June 27, 2023

Doula Program Improves the Birthing Experience and Patient Outcomes

Nurses and doulas work together to care for expectant moms


Cleveland Clinic Indian River Hospital in Vero Beach, Fla., partners with Indian River County Healthy Start to offer a doula program for expectant mothers.


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“A doula is a non-medical support person that helps women during their pregnancies, through birth and during the postpartum period,” says Megan McFall, B.Ed., RN, who helped launch the program as director of women’s health at the hospital.

The program has impacted outcomes at Indian River Hospital in several areas, including:

  • A reduction in preterm births – 3% of program participants deliver before 37 weeks gestation compared to 10.4% throughout Florida
  • Fewer babies born with low birth weight (below 5 pounds, 8 ounces) – 2.7% of program participants compared to 9% statewide

Equally important, the program improves the patient experience.

“The doula program isn’t just support for the laboring mother. It provides emotional, physical and spiritual support from woman to woman,” says Hope Johnson, RNC, assistant nurse manager in labor and delivery at Indian River Hospital.

How the program works

The doula program at Indian River Hospital began in 2016, when the CEO of Indian River County Healthy Start approached McFall after visiting a 16-year-old new mom at home with a health educator. The young woman had delivered her baby the night before in the hospital, by herself, with no support person.

“Unfortunately, there are multiple individuals who come in on a yearly basis and deliver either alone or with a support person who is less than supportive,” says McFall.

McFall and other leaders at Indian River Hospital agreed to collaborate with Healthy Start and implement the G.R.O.W. (guidance, resource, openhearted wisdom) doula program for first-time moms, patients of color or women with no support person at home. That constitutes 75% of Indian River Hospital’s expectant moms, says McFall.


Healthy Start goes into the local community and seeks out prospective doulas, who are then trained by a certified educator from DONA International. The doulas are contracted by Healthy Start and work with a liaison employed by Indian River Hospital.

A maternity navigator from Healthy Start meets with patients during a visit to their obstetrician and explains all the free programs offered by the organization to pregnant women and their families – including the G.R.O.W. doula program. If patients are eligible for a doula, their information is sent to a doula coordinator within their community.

“There is a marriage that takes place behind the scenes to pair up the best doula for each individual,” says McFall.

The doula reaches out to the expectant mom late in her second trimester. They discuss birth plans, and the doula attends some physician appointments to ensure everyone is on the same page. The doula shows up during active labor, stays with the mom until she gives birth and follows up with patients postpartum, offering emotional support, guidance on breast or bottle feeding, information on newborn behavior and more.

Growing pains

More than 70 trained doulas are available to partner with patients at Indian River Hospital, and approximately 110 women each year are supported through the program. But McFall admits the G.R.O.W. doula program had a slow start.

In 2017-2018, Indian River Hospital began partnering with the Florida Perinatal Quality Collaborative (FPQC) on a quality improvement project to promote vaginal delivery and decrease the NTSV (nulliparous, term, singleton, vertex) C-section birth rate. McFall realized doulas could be an instrumental part of the project, and she invited them to join the FPQC project.

“By partnering with FPQC and allowing doulas to advocate for patients and join in shared decision-making, we went from an NTSV rate of 32% in 2019 to 21% a year later,” says McFall. Today, Cesarian section rates for doula program participants at Indian River is 19%.


Those outcomes convinced caregivers of the value of doulas, who are now an accepted part of the women’s health team. There is mutual respect among clinical nurses and doulas for each other’s roles.

“Doulas and nurses work together to ensure the best patient experience by meeting and reviewing the patient’s history and personal needs through the labor process,” says Johnson. “The doula truly is an extension of the nurses. If the nurse has more than one patient, the doula is able to give that patient the support needed while the nurse is taking care of other patients.”

Advice for nursing professionals

McFall, who became CEO of Indian River County Healthy Start in June 2023, offers the following advice to nursing leaders who are considering a doula program:

  • Forget your preconceived notions and biases. When McFall was a clinical nurse in labor and delivery, she had a negative experience with a private doula who turned off Pitocin® for a patient whose labor wasn’t “If the former CEO of Healthy Start hadn’t checked my biases, I could’ve immediately shut down the idea. But I paused and listened to her,” says McFall. “Recognize that you as a nursing leader may have biases, put them at bay and go in with an open mind.”
  • Collect data to support the idea. “You’ll need data to convince scientifically trained physicians and midwives that a doula is more than just another person they have to work around and explain things to in the room,” says McFall. “Show them data about how doulas can help decrease C-sections, provide breastfeeding support, help get babies to their first birthdays – all the things that matter.”
  • Have candid conversations during development of the program and after it’s in place. “You need to have an open relationship with the collaborating entity and understand there will be hard conversations if something isn’t working,” she says. “As a nursing leader, you have to be open to hearing feedback and actually taking action on it, if necessary.”

As an assistant nurse manager, Johnson routinely teams with doulas and has one simple piece of advice: “Do it! The support doulas give patients is irreplaceable.”

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