The Case for A Nationwide Regulatory Body for Labor and Birth Doulas by MERCEDES A. JONES
For over two decades The United States has been struggling to address the problem of a rising maternal mortality rate (MMR). According to the World Health Organization the MMR “is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period” (Cresswell, n.d.). Globally, this rate is important in understanding the quality of a nation’s health care system; a fact that is notable when according to the Center for Disease Control and Prevention (CDC), about 700 women die from pregnancy related complications every year in the United States (CDC, 2019). One Maternal health specialist, Jennifer Villavicencio was quoted saying “the United States has the highest MMR in the developed world, making it the most dangerous industrialized country in which pregnant women can live and deliver” (2020). In June of 2022 the White House acknowledged this to be not just a health problem, but a maternal health crisis (The White House, 2022). It is becoming increasingly imperative that this health crisis be addressed in substantive ways. I will be arguing that one quantifiable way to begin to address this nationwide issue is to increase both awareness and access to Labor doulas. Furthermore, it is essential that we undercut the negative relationship that exists between doulas and the medical community, and instead make strides to establish secure interprofessional relations. I will argue for the positive impacts of a labor and birth doulas presence throughout the pregnancy and birth process; while providing measurable proof that the presence of a doula results in improved outcomes for mothers and fewer pregnancy related complications overall. I will demonstrate that ensuring nationwide access to doula care is an important step to take in decreasing the devastatingly high Maternal Mortality Rate in America.
While the Maternal Mortality rate is astonishingly high now (CDC, 2019), that hasn’t always been the case. From 1900 to 1997, maternal mortality decreased by nearly 99 percent (CDC,1999); Dr. Michael C. Lu, of the U.S. Department of Health and Human Services called that “one of the greatest public health achievements of the 20th century” (Begleiter, 2015). Unfortunately, that achievement was short lived; In more recent years the maternal mortality rate has been rising to what is now considered a Maternal Health Crisis (The White House, 2022). Dr. Aaron Carroll posits that there is a lack of sufficient data to triangulate the cause of this rising mortality rate, but the data we do have suggests some of the causes to be an increased prevalence of cesarean deliveries, advanced maternal age, a lack of access to prenatal care, and a growing presence of chronic health conditions (Aaron, 2017). With such a broad spectrum of probable causes, a true effort to lower the maternal mortality rate would require a multidisciplinary approach with one of those approaches being an addition to the currently recognized maternal care team.
A Maternal Care Team, more commonly referred to as a “Birth Team” consists of a birthing person and the team that they choose to surround themselves with. Most commonly this team consists of an OB and other hospital staff. One resource available that women with financial means can add to their birth team are Labor and birth Doulas. Doulas are non-medical support people who provide unbiased and unconditional support to parents throughout pregnancy, as well as physical and emotional support during labor and birth. The existing literature on Doulas indicates that their presence throughout a woman’s pregnancy, and especially in the birth room, results in several improved birth outcomes for mothers. Included in these improvements are the findings that women who utilize doula support services are four times less likely to have a low birth weight baby and two times less likely to experience a birth complications involving themselves or their baby (Gruber, 2013). Considering one of the suspected causes of the current MMR is increased cesarean births, it is worth noting that the evidence shows that doulas reduce cesareans by anywhere from 28 percent (Hodnett et al. 2012) to 56 percent (Kozhimannil et al., 2016). Knowing that these findings exist, it is clear that doulas should hold a larger presence in birth rooms across America.
One very important part of the Maternal care team is that they work together cohesively to provide the best care possible (Adams, 2021). Unfortunately, the worlds of alternative birth and of medically assisted birth have not been well prepared to work together cohesively, and this puts a strain on the interprofessional relations that are a necessary part of sharing space on a birth team. Before the days of hospitals, women gave birth at home. Often, they had a midwife present, but nearly always there were other women present to guide a woman through the birth process. Over time, that role was seen more and more as essential, and took on a more formal role in the birth space (Bar-Yam, 2003). Unfortunately, because of the historical roots in what has been coined “natural birth”, some doulas struggle to provide unbiased support to clients who choose to give birth in a hospital. Those Doulas consider themselves more of birth advocates than support persons, and often place themselves between their clients and the rest of their clients chosen birth team in order to protect their clients from what they consider unnecessary medical interventions (Williamson, 2022). While this demographic of doulas is small, their impact has been effective in harming relations between doulas and medical staff, to the point where some hospitals have gone as far as to ban doulas from the maternity floor (Paul, 2008). This discord between doulas and hospital staff stems from a lack of understanding of expectations, and unclear professional boundaries and limitations. In order for these strained interprofessional relationships to mend it is important for doulas to have a very clear understanding of the scope and limitations of their role, things that are currently ill defined and depend mostly on individual doulas personal birth philosophies than anything else. It is equally important for medical staff to be more prepared with a knowledge of what to specifically expect from the presence of a doula in the birth room. As there is very little overlap between the roles of a doula, and the roles of various members of hospital staff it is entirely possible that with defined expectations it is possible for a doula to join a medically focused birth team in an agreeable and collaborative way.
Historically, births that took place in hospitals were supported by Nurses. In more recent times though, maternity care practices have had to adjust to a decrease in staff resulting in equally decreased availability for Nurses to be able to stand in as the emotional and physical support that laboring mothers need. In fact, studies show that when women go into labor and head to the hospital their expectation of support matches the relayed experience of their mothers, in other words it is expected that a nurse will be available to provide them with support for around 53% of the time; Unfortunately, the reality is that modern nurses are only able to be present for support services 6-10% of the time, leaving mothers to labor unsupported for the remainder (Gruber, Kenneth. et al., 2013). This is not the fault of nurses, but it does demonstrate a gap in care that laboring mothers are not receiving. Care that has been proven to save lives. All this evidence suggests that the formation of a governing body with the ability to enforce agreed upon standards of scope and limitations for the doula profession would be the best outcome for all involved parties (Gebel, 2020). Nurses need support in providing the best possible care for their patients, Mothers need support in order to increase the chances of positive birth outcomes, and doulas can provide that support. But not until as a profession, they are all on the same page.
While examining the existing evidence, it becomes observable that there are two main problems hindering greater accessibility to doula care. The first problem is the inability to enforce a universal acceptance of core values across doula professionals. While a great majority of doulas understand that their profession commits them to providing unbiased and compassionate support to pregnant women and their families, while promoting informed decision-making, and offering physical and emotional encouragement during a time when support is needed. Doulas that believe and promote old-school values of biased advocacy poison societal understanding of what a doula is and undermine the importance of a doula’s presence on the birth team. The other problem is a branch off the first, that same societal poisoning and those same old-school doulas have made a lasting effect on interprofessional relations between doulas and medical staff in hospital settings. It is unfortunate that while some evidence suggests that the easiest way to expand access to doula care across all socioeconomic backgrounds is through the implementation of state funded doula reimbursement programs (Gebel, 2020; Strauss, 2016). Dr. Strauss, posits that a poor professional reputation and an unclear scope of practice both contribute to the difficulty in securing that government funding for a service that would be clearly beneficial in lowering the MMR in America (Strauss, 2016). These problems highlight the need for some level of regulation, in outlining clear professional standards and expectations hospitals would have an awareness of the services that a doula is permitted to undertake, as well as an authority to speak with if a doula were to step past the boundaries of those limitations. Additionally, Doulas would have set standards to adhere to, and established boundaries of care. This would serve to eliminate unbiased doulas from the profession, and work toward mending strained relations with the medical community.
In order to develop a full perspective on this topic, it is important to understand what is meant when discussing the implementation of a regulatory body. According to the Encyclopedia Britannica, a regulatory agency is an “independent governmental body established by legislative act in order to set standards in a specific field of activity, or operations, in the private sector of the economy and then to enforce those standards” (2019). These institutions exist as ways to curtail abuse of power, promote standards of safety, and unify organizations under a binding understanding of accepted mission statements. Today, there are many regulatory bodies in existence that were all put in place to serve commonly understood functions in preserving the safety and effectiveness of their respective fields. Notably The Food and Drug Administration (FDA), The Occupational Health and Safety Administration (OSHA), and the Federal Emergency Management Agency (FEMA).
According to United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), some of the risks of not utilizing a regulatory body in the private sector include:
· Inadequate and inconsistent service level and quality
· Low efficiency in production of goods and/or services
· Non-compliance in contractual obligations to users
· Frequent discontent amount involved parties
In order to mitigate these risks, especially in growing fields, a regulatory system should be in place (n.d.). However, not everyone agrees with this level of government involvement in private sector operations. Some propose that it is a mistake to assume that regulation necessarily needs to involve the government at all. In their PHD Thesis, Yesim Yilmaz (1998) argued that “federal regulations take too much time, money, and resources to deliver results” (p. 3.) and that the most mutually beneficial solution to private sector issues involve private sector regulation. Yesim stated:
Independent third parties are flexible and responsive. They are open to suggestions by industry members, consumers and consumer groups, academic institutions like universities or other scientific organizations, and even government agencies. As a result of that dynamic relationship, independent third parties closely follow changes and technological advancements to preserve their expert status. They continuously revise their standards or certification procedures (p. 12).
Whether in favor of private sector regulation with responsive and flexible standard enforcement processes, or government regulation with its proven track record of regulation application, there are options to consider with regard for the regulation of the doula profession. No matter the outcome of this discussion, the conversation is necessary when the goal is increased access to doula care in order to increase positive birth outcomes and support women by offering more effective reproductive care.
These days reproductive justice topics are at the forefront of social discourse, but the current maternal health crisis is not something that most Americans are aware of. Women in the U.S. face an alarmingly high likelihood of not surviving childbirth, and as demonstrated doulas could play a huge part in curtailing that rising rate of mortality and morbidity. Doulas are just one small part of the equation, but as the literature shows us, that small part is significant. Regulating the doula profession is the first step in making those support services equitably available, a decision we can reasonably assume would save lives by taking necessary steps toward a lower maternal mortality rate.
Works Cited
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Paul, P. (2008) And the doula makes four. The New York Times. Retrieved from www.nytimes.com/2008/03/02/fashion/02doula.html.
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Hodnett, E. D., & Gates, S. (2012). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, CD003766.
Britannica, T. Editors of Encyclopaedia (2019, October 1). regulatory agency. Encyclopedia Britannica. https://www.britannica.com/topic/regulatory-agency
United Nations Economic and Social Commission for Asia and the Pacific. Functions of a regulator. (n.d.). Retrieved November 10, 2022, from https://www.unescap.org/ttdw/ppp/ppp_primer/51_functions_of_a_regulator.html
Yilmaz, Yesim. (1998). Private regulation: A real alternative for regulatory reform. George Mason University. Retrieved from https://www.cato.org/sites/cato.org/files/pubs/pdf/pa-303.pdf
MERCEDES A. JONES is a senior pursuing a degree in English. Selected by Trish Jenkins.