The state of doula care

What is a doula? And other answers to common questions.

(Holly Stapleton for The Lily)
(Holly Stapleton for The Lily)
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This is part of a series from The Lily that examines how the role of doulas intersects with private and public insurance, race, socioeconomic status, policy and the medical community.

Over the last decade, as maternal health outcomes have worsened and racial disparities have persisted, the role of doulas in birth outcomes has become more widely discussed.

Nationwide, lawmakers have introduced bills related to doula care as a way to help increase health equity and reduce disparities. Most recently, Congress passed a bill that included funding for the U.S. military to launch a doula pilot program for service members and their families.

Despite being familiar with the term, you may still be wondering: What exactly is a doula? Here is a brief introduction to a group of birth workers who call themselves “essential.”

What is a birth doula? Are birth doulas different from midwives?

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A birth doula works with an individual before, during and shortly after birth. They provide nonclinical physical, emotional and informational support, with the goal of ensuring that their clients’ desires and questions are addressed and respected. There are various types of doulas, including community-based doulas, postpartum doulas and full-spectrum doulas, who provide support for all reproductive experiences including abortion.

Did you use a postpartum doula after giving birth? Tell us about your experiences.

Although midwives and doulas can work side by side, they serve different purposes, particularly during labor and delivery, when midwives “catch” babies. Doulas do not deliver babies or provide medical care.

During pregnancy, doulas help clients prepare for labor in a number of ways: They might discuss their patient rights, review or help draft birth plans, practice breathing techniques or prep partners for labor support. If needed, doulas may also connect their clients to social service resources.

Doulas are a “constant presence” during labor and delivery and focus on the birthing person’s needs. They may use different techniques, such as massage and aromatherapy, to help their client with pain management. After the birth, doulas may offer breastfeeding support, help clients adjust to life as a parent and encourage them to attend postpartum visits with their doctor.

How are birth doulas beneficial?

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Research shows that those who have continuous labor support, such as a doula, are less likely to have a Caesarean section and use pain-relieving drugs. One study conducted in California, for example, found that 22 percent of individuals with doula support had a Caesarean birth, compared with 31 percent who had no labor doula support. Shorter labor hours, lower preterm birthrates and fewer complications have also been tied to the presence of doulas.

Doulas value providing emotional support, which can contribute to a positive birth experience, regardless of birth type.

“Parents can be well-situated to be safe, grounded, present parents when they do not have birth trauma,” said Rachel Basolo, a doula based in Eugene, Ore. “We know that having culturally matched, individualized support that’s not part of the medical system reduces those traumas and improves outcomes.”

How do birth doulas specifically benefit communities of color?

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Black, Native American and Pacific Islander communities are disproportionately affected by pregnancy-related deaths, infant mortality and other adverse birth outcomes. Meanwhile, 20 percent of Latinas of reproductive age are not insured. If someone is pregnant, this can greatly hinder access to prenatal care.

During pregnancy and childbirth, people of color may also face racism and bias in health-care settings. A central goal for many doulas is to remind clients that it’s their right to ask questions, state their desires and be heard.

If doulas notice their clients being silenced, their role is to speak up.

Having a doula who is culturally representative can be key for some: If doulas and their clients share similar backgrounds, the pregnant person might feel more comfortable during doctor’s appointments and throughout labor.

With a doula there to listen, check in and make sure needs and concerns are brought to the attention of providers, the person could potentially see better outcomes, advocates say.

Why do some people dislike the term “doula”?

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The word doula means “female servant” in Greek. Although some doulas do not mind the term, others think the word has misogynistic roots and may feel uncomfortable with its connotation. They might prefer to be called “birth workers.”

The connotation of the meaning can also make birth work seem exclusively female-oriented, critics say. In reality, men and people who are nonbinary work as doulas, too.

How many people use doulas during labor and delivery?

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Six percent of birthing individuals received supportive care from a doula during labor, according to the most recent nationwide Listening to Mothers survey, which was published in 2013. Generally, doula support during labor and delivery is not widespread in the United States.

Do obstetricians, midwives and nurses work well with doulas?

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The American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives support the use of doulas in addition to regular nursing care. However, providers who do not regularly work with doulas may not understand their purpose.

Unlike nurses, midwives and obstetricians, doulas spend the duration of labor with the person who is giving birth. This benefits the patient and the maternal care team, said Allison Campbell, a registered nurse.

“As a nurse, you’re doing multiple things at the same time whereas the doula really focuses on the mom,” said Campbell, who’s a clinical care supervisor at Hennepin Healthcare Birth Center in Minneapolis. While someone is laboring, Campbell could be in and out of the room tending to other patients, filling out medical charts or, depending on how long the person is in labor, switching shifts.

How much do birth doulas usually charge for their services? Are birth doulas ever covered by insurance?

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The cost of doula care can vary. Doulas usually set their own rates based on the service package, as well as their years of experience and where they live. Private doulas generally charge between $600 to $2,000 for prenatal and postpartum visits and labor support, according to one estimate.

People often pay out of pocket for doula services, as most private and public health plans do not cover doula care. If you have insurance and would like to hire a doula, it doesn’t hurt to call your member hotline and ask if doulas are part of your benefits package. Even if the answer is no, a representative may be able to connect you with local nonprofits that offer low-cost or free services. Some hospitals and birth centers also have volunteer doula programs.

Does your employer-based health plan cover doula services? We want to hear from you.

If you have Medicaid coverage, you can get a doula at no cost if you live in Oregon, Minnesota, Indiana and New Jersey. In 2019, New York launched a pilot project in Erie County and will eventually expand to Kings County. If you are covered by Medicaid but do not live in these states, it’s still important to call your health plan if you’d like to access a doula. Some managed care plans, which oversee Medicaid enrollees in most states, offer additional benefits, including doula services.

How does someone find a birth doula?

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Because many clients find doulas through word of mouth, asking friends, family members, social service providers and maternal care coordinators for suggestions may be a good place to start. Online, DoulaMatch.net allows people to search for doulas by geography, race/ethnicity and language spoken. The National Black Doula Association maintains a directory, and most doula-certifying organizations, such as DONA International and the Childbirth and Postpartum Professional Association, have databases.

Are birth doulas trained? What does the training entail?

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Formal training is not required to become a doula. However, many doulas attend some sort of training before they begin supporting clients. Others rely on knowledge passed down through generations. In both instances, doulas often refine their skills over time and may participate in multiple trainings over the course of their professional life.

Formal doula trainings typically last a few days, and participants learn about a range of topics, including how to provide nonjudgmental support, the basics of childbirth and breastfeeding, labor coping strategies and how to attract clients and build a business.

Some community-based organizations argue that traditional doula trainings lack historical, educational and cultural context key to fully understanding health disparities. Many doulas of color advocate for community-based trainings, which provide doulas with a greater understanding of the challenges their clients face. Trainings can range from a few hundred dollars to $1,000 or more.

For a list of the most common doula training organizations, click here.

What is a ‘certified’ birth doula?

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If a doula wants to become “certified” through an organization, attending a doula training is usually step one. After the training is over, doulas typically have up to two years to complete an organization’s requirements, which vary. Common tasks include attending a certain number of births, reading specific books, writing essays, completing workbooks and taking additional childbirth education courses.

Not all doulas pursue certification after attending trainings. Because the occupation is “unlicensed and unregulated,” certification is not always necessary.

States that cover doula services through Medicaid programs have different requirements. To be put on the state’s registry and considered for Medicaid reimbursement, doulas must meet the state’s criteria. As government involvement increases, some doulas fear overregulation will limit who can serve their communities, similarly to how standards established in the late 19th and early 20th centuries contributed to a decline in the number of Black midwives.

Why were birth doulas kept out of some hospitals when the pandemic began? Are birth doulas allowed in hospitals now?

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Beginning in March, some people were forced to give birth alone when hospitals banned most visitors, including partners and doulas, to minimize the spread of the coronavirus. These decisions, which were not uniform across the United States, made headlines. Online petitions spearheaded by doulas garnered thousands of signatures. Several governors struck down these policies, agreeing that support through labor is necessary.

Some hospital administrators may not have foreseen such an outcry from doulas, who aren’t typically employed by hospitals. Although there is still a lack of awareness surrounding the importance of doulas, the pandemic has helped draw attention to their work.

How has the pandemic affected your pregnancy, birth or first year as a parent? Tell us about your experience.

As hospitals learned to navigate the realities of coronavirus, more doulas were allowed to attend births. However, visitor policies still vary by hospital. Make sure you check your hospital’s visitor policy before your birth if you intend to have a doula.

Is there a pathway for doula care to be covered by private and public insurance through the Patient Protection and Affordable Care Act (PPACA)?

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Some believe that there could be a pathway to public and private insurance coverage of doula care. The PPACA states that health plans must provide coverage of evidence-based items or services reviewed by the U.S. Preventive Services Task Force (USPSTF) if the recommendation receives an “A” or “B” rating.

In order for doula care to be considered, the USPSTF would have to determine that continuous labor support — which a doula provides — fits into one or more of its three categories for public health recommendations: preventive medicine, screening and behavioral counseling. After reviewing related research, the task force would then assign it a rating.

“Birth doula services do not fall into one of these categories, and thus are outside of the Task Force’s scope and not a topic we would consider,” said Melissa Simon, a member of the USPSTF who is also an obstetrician-gynecologist and professor at the Northwestern University Feinberg School of Medicine.

Carol Sakala, director for maternal health at the National Partnership for Women and Families, suggests a better pathway may be through the Women’s Preventive Services Initiative as the “scope of eligible preventive services appears to be more inclusive than USPSTF.”

Ashley Nguyen contributed to this report.

This doula series is funded by the O’Brien Fellowship in Public Service Journalism at Marquette University. Marquette University and administrators of the program played no role in the reporting, editing or presentation of this project. To learn more about this reporting project, click here.

About this story

Editing by Neema Roshania Patel and Lena Felton. Copy editing by Anne Kenderdine. Illustration by Holly Stapleton. Art direction by María Alconada-Brooks. Design editing by Rachel Orr. Design and development by Christine Ashack.