A doula (/ˈduːlə/; from Ancient Greek δούλα 'female slave'; Greek pronunciation: [ˈðula]) is a trained professional who provides expert guidance for the service of others and who supports another person (the doula's client) through a significant health-related experience, such as childbirth, miscarriage, induced abortion or stillbirth, as well as non-reproductive experiences such as dying.^[1][2][3][4] A doula might also provide support to the client's partner, family, and friends.^[5][6]

The doula's goal and role is to help the client feel safe and comfortable, complementing the role of the healthcare professionals who provide the client's medical care. Unlike a physician, midwife, or nurse, a doula cannot administer medication or other medical treatment or give medical advice.^[7][2] An individual might need to complete training to work as a doula, although training and certification processes vary throughout the world.^[7][3][4][8]

Some doulas work as volunteers; others are paid for their services by their client, medical institutions, or other private and public organizations. Doulas receive varying amounts of training, and their professionalism also varies.^[4][9]

The contributions of doulas during reproductive experiences and end-of-life care have been studied and have been shown to benefit their clients.^{[4][10][11][12]} For example, a birth doula providing support during childbirth might increase likelihood of vaginal birth (rather than Caesarean section), decrease the need for pain medication during labor, and improve the perception of the birthing experience.^[13][14]

The benefits of a doula providing other types of support have been less well studied, but might improve a client's experience with medical care or help an individual cope with health transitions.^{[15][16][4][17]}

History and etymology

The concept of having a companion providing support to the birthing woman dates back to prehistoric times, evidenced by archeological findings of stone carvings and statues and anthropological studies.^[18] However, the contemporary role of "doula" first emerged from the grassroots natural birth movement in the United States in the 1960s when women began desiring unmedicated, low-intervention births and began to have friends and others with formal or practical knowledge about childbirth provide them with support during pregnancy.^[19]

The term doula was first used in a 1969 anthropological study conducted by Dana Raphael, a protégée of Margaret Mead, with whom she co-founded the Human Lactation Center in Westport, Connecticut, in the 1970s.^[20] Raphael suggested it was a widespread practice that a female of the same species be part of childbirth, and in human societies this was traditionally a role occupied by a family member or friend whose presence contributed to successful long-term breastfeeding.^[20] Raphael derived the term from modern Greek (δούλα, doúla (Greek pronunciation: [ˈðula]), "slave"^[21]), as told to her by an elderly Greek woman,^[22] Eleni Rassias,^[23] and described it as coming from "Aristotle's time," an Ancient Greek word δούλα meaning "female slave."^[24]

Two physician-researchers, Marshall Klaus and John Kennell, who conducted clinical trials on the medical outcomes of doula-attended births, adopted the term to refer to a person providing labor support.^[7] In 1992, Doulas of North America (later DONA International) was co-founded by Klaus, Kennell, Phyllis Klaus, Penny Simkin, and Annie Kennedy, becoming the first organization to train and certify doulas.^[25][26] The organization with the backing of the research of Klaus and Kennell helped lend credibility and professionalize doulas.^[27] Due to the lobbying efforts of DONA International, the term doula was accepted into the American Heritage Dictionary and Oxford Dictionary in 2003, followed by Merriam Webster Dictionary in 2004.^[26] Alternative names to this role include "childbirth assistant" and "monitrice," but they did not catch on as "doula" had.^[19]

In 2008, activists in New York City began the Doula Project, to expand the role of the doula to other reproductive experiences beyond birth, grounded in reproductive justice framework.^[28][29] The participants began working as abortion doulas and coined the term "full-spectrum doula" who support all pregnancy experiences and outcomes such as pregnancy termination, miscarriage and fetal loss.^[28][30] Full spectrum doula groups can be found in major cities in the United States.^[31]

In 2019, Black maternal health advocate and Parents writer Christine Michel Carter interviewed Vice President Kamala Harris about the popularity of doulas in the Black community.^[32] As a senator, in 2019 Harris reintroduced the Maternal Care Access and Reducing Emergencies (CARE) Act which aimed to address the maternal mortality disparity faced by women of color by training providers on recognizing implicit racial bias and its impact on care. Harris stated:

"We need to speak the uncomfortable truth that women—and especially Black women—are too often not listened to or taken seriously by the health care system, and therefore they are denied the dignity that they deserve. And we need to speak this truth because today, the United States is 1 of only 13 countries in the world where the rate of maternal mortality is worse than it was 25 years ago. That risk is even higher for Black women, who are three to four times more likely than white women to die from pregnancy-related causes. These numbers are simply outrageous."

Types of support

Birth

Role

A doula focused on birth is also known as birth companion, nonclinical birth worker, birth coach or post-birth supporter, by providing continuous care before, during, or after in the form of information, advocacy, physical support, and emotional support.^{[2][14][8][10]} A birth doula is also called a labor doula. A birth doula might accompany a pregnant woman during labor and birth in place of or in addition to a partner, family member or friend. Unlike these other birth companions, a doula has formal training in labor support.^[2][14] The kinds of support provided during childbirth might include physical assistance and comfort (massage, maintaining a supporting posture or providing water), emotional support (providing company, encouragement or simply talking in a soothing tone of voice), acting as an advocate during childbirth (supporting the birthing woman's right to make decisions about their own body and baby to the medical team) and informational support (provide information about the birthing process and non-medication based forms of pain relief, and facilitating communication between their client and health providers).^[14][5]

Most doula-client relationships begin a few months before the baby is due. Before the labor, the doula and the family can develop a relationship where the pregnant woman and their support person (for example the father of the baby) feel free to ask questions and express fears and concerns, and discuss birth preferences.^[24]

Benefits and limitations

Continuous support during labor provided by doulas has been associated with improved outcomes for both birthing women and babies, including shorter delivery, fewer caesarean sections and complications, the use of fewer medications and fetal extraction tools, less time in neonatal intensive care units, positive psychological benefits, more satisfying birth experiences, and increased breastfeeding.^[11][5] Cross-country research on the effects of doulas on childbirth and postnatal care is complicated by the variety of settings, cultures and medical systems of individual countries and characteristics of patients. These benefits appear to be contingent on the doula providing continuous rather than intermittent assistance and having knowledge about the specific social and cultural setting within which their services are provided.^[33] Doula care can help reduce health disparities of those with the greatest need including those with less education, lower incomes, less preparation for childbirth and those lacking social support.^{[34][35][36][37]} Research also supports the effectiveness of female friends or relatives, after minimal training, as a low-cost alternative to professional doulas.^[11][38]

In March 2014, the American College of Obstetricians and Gynecologists (ACOG) put out a Consensus Statement titled "Safe Prevention of Primary Cesarean Delivery" in which it said, "Increasing [a woman's] access to non-medical interventions during labor, such as continuous labor support, also has been shown to reduce cesarean birth rates."^[39] As more research has become available on the positive benefits of trained labor support provided by someone not employed by the hospital, in 2017 ACOG officially announced the need for all birthing individuals to have access to continuous labor support outside hospital staff, and said, "Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes."^[40][41] The official committee opinion put out by ACOG also offers other recommendations that allow birthing women more choice and access to more supportive care. Doulas could be utilized to help achieve many of these recommendations as they move towards better collaboration.^[42]

In 2017 the United Kingdom's Royal College of Midwives published a position statement on doulas, which supports the choice of the individual to hire a doula for their birth as long as the doula does not provide medical care.^[43]

A 2018 study examined women's perceptions of doulas in several different countries, including Egypt, Lebanon, Syria, Malawi, Sweden, Nepal, Russia, Canada, and the United States of America and found that having continuous support from a companion such as a doula was highly appreciated by most women.^[10] However, perceptions may vary from country to country due to cultural factors, such as an emphasis on modesty and privacy, which might affect what kind of support a woman prefers.^[10]

A 2018 study examined news media discourse in China noted that Chinese doulas needed to register with official departments or organizations and are closely linked with midwifery. The doula profession was introduced in 1996 to mainland China and demand of their services increased since then, with women citing a dissatisfaction of medical care. After China's implementation of the Second-Child Policy, doula care was strongly linked to doula support in regards to family planning.^[44]

Tensions between doctors, nurses and doulas have sometimes been described as a "turf battle,"^[45] though it is also recognized that doulas and nurses can occupy complementary roles that provide opportunities for mutual learning and assistance.^[46] Some hospitals have created internal doula training programs to reduce conflict between doulas and medical staff.^[45][47]

Training and certification

There is no law requiring doulas to become certified, however certification can benefit professional doulas by providing structured education prior to entry into the field, access to a mentor, opportunities for networking, and client confidence.^[48] In North America, training generally takes the form of a two- to three-day seminar, and some experience with childbirth.^[49] Trainees might have hands-on practice with various techniques used during childbirth, including maternal positions and movements, relaxation and breathing exercises and other measures that could be used for comfort. Certification can occur through organizations at various levels (local, national or international) and some require positive evaluations from medical professionals. Certification may also require, in addition to attending a training course, time spent working or learning about maternity care and childbirth classes and possibly a written exam.^[17] Some doulas train through distance education.^[46]

There is a movement to encourage certification, and provide documentation of it on consumer websites such as DoulaMatch where an individual can find certified doulas, childbirth educators, yoga instructors, and other birth-related professionals.^[46] Doulas not trained by a formal organization can be controversial within medical settings due to a lack of formal medical education when a discussion regarding medical interventions in labor versus pursuing natural childbirth without an epidural or caesarean section arises.^[45]

Major doula organizations that offer certification programs include Birth Arts International, Birth Works, Birthing from Within, Childbirth and Postpartum Professional Association (CAPPA), DONA International, Hypnobirthing, International Childbirth Education Association (ICEA), and ProDoula.^[50] Because of the lack of standardization, doula organizations provide different courses with varying requirements and anyone can refer to themselves as a doula.^[51] Doulamatch.net, an online referral page for doulas, has offered a list of items that students should look for as they begin looking for training. Amy Gilliland, a researcher on doula care and culture, also lists some qualities a training program should have.^[52] Some theorists have stated that it might take college-level work or more in-depth online education in order to provide some of the communication skills that might be necessary.^[53]

Motivations and challenges

In 2010, a survey of professional Canadian doulas found that the common motivations for doula work include "desire to support women in childbirth, personal interest, and a wish to share their own positive birth experience with others" but did not see the work as a means to create steady income.^[54] Doulas of color also found motivation in providing care for their racial, ethnic and cultural communities so as to provide culturally competent care.^[55] Volunteer doulas often saw doula work as a way to "help others, to establish a practice as an employed doula, and to have a route into nursing or midwifery."^[56] From 2021 to present, Canada has specifically focused research on the cultural significance of indigenous practices in doula work.^[57][58][59]

A 2004 study of North American doulas identified challenges to doula work such as lack of support from clinicians, balancing doula work with family and other work obligations, and being on call.^[60] Volunteer doulas also found challenges in individuals' poor understanding of the doula's role, lack of clear boundaries, and complex socio-economic issues.^[56] Additionally, doulas often are challenged with the task to navigate their role in medicalized (hospital) births.^[61] Due to the social hierarchy and privilege that medical professionals have in medical settings doulas are often subordinate to doctors and physicians. Doulas have to negotiate the power dynamics between the patient and medical provider, while also establishing their legitimacy and role in the process of childbirth.^[62] They, therefore, have to be cognizant of the medical environment in which their client chooses to give birth in order to effectively advocate for their client's needs.^[63]

Antepartum

An antepartum doula provides help and support to someone who has been put on bed rest or is experiencing a high-risk pregnancy. Emotional, physical and practical support can be provided by an antepartum doula in this circumstance.^[64]

Postpartum

Postpartum doulas provide educational support and practical support in the home in the first weeks and months after childbirth or after adding an infant to the family. The same doula often provides both birth and postpartum services.^[2] Their services include a mixture of emotional support and practical help, such as infant care, breastfeeding support, information, advocacy and referral, partner support, sibling care, and household organization/work as the family adjusts to the addition of a new baby.^[65] There is some evidence that postpartum doula support can increase breastfeeding and decrease postpartum depression.^[5][66]

Other workers overlap in some of these services, such as maternity nurses, health visitors, newborn care specialists, lactation consultants, and, historically, monthly nurses.

Full-spectrum

Full-spectrum doulas extend the role of a birth attendant and provide support for all reproductive experiences which connect the role to the larger reproductive justice movement.^[3] This can include support for abortion, miscarriage, stillbirth, queer family planning, adoption, and fertility as well as extending services to women, men, transgender and gender non-conforming individuals.^[3][67][68] Abortion doulas focus on providing support to clients having an induced abortion. They provide emotional, physical, and informational support virtually or in person.^[3][15] Full-spectrum doulas often identify as activists as well as service providers and emphasize the human rights of their clients in the hopes of ending social stereotypes.^[3]

Abortion

Abortion doulas provide care before, during, and after an abortion, with support varying by person and their informational, emotional, physical, and practical needs. Doulas work in a variety of situations, including community collectives and as solo practitioners and provide abortion support as a service in their full-spectrum practice. There are no certifications specifically for abortion doulas that are administered nationally or through individual states.^[69]

In the United States following the landmark decision, Dobbs v. Jackson Women's Health Organization, doulas expect to be contacted more frequently about abortion support as access becomes more limited. They are taking precautions to retain online anonymity to better protect patients and themselves and navigating threat of legal action.^[69]

Gender transition

A gender doula provides care before, during and after the gender transition process for transgender and non-binary individuals.^[70] Gender doulas may also serve as patient advocates for their clients against medical practitioners who may misgender or undermine the gender identity of the client.

End-of-life and critical care

End-of-life or death doulas care for critically ill adults in geriatric care,^[17] and during death.^[71] While some doulas work independently or on a volunteer basis, others might work in association with a health care service, such as a palliative care service.^[4] The roles of an end-of-life doula include not only physical tasks, such as assisting with posture or making the bed comfortable, but also emotional and psychological tasks, such as providing guidance and support.^[4]

Integration of doulas into formal medical care

Birth doulas

In the United States, doulas can be found in hospital, community-based programs as well as private practice or doula agencies. They might also be reimbursed by insurance companies or out-of-pocket by clients.^[72][73][74] Since insurance companies typically do not cover the cost of hiring a doula, they are more popular among middle- and upper-class parents than amongst parents with lower incomes.^[45][75] Since doula care has the potential to lower maternity costs and reduce health disparities, there is a push for coverage through Medicaid reimbursement programs. As of 2022, four states, Oregon, Minnesota, Virginia and Wisconsin, have implemented reimbursement programs.^[34][76] In 2019, New York State launched a doula pilot program for Medicaid reimbursement in Erie and Kings Counties.^[77] In that same year, New York State passed a bill to certify doulas to lend legitimacy to the profession and to pave the way for Medicaid reimbursement from the federal government, becoming the first state to do so. Doulas in New York, however, expressed concern about the bill, having not been involved with the bill's writing, citing that state certification would make doulas more beholden to the formal medical system, be a hit to business if certification programs are not approved by the state, and might prevent community doulas from working with low-income individuals.^[78][79]

In the UK, the National Health Service and promotion of midwifery for low-risk pregnancies provide a continuity of care unavailable to North American pregnant women, but still are seeing an upswing in doulas. This pattern has been suggested to result from the lack of midwives available and a move to provide doulas to individuals at greater risk for poor outcomes.^[56]

A 2019 study reviewed perceptions of labor companionship across mostly high income countries and found barriers that prevent the universal implementation of doula care. These challenges are due to a multitude of factors dealing with perception (for example, providers not understanding the benefits or roles and other medical aspects being seen as more important) and logistics (chiefly, gaps in policy, difficulty of integration, and lack of training).^[80]

Community-based doulas

Community-based doulas work with underserved communities of which they are often members to provide a sense of cultural humility that fosters trust and strengthens relationships between the doula and their client. The services provided are often low cost, and expand in the amount of support offered compared to traditional doulas and consider physical, social spiritual and emotional needs. Services include an increased amount of home visits, preparation for the birthing experience, education, guidance navigating health care systems, language support, screening for mental health, and food security needs.^[81]

Additionally, community-based doula models provide insight in the creation of policies that will support those families and underserved communities.^[81] These doulas also actively engage policy makers by recommendations on certification and Medicaid coverage, integration into medical care, and participating on advisory boards.^[82]

Prison doulas

Since the 1980s, women incarcerated in the US has increased nearly 800 percent, of which an estimated 12,000 pregnant women are incarcerated annually. Pregnant prisoners are allowed to be shackled in more than 20 states and are forced to return to jail within 24 hours without their infants.^[83] The environmental factors of the penal system are shown to increase the risks associated with poor perinatal outcomes and have long-term health risks for the women and their children.^[84] The implementation of prison doulas rose out of the movement to end shackling for pregnant and laboring women from the prison abolition, human rights, reproductive justice, and birth justice movements in the early 2000s.^[84][85] Prison doula organizations work with those incarcerated to provide prenatal care, childbirth education, birth attendance, and breast feeding support. By providing doula services to jails, prisons, recovery centers, and county hospitals, doulas work to improve birth experiences and bonding as well as to challenge the dehumanizing penal environment.^[85] In studies of women who received doula services while incarcerated, the women reported increased happiness around their pregnancy; greater feelings of empowerment; a sense of normalcy around birth; and support during separation from their infant.^[84][86]

While well-received, prison doula support is not widespread in the United States and most programs are local due to the lack of an established federal standard of medical care for pregnant incarcerated individuals.^[83] In 2018, Washington was the first state to provide access to midwifery and doula services for incarcerated women for prenatal care, delivery, and postpartum care. However, the bill does not establish means of funding the services, and does not establish guidelines for care.^[87]