Doula

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.{{cite web |title=Anthropologist's studies of childbirth bring new focus on women in evolution |url= http://www1.udel.edu/udaily/2009/feb/childbirth021609.html |access-date=23 October 2020 |work=www1.udel.edu}} 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.{{sfnp|Morton|Clift|2014|pages=51–101}}

The term doula was first used in English 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.{{cite news|last=Roberts |first=Sam |author-link=Sam Roberts (newspaper journalist) |name-list-style=vanc |date=19 February 2016 |title=Dana Raphael, Proponent of Breast-Feeding and Use of Doulas, Dies at 90 |work=The New York Times |url= https://www.nytimes.com/2016/02/21/nyregion/dana-raphael-proponent-of-breast-feeding-and-the-use-of-doulas-dies-at-90.html?_r=0 |access-date=17 January 2017}} 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.{{sfnp|Roberts|2016}} Raphael derived the term from modern Greek ({{lang|el|δούλα}}, doúla ({{IPA|el|ˈðula}}), 'slave'{{cite web |title=δούλα - Ελληνοαγγλικό Λεξικό |url= https://www.wordreference.com/gren/%CE%B4%CE%BF%CF%8D%CE%BB%CE%B1 |access-date=16 February 2022 |work=WordReference.com |language=el}}), as told to her by an elderly Greek woman,{{cite web |last=Jones |first=Maggie |name-list-style=vanc |date=21 December 2016 |title=Dana Raphael Opened Up the Mysteries of Nursing |work=NYT Magazine |url= https://www.nytimes.com/interactive/2016/12/21/magazine/the-lives-they-lived-dana-raphael.html |access-date=17 January 2017}} Eleni Rassias,{{cite book |last=Raphael |first=Dana |author-link=Dana Raphael |name-list-style=vanc |date=1973 |title=The Tender Gift: Breastfeeding}} and described it as coming from "Aristotle's time", an Ancient Greek word {{lang|grc|δούλα}} meaning 'female slave'.{{cite book |vauthors=Mander R |date=2001 |title=Supportive Care and Midwifery |publisher=John Wiley & Sons |isbn=978-0632054251 |pages=113–33 |chapter=The doula |chapter-url= https://books.google.com/books?id=AWvQy8rtyqgC&pg=PA113}}

Two physician-researchers, Marshall H. Klaus and John H. Kennell, who conducted clinical trials on the medical outcomes of doula-attended births, adopted the term to refer to a person providing labor support.{{sfnp|Klaus|Kennell|Klaus|2002}} 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.{{cite journal |vauthors=Torres JM |title=Breast milk and labour support: Lactation consultants' and doulas' strategies for navigating the medical context of maternity care |journal=Sociology of Health & Illness |volume=35 |issue=6 |pages=924–38 |date=July 2013 |pmid=23398567 |doi=10.1111/1467-9566.12010 |url= https://deepblue.lib.umich.edu/bitstream/2027.42/99048/1/shil12010.pdf |hdl=2027.42/99048 |doi-access=free}}{{cite web |url= https://www.dona.org/the-dona-advantage/about/history/ |title=History of DONA International |work=DONA International |date=7 August 2014 |access-date=9 April 2019 |ref={{sfnref|DONA Intl.|2014}} }} The organization with the backing of the research of Klaus and Kennell helped lend credibility and professionalize doulas.{{cite book |last1=Simonds |first1=Wendy |last2=Katz Rothman |first2=Barbara |last3=Meltzer Norman |first3=Bari |name-list-style=vanc |date=2013 |title=Laboring On: Birth in Transition in the United States |publisher=Routledge |isbn=9781135939984 |url= https://books.google.com/books?id=yaHbAAAAQBAJ}} 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.{{sfnp|DONA Intl.|2014}} Alternative names to this role include "childbirth assistant" and "monitrice", but they did not catch on as "doula" had.{{sfnp|Morton|Clift|2014}}

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.{{sfnp|Mahoney|Mitchell|2016}}{{cite book |last=Pérez |first=Miriam Zoila |name-list-style=vanc |date=2012 |title=The Radical Doula Guide: A Political Primer for Full Spectrum Pregnancy and Childbirth Support}} 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.{{sfnp|Mahoney|Mitchell|2016}}{{cite journal |last=Basmajian |first=Alyssa |name-list-style=vanc |date=2014 |title=Abortion Doulas: Changing the Narrative |journal=Anthropology Now |volume=6 |issue=2 |pages=44–51 |doi=10.1080/19492901.2014.11728432 |s2cid=80163473 |issn=1942-8200}} Full spectrum doula groups can be found in major cities in the United States.{{cite web |url= http://bayareadoulaproject.org/ |title=Bay Area Doula Project |access-date=21 August 2019}}

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.{{cite web |title=How Doulas Provide the Advocacy and Support Black Women Need |url= https://www.parents.com/pregnancy/giving-birth/doula/do-black-women-need-doulas-more-than-anyone/ |access-date=21 June 2023 |work=Parents |archive-url=https://web.archive.org/web/20200222010535/https://www.parents.com/pregnancy/giving-birth/doula/do-black-women-need-doulas-more-than-anyone/ |archive-date=22 February 2020 |url-status=dead }} 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:

{{blockquote|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.}}

A doula focused on birth is also known as a 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.{{sfnp|DONA Intl.|2019}}{{sfnp|Bohren|Berger|Munthe-Kaas|Tunçalp|2019}}{{sfnp|Steel|Frawley|Adams|Diezel|2015}}{{sfnp|Lunda|Minnie|Benadé|2018}} 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.{{sfnp|DONA Intl.|2019}}{{sfnp|Bohren|Berger|Munthe-Kaas|Tunçalp|2019}} 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).{{sfnp|Bohren|Berger|Munthe-Kaas|Tunçalp|2019}}{{sfnp|EBB|2017}}

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 (e.g. the other parent) feel comfortable asking questions, expressing their fears and concerns, and discussing birth preferences.{{sfnp|Mander|2001}}

Continuous support during labor provided by doulas has been associated with improved outcomes for both birthing women and babies, including shorter delivery, fewer cesarean 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.{{sfnp|Bohren|Hofmeyr|Sakala|Fukuzawa|2017}}{{sfnp|EBB|2017}} 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 the characteristics of patients. These benefits appear to be contingent on the doula providing continuous rather than intermittent assistance and knowing the specific social and cultural setting within which their services are provided.{{cite journal |vauthors=Scott KD, Berkowitz G, Klaus M |title=A comparison of intermittent and continuous support during labor: A meta-analysis |journal=American Journal of Obstetrics and Gynecology |volume=180 |issue=5 |pages=1054–9 |date=May 1999 |pmid=10329855 |doi=10.1016/s0002-9378(99)70594-6}} 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.{{cite journal |vauthors=Strauss N, Giessler K, McAllister E |title=How Doula Care Can Advance the Goals of the Affordable Care Act: A Snapshot From New York City |journal=The Journal of Perinatal Education |volume=24 |issue=1 |pages=8–15 |date=2015 |pmid=26937157 |pmc=4720857 |doi=10.1891/1058-1243.24.1.8}}{{cite journal |vauthors=Coley SL, Zapata JY, Schwei RJ, Mihalovic GE, Matabele MN, Jacobs EA, Anderson CK |title=More Than a "Number": Perspectives of Prenatal Care Quality from Mothers of Color and Providers |journal=Women's Health Issues |volume=28 |issue=2 |pages=158–164 |date=2018 |pmid=29208354 |pmc=5835403 |doi=10.1016/j.whi.2017.10.014}}{{cite journal |vauthors=Everson CL, Cheyney M, Bovbjerg ML |title=Outcomes of Care for 1,892 Doula-Supported Adolescent Births in the United States: The DONA International Data Project, 2000 to 2013 |journal=The Journal of Perinatal Education |volume=27 |issue=3 |pages=135–147 |date=June 2018 |pmid=30364259 |pmc=6193361 |doi=10.1891/1058-1243.27.3.135}}{{cite journal |vauthors=Spiby H, Green JM, Darwin Z, Willmot H, Knox D, McLeish J, Smith M |title=Multisite implementation of trained volunteer doula support for disadvantaged childbearing women: A mixed-methods evaluation |journal=Health Services and Delivery Research |volume=3 |issue=8 |pages=1–332 |date=2015 |pmid=25834865 |doi=10.3310/hsdr03080 |doi-access=free}} Research also supports the effectiveness of female friends or relatives, after minimal training, as a low-cost alternative to professional doulas.{{sfnp|Bohren|Hofmeyr|Sakala|Fukuzawa|2017}}{{cite journal |vauthors=Campbell D, Scott KD, Klaus MH, Falk M |title=Female relatives or friends trained as labor doulas: Outcomes at 6 to 8 weeks postpartum |journal=Birth |volume=34 |issue=3 |pages=220–7 |date=September 2007 |pmid=17718872 |doi=10.1111/j.1523-536X.2007.00174.x |s2cid=923119}}

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 wrote: "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."{{cite journal |author1=American College of Obstetricians and Gynecologists |author2=Society for Maternal-Fetal Medicine |title=Obstetric care consensus no. 1: Safe prevention of the primary cesarean delivery |journal=Obstetrics and Gynecology |volume=123 |issue=3 |pages=693–711 |date=March 2014 |pmid=24553167 |doi=10.1097/01.AOG.0000444441.04111.1d |url= http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery |access-date=21 December 2015 |archive-date=2 March 2014 |archive-url= https://web.archive.org/web/20140302063757/http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery|url-access=subscription }} 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 wrote: "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."{{cite journal |vauthors=Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M |title=Doula care, birth outcomes, and costs among Medicaid beneficiaries |journal=American Journal of Public Health |volume=103 |issue=4 |pages=e113-21 |date=April 2013 |pmid=23409910 |pmc=3617571 |doi=10.2105/AJPH.2012.301201}}{{cite journal |author1=Committee on Obstetric Practice |author2=American College of Obstetricians and Gynecologists |title=Committee Opinion No. 687: Approaches to Limit Intervention During Labor and Birth |journal=Obstetrics and Gynecology |volume=129 |issue=2 |pages=e20–e28 |date=February 2017 |pmid=28121831 |doi=10.1097/AOG.0000000000001905 |url= https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth|url-access=subscription }} 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.{{cite news |url= https://www.trainingdoulas.com/general/women-access-doula-care/ |title=All women should have access to doula care |last=Leavitt |first=Rachel |name-list-style=vanc |date=5 June 2017 |work=New Beginnings Doula Training |access-date=8 July 2018}}

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.{{cite web |url= https://www.rcm.org.uk/sites/default/files/Doulas%20V.2_3.pdf |title=Doulas Position Statement |date=October 2017 |publisher=The Royal College of Midwives |archive-url= https://web.archive.org/web/20180827142636/https://www.rcm.org.uk/sites/default/files/Doulas%20V.2_3.pdf |archive-date=27 August 2018}}

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.{{sfnp|Lunda|Minnie|Benadé|2018}} 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.{{sfnp|Lunda|Minnie|Benadé|2018}}

A 2018 study examining 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 dissatisfaction with medical care. After China's implementation of the Second-Child Policy, doula care was strongly linked to doula support in regard to family planning.{{cite journal |last=Dai |first=Zehui |name-list-style=vanc |date=October 2018 |title=Chinese News Media Discourse of Doulas and Doula Care |journal=The Journal of Perinatal Education |volume=27 |issue=4 |pages=243–252 |doi=10.1891/1058-1243.27.4.243 |issn=1058-1243 |pmc=6491159 |pmid=31073270}}

Tensions between doctors, nurses, and doulas have sometimes been described as a "turf battle",{{cite news |vauthors=Hwang S |date=19 January 2004 |title=As 'Doulas' Enter Delivery Rooms, Conflicts Arise: Hired to Help in Childbirth, They Sometimes Clash With Doctors and Nurses |work=The Wall Street Journal}} though it is also recognized that doulas and nurses can occupy complementary roles that provide opportunities for mutual learning and assistance.{{cite journal |vauthors=Ballen LE, Fulcher AJ |title=Nurses and doulas: Complementary roles to provide optimal maternity care |journal=Journal of Obstetric, Gynecologic, and Neonatal Nursing |volume=35 |issue=2 |pages=304–11 |date=2006 |pmid=16620259 |doi=10.1111/j.1552-6909.2006.00041.x |s2cid=23409222}} Some hospitals have created internal doula training programs to reduce conflict between doulas and medical staff.{{sfnp|Hwang|2004}}{{cite web |url= https://www.prodoula.com/hospital-credentialing-for-doulas-yea-or-nay/ |title=Hospital "Credentialing" For Doulas? Yea or Nay? |date=24 October 2015 |work=Become a Doula with ProDoula |access-date=18 April 2016}}

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.{{sfnp|Simonds|Katz Rothman|Meltzer Norman|2013}} In North America, training generally takes the form of a two- to the three-day seminar, and some experience with childbirth.{{cite web |title=Doula Training: Become a Doula |work=ProDoula.com |url= https://www.prodoula.com/ |access-date=18 April 2016}} 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.{{sfnp|Balas|Gale|Kagan|2004}} Some doulas train through distance education.{{sfnp|Ballen|Fulcher|2006}}

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.{{sfnp|Ballen|Fulcher|2006}} 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 cesarean section arises.{{sfnp|Hwang|2004}}

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.{{cite web |url= http://transform.childbirthconnection.org/action/consumeradvocate/cbe-doula/ |title=Childbirth Education and Doula Organizations {{!}} Transforming Maternity Care|access-date=1 April 2019}} Because of the lack of standardization, doula organizations provide different courses with varying requirements and anyone can refer to themselves as a doula.{{cite news |vauthors=Paul P |date=2 March 2008 |title=And the Doula Makes Four |work=The New York Times |url= https://www.nytimes.com/2008/03/02/fashion/02doula.html |access-date=22 March 2012}} 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.{{cite news |title=What Makes the Best Doula Training Program? |last=Leavitt |first=Rachel |name-list-style=vanc |date=13 June 2017 |work=New Beginnings Doula Training |url= https://www.trainingdoulas.com/doula-training/best-doula-training/ |access-date=8 July 2018}} 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.{{cite journal |vauthors=Meadow SL |title=Defining the doula's role: Fostering relational autonomy |journal=Health Expectations |volume=18 |issue=6 |pages=3057–68 |date=December 2015 |pmid=25327532 |pmc=5810740 |doi=10.1111/hex.12290}}

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.{{cite journal |vauthors=Eftekhary S, Klein MC, Xu SY |title=The life of a Canadian doula: Successes, confusion, and conflict |journal=Journal of Obstetrics and Gynaecology Canada |volume=32 |issue=7 |pages=642–9 |date=July 2010 |pmid=20707952 |doi=10.1016/S1701-2163(16)34567-4}} Doulas of color also found motivation in providing care for their racial, ethnic and cultural communities so as to provide culturally competent care.{{cite journal |vauthors=Hardeman RR, Kozhimannil KB |title=Motivations for Entering the Doula Profession: Perspectives From Women of Color |journal=Journal of Midwifery & Women's Health |volume=61 |issue=6 |pages=773–780 |date=November 2016 |pmid=27862907 |pmc=5143171 |doi=10.1111/jmwh.12497}} 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".{{cite journal |vauthors=Spiby H, Mcleish J, Green J, Darwin Z |title='The greatest feeling you get, knowing you have made a big difference': Survey findings on the motivation and experiences of trained volunteer doulas in England |journal=BMC Pregnancy and Childbirth |volume=16 |issue=1 |pages=289 |date=September 2016 |pmid=27680500 |pmc=5041283 |doi=10.1186/s12884-016-1086-6 |doi-access=free}} From 2021 to present, Canada has specifically focused research on the cultural significance of indigenous practices in doula work.{{cite journal |last1=Doenmez |first1=Caroline Fidan Tyler |last2=Cidro |first2=Jaime |last3=Sinclair |first3=Stephanie |last4=Hayward |first4=Ashley |last5=Wodtke |first5=Larissa |last6=Nychuk |first6=Alexandra |name-list-style=vanc |date=16 January 2022 |title=Heart work: Indigenous doulas responding to challenges of western systems and revitalizing Indigenous birthing care in Canada |journal=BMC Pregnancy and Childbirth |volume=22 |issue=1 |pages=41 |doi=10.1186/s12884-021-04333-z |issn=1471-2393 |pmc=8761381 |pmid=35034612 |doi-access=free}}{{cite web |last1=Cidro |first1=Jaime |last2=Hayward |first2=Ashley |last3=Wodtke |first3=Larissa |name-list-style=vanc |date=January 2022 |title=Position Paper: Indigenous Doulas as Intervention for Violence against Indigenous Women and Girls |url= https://www.ohchr.org/sites/default/files/2022-03/cidro-hayward.pdf}}{{cite journal |last1=Cidro |first1=Jaime |last2=Doenmez |first2=Caroline |last3=Sinclair |first3=Stephanie |last4=Nychuk |first4=Alexandra |last5=Wodtke |first5=Larissa |last6=Hayward |first6=Ashley |name-list-style=vanc |date=26 August 2021 |title=Putting them on a strong spiritual path: Indigenous doulas responding to the needs of Indigenous mothers and communities |journal=International Journal for Equity in Health |volume=20 |issue=1 |pages=189 |doi=10.1186/s12939-021-01521-3 |issn=1475-9276 |pmc=8390212 |pmid=34446010 |doi-access=free}}

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.{{cite journal |vauthors=Lantz PM, Low LK, Watson RL |date=December 2004 |title=Doulas' views on the rewards and challenges of their work |journal=International Journal of Childbirth Education |volume=19 |issue=4 |pages=31 |url= https://www.proquest.com/openview/22acc6e65c0b3e4cefde94564916873b/1}} Volunteer doulas also found challenges in individuals' poor understanding of the doula's role, lack of clear boundaries, and complex socio-economic issues.{{sfnp|Spiby|Mcleish|Green|Darwin|2016}} Additionally, doulas often are challenged with the task to navigate their role in medicalized (hospital) births.{{cite book |vauthors=Hunter CA |date=2016 |title=Understanding Doulas and Childbirth Women, Love, and Advocacy |publisher=Palgrave Macmillan |isbn=978-1-137-48536-6 |oclc=1049995336}} 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.{{cite dissertation |last=Henley |first=M. M. |name-list-style=vanc |date=2016 |title=Science and Service: Doula Work and the Legitimacy of Alternative Knowledge Systems |type=Doctoral dissertation |publisher=University of Arizona}} 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.{{sfnp|Mahoney|Mitchell|2016}}

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.{{cite web |date=26 April 2019 |title=What is a Doula? |url= https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/having-a-doula-616/ |access-date=24 February 2021 |work=American Pregnancy Association}}

{{See also|Postpartum confinement}}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.{{sfnp|DONA Intl.|2019}} 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.{{cite journal |vauthors=Gjerdingen DK, McGovern P, Pratt R, Johnson L, Crow S |s2cid=206826557 |title=Postpartum doula and peer telephone support for postpartum depression: A pilot randomized controlled trial |journal=Journal of Primary Care & Community Health |volume=4 |issue=1 |pages=36–43 |date=January 2013 |pmid=23799688 |doi=10.1177/2150131912451598 |doi-access=free}} There is some evidence that postpartum doula support can increase breastfeeding and decrease postpartum depression.{{sfnp|EBB|2017}}{{cite web |url= http://www.nationalpartnership.org/our-work/resources/health-care/maternity/overdue-medicaid-and-private-insurance-coverage-of-doula-care-to-strengthen-maternal-and-infant-health-issue-brief.pdf |title=Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health |date=January 2016 |publisher=National Partnership for Women and Families}}

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 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.{{sfnp|Mahoney|Mitchell|2016}} 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.{{sfnp|Mahoney|Mitchell|2016}}{{cite journal |vauthors=Chor J, Goyal V, Roston A, Keith L, Patel A |title=Doulas as facilitators: The expanded role of doulas into abortion care |journal=The Journal of Family Planning and Reproductive Health Care |volume=38 |issue=2 |pages=123–4 |date=April 2012 |pmid=22454010 |doi=10.1136/jfprhc-2011-100278 |doi-access=free}}{{cite web |url= http://www.birtharts.com/a-call-for-full-spectrum-doulas/ |title=A Call for "Full Spectrum" Doulas |date=19 August 2015 |work=Birth Arts International |access-date=30 March 2019}} Abortion doulas focus on providing support to clients having an induced abortion. They provide emotional, physical, and informational support virtually or in person.{{sfnp|Mahoney|Mitchell|2016}}{{sfnp|Chor|Lyman|Tusken|Patel|2016}} 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.{{sfnp|Mahoney|Mitchell|2016}}

{{Main|Abortion doula}}

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.{{cite web |last=Vásquez |first=Tina |name-list-style=vanc |date=26 June 2022 |title=Abortion Doulas Prepare for Increased Criminalization |work=NextCity.org |url= https://nextcity.org/features/abortion-doulas-prepare-for-increased-criminalization-roe-v-wade-falls |access-date=29 June 2022}}

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 navigate the threat of legal action.{{sfnp|Vásquez|2022}}

A gender doula provides care before, during, and after the gender transition process for transgender and non-binary individuals.{{cite web |title=Serious About Gender Exploration? There's a Doula for That |work=Yes! Magazine |url= https://www.yesmagazine.org/health-happiness/2024/04/15/gender-transition-doula-transgender |access-date=20 April 2024}} 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.

{{Main|Death midwife}}

End-of-life or death doulas care for critically ill adults in geriatric care,{{sfnp|Balas|Gale|Kagan|2004}} and during death.{{cite web |last=Slevin |first=Debbie |name-list-style=vanc |date=10 April 2016 |title=Doulas for the Dying |work=Huffington Post |url= http://www.huffingtonpost.com/debbie-slevin/doulas-for-the-dying_b_9601780.html |access-date=11 April 2016}} 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. 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.

In the United States, doulas can be found in hospitals, in community-based programs, in doula agencies, and as private practitioners. They might also be reimbursed by insurance companies or out-of-pocket by clients.{{sfnp|Ballen|Fulcher|2006}}{{cite web |title=Career Choices for Becoming a Doula |date=2019 |work=Doulasa.com |publisher=ProDoula |url= https://www.doulasa.com/career-choices-for-becoming-a-doula/ |access-date=18 April 2016}} {{Dead link|date=April 2025|fix-attempted=yes}}{{cite web |last=Viswanathan |first=Meera |name-list-style=vanc |date=4 February 2024 |title=Impact of Doula Support During Pregnancy, Childbirth and Beyond (A Health Equity Systematic Review) |work=PCORI.org |publisher=Patient-Centered Outcomes Research Institute |url= https://www.pcori.org/research-results/2023/impact-doula-support-during-pregnancy-childbirth-and-beyond-health-equity-systematic-review |access-date=4 February 2024}} Since insurance companies typically do not cover the cost of hiring a doula, they are more popular among middle- and upper-class parents than among parents with lower incomes.{{sfnp|Hwang|2004}}{{cite web |title=Doulas, a Mom's Best Friend During Labor, Grow in Popularity |date=22 February 2010 |work=MissionLocal.org |url= http://missionlocal.org/2010/02/doulas-a-moms-best-friend-during-labor-grow-in-popularity/ |access-date=2 February 2014}} 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 – had implemented reimbursement programs.{{sfnp|Strauss|Giessler|McAllister|2015}}{{cite web |last=McIntyre |first=Meghan |name-list-style=vanc |date=10 October 2022 |title=Doula services now covered under Virginia Medicaid expansion |work=Virginia Mercury |url= https://www.virginiamercury.com/2022/10/10/doula-services-now-covered-under-virginia-medicaid-expansion/ |access-date=30 November 2023}} In 2019, New York State launched a doula pilot program for Medicaid reimbursement in Erie and Kings Counties.{{cite web |title=New York State Doula Pilot Program |work=Health.NY.gov |url= https://www.health.ny.gov/health_care/medicaid/redesign/doulapilot/index.htm |access-date=30 March 2019}} 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.{{cite web |last=Meyerson |first=Collier |name-list-style=vanc |date=19 July 2019 |title=A Landmark Bill Will Change the Way Doulas Do Business in New York |work=Intelligencer |url= http://nymag.com/intelligencer/2019/07/doula-certification-bill-in-new-york-state.html |access-date=31 July 2019}}{{cite web |title=NY State Senate Bill S3344B |date=5 June 2019 |work=NYSenate.gov |publisher=NY State Senate |url= https://www.nysenate.gov/legislation/bills/2019/s3344/amendment/b |access-date=31 July 2019}}

In the UK, the National Health Service and promotion of midwifery for low-risk pregnancies provide a continuity of care to pregnant women, but there has still been an upswing in doulas in the country. 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.{{sfnp|Spiby|Mcleish|Green|Darwin|2016}}

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 of doulas, and medical aspects of treatment being seen as more important) and logistics (chiefly gaps in policy, difficulty of integration, and lack of training).{{sfnp|Bohren|Berger|Munthe-Kaas|Tunçalp|2019}}

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.{{cite report |vauthors=Bey A, Brill A, Porchia-Albert C, Gradilla M, Strauss N |date=2019 |title=Advancing Birth Justice: Community-based Doula Models as a Standard of Care for Ending Racial Disparities |work=BlackMamasMatter.org |publisher=Ancient Song Doula Services, Village Birth International, Every Mother Counts |url= https://blackmamasmatter.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf}}

Additionally, community-based doula models provide insight in the creation of policies that will support those families and underserved communities.{{sfnp|Bey|Brill|Porchia-Albert|Gradilla|2019}} These doulas also actively engage policy makers by recommendations on certification and Medicaid coverage, integration into medical care, and participating on advisory boards.{{cite web |title=Community-Based Doulas and Midwives |url= https://www.americanprogress.org/article/community-based-doulas-midwives/ |access-date=17 December 2021 |work=Center for American Progress |date=14 April 2020}}

Since the 1980s, women incarcerated in the US have increased nearly 800 percent, including an estimated 12,000 pregnant women incarcerated annually. Pregnant prisoners are allowed to be shackled in more than 20 states and are forced to return to jail within 24 hours after giving birth, without their infants.{{cite web |last=Conway |first=Sarah |name-list-style=vanc |date=20 December 2019 |title=Chicago Is Making the Case for Releasing Pregnant Inmates |work=The Atlantic |url= https://www.theatlantic.com/health/archive/2019/12/doulas-county-jail/603730/ |access-date=24 December 2019}} 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.{{cite journal |vauthors=Shlafer RJ, Hellerstedt WL, Secor-Turner M, Gerrity E, Baker R |title=Doulas' Perspectives about Providing Support to Incarcerated Women: A Feasibility Study |journal=Public Health Nursing |volume=32 |issue=4 |pages=316–26 |date=July 2015 |pmid=24980835 |pmc=4281502 |doi=10.1111/phn.12137}} The implementation of prison doulas rose out of the movement to end shackling for pregnant and laboring women from the prison abolition, human rights, and reproductive and birth justice movements in the early 2000s.{{sfnp|Shlafer|Hellerstedt|Secor-Turner|Gerrity|2015}}{{cite book |last1=Oparah |first1=Julia Chinyere |last2=Bonaparte |first2=Alicia D. |name-list-style=vanc |date=2015 |title=Birthing Justice: Black Women, Pregnancy, and Childbirth |publisher=Routledge |isbn=978-1-317-27720-0 |url= https://books.google.com/books?id=4UVACwAAQBAJ&pg=PT251}} 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.{{sfnp|Oparah|Bonaparte|2015}} 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.{{sfnp|Shlafer|Hellerstedt|Secor-Turner|Gerrity|2015}}{{cite journal |vauthors=Schroeder C, Bell J |title=Doula birth support for incarcerated pregnant women |journal=Public Health Nursing |volume=22 |issue=1 |pages=53–8 |date=January 2005 |pmid=15670325 |doi=10.1111/j.0737-1209.2005.22108.x}}

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.{{sfnp|Conway|2019}} 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.{{cite web |title=HB 2016 – 2017–18: Concerning midwifery and doula services for incarcerated women |date=2018 |work=App.Leg.WA.gov |publisher=Washington State Legislature |url= https://app.leg.wa.gov/billsummary?BillNumber=2016&Year=2017 |access-date=20 December 2019}}

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• {{cite web |last1=Vanderzee |first1=Ruby |last2=Wright |first2=Emily |last3=Shier |first3=Emily |name-list-style=vanc |date=28 April 2011 |title=MoMS Noon Talk: Doulas 101 |format=MP4 video |work=Videos.Med.Wisc.edu |publisher=University of Wisconsin School of Medicine and Public Health |url= http://videos.med.wisc.edu/videos/32674}}
• {{cite web |last=Raphael |first=Dana |name-list-style=vanc |title=The Evolving Role of the Doula |work=TheHumanLactationCenter.com |url= http://www.thehumanlactationcenter.com/doula.html |archive-url= https://web.archive.org/web/20170118031516/http://www.thehumanlactationcenter.com/doula.html |archive-date=18 January 2017}}

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Category:Childbirth

Category:Natural childbirth

Category:1969 neologisms