Literature Review: Looking at the Evolving Role of Doulas in Maternal and Reproductive Healthcare
Updated: 23 hours ago
Abstract
Doulas are professionals who have received specialized training to offer constant, one-on-one emotional and informational support to mothers during the perinatal period (Kozhimanni, 2017). The primary role of a doula is to provide continuous non-clinical care before, during, and after the labor process. Doulas do not have formal medical education but receive training on the non-medical aspects of pregnancy, such as emotional support and patient advocacy. They can offer physical support such as massages, focused breathing, and repositioning, but do not perform clinical tasks. There is a substantial amount of literature discussing health outcomes for patients receiving care from doulas that are both qualitatively and quantitatively measurable. The purpose of this literature review is to provide context for where current research stands regarding doulas and where gaps in the data exist.
Introduction
In the past few decades, the definition of a doula has transcended beyond simply tending to a mother during childbirth. What it means to be a doula has evolved to include a broader range of events, such as abortion, miscarriage, adoption, end-of-life care, gender-affirming care, and other prominent medical events (Hernandez, 2024). The role can also extend to advocacy for patient autonomy by helping to alleviate health disparities that are at risk of racial and socioeconomic prejudice (Sobczak, 2023). The need for this new, all-encompassing role has increased as the United States has trended toward more medicalized births and reproductive healthcare (Hernandez, 2024). This calls for more emotional and physical support as the stresses of overmedicalization can cause negative outcomes. Overmedicalization occurs when nonmedical problems are viewed within the scope of issues that require medical treatment (Conrad, 2010). This phenomenon is evident in hospitals through problems such as unnecessary cesarean sections, diminished emotional support throughout the birthing process, and even medically unnecessary procedures occurring during recovery. As a result of the negative outcomes caused by overmedicalization, more emotional and physical support is needed.
The late 19th and 20th centuries saw a change in Western medicine birthing practices, transitioning from home births to hospitals. Historically, medical needs were accounted for by the family and respective community of the patient (Hernandez, 2024). Due to contemporary differences in birthing style, it could be the case that childbirth feels isolating and challenging for some individuals more than in previous generations. In these instances, a doula can mediate between medical care and a stable, supportive community. They can address any gaps in the knowledge that mothers have about procedures, emotional techniques, communication with doctors, and advocacy, providing immense reassurance in the process. As patient-provider relationships have shifted to become less personal, despite the highly vulnerable and confusion-inducing nature of giving birth, some argue that the need for doula care and assistance is more important than ever. Recent studies show that the diminished rate of support during the birthing process can hurt the child, such as preterm delivery and low birth weights, as well as the mother. These issues can induce problematic effects during early development and have lifetime consequences (Sobczak, 2023).
There is also discussion about the benefits of doula care, especially for low-income mothers, which has sparked debate regarding the inclusion of this practice in health insurance coverage, such as Medicaid (Kozhimannil, 2017). Despite the upcoming discovery of the benefits of doulas, the overall use of their care in America was only 6% in 2011 and 2012. Although these numbers are climbing, it brings into question the cost barriers and accessibility of doula services. A lack of racial and socioeconomic diversity can be viewed within the population of mothers who have utilized them, as most research on doula use has sampled primarily caucasian, upper-middle-class women (Kozhimannil, 2017).
Relevance
Despite their lack of formal medical education, data suggests that Doulas are associated with better health outcomes for both the mother and child (Sobczak, 2023). Moreover, in the current American Healthcare System, access to affordable, quality healthcare is an issue that excludes a subset of the population during childbirth (Kozhimannil, 2016). The introduction of doulas into the healthcare of women who may otherwise struggle to access healthcare that is both affordable and high-quality during childbirth has helped satisfy this unmet demand. Given the current state of health policy, which is likely to be seen about healthcare access inequalities, Doulas can serve as mediators for women needing healthcare as they deliver their newborns.
Health Benefits of Doulas
Undoubtedly, there are many evidence-based health benefits of doula support. Prominently, it has been demonstrated that women who had doula support had lower chances of cesarean delivery and decreased rates of non-indicated cesarean among a nationally representative sample of U.S. women who gave birth between 2011 and 2012. An important thing to acknowledge, however, is that actual support from doulas, not the desire for support, is associated with lower odds of non-indicated cesarean relative to non-supported births (Kozhimannil, 2017). This association is likely attributable to the fact that women benefit immensely from “greater counseling and support” during and before labor through the use of complex interventions. This trend is especially relevant when there is no “definitive medical indication” (Kozhimannil, 2017). Since there are health risks that come with non-definitely indicated cesarean deliveries, doulas can provide emotional support for mothers going through distressing conditions.
Doula Accessibility Issues
However, the women who desire doula support the most, such as uninsured women, women on Medicaid, and women of color, are the ones who have the least access to it. Especially for low-income families, doula support is costly, ranging from several hundred to several thousand dollars, considering all the additional costs that come with having a baby. Some other barriers to access include cultural issues (e.g., trust in medical providers and personal beliefs/traditions), distance from doulas for rural women, or family objections. This is severely problematic, considering that the benefits of doula care are proven to be “greater for women who were socially disadvantaged, low income, unmarried, or had experienced language/cultural barriers” (Vonderheid, 2011). This is a problem that needs to be addressed by a combination of public health forces and policy-makers, considering how particularly beneficial doula support is for minority groups.
Addressing the Doulas' Accessibility Issue
There is undeniably an issue when it comes to accessing doulas for pregnant women who fall into a lower income bracket relative to their middle and upper-class counterparts (Marudo, 2023). To address this inequity, hospitals nationwide have implemented doula programs to meet the needs of underserved patients. Current examples of these existing programs, which are growing annually, are Birth Sisters at Boston Medical Center and Dial-A-Doula at Mott Children’s Hospital, along with other programs across the country that seek to meet this unmet need (Marudo, 2023). Currently, funding for these programs is being addressed primarily by the private sector, with over 70% of funding for doula programs coming from private foundation grants as of 2017 (Gebel, 2020).
Discussion
Currently, existing evidence suggests that doulas play a key role in improving both maternal and infant health outcomes. Specifically, data supports the claim that doula support can lower rates of non-indicated cesarean sections, preterm births, and possibly low birth rates (Kozhimannil, 2017). However, data also demonstrates that significant barriers exist for women of color and people who earn a low income (Kozhimannil, 2017). Addressing this issue is something that will require a joint effort between private and public funding sources, given that of the existing doula support programs that exist currently, which still do not meet the needs of underserved populations, over 70% of the funding comes from private donors (Gebel, 2020).
Conclusion
Thus, it is clear that there are health benefits to the use of doulas during the birthing process. Moreover, the literature shows that the definition and expected role of a doula have expanded over time. These definitions may coincide with the shift in the expected roles of healthcare providers over the past few decades. Data also suggests the need for support throughout pregnancy and that doulas can provide this support, fostering better health outcomes for the woman and her newborn. Finally, the authors note that doula access remains a serious public health issue, and, therefore, future efforts should focus on removing these barriers and promoting equitable access for all birthing individuals to promote better outcomes for pregnant women and their newborns.
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Health & Social Care in the Community, 22(4), [page range if available]. https://doi.org/10.1111/hsc.12112
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