A Doula’s Role: Protecting, Promoting, Supporting Respectful Care

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by Debra Pascali-Bonaro LCCE, BDT/PDT (DONA)

A doula is in a unique position to protect, promote, support and advocate for respectful care for all MotherBabies. Doulas offer one on one care that is often lacking in childbirth around the world.  Doulas have a unique viewpoint and have become guardians of respectful birth, both for their clients in the moments of labor and birth, and also as birth advocates, a second role that most doulas take on.  With their first-hand look at birth in many settings and with many providers, doulas may have the best vantage point to see the many variations of care that exist in a community and thus advocate for and share with their clients where and with which providers they are likely to receive the most respect, dignity, quality and compassionate care.

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Hugging closed eyesDONA International explains “ the word “doula” comes from the ancient Greek meaning “a woman who serves” and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.   Studies have shown that when doulas attend birth, labors are shorter with fewer complications, babies are healthier and they breastfeed more easily.”

Using numerous studies documenting the benefits of doula care,  the Cochrane Collaborative rates doulas in category- 1: Beneficial and the American College of Obstetricians and Gynecologists, (ACOG) give them an A rating.  The late Dr. John Kennell said in 1999 – “with all the proven data on the effectiveness of doulas’ continuous companionship during childbirth, if a doula were a drug it would be unethical to withhold her.”  Yet, in 2015 we still see barriers around the world to recognizing the benefit of continuous female companionship in childbirth.

DSC03284With the rising cesarean birth rates around the world, research tells us that “Women with doula support have lower odds of non-indicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in non-indicated cesarean rates.”

While the benefits of improving birth outcomes and women’s satisfaction in childbirth are strong, doulas have been underutilized as a key resource in helping every MotherBaby receive respectful care in childbirth. The White Ribbon Alliance Respectful Care Charter states in article 3: “Every woman has the right to information, informed consent and refusal, and respect for her choices and preferences, including companionship during maternity care.”  

Another global initiative with a human rights framework is The International MotherBaby Childbirth Initiative, IMBCI .  Step 1 requires all providers and facilities to: “Treat every woman with respect and dignity, fully informing and involving her in decision making about care for herself and her baby in language that she understands, and providing her the right to informed consent and refusal” and Step 3 states: “Inform the mother of the benefits of continuous support during labour and birth, and affirm her right to receive such support from companions of her choice, such as fathers, partners, family members, doulas, or others. Continuous support has been shown to reduce the need for intrapartum analgesia, decrease the rate of operative births and increase mothers’ satisfaction with their birthing experience.”  Doulas are being included in respectful care on paper, now it’s time to move to implementation.  Doulas are ready to scale, for a relatively low cost and potential large cost saving.

Debra 11A  doula recognizes birth as a key experience the mother will remember all her life, in this a doula values the importance of respecting the MotherBaby and family. Doulas also bring respect to all who enter her birthing space and in doing so set the tone for respectful care by all.

Doulas are educated in the hormonal physiology of birth and on how the emotional needs of safety, privacy and respect as well as how any emotional barriers can hinder a woman in labor.  Doulas develop a relationship with the woman, husband/partner and assist them in preparing for and carrying out her preferences for birth.  Doulas are particularly useful in helping women get the information they need to make informed decisions, ensuring the mother is a part of collaborative decision making, with the right to informed consent or informed refusal.  Doulas often play a vital role in facilitating positive communication between the laboring woman, her partner and her clinical care providers.  A doula should never speak for the woman and her partner, but instead should help facilitate each to have their voice heard and participate at her/his level of comfort.

A doula stays with the woman throughout her labor, birth and the first golden hour as a continuous nurturing presence offering emotional support, physical comfort measures and an objective viewpoint, as well as protecting the woman’s memory of the birth experience.

With the many benefits of doula care for a gentler birth with less surgery and interventions, increased satisfaction, healthier babies and more breastfeeding,  it is time to include the doula’s nurturing touch to bring more respect to maternity care.  Doulas offer their care, helping both women and caregivers transform an often dysfunctional system into one that offers everyone more respect and love.  Doulas are uniquely qualified and available.   Doulas are women from the community who in a 3  – 10 day workshop awaken their own nurturing skills and learn about childbirth and comfort measures to ease pain and increase pleasure and joy.  As the White Ribbon Alliance says:

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“Childbirth can be a very frightening experience for many women, but it should be a joyous occasion—and every woman should feel valued, respected, and appreciated by all those who aid her in her journey of bringing new life into the world.” A guide for Advocating for Respectful Care: Respectful Maternity Care Charter: The Universal Rights of Childbearing Women, White Ribbon Alliance.

What is holding back the acceptance of doulas?  Is it caregivers worry that they will have an observer?  Is it a sense that our system is naked and while women in labor are vulnerable from fear and have been conditioned not to recognize institutional violence, doulas see it clearly? Is change just so hard and lagging behind the research?  It’s hard to know why doulas are taking so long to be implemented but it’s clear they are growing in number around the world. Two states in the U.S already have regulations that require Medicaid to cover doulas and more are looking into including doulas into our healthcare system.  I believe it should be every MotherBaby’s right to have continuous care from doulas and anyone they choose.  We know from the research that our clinical caregivers rarely are able to guarantee they will be with a woman continuously from start of labor to an hour after birth.  Even if they can provide continuous care and won’t change shifts,  they must attend to the physical well-being of MotherBaby which often mean they will not have the time or ability to support the mother emotionally, or with comfort techniques such as holding her hand, rubbing her back, or gently whispering encouragement  into her ear.  The Cochrane Study is clear the doula must have no other role.  “In present maternity care environments, benefits of continuous support are likely to be greater with companions who are not hospital staff members than with members of the hospital staff … Given the clear benefits and absence of adverse effects of continuous labour support, policymakers should consider including it as a covered service for all women.”

Women from the community who become doulas pass their information along formally and informally, transforming their own births, their families’ births and the women they touch.  It is time we return to this ancient women-to-women wisdom, creating a circle of support in childbirth of doulas, nurses, midwives and physicians, and in doing so helping to ensure that every Mother will remember her birth with joy, as an event during which she felt respected and empowered by the tender, loving care she received.


  1. DONA International www.dona.org
  2. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews2012, Issue 10.
  3. Berghella, Baxter, Chauhan,Evidence-based labor and delivery management, American Journal of Obstetrics & Gynecology, Nov 2008
  4. Am J Manage Care. 2014;20(6):e340-e352
  5. A guide for Advocating for Respectful Care: Respectful Maternity Care Charter: The Universal Rights of Childbearing Women, White Ribbon Alliance, www.whiteribbonalliance.org
  6. International MotherBaby Childbirth Initiative, 10 steps to optimal MotherBaby Care www.imbci.org
  7. Pascali-Bonaro, 10  Tips for Doulas to support the MotherBaby Hormones: Lessons Learned From the Hormonal Physiology of Childbearing Report, International Doula Volume 23, Issue 2, pg 12 -15, 19

HealthConnect One. (2014).
The Perinatal Revolution: New research supports the critical role Community-Based Doula Programs can play in improving maternal and child health in underserved birthing populations

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Abstract / Full Text / Full Text (PDF)

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Katy Backes Kozhimannil, Rachel R. Hardeman, Laura B. Attanasio, Cori Blauer-Peterson, and Michelle O’Brien.  Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health: April 2013, Vol. 103, No. 4, pp. e113-e121.
doi: 10.2105/AJPH.2012.301201 http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301201

Romano, A. (2014, November 14). Care Models That Work: Community-Based Doulas
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Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD – Potential Benefits of Increased Access to Doula Support During Childbirth – See more at:   http://www.ajmc.com/journals/issue/2014/2014-vol20-n8/potential-benefits-of-increased-access-to-doula-support-during-childbirth

Lombardi, J., Mosle, A., Patel, N., Schumacher, R. and Stedron, J. (2014).
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There’s No Place Like Home: Home Visiting Programs Can Support Pregnant Women and New Parents
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Gentry, Q. M., Nolte, K. M., Gonzalez, A., Pearson, M., and Ivey, S. (2010).
Going Beyond the Call of Doula: A Grounded Theory Analysis of the Diverse Roles Community-Based Doulas Play in the Lives of Pregnant and Parenting Adolescent Mothers
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Amnesty International Publications. (2010).
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Brown, M. H. (2008, April 11).
Chicago Project Delivers Support to Young Mothers-to-Be
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