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The Doula Research Gap

By Amy Gilliland

Doulas are disrupting the existing system of medicalized birth. So why haven’t we seen more research on their effect?

As a young woman, at the beginning of my doula career, I naively thought that major medical journals would be regularly publishing research on doulas, since the evidence of their effectiveness seemed to be overwhelming. I thought nursing and medical students working on research degrees would pair with their professors and community members to answer pressing questions. The fact that our answers could affect future generations would provide enough incentive. By offering two commodities that are scarce in the hospital system—time and a listening ear— doulas could stop women’s bodies from being permanently damaged by outmoded obstetric practices and facilitate trust and communication between client and caregiver. We could help mothers and babies have the best possible connection from the very beginning. We could increase physicians’ and nurses’ sense of connection to their patients and colleagues, thus improving their mental health outcomes.

I am no longer young—and the medical journals are largely silent on doulas. My only explanation for this is that anyone wanting to study doulas from a medical perspective must have been shushed or shut down. They’ve been quietly steered to other topics that would be more acceptable to medical or nursing professors serving on the approval boards or review committees. While there are plenty of theses and dissertations on doula topics, very few of them actually add to our understanding of doula support. They are almost exclusively from the social science perspective, not the medical field. Most focus on the way labor support is experienced by parents or doulas, because that aspect is accessible.

My conclusion is there are few doula research studies because of obstacles from medical politics and outmoded beliefs.

Politics and Power

Doulas represent the laboring person. They don’t want to maintain the system as it is; they exist to disrupt the system from offering impersonal care. Their very existence demands that the hospital see the birthing woman as an individual, with her own particular needs. Anyone who has a vested interest in maintaining the status quo will actively resist any research on birth doula support.

Doulas are unpredictable. Because they make a stand for the primacy of their client’s interests, no one is quite sure what they will do. Will they ask for a squatting bar or a birthing ball? Will they suggest that she use the shower to manage her pain? Even wanting a spontaneous labor to take as long as it needs to, rather than following a predictable timeline, is heresy in some labor and delivery units. Doulas actually interrupt physicians from doing interventions so they can be discussed with the patient first.

Doulas disrupt the power imbalance in the labor room. Doulas insist that power be shared with the laboring person, and that medical care providers discuss benefits, risks, and alternatives. Doulas assist their clients to develop a collaborative relationship with their doctors, even when that is not the wish of the physician. Many doctors are used to making autocratic decisions and not having their opinions questioned. They do not see the benefit to the patient or to themselves, even though the discussion leads to charting the conversation, which benefits the physician if there is need for a review or inquiry.

Doulas empower women. Current western society is still built on the premise that women are not equal to men. The existing system sees sharing power as a loss rather than a gain. Since doulas are basically disruptive to the status quo, they are barred from research funding or internal review board project approvals.

There’s no clear way for hospitals or medical systems to make money exploiting doula support. Although there’s a lot of controversy about the unpredictability of maternity care billing, as a general rule the current system pays more money for a birth when more interventions are used. Since doulas have been shown to reduce the use of those interventions, and doulas cost money, there’s no financial incentive to explore labor support research. Until the billing and funding systems change, there will remain no financial reason to explore doula care, except for Medicaid patients.

Medical systems that employ doulas often do so because it solves their other problems, not because it primarily benefits women or babies. That’s why these systems haven’t published studies on the positive obstetrical outcomes of these particular programs, because there aren’t many. From what I’ve observed, these programs only exist when they help the hospital attract customers, or when the doulas solve other problems in the labor and delivery unit. They don’t recognize a doula’s vital role in reducing complications from interventions, or empowering patients in the medical system, and thereby improving outcomes.

Outmoded Beliefs

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

We can see how toxic each of these beliefs are, and how they betray the normal physiology of birthing women. Yet they are still present in how labor and delivery units are designed, and how people in that system do their jobs.

Acting as if those beliefs are wrong is heresy. Yet that is exactly what doulas do. So it’s no wonder that no one wants to pay money or spend time to do research on birth doulas, unless they are also invested in changing the way medicine is practiced. Think about it: The changes that many people wish to see in the way obstetrics or hospital midwifery is performed challenge one or more of those founding beliefs. My cynical side says that hospitals have no reason to worry, as it takes an average of 17 years for evidence from scientific research to actually become medical practice.

It’s been 40 years since I attended my first birth, and I had hoped that we’d be further along in respecting women or desiring to create a better future for our families by now. Any revolution needs tools, and any social movement needs accurate information. Yet when the academic institutions that generate that information are in collusion to maintain the existing gendered power structure in our society, those studies are not conducted. We have to demand more— from our universities and from our medical systems. They must do better, and fund and carry out quality birth doula research focusing on obstetric, neonatal, and postpartum outcomes. It matters.