Brief Communication

Translating evidence to practice in the health professions:

a randomized trial of Twitter vs Facebook

Jacqueline Tunnecliff,1 John Weiner,2 James E Gaida,3 Jennifer L Keating,1

Prue Morgan,1 Dragan Ilic,2 Lyn Clearihan,4 David Davies,5 Sivalal Sadasivan,6

Patitapaban Mohanty,7 Shankar Ganesh,7 John Reynolds,2 and Stephen Maloney1

1Department of Physiotherapy, Monash University, Frankston, Australia, 2Department of Epidemiology and Preventive Medicine,

Monash University, Melbourne, Australia, 3Discipline of Physiotherapy and University of Canberra Research Institute for Sport

and Exercise (UCRISE), University of Canberra, Canberra, Australia, 4School of Primary Health, Monash University, Melbourne,

Australia, 5Warwick Medical School, University of Warwick, Coventry, United Kingdom, 6JC School of Medicine & Health Scien-

ces, Monash University Malaysia and 7Swami Vivekanand National Institute of Rehabilitation Training and Research, Odisha,

India

Correspondence to Associate Professor Stephen Maloney, Department of Physiotherapy, Monash University, PO Box

527, Frankston, 3199, Victoria, Australia; [email protected]

Received 7 October 2015; Revised 21 April 2016; Accepted 30 April 2016

ABSTRACT

Objective: Our objective was to compare the change in research informed knowledge of health professionals

and their intended practice following exposure to research information delivered by either Twitter or Facebook.

Methods: This open label comparative design study randomized health professional clinicians to receive

“practice points” on tendinopathy management via Twitter or Facebook. Evaluated outcomes included knowl-

edge change and self-reported changes to clinical practice.

Results: Four hundred and ninety-four participants were randomized to 1 of 2 groups and 317 responders ana-

lyzed. Both groups demonstrated improvements in knowledge and reported changes to clinical practice. There

was no statistical difference between groups for the outcomes of knowledge change (P¼ .728), changes to clini-

cal practice (P¼ .11) or the increased use of research information (P¼ .89). Practice points were shared more by

the Twitter group (P< .001); attrition was lower in the Facebook group (P< .001).

Conclusion: Research information delivered by either Twitter or Facebook can improve clinician knowledge and

promote behavior change. No differences in these outcomes were observed between the Twitter and Facebook

groups. Brief social media posts are as effective as longer posts for improving knowledge and promoting

behavior change. Twitter may be more useful in publicizing information and Facebook for encouraging course

completion.

Key words: social media, evidence-based practice, communication, education, professional, computer-assisted instruction

INTRODUCTION

A significant gap remains between research generated healthcare

knowledge and clinical practice.1–3 Social media can rapidly link

researchers and clinicians from diverse geographical regions,

disciplines, and areas of practice; making it an ideal medium for

knowledge exchange and education. Approximately 25% of

health professionals currently use social media for obtaining

research information.4

Social media has been defined as a “collection of web-based

technologies that share a user-focused approach to design and func-

tionality, where users can actively participate in content creation

VC The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved.

For Permissions, please email: [email protected]

403

Journal of the American Medical Informatics Association, 24(2), 2017, 403–408

doi: 10.1093/jamia/ocw085

Advance Access Publication Date: 29 June 2016

Brief Communication

and editing through open collaboration between members of com-

munities of practice.”5 The use of social media in education may

lead to positive learning experiences,5,6 increases in knowledge and

skills,7–10 and changes to the clinical practices of health professio-

nals.10,11 However, there is a need for studies to evaluate the relative

effectiveness of different social media based applications.12

Two of the largest social media applications are Facebook (1.49

billion monthly active users) and Twitter (316 million monthly

active users).13,14 Both sites promote user interaction and allow

posting of text, videos, and weblinks; however, Twitter limits posts

to 140 characters. Neither site charges access costs. The popularity

and features of these sites indicate their potential application in

communicating research information and, therefore, were chosen

for investigation in this study.

OBJECTIVE

The primary objective of this study was to determine if research

information delivered by Twitter or Facebook would result in

greater changes in research informed knowledge and practices of

health professionals. The secondary aim was to compare participant

behavior and engagement with the two mediums.

METHODS

Design An open label randomized comparative design was used, with a

mixed methods approach to data collection and analysis. The Mon-

ash University Human Research Ethics committee (CF 14/1372 –

2014000640) approved the study.

Participants Health professional clinicians of any discipline (e.g., medicine, phys-

iotherapy, podiatry), geographical location, or level of expertise

(including undergraduate students), were eligible to participate.

Recruitment occurred via an email invitation distributed to clinical

affiliates and departments of Monash University, Faculty of Medi-

cine, Nursing and Health Sciences, Australia; Monash University

Malaysia; Swami Vivekanand National Institute of Rehabilitation

Training and Research, India; and the University of Southern Cali-

fornia. Professional associations representing professions registered

with the Australian Health Practitioner Regulation Agency15 were

also invited to distribute the invitation to participate via email or

their own social media sites.

Intervention A short course, consisting of the same 8 “practice points” or key

educational messages of 140 characters or less, on topics related to

tendon management were delivered to each group via posts on Twit-

ter16 and Facebook17 web pages. Each practice point was linked to

supplementary information in the form of peer-reviewed journal

articles or podcasts by clinical experts. The course was designed by

educational, clinical, and research experts, and was identical except

that the Facebook posts contained the practice point plus an addi-

tional 2–6 short written statements (1–2 sentences) that highlighted

key concepts from the supplementary information. The practice

points were delivered evenly over a 2 week period, to both groups at

the same time points. The pages were not restricted access.

Procedure Clinicians consented to participate by providing contact details

through an online survey. Those who provided a valid email address

were enrolled. Participants were stratified by role (student, clinician,

or other) and randomized to receive the practice points via Twitter

or Facebook. Participants received video and written instructions on

obtaining a social media account and accessing the practice points

from their allocated site. The instructions also encouraged interac-

tion on the allocated site. Participants were sent three reminder

emails at each data collection point to minimize attrition. The study

was conducted between August and October 2014.

Outcomes Data was obtained via an anonymous online survey completed 1

week before (baseline assessment) and after (post-intervention

assessment) the short course. A password was used to match pre-

and post-course data. Demographic details, information on tendon

management experience, and current use of social media were

obtained.

Outcomes were determined based on the Kirkpatrick hierarchi-

cal levels of evaluation 1–3.18 Participation and engagement data

was also collected. A data collection summary can be found in

Appendix 1.

Kirkpatrick Level 1: Participant Reactions The Social Media Use and Perception Instrument (SMUPI), a ques-

tionnaire of 10 items with high internal consistency,19 measured

attitudes towards using social media in continuing professional

development.

Kirkpatrick Level 2: Knowledge Sixteen multiple choice questions assessed knowledge (A–E

responses) (Appendix 2). One question correlated with each

“practice point” and one correlated with information from each

piece of supplementary information. The questions in both assess-

ments were identical, but question and response order were random-

ized to minimize score improvements based on pattern recognition.

Participants were not given assessment answers until the conclusion

of the study. Self-rated measures of tendon management confidence

and knowledge were also obtained.

Kirkpatrick Level 3: Behavior Change Participants were asked “has the education you have received via

social media during this trial changed the way you practice, or

intend to practice, with musculoskeletal clients?” and “has the edu-

cation you have received during this trial increased your use of

research evidence within your clinical practice?”

Participation was evaluated via the number of participants who

connected with the social media pages and completed the assess-

ments. Data on interaction was obtained through participant self-

report and from the number of times posts were approved of

(“liked” or “favorite”), shared or commented on.

Analysis Mixed linear models were used to analyze the repeated measure-

ments (pre- and post-exposure to the intervention) on the partici-

pants. The restricted maximum likelihood method (REML), as

implemented in the GenStat statistical package,20 was used to fit the

models, calculate predicted means and test, using F-tests, the main

effects of group (Twitter vs Facebook) and time (pre vs post) as well

404 Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2

as their 2-way interaction. Pairwise least significant difference tests of

the group-by-time means were based on these analyses and conducted

at the 5% significance level. Diagnostic plots of residuals were

checked for assumptions on which these methods are based. Analyses

of the 5-point Likert scale responses also used the restricted maximum

likelihood method as is customary with large datasets.21 The analyses

of binary response outcomes, measured post intervention, were based

on logistic regression models, also fitted using GenStat. Discrete count

data from Twitter and Facebook sites were analyzed using a variance-

stabilizing transformation in an analysis of variance.

RESULTS

Five hundred clinicians consented to participate. Five were excluded

due to an invalid email address, and one participant asked to be

removed. Four hundred and ninety-four participants were randomized.

The attrition rates from randomization to baseline assessment were

48.2% for the Twitter group and 41.7% for the Facebook group; the

difference was not significant [v2 (1, n¼494)¼2.09, P¼ .148]. Attri-

tion from baseline assessment to post intervention assessment was

32.8% for the Twitter group and 8.3% for the Facebook group; this

difference was significant [v2 (1, n¼494)¼17.37, P< .001]. Three

hundred and seventeen responses were analyzed (140 Twitter, 177

Facebook). There were 99 baseline assessments, 45 post intervention

assessments, and 173 matched baseline and post intervention assess-

ments. A consort flow-chart is available in Figure 1.

Demographics Demographic data and data on tendon management experience and

social media use was obtained from the baseline assessment and is

presented in Table 1.

Kirkpatrick levels 1, 2 and 3 Following the intervention, (the short course consisting of practice

points) there were statistically significant increases in SMUPI score,

self-rated confidence, self-rated knowledge and multiple choice

assessment score; but no statistically significant differences between

the groups in their changes over time. Participants in both groups

reported a change in practice/intended practice and increased use of

research in practice/intended practice as a result of the intervention

but there was no statistically significant difference between the

groups. This is shown in Table 2.

The Twitter page developed 428 “followers” and the Facebook

page received 155 “likes.” An estimated 10.0% (8/80) of the Twitter

group and 7.8% (9/115) of the Facebook group reported interacting

online. The difference between groups was not significant [v2 (1,

n¼195)¼0.28, P¼0.597)]. An estimated 42.6% (20/47) of the Twit-

ter group and 34.8% (24/69) of the Facebook group reported lack of

time as a reason for lack of interaction on the social media sites.

Statistically significant differences were found between groups

for number of times information was shared (mean shares per post

Twitter 10.40, Facebook 0.20, SED 3.030, P< .001) and approved

of (“liked”/”favourite”) (mean Twitter 14.00, Facebook 8.00, SED

1.414, P¼ .005).

DISCUSSION

This study has demonstrated that research information delivered by

either Twitter or Facebook can improve clinician knowledge and

Expressed interest in par�cipa�ng (n=500)

Excluded (n=6) n=1 complaint about process n=5 no email address provided

Randomized (n=494)

Allocated to Facebook (n=247)Allocated to Twi�er (n=247)

Comple�on of baseline Assessment (n=128)

Withdrew (n=1) Reason unknown

Comple�on of baseline Assessment (n=144)

Comple�on of post interven�on assessment (n=86)

Comple�on of post interven�on assessment (n=132)

Figure 1. Consort flow chart showing attrition of study participants.

Table 1. Participant demographics and participant characteristics

Twitter Facebook

N (%)a N (%)a

Baseline demographic data sets 128 144

Area of practice

Physiotherapy/physical therapy 95 (74.2) 98 (68.1)

Medicine 18 (14.1) 19 (13.2)

Osteopathy 2 (1.6) 3 (2.1)

Podiatry 7 (5.5) 11 (7.6)

Other 4 (3.1) 11 (7.6)

Not stated 2 (1.6) 2 (1.4)

Role

Undergraduate Student 33 (25.8) 36 (25.0)

Postgraduate Clinical Trainee 9 (7.0) 13 (9.0)

Clinician 78 (60.9) 78 (54.2)

Other 8 (6.3) 17 (11.8)

Not stated 0 (0.0) 0 (0.0)

Age

Under 18 0 (0.0) 0 (0.0)

18–24 28 (21.9) 39 (27.1)

25–34 59 (46.1) 64 (44.4)

35–44 31 (24.2) 28 (19.4)

45–54 8 (6.3) 8 (5.6)

55–64 2 (1.6) 4 (2.8)

65þ 0 (0.0) 1 (0.7)

Sex

Male 79 (61.7) 71 (49.3)

Female 47 (36.7) 71 (49.3)

Not stated 2 (1.6) 2 (1.4)

Country

Australia 48 (37.5) 59 (41.0)

India 14 (10.9) 14 (9.7)

Malaysia 5 (3.9) 6 (4.2)

UK 29 (22.7) 23 (16.0)

USA 12 (9.4) 17 (11.8)

Other 19 (14.8) 24 (16.7)

Not stated 1 (0.8) 1 (0.7)

Tendon management experience

Provide health care to clients with

tendon disorders once a week or more

61 (47.7) 62 (43.1)

Social Media experience

Use Twitter 75 (58.6) 66 (45.8)

Use Facebook 106 (82.8) 130 (90.3)

aPercent of group (Twitter or Facebook) that provided baseline data.

Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2 405

promote behavior change. No statistical differences in these out-

comes were observed between the Facebook and Twitter groups.

This research is consistent with previous literature that indicates

that web based or social media programs are useful as learning

tools,5,7,8,10,11 and can improve clinician knowledge and promote

behavior change.10

This study has also found that the provision of extra informa-

tion, beyond a 140 character message, did not impact on knowledge

or behavior change. Short messages may be beneficial to busy

healthcare workers as lack of time is often cited as a barrier to evi-

dence based practice.1 However, trustworthiness of information

gathered via social media is a key concern of clinicians.4 Our data

indicates that brief messages, when obtained from a reputable

source and linked to full sources of information may be acceptable

to clinicians.

There were two interesting differences between the groups.

There was greater overall attrition from the Twitter group. Site

familiarity may be a factor, as more health professionals use Face-

book than Twitter.4 In this study, over 80% of clinicians in each

group use Facebook; <60% in each group use Twitter. The prefer-

ence of clinicians to use Facebook over other social media sites for

obtaining research information may also be a factor.4 Therefore, the

use of Facebook may have encouraged online course completion.

The Twitter page developed a far greater following than the

Table 2. Kirkpatrick level 1–3 outcomes

Baseline measures

Predicted Mean (n)

Post-Intervention measures

Predicted Mean (n)

Difference (SED)b P-value

Kirkpatrick level 1 outcomes

SMUPIa

Twitter 40.34 (126) 41.85 (86) 1.51 (0.66) .024

Facebook 39.53 (143) 40.86 (127) 1.33 (0.58) .022

Difference (SED)b �0.81 (0.82) �0.99 (0.91)

P-value .326 .277 .841d

Kirkpatrick level 2 outcomes

Self-rated confidence in tendon managementc

Twitter 3.380 (128) 3.784 (86) 0.404 (0.083) <.001

Facebook 3.216 (143) 3.644 (131) 0.428 (0.072) <.001

Difference (SED)b �0.164 (0.106) �0.141 (0.116)

P-value .124 .227 .830d

Tendon management self-rated knowledgec

Twitter 3.181 (127) 3.727 (86) 0.546 (0.082) <.001

Facebook 3.027 (143) 3.570 (131) 0.543 (0.071) <.001

Difference (SED)b �0.154 (0.102) �0.157 (0.112)

P-value .135 .163 .975d

Multiple choice assessment total score (max score 16)

Twitter 7.649 (123) 10.308 (80) 2.659 (0.381) <.001

Facebook 6.599 (136) 9.435 (118) 2.835 (0.331) <.001

Difference (SED)b �1.050 (0.469) �0.874 (0.521)

P-value .026 .095 .728d

Assessment score for questions that addressed the practice points (max score 8)

Twitter 4.155 (123) 5.523 (80) 1.368 (0.233) <.001

Facebook 3.789 (136) 5.431 (118) 1.642 (0.203) <.001

Difference (SED)b �0.366 (0.259) �0.093 (0.293)

P-value .159 .752 .378d

Assessment score for questions addressing the supplementary information (max score 8)

Twitter 3.485 (123) 4.819 (80) 1.333 (0.211) <.001

Facebook 2.848 (136) 4.025 (118) 1.177 (0.184) <.001

Difference (SED)b �0.637 (0.255) �0.793 (0.211)

P-value .013* .006* .578d

Number reporting change (n) % of group (95% CI) P (between group

differences)

Kirkpatrick level 3 outcomes

Reported change in practice due to intervention

Twitter 59 (77) 77 (67-86) .11

Facebook 77 (117) 66 (57-74)

Reported increased use of research in practice

Twitter 55 (78) 71 (60-81) .89

Facebook 80 (115) 70 (61-78)

aTotal of ten items, each measured on a 5 point Likert scale, whereby higher score¼more favorable attitude. bSED¼ Standard Error of the Difference. cMeasured on a 5 point Likert scale 1¼ very poor, 5¼ very good. dP-value is for the F-test of a two-way interaction.

*Statistically significant difference between groups.

406 Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2

Facebook page, and more participants in the Twitter group shared

the received information within their own social networks. Twitter

is particularly useful in publicizing information, and it appears this

also applies to research information.

Social media promotes online social interactions, which may

enhance learning22 and promote change through social influence.23

Interaction in this study was encouraged in the course instructions, and

a tendon expert was available to answer questions. However, 10% or

less of the participants in each group reported interacting online. Over

30% of participants in each group cited lack of time as a key barrier to

interacting. Approximately 60% of clinicians are evidence

“pragmatists” – those to whom validity of evidence is secondary to the

daily demands of practice.2 Therefore, the interaction in this study may

reflect everyday professional use of social media for accessing research

evidence. Concerns about professional image may also influence online

interactions.4 Herein lies the paradox of social media based learning

communities; the openness and diversity which can enrich learning

may also negatively impact upon the socio–emotional aspects of group

formation which may be beneficial for collaborative learning.24

While significant improvements in knowledge occurred, the

improvements were small (an increase in total assessment score of

<3). A lack of time to read or listen to supplementary information

may have influenced this result. The practice points may also have

been lost among the large volumes of information that can appear

on social media accounts, or may have been filtered out by the social

media sites themselves.

There are several limitations to this study. Baseline measures

were collected shortly after randomization had occurred, potentially

resulting in chance bias. However, participant assessments were

anonymous, therefore randomization after completion of baseline

measures was not possible. There was no control group to assess the

impact of a learning effect from the assessment or to see if the course

was equally effective if delivered via email or text message. How-

ever, this study aimed to compare social media modalities and the

benefits and limitations of each. Participants from the Twitter group

had a statistically significant higher baseline assessment score for

knowledge related to the supplementary information. There are a

number of health professional information sharing sites on Twitter,

and participants allocated to Twitter may be more inclined to partic-

ipate if they had previous exposure to these sites. An error resulted

in 5 participants from the Twitter group obtaining the course infor-

mation for both Twitter and Facebook, however due to the small

number of participants affected, this is unlikely to have impacted the

results. Both Facebook and Twitter sites were publically available,

and participants were not asked to keep group allocation or infor-

mation confidential, meaning the groups may not have been mutu-

ally exclusive. However, participants were not informed of the

alternate group, and the diversity of participants limits the potential

impact of this confounding factor. The sites were open access; there-

fore people other than study participants may have interacted on the

sites. The same assessment was used before and after the interven-

tion however, question and answer order were randomized to limit

any potential learning effects. The high attrition rates may have

resulted in attrition bias,25 however, given that online courses often

have dropout rates of �50%26,27 the attrition level is not abnormal

for this type of education.

CONCLUSION

Evidence based “practice points” on tendinopathy management can

increase clinician knowledge and influence changes in practice,

whether delivered by Facebook or Twitter. No differences in these

outcomes were observed between the Twitter and Facebook groups.

Messages of 140 characters or less are as effective as longer posts in

conveying research information.

Future research directions may include investigating social media

interaction and the subsequent impact on learning and behavior

change, and how perceived e-professionalism influences clinicians

image1.jpeg

8403 Colesville Road, Suite 1230, Silver Spring, MD 20910-6374 • ph. 240.485.1800 • fax: 240.485.1818 • www.midwife.org | 1

POSITION STATEMENT

Birth Doulas

Doulas are trained to provide physical, emotional, and informational support to a laboring person

and their support people. Their work on the maternity care team is known to improve birth

outcomes and increase satisfaction with the birth experience.1 Birth doulas are an integral part of

the maternity care team, promoting physiologic birth,2 attending to the nonclinical needs of the

laboring person, and enhancing communication and relationships among the client and their

midwife, physician, and nurse.

The continuous labor support provided by birth doulas is consistent with the hallmarks of

midwifery: incorporation of scientific evidence into clinical practice; promotion of patient- and

family-centered care; recognition of the therapeutic value of human presence; collaboration with

members of the interprofessional health care team; and advocacy for informed choice, shared

decision-making, and the right to self-determination.3 Federal, state, local, and institutional

policies that promote continuous labor support will yield optimal birth outcomes for mothers and

babies and result in substantial cost savings overall.4,5

The American College of Nurse-Midwives (ACNM) affirms the following:

• The skill, training, and expertise provided by doulas make them a valuable part of the

health care team, working collaboratively to facilitate a safe, satisfying, and client-

centered labor and birth experience.

• Decades of research clearly demonstrate that continuous labor support contributes to

improved outcomes, such as lower cesarean rates, lower rates of epidural anesthesia

use, and higher rates of breastfeeding initiation, without risk of harm.2,6

• Given that states now recognize investments in doula care as an integral part of

maternity care reform, ensuring adequate remuneration and investment in all

evidence-based maternity care will advance sustainable efforts to improve maternal

and infant health outcomes.7

• By providing culturally congruent, client-centered care and advocacy, community-

based doulas may give support that will help protect parents from the effects of

racism and racial bias in health care settings.8

Background on the Benefits of Continuous Labor Support

Physical, emotional, and informational support is essential to ensuring the best perinatal

outcomes. The physical support provided by a birth doula can include guiding position changes

during labor, ensuring adequate energy and hydration for the client, and relieving the client’s

discomfort and pain by offering comfort measures. Physical support can also include massage

and help with ambulating or getting in and out of the bathroom or tub. This type of support not

only increases a laboring person’s sense of well-being, confidence, and comfort, but it also may

shorten the duration of labor.9 Emotional support is essential because labor and birth are intense

8403 Colesville Road, Suite 1230, Silver Spring, MD 20910-6374 • ph. 240.485.1800 • fax: 240.485.1818 • www.midwife.org | 2

life experiences, often occurring in an unfamiliar health care setting. The relationship among a

doula and the birthing person, their support persons, and the provider can enhance the birthing

person’s confidence and trust in themselves and the birth process and increase pride and

satisfaction in labor and birth. Making positive memories of the birth experience can create a

strong foundation for the future challenges of parenting. Informational support expands and

explains what the other perinatal care providers may be offering, provides reassurance about the

normal course of labor and birth, and allows access to evidence-based information about options

in labor and birth for the laboring person and their support person.10 Trained birth doulas can

assist maternity care providers in explaining health care jargon, terminology, and routine

processes to the people they serve in culturally congruent ways. Informed and shared decision-

making is enhanced when a doula is part of the maternity care team.

In addition to their work during birth, doulas provide support to birthing people before and after

birth. Prenatally, doulas meet one on one to aid with readiness for labor as well as provide

education about how to cope. Postnatally, doulas often support the family by cooking, cleaning,

and caring for other children. This allows the parent(s) to focus on bonding with and feeding the

baby. Many doulas are also certified breastfeeding counselors and can work to improve the

breastfeeding/chestfeeding experience.

ACNM supports the collaborative role doulas play in the care of pregnant and birthing people

and recognizes the importance of their skill set as a positive addition to the health care team.

References

1. Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for

women during childbirth. Cochrane Database Syst Rev. 2017;7(7):CD003766.

doi:10.1002/14651858.CD003766.pub6

2. Zielinski RE, Brody MG, Low LK. The value of the maternity care team in the promotion

of physiologic birth. J Obstet Gynecol Neonatal Nurs. 2016;45(2):276-284.

doi:10.1016/j.jogn.2015.12.009

3. American College of Nurse-Midwives. ACNM core competencies of basic midwifery

practice. Published March 20, 2020. Accessed April 5, 2021.

https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000050/AC

NMCoreCompetenciesMar2020_final.pdf

4. Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C,

Howell EA. Modeling the cost-effectiveness of doula care associated with reductions in

preterm birth and cesarean delivery. Birth. 2016;43(1):20-27. doi:10.1111/birt.12218

5. Greiner KS, Hersh AR, Hersh SR, et al. The cost-effectiveness of professional doula care

for a woman's first two births: a decision analysis model. J Midwifery Womens Health.

2019;64(4):410-420. doi:10.1111/jmwh.12972

6. Thurston LAF, Abrams D, Dreher A, Ostrowski SR, Wright JC. Improving birth and

breastfeeding outcomes among low-resource women in Alabama by including doulas in

the interprofessional birth care team. J Interprof Educ Pract. 2019;17:100278.

doi:10.1016/j.xjep.2019.100278

8403 Colesville Road, Suite 1230, Silver Spring, MD 20910-6374 • ph. 240.485.1800 • fax: 240.485.1818 • www.midwife.org | 3

7. Mehra R, Cunningham SD, Lewis JB, Thomas JL, Ickovics JR. Recommendations for the

pilot expansion of Medicaid coverage for doulas in New York State. Am J Public Health.

2019;109:217-219. doi:10.2105/AJPH.2018.304797

8. Ogunwole SM, Bennett WL, Williams AN, Bower KM. Community-based doulas and

COVID-19: addressing structural and institutional barriers to maternal health equity.

Perspect Sex Reprod Health. 2020;52(4):199-204. doi:10.1363/psrh.12169

9. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during

first stage labour. Cochrane Database Syst Rev. 2013;(8):CD003934.

doi:10.1002/14651858.CD003934.pub3

10. American College of Nurse-Midwives. Appropriate use of technology in childbirth.

Published April 2001. Updated May 2014. Accessed January 17, 2021.

https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/0000000

00054/Appropriate-Use-of-Technology-in-Childbirth-May-2014.pdf

Note. The terms midwifery and midwives as used throughout this document refer to the education

and practice of certified nurse-midwives (CNMs) and certified midwives (CMs) who have been

certified by the American Midwifery Certification Board (AMCB).

Original Source: Division of Advocacy and Government Affairs

Approved by the ACNM Board of Directors: 2022