A Qualitative Study of Hospitals and Payers Implementing Community Doula Support

The impact of doula care on birth outcomes is well-established; however, doula support remains underutilized. Identifying barriers and facilitators to implementation is integral as the demand for doula care increases. The primary objective of this study was to examine doula program implementation across hospitals and payers at varying stages of implementation.

Representatives from 4 hospitals and 2 payers participated in focus group discussions. The doula programs were categorized as anticipated, initial, and advanced implementation statuses. Coding and thematic analysis were conducted using a deductive application of the Consolidated Framework for Implementation Research.

There were 20 participants across 5 focus group discussions. Participants were mostly female, and nearly all had worked at their organization for at least 2 years. Salient themes shared across participants included valuing internal outcome data or peer-reviewed literature to support doula care as well as anecdotal stories; the reality of the resource-intensive nature of doula care implementation that goes beyond funding for doulas; and both the need for individual champions for change, such as midwives, and a supportive organizational culture that values health equity.

The findings of this study highlight 3 contextual aspects that should be considered when implementing doula programs. These recommendations include: (1) use of a combination of research evidence and anecdotes when eliciting stakeholder support; (2) consideration of resources beyond funding such as program implementation support; (3) critical evaluation of organizational culture as a primary driver influencing the implementation of doula care. The future of the doula workforce in United States hospitals rests on the crux of intentional buy-in from hospital administration and clinical providers as well as the availability of requisite resources.