Most people don’t know much about the research process or how difficult and time consuming it can be to publish in a peer reviewed journal. This essay exposes the barriers that are unique to publishing doula research examining obstetrical or neonatal outcomes. Part II covered the medical politics and power dynamics that negatively influence doula research projects, while Part I listed fourteen research questions that have not been answered in the 35 years since the first doula study. To conduct a doula study similar to the ones I listed in Part I, there are four to six different groups who will need to approve of the project. But first, the whole study has to be planned out in advance – and that’s before anyone ever gets paid for doing that work. So barrier number one is having the economic independence to spend the time planning a detailed doula study without any idea whether it might be funded or approved.
Graduate Student Researchers
Graduate students are more likely to pursue a doula study than a professor at a university. I judge this by the number of published theses and dissertations on doula topics. If a graduate student’s goal is an academic career, their thesis and dissertation need to be intriguing to future employers. Plus they want to hire people who have received grant money. So one’s choice of topic influences one’s employability. That might lead people away from a doula study because you want to choose a topic that looks appealing to funders for the long term.
Graduate students have the added burden of having to pay tuition while they are waiting for project approvals. Most of the time a student can’t propose a project until after all of their classes are completed. Tuition needs to be paid to keep their student status while the project is being approved. As you can see this is often an insurmountable financial barrier. One recent graduate who wanted to study doulas and breastfeeding outcomes confided to me that her committee steered her away from anything medical because it would take about a year to get the approvals and cost additional tuition (typically US $10,000).
Some graduate students develop small projects nested inside the larger research study of an established university professor. But to my knowledge only one person, Katy Kozhimannil, is consistently publishing doula studies. So they are not attracting graduate students to work on their projects or develop expertise on the subject. While not exactly a barrier, this factor definitely influences why there have been few researchers pursuing doula support studies.
Funding
How might one fund a doula study? The first option is grant funding by the National Institutes of Health, which is based on what they determine to be health care priorities. In years past there’s been specific funding priorities for research on opioids or obesity and their effects on pregnant women and babies. These priorities eventually show up as a publication trend in research journals. Less money is “unspecified” so a doula project would be competing with other proposal topics like infant sleep, breastfeeding, and long-term effects of third degree lacerations. NIH grant funding has several cycles per year and the applications are slightly different depending on the priority. So part of the research question and hypotheses might be changed to fit the funding criteria.
A second option is to apply for private foundation grants like those from the March of Dimes, Kellogg Foundation, or Robert Wood Johnson Foundation. Once again the project will need to fit their funding priorities. Each of these organizations has funded doula studies or programs in the past (see pdf below). The budget will need to be precise and include compensation for the researcher, study director, doulas, study participants and cover any project expenses (rent, paper, and so forth).
Lastly, some smaller studies are funded by multiple small grants from local funding sources who are interested in a specific outcome. For example, if a specific population of people is targeted, there may be funds from an organization to see if breastfeeding initiation increases when doulas support this group. That might not be the main point of the study but by including this outcome you can receive financing. So funding sources influence the research proposal and design too.
Planning The Study and IRB Approvals
When planning a study, most people might think a detailed outline would be sufficient at this stage. Actually, every decision is made during this early planning stage down to the smallest detail. The first task is to read everything already published and summarize it in a literature review. Then all the decisions about research methods are made including hypotheses, data collection methods, sample size and recruitment, analysis methods, and statistical power. This research plan or proposal includes the small details that are needed to implement the project such as participant recruitment letters and emails, interview locations, and compensation. This is a good time to ask for input from the people whose cooperation will be needed to conduct the study, such as physicians, nurses and other hospital staff. Funding possibilities and journal requirements also influence the study’s design. Coming up with a plan that meets research goals, funding priorities, and is amenable to the facility and staff where the researcher will be conducting the study is imperative to its success.
A graduate student would make changes to their proposal until the three to five members of their committee approved it. After that they are in the same position as a university faculty or staff researcher, and the plan would be submitted to the Internal Review Board (IRB) of the college. They examine the proposal for its impact on the human participants in the study. They also examine funding sources for possible conflicts of interest.
If researchers are collaborating from different universities, the project needs to be approved by each university’s IRB. At any point the review board can request changes that they feel improve the project. Each request often takes another week to ten days to address and may require significant changes to the proposal.
Once the university approves the project it is time to formally approach the hospitals to support the study. The proposal now needs to go before the hospital’s IRB, which has different priorities and concerns than the university’s review board. Hopefully the researcher has connections with the hospital staff and administration who are open to the changes that conducting a doula study within its walls will bring. The project will also require permission from the physician head of obstetrics, the director of nursing for the labor and delivery unit, and other affected departments. But since it’s already been approved by two IRB’s, no changes to the proposal can be made at this stage. By this time a year may have gone by. Remember, no one has been paid yet.
What Journals Will Publish Your Doula Study?
Along with applying for funding and IRB approvals, a researcher is also considering which journals will publish their doula research study. This is really difficult, much more so than with other perinatal topics. Doula research has no journal home. The Journal of Perinatal Education has published more doula studies than any other journal, however the theme of perinatal education needs to be relevant in the study. Midwifery has been inclusive by publishing doula studies from across the globe, including mine. But it is a very competitive journal. Nursing journals such as MCN or JOGNN reject studies that do not have clinical implications for the ways nurses practice. Many of the doula studies I’d like to see won’t have those clinical implications as a main finding, making nursing journals a poor prospect. Physician journals have similar standards for providing strong clinical implications for the practice of physicians and desiring physician authors.
On top of that, no profession pays attention to findings published in another profession’s journal. This tendency to isolate research findings to a specific profession is called “silo-ing”. Like corn stored in a barn silo, knowledge is kept separate and locked away. This practice is named as one of the main barriers by perinatal health care quality improvement organizations to applying evidence based practices in a timely manner.
While there are many lesser journals and open source ones available, that will not help a doula study to be spread widely unless the journal is peer reviewed AND included in respected databases. I’ve been personally facing this dilemma for years. I have a completed study on the experiences of hospital-based doulas from four different programs but no clear place to submit it. It has few clinical implications for nurses or physicians, but plenty for administrators of doula programs and other doula researchers. But what journal would welcome this piece? One of the main reasons I started this blog was to publish many of the smaller research findings in my doula studies. I’ve been able to disseminate them in an informal way and reach the people who find them useful.
Savvy researchers know the journals they want to submit to when they are in the planning process and will create hypotheses and a research design that they know will appeal to the reviewers for that journal. Even though reviewers are anonymous and change depending on the subject matter of the submitted article, the journal’s previous publications and criteria for inclusion make their priorities known. Without a research “home” for doula studies, this part of the process is more difficult. What Birth publishes is different from the Journal of Midwifery and Women’s Health.
Multiple challenges inherent to the process of conducting a doula study have led (in part) to a dearth of research. Along with the political pitfalls of challenging the status quo in how perinatal care is practiced, and lack of a political agenda that reflects the entire spectrum of how women live in their bodies, there is a trifecta of influences keeping any new knowledge contained. The real tragedy is that without the research exploring the possible greater impacts of doula support we don’t know what other positive effects we are missing.
Related Content: Sustainable-Funding-for-Doula-Programs-A-Study_for-web For more information, please visit Health Connect One.
Coming Soon: Part IV: Being Let Down By The U.S. Women’s Movements and Moving Forward