Doulas and Peer Review

Recently it came to my attention that some people had no idea that doulas can, should, and (many) do participate in peer review.

Peer review is a valuable tool that helps doulas and their clients stay safe. Safe legally, physically, professionally, and emotionally.

Peer review is a process of self-regulation by a profession or a process of evaluation involving qualified individuals within the relevant field. Peer review methods are employed to maintain standards, improve performance and provide credibility. - Wikipedia

A more in-depth definition includes:

Peer review is the evaluation of creative work or performance by other people in the same field in order to maintain or enhance the quality of the work or performance in that field. It is based on the concept that a larger and more diverse group of people will usually find more weaknesses and errors in a work or performance and will be able to make a more impartial evaluation of it than will just the person or group responsible for creating the work or performance.

Peer review utilizes the independence, and in some cases the anonymity, of the reviewers in order to discourage cronyism (i.e., favoritism shown to relatives and friends) and obtain an unbiased evaluation. Typically, the reviewers are not selected from among the close colleagues, relatives or friends of the creator or performer of the work, and potential reviewers are required to disclose of any conflicts of interest.

Peer review helps maintain and enhance quality both directly by detecting weaknesses and errors in specific works and performance and indirectly by providing a basis for making decisions about rewards and punishment that can provide a powerful incentive to achieve excellence. These rewards and punishments are related to prestige, publication, research grants, employment, compensation, promotion, tenure and disciplinary action.- Linfo.org

Doula peer review brings together doulas on either a regular basis or a as-needs basis to discuss their cases and learn from each other. It creates an opportunity for community cohesiveness. When a difficult situation arises, as will happen in every community at some point, peer review provides a stable environment that allows for problem solving, resolution, and professional accountability.

Participation is always recommended, but never required.

Why might a doula want to submit to peer review? A doula who submits to professional accountability will have the opportunity to take part in a powerful and impacting learning experience as well as a resolution board for ethical concerns.

Peer review also adds validity to the doula profession and the doula herself. It lets the public, as well as the medical community know, that there is a standard that this particular doula and the doula community at large will maintain and be held to.

Unlike certification standards, peer review will look at cases and doulas on a case by case basis and an autonomous level. Doulas with different training and experience will be held to different standards, and cases can be reviewed for both safety of the doulas involvement and the women we serve.

Peer review can come in the form of a group of doulas, a board of doulas, or a cooperative of doulas. All forms are acceptable, and all have benefits and drawbacks unto their own. Not sure what peer review may look like?

Here is an example of prenatal peer review*:

"Jane Doe, grand multip with 3 prior abdominal surgeries, two of which were cesareans, one of which was for non-pregnancy related issue. History of physical and substance abuse. Claims 'clean and with a loving partner' now. GBS positive. medium BMI and normal weight gain for pregnancy. Review of diet shows much improvement could be made and refined/processed foods could be left out. Recommendations made. At hire, planned TOL, anticipated VBAC at a hospital with a supportive OB. Since hire, has changed plan to TOL at home, anticipating an unassisted VBAC at home. Doula role has been changed from initial hire and now is being retained to watch older children in the home while partner attends Jane Doe and to help with initial postpartum care. Mrs. Doe revealed her new plan to Doula at 34 week in-home prenatal. Doula was not, prior, made aware of these plans. Considering referring this client out to another doula who may be more comfortable with mother's new birth options. Suggestions, critique, and professional remarks appreciated."

Here is an example of birth peer review*:

"I attended a birth where mom was induced for high BP and low amniotic fluid levels. Prior to induction, she, her partner, and I went over different induction techniques and the risks/benefits. We also modified her birth plan accordingly. Night of induction, she agreed to cytotec. I arrived 3 hours after administration of the drug, 30 minutes after her first contractions were noted. She was contracting every 5 minutes, lasting 60 seconds. Three hours later, or 6 hours after first cytotec administration, she was given a second dose. Contractions were still 'light and crampy'. They had her in the bed, I had her on her sides, alternating every 30 minutes. An hour after the second dose was administered, her contractions were coming really hard, every 4 minutes, lasting 90 seconds. Painful and in her thighs and over her belly button. I recommended getting out of bed and on the ball. Side note, up until this point, they were doing intermittent monitoring. Once she was up on the ball, they were continuously monitoring her with an external monitor. I was applying double-hip squeeze while dad was applying cool compresses to her neck and forehead. Mom reported abnormal pain over her belly button on a number of occasions, which I relayed to the nurse and doctor whenever they would come in to the room, which was once an hour. At 9 hours after first administration of cytotec, her cervix was checked and found to be 1 cm. At this point, without asking patient, doctor broke her water with an amniotomy finger cot. Water was dark with meconium. Fetal heart tones dropped significantly with the next two contractions, which were done on mom's back in bed.

I recommended she turn on her left side after the first one, and mom began to comply until the doctor said no and pushed her legs back so she was on her back. After the second deceleration, doctor requested an IUPC and internal monitor. I conveyed what doctor was planning while doctor unpacked the device and asked patient if she had any questions of doctor. Mom declined the IUPC and internal monitor until she was given the chance to correct FHTs by turning on her side. Doctor allowed her to turn on her side and left the room after telling her she was probably 'damaging her child'.

FHTs were fine after that point. Mom continued to labor on  her side for another 2 hours before spontaneous pushing began. Mom turned onto hands and knees to push. 3 contractions later, late decels began appearing. Nurse and I had mom turn onto her side, where she checked mom's cervix. Head was presenting at +2, 10cm, 100%, OA. Doctor was called, mom continued pushing on her side. Baby crowned before doctor's arrival. Doctor entered and had mom turn onto her back. No contractions, but doctor began pulling on babies head to deliver shoulders, despite mom telling him to stop. Mom tore as a result. With the next pushing contraction, baby came out. 1-10cm in 2.3 hours, heavy meconium, and perineal laceration. Baby arrived with apgars of 2 and 4. Babies collar bone was fractured in the birth. Doctor says it was shoulder dystocia. I didn't see any turtling. Parents are considering reporting the event. Did I do anything wrong? Should I  have done anything more? What can I expect if they plan on reporting the event if I am called to 'give testimony'?"

Here is an example of postpartum peer review*: 

"Arriving at clients home for postpartum care, I found the house in disarray. Mom is 1 week postpartum with a single infant. Prior stillbirth of 34 week child 5 years ago. This pregnancy was an anticipated twin birth but one was lost at 37 weeks gestation. Partner works long hours and not available to help. After meeting with her regarding breastfeeding and holding infant so mom could get a shower, I tucked them both into bed with lunch for mom and a book for her to read, if she wanted. 

I cleaned the kitchen, ran the dishes, tidied the living room and folded a pile of laundry. The entire process took an hour and a half from the time I walked in the door. Partner arrived, said hi, and went to his study, closing and locking his door. Client called me into her room. I sat on her bed where she had pulled out a shoe box. She then, over the next 30 minutes, showed me pictures of her two stillborn babies and tell me stories about them. She revealed she sometimes fantasizes that they are still alive. She believes she is coping well, 'in my own quirky way', but is worried about her partner who is working more and more, and it all started with her first stillbirth. He refuses to hold baby or change a diaper - saying it is her job.

Personally, I need to be able to process. I hadn't emotionally prepared myself to see her babies' pictures and had never seen stillborn pictures. Is there a support group I can be a part of or a book I can read to process some of my feelings? Is it possibly for a doula to mourn babies that aren't hers? Is that healthy? Should I refer them to another doula more equipped with their special circumstance or can I support them ok? Professionally: what to do about partner? Is it in my professional duty to refer mom/partner to a grief counselor? Any other thoughts?"

Peer review give doulas a chance to grow and process in a safe environment - because birth affects us professionally, personally, and emotionally, just as it does the women we serve... it also gives them accountability and critique. It can keep doulas from a situation that can professionally hurt them, it can also help a doula have another perspective and more information to present to her client. Finally, it can help a doula process the difficult births where, otherwise, a doula might not have space and ability to process it.

FAQs about peer review: 

Doesn't this violate HIPAA code? 
I will refer to the Feminist Breeder for that answer,

Essentially [HIPAA] means that it is illegal to release the specifics of a patient case you may have either attended or witnessed. Thinking in terms of a laboring woman, what happens in her hospital room stays in her hospital room.

Doulas are not bound to HIPAA, but we do carry a professional code of ethics which makes it unprofessional to openly discuss our clients’ cases. Some of us may gather in small circles to privately work out our thoughts on situations we may have been in, and try to grow our knowledge base by sharing experiences. However, it is considered quite unprofessional to openly discuss any identifying details of a specific mother’s birth experience. - The Feminist Breeder

HIPAA covered entities include those that are listed here. Doula's are not a part of that list. That SAID....

What About the Client Confidentiality? 

My CC form states:

I, ______________________________________, give my permission, for my doula, Cole Deelah, to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth, and postpartum, as well as any information regarding my child/ren. I realize that this information may be shared with the doula that may be providing back-up support. I understand that my doula may use this information to provide me with a summary for my own personal use. 

Additionally, any peer review usually CAN adhere to HIPAA codes, but this is a matter of trust and respect. Your doula should be able to be trusted to only share pertinent information to help resolve concerns and review scenarios/doula work. Identifying information can usually easily be left out for peer review purposes because it is not usually necessary for the intent and purpose of a review.  

What do I do if a doula is sharing outside her peer review/accountability group about me or someone I know? 

Talk to her about it and give her a chance to tell you her perspective. If you don't believe it is resolved at that point, talk to her certifying organization about your concerns. If she is not certified, talk to her cooperative or doula community chairs for resolution, or consider contacting a local birth workers dispute resolution board similar to this one.

Conclusion:

Peer review is beneficial for the doula and for the women we serve. The intent is for the safety and wellbeing of mother's and doulas and to help community see us as professionals in the childbirth industry with standards of practice and accountability.

Do you, as a doula, use peer review to better your practices and expertise? Do you, as a doula, use peer review to give your clients the best possible care? 

For information on how the cooperative that I am involved in seeks peer review, as well as a little more on the situation in Houston that spurred this blog post, see D.o.u.l.a. Confidential, by my lovely doula-sister, and peer-reviewer, Nicole Yunker. 

*these situations are fictional.