reported trust in doulas (0.23, 95% CI: 0.12, 0.34) and doula-clinician communication (0.25, 95% CI: 0.12, 0.38). Clinicians had a limited understanding of the doula’s role, and that understanding did not significantly improve.

Conclusions

Using implementation mapping as a guide to collaborative work can lead to meaningful health system changes. Regular review of implementation outcomes could allow for adaptation and tailoring of implementation strategies.

Peer Review reports

Background

Over the past decade, a plethora of epidemiologic and qualitative evidence has described poor outcomes for perinatal people, especially among those from marginalized communities. National data depict increases in maternal mortality, with Black individuals being nearly three times as likely as white individuals to die during the perinatal period [1]. Massachusetts continues to be a high-performing state for maternal health outcomes, with one of the lowest rates of all-cause maternal mortality [2]. However, upon closer look, severe maternal morbidities (SMM)—unexpected labor and delivery complications that can lead to long-term health consequences—and the inequities within tell a different story. In 2016–2018, the SMM rate for Black perinatal people (174 per 10,000 deliveries) was 128% and 87% higher than the rates for white and Hispanic perinatal people, respectively [3]. Racial inequities also exist in experiencing perinatal depressive symptoms, accessing mental health care, and in experiences around labor and delivery [4, 5].

Proposed solutions to these longstanding, pervasive inequities range from policy-level interventions to individual behavioral changes. The use of doulas for labor and birth support is one intervention with a long history of implementation and evidence base of support. Doulas are trained professionals who provide non-clinical physical, emotional, and informational support to perinatal individuals during pregnancy, birth, and postpartum. The continuous, one-to-one care offered by doulas throughout the perinatal period has been linked to positive outcomes for pregnant people and their infants. Evidence suggests that doula care reduces cesarean delivery rates, length of labor, and the likelihood of having a low birthweight baby [6, 7]. Support from a doula has also been associated with greater satisfaction with the childbirth experience, higher newborn Apgar scores, and an increased likelihood of breastfeeding initiation and continuity [6, 8,9,10]. Furthermore, cost-effectiveness analyses posit that doulas can be financially beneficial [11]. Doula care reduces overall medical spending by limiting unnecessary medical interventions and avoiding consequent complications and chronic conditions [11]. Finally, doulas may be able to contribute to more equitable birthing experiences and outcomes through their roles in education and advocacy [12].

There are multiple models for doula support within hospital systems. Doulas may maintain contractual relationships with institutions, supporting patients as hospital volunteers or employees through a fully integrated, hospital-based program [13]. Additionally, community-based doula organizations may partner with hospitals to create a coordinated referral network for patients [14]. In both instances, doulas are assigned to patients prenatally or assume on-call shifts; some programs offer both. Another model includes nursing and medical education schools establishing volunteer doula programs as a service-learning opportunity for their students, enhancing the curriculum with hands-on patient care experience [15]. Lastly, pregnant patients can hire doulas from private or community-based organizations independent of the hospital.

Despite the evidence endorsing doula care as an effective tool to improve perinatal outcomes and reduce medical expenditure, effective collaboration and coordination between hospital teams and community doulas and integration of doula support into hospital births remains a challenge [16,17,18]. Hospital-administered doula programs can be a resource-intensive intervention, requiring consistent support personnel to operate effectively [16]. In the hospital setting, doulas also face the challenge of navigating varied practitioner perceptions [17, 18]. Negative perceptions of doulas, coupled with limited practitioner knowledge of the doula role, can create an unsupportive organizational culture that impedes doula implementation success [16, 18]. Overall, these challenges limit access to doula services, which adds to barriers to access experienced by perinatal people in low-income and otherwise marginalized communities [19].

This study used implementation mapping to facilitate collaboration with doulas in a labor and delivery unit [20]. We aim to evaluate the feasibility of using implementation mapping and its effect on clinician perceptions of collaborative work with doulas.

Methods

We conducted a single-site feasibility study of the use of implementation mapping to make systemic changes to clinician-doula collaboration for labor and delivery. Implementation mapping is a structured approach designed to bridge research-to-practice gaps while promoting adaptability, collaboration, and the engagement of diverse cadres [20]. Through this process, teams identify, develop, implement, and evaluate implementation strategies designed with consideration to mechanisms of change. Given that these aspects are particularly suited for addressing the complexities of clinician-doula collaboration in a dynamic clinical environment, we applied the implementation mapping framework to systematically evaluate and structure our approach. Implementation activities received a non-human subjects research determination and the evaluation was reviewed as ‘exempt’ by the Committee on Clinical Investigations (institutional review board) at Beth Israel Deaconess Medical Center.

Setting

The study site was a large, urban, academic medical center in Massachusetts, USA. The labor and delivery unit serves over 5,000 patients annually and includes over 100 obstetricians (inclusive of 24 resident physicians) and over 125 labor and delivery nurses. The labor and delivery unit does not, and did not during the time of study implementation, have nurse-midwives on staff. The hospital supports births for patients who receive their prenatal care at multiple hospital-owned and hospital-affiliated office practices, including 3 affiliated federally qualified health centers (FQHCs). The intervention targeted by implementation mapping is doula care. While the hospital does not have an in-house doula program, one of the affiliated health centers partnered with a local community-based doula organization and an insurance company to offer doula support to patients with Medicaid insurance coverage. Those doulas did not receive funding from the hospital or health center. A second affiliated FQHC, had a labor coach program which provided labor coaches to all their FQHC patients during labor, delivery, and postpartum. These labor coaches are employed by the health center, have hospital badges, and assist with interpretative services in addition to labor coaching. Several patients also accessed private or community-based doulas.

Implementation mapping process

Fernandez et al. include five steps in implementation mapping. [20] The first step incorporates two parts: identifying program adopters and implementers and conducting a needs assessment. The lead researcher first met with individuals directly involved in implementing doula support at the hospital (community-based doulas, a labor coach, and two obstetricians). Through discussions and a review of the literature, the team identified all cadres of individuals who interact with doulas in the hospital. These discussions also identified the broad needs for doula implementation to be successful, many of which led back to the need for collaborative work across adopters and implementers at the individual, community, and system level. Representatives from each identified cadre were thus invited to join a new collaborative, called the “Supportive Birth Collaborative” (SBC).

The second step is to “identify adoption and implementation outcomes, performance objectives, determinants, and change objectives.” [20] This was done through a meeting with the SBC. The SBC met virtually. After initial introductions, the session leader presented the group with a virtual whiteboard via Mural©. The whiteboard included headers for inputs, activities, short-term outcomes, long-term outcomes, and ultimate goals/impacts (Fig. 1). The “ultimate goals/impacts” “long term outcomes” and overarching box for “equity in care and outcomes” were completed in advance based on health system models for equitable, high-quality care [21, 22]. The group then embarked on a discussion of what they felt were the most salient items to fall into the rest of the framework.

Fig. 1
figure 1

Logic model co-developed by members of the Supportive Birth Collaborative diagramming how activities related to improving support for doulas could improve perinatal outcomes

Full size image

The third step is to “choose theoretical methods (mechanisms of change) and select or design implementation strategies.” Through subsequent quarterly meetings with the full SBC as well as working group meetings with smaller groups, SBC members developed an implementation plan that identified responsible individuals and the activities that would be implemented. The research team mapped these practical applications to theoretical implementation strategies [23]. The fourth step is to produce implementation protocols and materials, which was done within the small working groups.

The final step is to evaluate implementation outcomes. First, we conducted a program document review to identify the adoption and penetration of each implementation strategy identified in step two of the implementation mapping process (Fig. 1). Second, we evaluated the targets of implementation strategies, that is in the short-term outcomes, by assessing clinician perceptions of doula support. We conducted a structured survey with clinicians at baseline and one-year follow-up. Clinicians were eligible if they were a nurse, obstetrician, or anesthesiologist providing care on the labor and delivery unit during the time of survey. Data were collected via a REDCap [24] survey that was emailed to all individuals in the email listservs for the three clinical groups. Individual follow-up emails were sent every three days for a total of up to four email contacts. Clinicians were offered a $10 gift card to a coffee shop if they completed the survey. The baseline survey was initiated in May 2022 and the follow-up survey was initiated in July 2023 (Supplemental Fig. 1).

Variables

We used or adapted validated indices to assess change in targets of the implementation strategies (Appendix 2). To measure perceived clinician-doula communication, we adapted the communication scale questionnaire from a study assessing nurse-physician communication in hospitals of southwest Ethiopia (scale created from five questions, possible range 1–5) [25]. To measure clinician trust in teams with doulas, we used a validated multidimensional instrument designed to measure trust within teams (possible range 1–7) [26]. We also created a four-item scale to assess clinician trust in doulas (possible range 1–5). To evaluate clinician understanding of a doula’s role, we created an 11-item summative index (possible range 1–11 constructed from the number of items the respondent agreed to) based on previously reported measures [27]. Organizational readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC); possible range 1–5 [28]. Other variables include belief that doulas improve maternal & newborn outcomes (five options from ‘strongly disagree’ to ‘strongly agree’), how doulas influence labor progress (four options from ‘negative influence’ to ‘positive influence’), comfort caring for patients with a doula (five options from ‘very uncomfortable’ to ‘very comfortable’), and experience working with doulas (five options from ‘very poor’ to ‘very good’).

Statistical methods

Respondents were included in analysis if they completed at least 20% of the survey. Data were reviewed at multiple points during data collection to assess patterns in missing data and to assess respondents’ eligibility. We calculated descriptive statistics for respondent sociodemographic characteristics and responses for each outcome item or scale. Changes from pre- to post-implementation were evaluated using linear and log-binomial regression models with clustering to account for respondents who completed both surveys. We conducted sub-group analyses by clinician cadre. All statistical analyses were completed using Stata v.17.

Results

Implementation mapping steps 1–4

The “Supportive Birth Collaborative” (SBC) was founded in November 2021. The first meeting included 19 people, who were obstetricians (based both at the hospitals and community health centers), anesthesiologists, nurses, doulas, students, social workers, administrators, researchers, and individuals who had given birth at the study hospital. The participants for the first meeting were racially and ethnically diverse, including individuals who identified as Black, white, Asian and multiracial, as well as both Hispanic and non-Hispanic identities. Participants were primarily female (95%). SBC members have changed over the years, but continue with the same diverse representation by cadre and race. SBC identified their goal as: to identify, apply, and evaluate implementation strategies that aim to improve patient experiences and outcomes during the perinatal period.

The logic model developed by the group initially included eight activities (implementation strategies) and six short-term outcomes, or targets of the implementation strategies (Fig. 1). The collaborative stated that key change objectives included clinicians’ improved understanding of doulas’ roles, improved collaboration and trust between clinicians. A follow-up interest survey was used to then divide the collaborative into three working groups that would focus on implementation protocols related to education, policy change, and research. These working groups identified 11 practical applications using Expert Recommendations for Implementing Change (ERIC) strategies (Table 1) [23].

Table 1 Description of the identified implementation strategies and their practical application
Full size table

From 2022–2023, the SBC adopted all 11 applications and piloted or fully implemented 10 of them (Table 2, Appendix 1). Implementation strategies ranged from updating departmental policies, to changing the electronic medical record, to providing patient-facing materials on doulas in two languages. The team focused on implementation strategies that were inclusive and standardized for all doulas to reduce opportunities for inequities in care because of the way doulas from different origins (e.g. private, organization, contracted) are treated. For example, the doula policy, name badges, and recording of doulas names on the whiteboard were implemented for all doula-supported births. Furthermore, no hospital employee was tasked with making the determination of who was a doula versus who was not – individuals who presented as doulas were accepted as such.

Table 2 Adoption and penetration of 11 implementation strategies designed to improve implementation of doula support during labor and delivery at a large urban hospital
Full size table

Implementation mapping step 5: evaluation

Of 257 eligible people approached at baseline, 104 (40.5%) responded, compared with 97 (43.1%) of 225 eligible clinicians at follow-up. There were 46 clinicians who participated in both the pre- and post-implementation surveys. All but one respondent reported having experience working with a doula in their career, and most respondents reported working with 1–5 doulas in the past six months (Table 3).

Table 3 Characteristics of respondents to clinician survey administered pre- (2022) and post- (2023) Supportive Birth Collaborative implementationa
Full size table

There was not significant improvement in clinicians’ understanding of a doula’s role when comparing baseline and follow-up responses (Appendix 2). For selected experience measures, there were significantly higher proportions of respondents at follow-up who reported feeling “comfortable” or “very comfortable” caring for patients with a doula (86% versus 72%; 95% CI, 1.0–1.4) and ranked their experience working with doulas as “good” or “very good” (66% versus 55%; 95% CI, 1.0–1.4). Respondents at follow-up indicated greater trust in doulas with an increase of 0.23 points (95% CI, 0.12–0.34) in the scale score (Table 4). Additionally, at follow-up, respondents were asked four questions related to how acceptable they found doula support. Possible scores on this index range from 1 to 5 with 5 indicating the highest acceptability. The average score was 4.0 (standard deviation: 0.78).

Table 4 Changes to identified targets of Supportive Birth Collaborative implementation strategies to improve the working environment for doulas supporting hospital births
Full size table

Discussion

This study evaluated implementation of the Supportive Birth Collaborative to improve effective collaboration and coordination of doula support for hospital-based births. The team successfully established a collaborative, implemented changes to education, policy, and structures within the health system, and observed improvements in clinician perceptions of doulas in a short period of time.

Informed by the implementation mapping protocol of Fernandez et al., we engaged in discussions with individuals crucial to doula support implementation at the hospital [20]. We hypothesized that early involvement of these key individuals would help pinpoint necessary changes for successful doula implementation. This collaborative approach not only led to the timely formation of a team but also facilitated the rapid development of a logic model that incorporated multiple perspectives. Consequently, the team was able to identify implementation strategies and execute applications tailored to the needs of various roles and the communities they serve.

We observed meaningful improvements in several implementation outcomes, including communication between doulas and clinicians, trust between doulas and clinicians, and clinician attitudes toward doulas. We fully implemented 10 of the 11 implementation strategies, demonstrating feasibility of making systematic change to clinician-doula collaboration in hospital settings. This study is among the first to evaluate implementation strategies for incorporating community doula support in a hospital setting by assessing clinician perceptions of collaborative work with doulas. Current efforts among maternal health advocacy teams in California, New York, and North Carolina have produced useful tools to outline the goals of integrating doulas into hospital-based practices [29,30,31]. Our current research complements these efforts by outlining actionable steps to achieve these goals.

Our study showed improvements in clinician-doula trust, communication, and attitudes. These improvements were modest, indicating room for continued improvement in collaboration between doulas and clinicians. Previous research has revealed varied perceptions of doulas among clinical care team members [17, 32]. A study assessing nurse-doula attitudes attributes this variation to factors such as familiarity and experience with the doula role. They suggest that addressing persistent gaps in interprofessional education and mutual understanding of roles could improve interdisciplinary practice and collaboration in hospital birth settings [32].

We also report the need for better understanding of the doula’s role among clinicians, as this improvement was not observed in our study.

The inability to make targeted change in clinician understanding of a doula’s role may be attributed to flaws in implementation or shortcomings in the theory of change. Clinicians were offered various educational opportunities that incorporated doula support. On three occasions, community doulas presented their work to clinicians during obstetric faculty grand rounds, obstetric resident didactics, and obstetric anesthesiologists’ team meeting. It is likely that these larger, presentation-driven, educational events do not allow for the necessary engagement across cadres that can lead to more meaningful understanding and knowledge growth. Alternatively, a medical student training simulation featuring a doula as a patient care team member did see improvement in student-reported understanding of the doula’s role and the students’ comfort in working with teams that have doulas [33]. It is possible that because the reach of potentially more effective strategies such as simulations, was low, their effect was diluted across the full sample of survey respondents. Prioritizing and improving the reach of more engaging educational opportunities, such as co-education events, training simulations, and incorporating doulas into the clinical setting [34] may lead to improved clinician understanding in the future.

As hospital teams embark on identifying and implementing strategies to improve quality of care, an important consideration is the organizations’ readiness to change. One commonly used measure, the ORIC, assesses both change commitment and change efficacy [28]. ORIC scores for implementing midwifery programs [35] and bundles of quality improvement interventions related to clinical outcomes [36] have generally been high. However the scores indicated by the respondents in relation to the doula program corresponded to responses averaged around neither agreeing nor disagreeing regarding being ready to change. This may reflect notable institutional tension related to doula implementation at the time and may have impacted the type of implementation strategies that were most effective. These findings are consistent with prior research demonstrating that readiness to implement doula services can vary due to institutional and individual clinician attitudes [37]. For instance, baseline assessments of a doula-hospital partnership program indicated high levels of readiness but also revealed mixed attitudes among clinicians toward doulas, with some clinicians reporting positive doula interactions and others sharing negative experiences. Such variability in clinician perceptions, as seen in our study, can impact collaboration and hinder doula implementation efforts. Although organizational readiness to change is just one factor in successfully introducing perinatal health improvements, clinicians being ready and willing to embrace change is a necessary precursor to successful execution of implementation strategies. When implementing the model tested in the current study, organizations may need to first consider their own readiness to change. Where there are gaps, pre-work on improving organizational culture around equity and eliciting knowledge holder support may be necessary [16].

This study had several strengths. Most notably was the diverse implementation and evaluation team. Team members represented a range of racial and ethnic identities, and included individuals from various professional backgrounds, including community organizers, doulas, nurses, obstetricians, and researchers. Additionally, this study is the first of our knowledge to implement and formally quantitatively assess organizational changes to a hospital setting to support all doula-assisted births, not just those affiliated with a specific doula program.

There are also limitations to this study. First, given that this study included one implementation site, our ability to draw conclusions about the impact of implementation mapping on implementation outcomes in diverse clinical settings is limited. We are also unable to assess the causal impact of the Supportive Birth Collaborative. However, the primary objective of this pilot project was to evaluate feasibility and proof of concept, while the evaluation of implementation outcomes was secondary. Our next step is to test implementation at scale with an appropriate comparison group. In future work, evaluators should test the impact of individual strategies, such as education events, to isolate their effects on the individuals receiving the education, rather than through a repeat cross-sectional design. The current study design allows us to assess changes among the full clinical team, but may dilute the effects of strategies that have yet to reach the full team.

A second limitation is that the response rate for the clinician survey was less than 50%. Given that all but one respondent had experience supporting a birth with a doula, it is possible that some clinicians chose not to respond because they had not experienced working with a doula. Future work could further explore clinician attitudes towards doulas prior to experiencing doula support firsthand. Moreover, negative clinician perceptions of doulas are anecdotal and not supported by quantitative data related to doulas’ impact on safety and quality of care. Exploring these perceptions could provide valuable insights into clinicians’ safety and quality concerns, allowing them to be refuted by existing evidence or further investigated to determine if such concerns are substantiated. A third limitation is the absence of reported doula- and patient-reported outcomes. Patient outcomes, including their uptake of doula services, their experiences of care, and their health, are crucial indicators of the effectiveness of implementation strategies. Since patients are the ultimate beneficiaries of doula support, the absence of these outcomes makes it challenging to comprehensively evaluate the impact of the implementation strategies. Furthermore, while doulas were key contributors to the implementation mapping process, this study did not capture outcomes specific to their role.

Conclusions

Using implementation mapping we successfully identified, developed, implemented, and evaluated implementation strategies to support the coordination of doulas in a clinical setting. Beginning with program implementer and knowledge holder engagement, this process evolved into a well-established collaborative that has driven meaningful change at the hospital level. Other institutions could follow the steps outlined in this study, together with the specific implementation strategies, to guide change in their settings. It is critical that future work continues to center equity in the selection and design of implementation strategies as well as in their evaluation.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

CI:

Confidence interval

FQHC:

Federally qualified health centers

ERIC:

Expert Recommendations for Implementing Change

ORIC:

Organizational Readiness to Implement Change

SBC:

Supportive Birth Collaborative

SD:

Standard deviation

References

  1. Hoyert D. Maternal mortality rates in the United States, 2021. NCHS Health E-Stats 2023.

  2. Collins SR, Radley DC, Roy S, Zephyrin LC, Shah A. 2024 State Scorecard on Women’s Health and Reproductive Care: Commonwealth Fund, 2024.

  3. Diop H, Declercq ER, Liu C-L, et al. Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades. Plos One. 2022;17(12):1–17.

  4. Declercq E, Feinberg E, Belanoff C. Racial inequities in the course of treating perinatal mental health challenges: Results from listening to mothers in California. Birth. 2021;49(1):132–40.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reproductive Health. 2019;16(1):1–18.

  6. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017; 7: CD003766.

  7. Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O’Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013;103(4):e113–21.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Bohren MA, Berger BO, Munthe-Kaas H, Tuncalp O. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019; 3: CD012449.

  9. Kozhimannil KB, Attanasio LB, Hardeman RR, O’Brien M. Doula care supports near-universal breastfeeding initiation among diverse, low-income women. J Midwifery Womens Health. 2013;58(4):378–82.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Sobczak A, Taylor L, Solomon S, et al. The Effect of Doulas on Maternal and Birth Outcomes: A Scoping Review. Cureus 2023.

  11. Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth. 2016;43(1):20–7.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kozhimannil KB, Vogelsang CA, Hardeman RR, Prasad S. Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. J Am Board Fam Med. 2016;29(3):308–17.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Morton CH, Basile M. Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One: Lamaze International, 2013.

  14. Bey A, Brill A, Porchia-Albert C, Gradilla M, Strauss N. Advancing Birth Justice: Community-based doula models as a standard of care for ending racial disparities: Ancient Song Doula Services, Village Birth International, Every Mother Counts; 2019.

  15. Munoz EG, Collins M. Establishing a Volunteer Doula Program Within a Nurse-Midwifery Education Program: A Winning Situation for Both Clients and Students. J Midwifery Womens Health. 2015;60(3):274–7.

    Article  PubMed  Google Scholar 

  16. Gebel C, Larson E, Olden HA, Safon CB, Rhone TJ, Amutah‐Onukagha NN. A Qualitative Study of Hospitals and Payers Implementing Community Doula Support. Journal of Midwifery & Women's Health 2024.

  17. Neel K, Goldman R, Marte D, Bello G, Nothnagle MB. Hospital-based maternity care practitioners’ perceptions of doulas. Birth. 2019;46(2):355–61.

    Article  PubMed  Google Scholar 

  18. Steel A, Frawley J, Adams J, Diezel H. Trained or professional doulas in the support and care of pregnant and birthing women: a critical integrative review. Health Soc Care Community. 2015;23(3):225–41.

    Article  PubMed  Google Scholar 

  19. Kozhimannil KB, Attanasio LB, Jou J, Joarnt LK, Johnson PJ, Gjerdingen DK. Potential benefits of increased access to doula support during childbirth. Am J Manag Care. 2014;20(8):e340–52.

    PubMed  PubMed Central  Google Scholar 

  20. Fernandez ME, Ten Hoor GA, van Lieshout S, et al. Implementation Mapping: Using Intervention Mapping to Develop Implementation Strategies. Front Public Health. 2019;7:158.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196–252.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Roberts M, Hsiao W, Berman P, Reich M. Getting Health Reform Right; 2008.

  23. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015;10(1):1–14.

  24. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.

    Article  PubMed  Google Scholar 

  25. Hailu FB, Kassahun CW, Kerie MW. Perceived Nurse—Physician Communication in Patient Care and Associated Factors in Public Hospitals of Jimma Zone, South West Ethiopia: Cross Sectional Study. Plos One. 2016;11(9):1–21.

  26. Costa AC, Anderson N. Measuring trust in teams: Development and validation of a multifaceted measure of formative and reflective indicators of team trust. Eur J Work Organ Psy. 2011;20(1):119–54.

    Article  Google Scholar 

  27. Levine MS, Lowe NK. Measuring Nurse Attitudes About Childbirth: Revision and Pilot Testing of the Nurse Attitudes and Beliefs Questionnaire. J Nurs Meas. 2015;23(2):287–301.

    Article  PubMed  Google Scholar 

  28. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implementation Science. 2014;9(1):1–15.

  29. Hospital Doula-Friendliness Guidebook: New York City Department of Health and Mental Hygiene, Maternity Hospital Quality Improvement Network, Ancient Song Doula Services, Brooklyn Perinatal Network, BX (Re)Birth and Progress Collective, and Caribbean Women’s Health Association, 2024.

  30. Buys B, Cené, C, Pressley Byrd, D, Brickhouse, A, Woydak, C. Toolkit for Partnership with Community Based Doulas in Clinical Settings, 2023.

  31. Health Net MH, L.A. Care Health Plan, Anthem. Health Plans Expect Network Hospitals to Address the Role of Doulas in Birth Care Policies. 2024.

  32. Roth LM, Henley MM, Seacrist MJ, Morton CH. North American Nurses’ and Doulas’ Views of Each Other. J Obstet Gynecol Neonatal Nurs. 2016;45(6):790–800.

    Article  PubMed  Google Scholar 

  33. Goldfarb C, Daddario S, Pichardo L, Royce C, Myrick J, Larson E. Interprofessional Simulation to Improve Preclinical Medical Student Understanding of the Doula Role. Council on Resident Education in Obstetrics and Gynecology (CREOG) and the Association of Professors of Gynecology and Obstetrics (APGO) Annual Meeting. San Antonio, TX; March 1, 2024.

  34. Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Glob Health. 2018;6(11):e1163–75.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Adelson P, Yates R, Fleet J-A, McKellar L. Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia. BMC Health Services Research. 2021;21(1):1–6.

  36. Conklin CR, Macharia A, Kheyfets A, Vitek K, Larson E, Meadows AR. Assessing Hospital Readiness to Implement Consecutive Maternal Safety Bundles. MD: Society for Academic Specialists in General Obstetrics and Gynecology. Baltimore; May2023.

    Google Scholar 

  37. DaCosta MC, Mogaka J, Gebhardt L, Goff SL, Qasba N, Attanasio L. Readiness to Implement a Doula-Hospital Partnership Program. J Obstet Gynecol Neonatal Nurs. 2024;53(2):197–206.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors are incredibly grateful to the members of the Supportive Birth Collaborative at BIDMC and in particular to Susan Crafts and Dr. Mary Herlihy for their strong commitment and action toward improving equity and quality of care for our patients. We are grateful for Giana Davila for her assistance with data analysis. We also want to thank all of the clinicians who took the time to complete the survey and provide their honest feedback.

Funding

This work was funded, in part, by NIMH 1K01MH133966-01 and unrestricted funding from private donors of the BIDMC OB/GYN Task Force Advisory Committee including Ashley and Wesley Karger.

Author information

Authors and Affiliations

  1. Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02115, USA

    Jeannette C. Myrick, Lily Schneider, Kathleen Clarke, Lucy Chie, Chloe Zera & Elysia Larson

  2. Accompany Doula Care, PO Box 301896, Jamaica Plain, MA, 02130, USA

    Jeannette C. Myrick & Christina Gebel

  3. Belle Joie Doula Services, PO Box 220195, Dorchester, MA, 02122, USA

    Stephanie Crawford

  4. Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA

    Lucy Chie, Chloe Zera & Elysia Larson

  5. Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA

    Karen M. Emmons

Authors
  1. Jeannette C. Myrick
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  2. Lily Schneider
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  3. Christina Gebel
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  4. Kathleen Clarke
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  5. Stephanie Crawford
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  6. Lucy Chie
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  7. Chloe Zera
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  8. Karen M. Emmons
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  9. Elysia Larson
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Contributions

EL, CG, KC, SC, and LC conceptualized the project. EL obtained funding. JM and LS collected the data. JM and EL conducted the analysis and drafted the manuscript. EL, JM, CG, KC, SC, LC, CZ, and KE interpreted the data. LS, CG, KC, SC, LC, CZ, and KE edited the manuscript. All authors read and approved of the final manuscript.

Corresponding author

Correspondence to Elysia Larson.

Ethics declarations

Ethics approval and consent to participate

Implementation activities received a non-human subjects research determination (#2021D000963) and the evaluation was reviewed as ‘exempt’ (#2022P000190) by the Committee on Clinical Investigations (institutional review board) at Beth Israel Deaconess Medical Center.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Myrick, J.C., Schneider, L., Gebel, C. et al. The system can change: a feasibility study of a doula-clinician collaborative at a large tertiary hospital in the United States. Implement Sci Commun 5, 144 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s43058-024-00682-w

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s43058-024-00682-w

Keywords

Implementation Science Communications

ISSN: 2662-2211