More that Childbirth: Doulas and their Expanding Role

The Doulas has become more frequent and relevant in the past years. During the childbirth, support from Doulas is becoming more usual in healthcare in Western countries. The last Cochrane review about continuous labor support, published in 2018, the continuous labor support appears to offer impressive benefits and no harms to women and newborns, especially when provided by someone in a Doula role. This appears to be an important care practice for those who wish to improve the quality, outcomes, and experience of maternity care. 

But the role of Doulas has fast developed in many other ways of caring that includes more than childbirth. The Doulas role has expanded last years from the childbirth to encompass a person dedicated to provide physical, emotional, informational, and advocacy support to women during the pre, peri-, and postnatal period or even under another life experiences. Moreover, their role does not end with women. In this article, we will explore the Doula´s new rolls, which go further that caring for childbirth. 

The use of the word Doula started with the anthropologist and breastfeeding advocate Dana Louise Raphael (1926-2016) [1] who in her dissertation, published as a book in 1973 (“The Tender Gift: Breastfeeding.”) used this word to identify a woman who served as a supportive companion to a pregnant woman during childbirth [2]. The etymology of the word Doula is borrowed from Greek δουλα (doúla, “servant-woman”) and from Ancient Greek δουλη (doúla, “female slave”). Due to this translation, traditionally it seems accepted that Doulas are always women, but today Doulas can be of any gender. 

A Doula is a trained companion who is not a healthcare professional, does not perform clinical tasks or give any medical advice, and supports another individual (the Doula’s client) through her significant health-related experience. 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. 

The elements of Doula support by Simkin P [3] in the childbirth context have four pillars: 

• Attention to physical comfort
• Emotional support (praise, reassurance, encouragement and continuous presence). Information sharing (nonmedical advice, explanation of policies and procedures, anticipatory guidance)
• Advocacy (communication between woman and hospital staff to assist in making informed decisions) 

The benefits of support have been applied to other situations and they have been less well studied but might improve a client’s experience with medical care or help persons cope with health transitions.

The role of the Doula has been evaluated in some gynecological processes. Studies have been carried out on abortions, miscarriages, and office hysteroscopy. A randomized study by Chor J [4], examined the effect of pain in Doula support, during surgical abortion. Pain scores did not differ in the Doula and control group, but 96,2% of the women who received Doula support recommend it. Same author in 2016 [5] performed a study with semi structural interviews with women who got the option to receive Doula support during surgical abortion. The women that received the Doula support where were glad to have the verbal and physical support and felt it had been a positive experience. Most of the women that did not accept the Doula support regretted it. 

Another study by Chor J [6] explored the physician, staff, and Doula perspectives on doula support through focus group discussions with physicians, staff members and Doulas. Both physicians, Doulas and staff in this study believed that introducing Doulas resulted in more patient-center care. Doulas that can assist the patients with emotional needs, allows physicians and staff to focus on the technical aspects. A non-blinded randomized trial by Wilson SF [7] studied the impact of Doulas on physical and emotional responses to surgical abortion. The primary outcome was pain, and the secondary outcome was satisfaction, emotional state and a sense of personal empowerment. No statistically significant differences in primary outcome were found between the Doula and the control groups, but 97% of women who received Doula help reported it helped with the experience. 72 % of all participants reported the importance of having someone by their side while going throw the procedure, but it did not have to be a Doula. 

A recent pilot study by Montejo R [8] aimed to evaluate the feasibility of Doulas support in office hysteroscopy and the potential effectiveness of Doula support during office hysteroscopy to reduce anxiety and pain. The authors concluded that Doula support was feasible but not superior to routine care support in office hysteroscopy. The authors did not evaluate patient satisfaction, which is a limitation of this study. However, reports from staff and patient’s spontaneous comments after the procedure indicated that some aspects of Doula support are positive. The gynecologist and other staff members expressed appreciation for the Doula’s presence in examination rooms and that Doulas created a more patient-centered clinical experience.

Trauma informed Doulas 

Mosley EA [9] performed a narrative review of existing evidence in the peer-reviewed and gray literature on trauma-informed care in maternity and perinatal settings including Doula training curricula and community-based Doula guidelines on trauma-informed Doula care. The review included Post- Traumatic Stress Disorder (PTSD) and negative pregnancy-related outcomes such as substance use, prematurity, low birth weight, postpartum depression, difficulty bonding with the baby, children with PTSD, or even maternal and infant death. They concluded that to be trauma-informed, Doulas must first realize the scope and impact of trauma on pregnancy, including possible ways to recovery; then recognize signs and symptoms of trauma during pregnancy; be ready to respond by integrating evidence and sensitivity into all Doula training and practices; and always resist re-traumatization. By increasing Doula’s capacity to realize the scope and consequences, it is possible to deliver trauma-informed Doula care. This has the potential to mitigate the short- and long-term parental and child health effects of trauma and to interrupt the intergenerational cycle of trauma passed down from parent to child. 

End of life and critical care 

Lentz J promotes the Palliative Care Doula (PCD) as an innovative practice model of patient advocacy to assure patient-stated goals of care are reflected and decision- making is less burdensome. There were no programs like this that developed this kind of care model in the literature. The PCD was an experienced expert nurse or advanced practice nurse in palliative care. This nurse must have the commitment to provide a level of care to support the psychological and spiritual needs of the patient and family. Advanced practice or expert level of palliative care nursing was recommended, as much of the information provided to the patient and family entails complex medical terminology, understanding, and translation. After this first approach emerged another concept in Doula care called ‘Death Doulas’ (DD) with this relatively new role supporting dying people and their family members. There is a lack of clarity around how the role is enacted, and around the death Doula role within health and social care systems. 

For Rawlings D [10] the DDs work within health and social care systems is not understood and they conducted a systematic review to explore the published literature. They analyzed the papers to search into the relationship to health service, funding source, number and demand for services, training, licensing and ongoing support, and tasks undertaken. DDs are collaborating with people at the end of their lives in varied roles that are still barely understood and can be described like “an eldest daughter” or as a role that has similarities to specialist palliative care nurses. DDs may be a new direction for personalized care, directly controlled by the dying person, an adjunct to existing services, or an unregulated form of care provision without governing oversight. Same author in other study aimed to explore the ambiguity of the role of DDs in end-of-life care including the skills, training, and experience of death Doulas; how the role is communicated to the community; and the relationships to palliative care providers and other health professionals. 

A sub-group of 20 DDs from a larger quantitative survey participated in semi-structured video conference interviews. Interview data were evaluated using thematic analysis. Seven themes emerged from the qualitative analysis: what a DD offers, what a DD does, challenges and barriers, occupational preferences, family support, contract of service/fee and regulation. There is a general perception that healthcare professionals do not understand what it is that DDs do; thus, the study was helped to demystify the DD role and potentially reduce suspicion. 

An article about a holistic view from birth to the end of life, Fukuzama RK [11] develop the idea that although birth and death would appear to be opposites, they share common characteristics and challenges, such as tending to be treated in medicalized care settings, and that they both concern vulnerable parties. According to them, Doulas, with a holistic view encompassing birth and death may be able to contribute to the improvement of the healthcare system in modern societies. 

Community based Doulas 

The services of Doulas have been used in several different ways to improve community services. 

Pediatric care 

A randomized clinical trial by Edwards RC [12] examined whether young, low- income families receiving Doula-home-visiting services, compared to families receiving lower-intensity case-management services during the period between birth and 3 months of age. The Doulas provided home visits in addition to labor support found increases in breastfeeding initiation among young, low-income mothers. The Doulas services have also used in a Healthy Start Program to increasing Access for an Underserved Population [13]. Black women in the United States, particularly in high-poverty neighborhoods, experience high rates of poor birth outcomes, including cesarean section, preterm birth, low birthweight and infant mortality. The purpose of this study was to assess if Doula care was linked to improvements in many perinatal outcomes, but black women and low-income women often face barriers in accessing Doula support. Conclusion was that Doula services may be a vital component of an effort to address birth inequities. 

In same line, Wint K [14] published the Experiences of Community Doulas Working with Low-Income, African American mothers and concludes that support of Doulas can mitigate the negative effects of social determinants of health, specifically racism and classism. The Swedish study by Berbyuk N [15] study the role of Information and Communication Technology (ICT) and its potentially used to manage the Intercultural Pediatric Care. They develop a model to support mother’s whit Doulas who have the same linguistic and cultural backgrounds to serve as cultural bridges in interactions with health care professionals. Their findings suggested that ICT could be a bridging tool between health care professionals and migrants. 

A randomized controlled trial about the Doula-home-visiting services in the impact on maternal and infant health by Hans SL [16] studied the model that Illinois had developed utilizing evidence-based home-visiting models and incorporating community Doulas to focus on childbirth education, breastfeeding, pregnancy health and newborn care. They performed a randomized controlled trial to examine the impact of Doula-home-visiting. Their conclusion was that the Doula-home-visiting intervention was associated with positive infant-care behaviors but although Doula-home-visiting impacts on new- born care practices were found in the first weeks postpartum, group differences diminished by 3 months. By being present in the hospital and the earliest weeks when mothers first establish sleep practice and breastfeeding Doulas may have unique opportunities to explain to mothers and other family members the benefits of safe sleep and breastfeeding. The Doula-home-visiting intervention did not show impacts on postpartum maternal depressive symptoms. The lactation counseling throughout pregnancy and postpartum increased breastfeeding initiation, even among populations that have traditionally low breastfeeding rates. However, the intervention impact on breastfeeding was not sustained, and only about 20% of mothers were breastfeeding at 3 months. 

Prevention programs 

A study by Olsson E [17] examined how to promote the participation of foreign born into the cervical cancer screening in Sweden. The study suggests the obstacles that make that the participation was more difficult among foreign-born, including lack of knowledge concerning cancer, of preventive screening, and the unavailable childcare and language skills. Engaging Doulas with a shared background and the same native language to communicate was a way to overcome cultural barriers. The Doulas could target audience to verbally communicate information. The Doulas who helped to identify barriers and planned and executed interventions gained increased confidence and a sense of pride in assisting to bridge the gap between healthcare providers and users. 

Support to incarcerated women 

The population of imprisoned women in the United States is growing rapidly. A portion of these individuals are pregnant and will deliver while incarcerated. Although shackling laws for pregnant persons have improved, incarcerated patients are forced to labor without the support of anyone but a carceral officer and their medical staff. In this context, some programs with Doulas have been implemented. Doulas can replicate model programs that provide these women and their children with support, information, and empowering affirmation to improve parenting outcomes and decrease recidivism ([18]). 

Schroeder C [19] performed a multiagency intervention project to provide Doula birth services to pregnant women in urban jails. Program evaluation included interviews with women and written satisfaction surveys from providers and correctional officers. A convenience sample of 18 imprisoned women received Doula services. A Doula visited each woman in jail antepartum to review expectations for labor and birth; during hospitalization, the Doula provided continuous support throughout labor and birth. Doulas visited women postpartum to review birth events. Surveys administered to providers and officers demonstrated high satisfaction with the program and the support offering by the Doula services to all pregnant women in custody nurses. 

Shlafer RJ [20] performed a study on the logistical feasibility of a Doula program for pregnant imprisoned women, to assess Doulas perceptions of their achievements. The intervention was logistically feasible, suggesting that Doulas can adapt their practice for incarcerated women. Doulas may need specific training to prepare themselves for institutional restrictions that may conflict with the traditional roles of Doula care delivery. McLemore MR [21] made a case for novel and innovative reentry programs focused on black women and to describe policy recommendations to support the sustainability of these programs and the success of the women who participate in them. A review and analysis of the literature was performed to described job-training opportunities specifically targeted to women exiting jail and the impact on recidivism. The authors developed, implemented, and evaluated Doula training program for low-income and black women to determine if Doulas work could provide stable income and decrease recidivism. This reentry vocational program has been successful in producing 16 culturally relevant and appropriate black women Doulas. These women experienced no re-arrests and to date no program participant has experienced recidivism. 

Some prisons have implemented Maternal and Child Health (MCH) policies and programs. The objective of the study performed by Pendleton V [22] was to understand Corrections Officers (CO)s’ knowledge and perspectives on MCH policies and programs in a prison, with a specific emphasis on the prison’s pregnancy and birth support Doula program. They found that most COs strongly approved of the prison’s Doula program and the practice of not restraining pregnant women. COs reported that MCH policies and programs did not interfere, and in some cases helped, with their primary job task of maintaining safety and security health. 

Others rolls 

Sex doulas 

For most people, sex normally follows a natural trajectory: puberty, experimenting, intercourse and dating. This is not the case for many disabled persons who are often unable to discuss sex or dating with their parents or assistants and often go through a large part of life without ever being touched in a sexual manner [23]. This lack of education and opportunity can result in vulnerability and disadvantage. Consequently, many disabled people find themselves in need of sexual support which are both beyond the scope of parents, sex surrogates or sex therapists, and for which the healthcare system has no agent. At this point the authors promote a sex Doula program that should be provided with specific training related to the unique sexual needs of disabled persons.

There is no clear definition about the scope, roll and functions of Doulas. The many models of care in which Doulas operate make difficult to clarity on the subject. The models originated with birth Doulas have evolved into numerous other fields of action as we have mentioned in this article. Accordingly, a doula not only provides support at the event itself but can also extend care before and after to help person make informed choices. Most importantly, Doulas focus on their client’s needs offering women-centered support in different situations. Under this premise, it shouldn’t be problematic to integrate Doulas into the healthcare system. However, Doula’s extended work can overlap health professionals. Due to this, Doulas are considered often pseudo-professionals. More research is required to obtain conclusions on the results of Doulas care and to demonstrate the impact of their interventions. This will make possible to integrate Doulas into the healthcare system with a more evidence base.

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