“We don’t just want doulas. We want good doulas.” Examining the role of doula training in promoting perinatal mental health

Abstract

While research increasingly explores the role doulas can play in addressing perinatal health disparities, doula training itself remains unexplored. This paper examines the crucial role of doula training in enhancing birthing care accessibility and quality, particularly in addressing mental health disparities and fostering positive birth experiences. Through qualitative analysis, challenges such as cost, time constraints, and training accessibility issues are identified. Key recommendations include removing financial and logistical barriers, incorporating supplemental training for perinatal mood and anxiety disorders (PMADs), and fostering cultural sensitivity to meet diverse community needs, including rural and Indigenous populations.

Introduction

Maternal mortality in the U.S. surpasses that of every other country in the developed world, and persistent disparities in maternal and infant health outcomes highlight the urgent need for interventions like doula support (Shah et al., 2021). According to findings from the CDC (2024), mental health conditions contribute significantly to pregnancy-related deaths, with approximately 22.7% of those deaths attributed to mental health conditions, and 53% of pregnancy-related deaths occurring 7–365 days postpartum (Trost et al., 2022). In the U.S., maternal mortality remains disproportionately high among Black and Indigenous women compared to White women (Ehrenthal et al., 2020; Shah et al., 2021). In addition, rural communities often face limited access to obstetric care, contributing to adverse outcomes for pregnant individuals and infants (Statz & Evers, 2020; Ely et al., 2017).

Mental health causes for pregnancy-related deaths primarily include suicide and accidental overdose (CDC, 2024). The rise of these types of deaths in the postpartum period signify a need to better address perinatal mental health. Perinatal Mood and Anxiety Disorders (PMADS) encompass a wide range of mental health conditions, including depression, anxiety, obsessive-compulsive disorder, postpartum post-traumatic stress disorder, bi-polar disorder, and postpartum psychosis (Shklarski & Kalogridis, 2022). Left untreated, PMADs not only impact maternal well-being, but can also contribute to adverse birth outcomes and long-term health consequences for both birthing parents and infants (McComish et al., 2013; McKee et al., 2020).

Doulas offer a promising avenue in addressing PMADs by providing emotional support, connecting individuals with appropriate support resources, and fostering a safe and supportive birthing environment (Black et al., 2024; Shklarski & Kalogridis, 2022). Doulas, often referred to as birth companions or labor coaches, offer continuous physical, emotional, and informational support to individuals throughout the perinatal time period (Gruber et al., 2013). Their role includes activities such as assisting expectant individuals in navigating medical systems, advocating for their needs, and providing various comfort measures during labor and delivery. This holistic approach to care aims to enhance the childbirth experience, promote autonomy, and improve birth outcomes (Bohren et al., 2017). Research indicates that doula care is associated with shorter lengths of labor, decreased use of birth interventions and Cesarean births, and better health outcomes (Falconi et al., 2022; Fortier & Godwin, 2015; Kozhimannil et al., 2016; Rousseau et al., 2021). Doula support has also been shown to reduce anxiety, depression, and stress and increase well-being and satisfaction throughout the birthing process (Sobczak et al., 2023; Campbell et al., 2007; Wolman et al., 1993). Additionally, doulas can help to mitigate disparities due to racial bias and lack of access to care by providing culturally sensitive support and acting as an advocate (Horton & Hall, 2020; Thurston et al., 2019). Recent scholarship has also explored the use of doulas to support people with substance use disorders (SUDs) (Black et al., 2024).

Organizations like Doulas of North America (DONA) International have been at the forefront of establishing training standards and certification processes for doulas (Howard & Low, 2020; DONA International, n.d.). These programs typically cover a wide variety of topics, including childbirth education, comfort techniques, communication skills, and understanding the physiological and emotional aspects of childbirth (Falconi et al., 2022). Ideally, doula training serves as a fundamental step in preparing individuals for the multifaceted responsibilities of being a doula, by providing them with the knowledge and tools necessary for lending evidence-based support, addressing diverse perinatal needs, and adapting to various birthing environments (Shklarski & Kalogridis, 2022). Further, training programs have the potential to empower doulas to respond to perinatal mental health concerns (Hall, 2021). By integrating PMAD-specific training into doula programs, doulas can potentially play an important role in identifying, mitigating, and preventing PMADs to improve maternal and infant health outcomes. However, to date, the extent to which doula training incorporates training in PMADs and the ways that doulas can support people with PMADs has been underresearched. Current maternal mortality data indicate an immediate need to investigate PMAD-specific doula training and training for postpartum doula care.

This study investigates the current landscape and emergent needs for PMAD specific doula training in Montana. As a primarily rural state, Montana faces unique challenges in the provision of maternal healthcare, including doula care. Over half of the counties in Montana are designated maternal healthcare deserts requiring perinatal people to travel long distances for care (Fontenot et al., 2023). As a result of this and other barriers to care, more than a quarter of perinatal people with high vulnerability receive inadequate prenatal care in Montana (Fontenot et al., 2023). Lack of access to care can increase the risk for maternal health complications, including PMADs. Doulas are a potential source of additional support to perinatal people, especially in rural areas. Notably, doulas are not covered by insurance in Montana. Expanding insurance coverage to include doulas is needed and would necessitate establishing requirements for eligibility and reimbursement, like provisions for training. For this reason, doula training in Montana is highly relevant. In addition, there are several doula interventions currently underway in Montana exploring expanding access to doula care in the state, highlighting the need for an analysis of what factors are most relevant in designing trainings for doulas.

The research question for this study is, “What gaps exist in PMAD-specific doula training in Montana and other rural states?” In addition to exploring opportunities for improvement, this study identified effective strategies of improving PMAD-specific doula training. This study is valuable for bolstering doula training programs at an important time and for promoting equitable access to maternal healthcare services in rural areas.

Methods

Research design

The study utilized a qualitative descriptive methodology to explore the perspectives and experiences of doulas, parents, and other birth workers in Montana. Qualitative data are particularly well suited for diving into nuanced complexities of human experiences, beliefs, and behaviors, offering insights into individuals’ unique realities (Tenny, 2022). The qualitative nature of the study enabled an exploration of participant narratives, shedding light on both individual experiences and broader issues within perinatal care. Thirty-three participants were interviewed from 11 counties in Montana by the second author from May-June 2023. Participants included individuals with experience with PMADs, maternal and mental healthcare or service providers, individuals who have utilized doula services previously, and practicing doulas, to ensure a broad representation of viewpoints regarding the impact of doula care and the needs of perinatal people with PMADs. The inclusion of these different categories of participants was determined through feedback from a Community Advisory Board, who informed all aspects of the study and piloted and provided feedback on the interview guides. All interviews were recorded with permission and transcribed verbatim using a professional transcription service. Transcripts were coded twice by two separate researchers, and inter-rater reliability was assessed using Cohen’s Kappa, which assesses for randomness of agreement (McHugh, 2012). High agreement (75%) between coders was found across all codes. An interview guide was developed in conjunction with a community advisory board (CAB) to ensure the interview questions were relevant and appropriate.

Setting and participants

Purposive and snowball sampling techniques were utilized to recruit individuals with relevant experiences and insights. Participants were recruited utilizing social work and public health listservs, social media, and through existing doula programs. Prior to interviews, participants completed informed consent via e-mail and provided permission for their interviews to be recorded. Participants were interviewed remotely via Zoom to facilitate accessibility and accommodate diverse locations. Institutional Review Board (IRB) approval from the University of Montana [ID number: 166-22] was obtained beforehand to ensure compliance with ethical standards and protect participants’ rights. In addition, measures were taken to uphold participant confidentiality and privacy.

The study engaged participants from various backgrounds and locations throughout the state of Montana to ensure the representation of diverse communities. Participants belonged to the following categories: 16 identified as having lived-experience with perinatal mental health disorders, seven identified as being doulas, and 16 identified as perinatal mental health providers, maternal healthcare providers, or as supervisors of programs to support perinatal people. One participant identified as a perinatal mental health researcher. Of note, many participants described belonging to more than one category. Participants were eligible to participate in the study if they identified as one of the members of the groups in the study and lived in Montana.

Participants reported residing in 11 different Montana counties for an average of 13 years. All but one participant identified as non-Hispanic, five participants identified as Native American, 27 identified as white only, and one participant identified as white and Asian. The average income among those who reported an income (n = 23) was approximately $73,000 a year (ranging $20,000–$200,000). All but one participant identified as a woman and the average age of participants was 37. Of those who responded, 95% reported having children (n = 22). Ninety-two percent reported being married or in a relationship (n = 23), and 93% reported having had some college education (n = 27).

Data collection

Data collection involved carrying out semi-structured interviews with 33 participants, between May and June of 2023. The interviews were audio-recorded and professionally transcribed verbatim for subsequent analysis. The use of Zoom allowed for flexible scheduling and eliminated geographical barriers, enabling the inclusion of participants from diverse backgrounds and locations. Interviews lasted approximately 30 min to 70 min with an average length of 45 min. Participants were provided with a $30 gift card to thank them for their time in participating in the interview.

Data analysis

A qualitative descriptive methodology was employed to analyze the interview data (Sullivan-Bolyai et al., 2005). This approach is well suited for use in semi-structured qualitative interviews exploring health-related topics (Sullivan-Bolyai et al., 2005). This approach prioritizes participants’ words over highly abstracted interpretations of experiences, and it is especially useful for producing findings translatable to interventions (Burnette et al., 2014; Sullivan-Bolyai et al., 2005). The research team reviewed the recorded interviews multiple times to create an initial coding scheme and emergent codes were added throughout the coding process. All interviews were coded twice using MAXQDA software by two different researchers. The coding rounds were compared to one another using Cohen’s kappa agreement to assess interrater reliability (MAXQDA, 2023). Cohen’s kappa evaluates the degree of agreement occurring by chance alone (McHugh, 2012). Coder agreement was at 75% or above across all codes. Member checks (sending a summary of study findings to all study participants who consented) were conducted to enhance the credibility of the findings, ensuring the participants’ perspectives were accurately represented.

Results

In discussing experiences and perspectives about doula training, three main themes emerged. These include 1) Standardized vs. Community-Based Training; 2) Barriers to Comprehensive Doula Trainings; 3) Recommendations for Improving PMAD Specific Trainings.

Standardized vs Community-based Training: “we have to keep this alive, not let it dead by putting licensing and restrictions on it”

Accessibility in Doula Training

Accessibility emerged as a key aspect of doula trainings for both standardized and community-based trainings. Flexibility was highlighted as a significant advantage to online standardized trainings that increased accessibility by doulas and doula program organizers, particularly in self-paced programs like those offered by Childbirth International (CBI). One participant, a doula program organizer, praised this structure, noting that individuals could adjust their study timelines to fit their lifestyle: “Childbirth International is our training program. And it can take three months if you want to bust through it. It’s like 10 hours a week for three months. But it’s all self-paced, so some people, they’ve got a full-time job and they’ve got kids, and so they take a year to slow down and go through it whenever they can” (1). This quote underscores the importance of flexibility in training programs, particularly for individuals who want to complete their training at their own pace or individuals with busy schedules or familial responsibilities. This same doula training (CBI) was praised for providing in-person support for trainees: Also, although it’s virtual, there’s a trainer that you have access to talk as well as they have a student Facebook group that you can join and have camaraderie with other women who are training to be doulas through that program” (2). In addition to providing a flexible environment, CBI was valued by participants for its support provided to trainees.

Participants shared feedback on how cost influences their participation, suggesting improvements to enhance accessibility. This participating doula spoke about their experience training with a postpartum resource group, and the perk of the financial support they offered: “Initially becoming a doula, I had connected with the postpartum resource group who was training doulas for… They were paying for the training in return for a year of volunteering. I was like, this is awesome. Perfect for me. There’s no major commitment other than volunteering, and I can vocalize when and when I can’t do that” (2). This quote highlights the efforts made by training programs to support and encourage continued education and professional development among doulas.

Tensions between Standardized and Community-based Training

Participating doulas had varying perspectives regarding the potential standardization of the doula profession and its implications for sustainability and client care. Currently, doula care is not covered by Medicaid in Montana. As a result, there are no specific criteria for doula training and certification. However, to enact insurance reimbursement for doula services, a certain level of standardization for doula care may be necessary and significant concerns about standardization were expressed. For example, one participant stated:

There’s a lot of conversations happening in the doula communities about whether or not we want to standardize this job further…if we end up being supported by the government, chances are very high that we will all make less money than we make now, and that makes the job less sustainable and would probably significantly impact our capacity to stay with a client for the whole time. And we would end up doing shifts just like nurses, which significantly impacts the client’s benefit, in my estimation. It’s still better than not having anyone who is an advocate for, or a supporter of the emotional and physical comfort.

(5)

This doula describes how standardization could potentially limit the length of time a doula was able to spend with a client and how reimbursement may result in lower pay for doulas.

Another doula expressed uncertainty about how criteria would be set for doula certification:“ … that’s a whole topic in itself is trying to figure out that if you’re not certified, how can you prove, based on what your training was, that you actually had some component of education, like a particular amount of hours or can you show an outline of the program itself?” (3). This participant’s concerns shed light on the tension between the need to create standards for certification and the difficulties in setting those standards.

While standardized doula trainings could provide clear cut certification requirements, participants also critiqued the generic nature of these programs. One doula stated, “DONA or whatever, that just pumps you out as like, ‘This is how you meet, this is what you talk about, and then you move on’” (7). Another doula that participated emphasized the importance of preserving diverse avenues for doula education and certification to protect and honor various methods of transmitting birth worker knowledge:

But my training was that non-DONA certified training. So when I started training here, I was like, why do you need a training to be certified? It’s great that there’s a route and that’s awesome. But the trainer that was coming here, it was kind of very generic and they didn’t go very deep into things. I love it that it’s an option for people, but that doesn’t have to be the only option. You’re a non-medical practicing person that will likely never be licensed. We shouldn’t just wipe out doulas or birth support and information by thinking that there has to be one specific training for it or certification for it… we have to keep this alive, not let it dead by putting licensing and restrictions on it. It’s simply a practice of women throughout time.

(3)

Having a wide variety of training options for people who want to become a certified doula may help to improve access to becoming a doula. These trainings were described as important for providing doulas opportunities to gain more in-depth and specialized knowledge. Moreover, allowing for both standardized and non-standardized trainings to count toward certification helps to ensure community-based trainings continue.

Community-based training programs were also viewed as essential for transmitting community-specific knowledge. Participating doulas emphasized the need for doulas to emerge from and serve their communities authentically in order to provide culturally congruent care. One participant voiced this sentiment, saying,

We have to think community based. The doulas have to come from community. And they should be people from community that go through this training, or learn about these things. Versus deploying all these doulas to come and save the day. It really needs to be strategic, because especially for tribal communities? I feel like doulas have the power to make social change.

(8)

This participant describes building the doula workforce from within the communities as an essential component to addressing maternal health disparities that impact marginalized communities in particular.

“ … it’s best practice, in my opinion, to assume that everybody is a survivor:” content – addressing PMADs and trauma-informed care

Participants described a wide variety of experiences accessing PMAD and trauma-informed specific training. While some participants reported that their training involved significant focus on clients’ mental and emotional health, others expressed that this was a needed area of improvement. The need for doulas to learn about trauma-informed care was emphasized in particular. As one doula stated, “With the rates that we have and how frequently it [sexual assault] goes unreported, it’s best practice in my opinion, to assume that everybody is a survivor, as heartbreaking as it is to say that” (5). The prevalence of sexual assault as well as perinatal mental health disorders calls for increased training regarding these topics specific to the birth.

Participants reported a lack of in-depth information regarding PMADS and trauma-informed care in standardized doula trainings. In describing their experience with a DONA training, one doula stated, “they [the trainers] talked a little bit about it, birth trauma and that sexual abuse in the past can show up during labor, being touched. Things like that can be triggers, but it was very glossed over” (10). Conversely, participants that engaged in community-based trainings expressed that learning how to address the mental health and trauma was an integral part of their training. For example, one participant recalled attending a doula training session that encouraged doulas to become experts in their own stories in order to provide better emotional and mental support to their clients:

And then I went to a training in 2019, I think, that was really incredible. I went to a 10-day training and she dove deep into a lot of that [mental and emotional support], and really encouraged us to create a doula practice that fit what we actually were passionate about and what we wanted … And become an expert at your own story. And become an expert at your own traumas, and learn how to turn that into this expertise that you can then take into other people’s stories.” And that gave me a lot of freedom to explore.

(7)

This particular training involved empowering doulas to utilize their own narratives to support others through similar challenges in the perinatal period.

Doulas also reported valuing trainings that were focused on the entire birth journey, from preconception through the postpartum period. In describing her community-based training program, one doulas stated:

I think that this is one of the things that makes this training really effective, is that it starts before conception and goes all the way through birth. And there’s so much focus and attention on the moment the baby emerges, which is understandable and correct, because that is a big moment. But your outcomes are significantly impacted by how you’re cared for and how you care for yourself during the entirety of pregnancy and really preconception.

(5)

This quote highlights the need to increase support for birthing people throughout the entirety of pregnancy, birth, and postpartum period and not just for the birth itself.

To fill gaps in standardized trainings, and gain in-depth knowledge about PMADS and trauma-informed care, participants reported seeking supplementary trainings. For example, one participant benefited from participating in a perinatal mental health conference: “Definitely I feel like the Perinatal Mental Health Conference did a really good job at teaching you how to do [mental health] screeners and how to have conversations around the screening questions” (9). Others described utilizing trainings provided by Postpartum Support International (PSI) to gain this content. PSI trainings were described as “a great intro overview” and “very available” (11). Another doula stated, that they “loved it,” though it was very lengthy and suggested that “hey broke it down more so it was easier to digest for some people.” (2) This feedback also highlights the need for training programs to consider the diverse needs of participants and circumstances in order to seek optimal learning outcomes.

Barriers to Comprehensive Doula Training: “doula trainings are for privileged, typically white women:”

Economic, Social, and Logistical Barriers to Comprehensive Training

Cost was mentioned multiple times throughout the interviews, emerging as a key obstacle. When asked about barriers to training, one participating doula immediately said, “Oh yeah, definitely the cost. I mean, doula trainings are for privileged, typically white women” (6). This quote sheds light on the disparities in access to doula training opportunities, suggesting that affordability may limit participation and contribute to a lack of diversity within the doula workforce. A maternal mental healthcare provider and doula echoed this statement, emphasizing the importance of quality training while also acknowledging the financial implications, stating, “And good trainings cost money, and obviously we want good training. We want good doulas. We don’t just want doulas. We want good doulas” (7).

In addition to cost, time constraints emerged as another significant barrier to doula training, specifically for individuals juggling work, childcare, and other responsibilities. As one participant who leads a doula program shared, “I do think that for some families or mothers or whoever the human is that wants to be a doula, if there’s barriers, like work and children, that are preventing them from being able to do that or just not having a supportive system at home that allows them to step away” (2). The time-intensive nature of doula training programs may pose practical challenges for many individuals who want to undergo training, further limiting their access to these opportunities.

Supplementary trainings like PSI are a potential method of gaining PMAD-specific knowledge. However, these trainings require doulas to spend additional time and money and are not accessible to all for this reason. One doula program organizer described how their doula training program paid for doulas to do PSI trainings to help mitigate these barriers:

And so, we actually try to get our doulas to do additional training. Yeah, we probably twice a year try to have our doulas, whoever is able, and again, they’re volunteers. They’ve got families and jobs and stuff, so it doesn’t work out every time, but we pay for them if they would like to attend the Postpartum Support International…a virtual conference … .

(1)

Paying for trainings helped address the barrier of cost. However, lack of time and capacity was still a significant challenge for doulas in engaging in supplemental trainings.

The logistical challenges of travel and associated expenses were also described as baring access to engaging in additional doula trainings. As articulated by one participant, “And I know people who have done DONA training and done this [other type of doula] training in Montana, so they’re getting a bit of both … But then that’s thousands of dollars and time and travel” (6). Cost and lack of time and capacity are significant barriers that limit doulas’ ability to engage in trainings, particularly supplementary trainings that provide in-depth information on topics like perinatal mental health. As a result, access to this knowledge is limited to those who can afford it, contributing further to a lack of diversity within the doula workforce.

Recommendations for Improving Trainings: “trauma, it’s not one size fits all”

PMAD-specific content

To enhance PMAD-specific content in doula trainings, participants emphasized several key recommendations. There was consensus among participants on the prevalence of PMADs and the importance of effectively addressing perinatal mental health concerns. As one participant stated, “I think doulas should really know a lot about mental health. Because that’s what the number one [birth] complication is, is mental health” (8). This participant described a need to “switch this narrative that you suffer through motherhood. Or you suffer through pregnancy. I think that’s some bullshit,” highlighting the importance of destigmatizing perinatal mental health (8). Other recommendations included specific methods of training doulas on how to identify PMADS and connect birthing people to care, as well as suggestions for content that could be included in trainings to increase knowledge of perinatal mental health.

Doulas who participated recommended a wide variety of training methods for teaching doulas about PMADS. For example, role playing was viewed as beneficial for helping doulas gain skills necessary for talking with clients about mental health: “I think that the scenario training that we just did, that training is super helpful when you throw yourself in the middle of a situation that you might come upon and do some role playing around that” (11). Another participant recommended teaching doulas some basic therapeutic tools, like ““validation, normalizing and deep listening” and “motivational interviewing to make different changes” to respond to mental health crisis in the moment (15). Specific training tools were also suggested, and one doula recommended “a really great worksheet” for teaching partners how to empathize and support the birthing person. This worksheet is aimed at helping partners to understand “what the birthing person might be saying or what their reactions might be, what they might be feeling, and then what you can say in response to them or how you can support them” (10). This type of support was described as important for helping to mitigate birth trauma, which can contribute to PMADS, “a lot of times that’s usually when birth trauma comes into place because they’re saying, ‘I can’t do this anymore. I can’t do this’” (10).

Another important recommendation was the need to teach doulas how to identify a wide variety of PMADS:

One thing that I would love to do someday…for doulas, especially prenatally to talk about these warning signs and red flags, what to look for, because I wouldn’t even know. You think about these horror stories of really terrifying psychosis or something like that, but you don’t really know what to look for in anxiety or depression or OCD.

(14)

This participant describes how identifying disorders that are perhaps less visible, like anxiety and depression, requires training doulas about warning signs specific to the perinatal period.

A maternal healthcare provider expressed the importance of doulas having access to comprehensive referral networks to connect clients with appropriate mental health support services:

“And then I know one of the biggest issues we run into, especially in our state, is referral resources. So being sure then that the doulas have those really good resources to be able to say, “Hey, here’s someone you could call. Here’s a group that I know of.” … to be able to then point the moms in the right direction.

(12)

Toward improving doula’s ability to connect clients with referrals, it was suggested that doula work “with local providers” and that “a community resource of the birth world coming together in areas would be really wonderful” (2).

Several participating doulas noted helpful supplementary trainings, asserting that they should be incorporated into standard doula training. One doula shared their experience with the Circle of Security training, describing the content and its value. She says, “And that maybe, also a big part of what doulas do and are trained in is attachment, is what that looks like, is how to support that. Because it’s so important for that baby’s whole entire life right? And the window is small…” (11.) Another doula shared their experience with Mental Health First Aid, describing the program as “really helpful because they almost gave scripts, ‘If someone is suicidal, this is what you can say to them. … So having some training around questions to ask, how to ask them, how to be direct but also empathetic” (10). Providing doulas with concrete tools was to address PMADS was generally viewed as valuable knowledge.

Increased training content related to PMADS was also suggested by participants. For example, one maternal healthcare provider recommended integrating trauma-informed care into doula training to help identify those most at risk of experiencing PMADS and connect them with needed support:

I think anything providing trauma-informed care would be huge. We see more and more women and people of childbearing age with increased ACE scores higher than we’ve seen before, and recognizing how that early trauma and just trauma in general can then lead into those mental health concerns is so important.

(12)

Another participant suggested increasing knowledge of birth trauma, “Because trauma, it’s not a one size fits all. A C-section, for example, could be completely fine. One person could come out completely mentally unscathed, and another person, it could be literally the worst thing that’s ever happened to them and super traumatized like PTSD from it” (10), highlighting how a multitude of factors influence a person’s experience of birth. The need to acknowledge and respect people’s individual experiences was also viewed as important for providing attuned care: “education on the diversity that comes with mental illness because no one two people’s mental illness journeys are the same” (13). One participant highlighted the need for training in handling sensitive topics such as abortion or infant loss, noting that these may not be situations a doula is prepared for but that they are integral to birth work: “some training potentially in abortion in all its ways, and child loss or infant loss. Having that just on their radar or in their education, because I think a lot of times that’s not what they’re signing up for. And so just making sure that they can handle that appropriately” (14).

Representation in Doula Care

Throughout the study, participants emphasized the need to make doula education more accessible to help diversify the doula workforce and empower doulas from within the communities they serve. Toward this goal, participants describe a need to financially support aspiring doulas. Increasing representation in the doula profession was viewed as important for improving culturally congruent doula care for marginalized populations. Participants also expressed a need for cultural sensitivity training for all doulas, regardless of their race or background.

When asked what a successful doula program would look like in their community, one doula said, “Flexibility and classes, scholarships … Maybe having an establishment to have classes at instead of just, it feels like it’s a little nomad thing. There’s classes here, classes there” (16). Additionally, participants emphasized the importance of providing doulas with financial support to engage in continued education regarding mental health: “I would really love to see access to continued education at either zero to no cost for doulas on fundamentals of behavioral health” (2) and the need to provide doulas with tools to build their business, “I also think financial training specific to doulas and how to run a business is important … I wish there was someone who was there that’s like, ‘Hey, as a doula, here’s how you can break things down,’ and stuff like that” (2).

Addressing the barrier of cost may help to expand access to doulas trainings and increase diversity in the doula workforce and training doulas from within communities was viewed as highly important for providing culturally relevant doula support: “…having more doulas of color of different sizes, different classes, all of that, so that they can be a better doula for their circle of people [in] their population” (6). Cultural awareness was viewed as particularly important for providing quality care as a doula and for navigating potential tensions between Western medicine and cultural practices: “if they are near any other culture, just having a little more insight on that and what they practice, because I know the culture, like a native culture could clash with the western medicine, or just the treating and the diagnosing really” (17).

While training doulas from within communities was viewed as highly beneficial, participants emphasized the need for cultural awareness training for all doulas regardless of their cultural background. For example, one doula described being called on to support Indigenous women and wishing she had had prior cultural knowledge: “I’ve seen some trainings out here for Indigenous women to become doulas, but I would also love a training on how to support Indigenous women through birth … And have that background training prior to that happening, so I wasn’t fumbling through it and learning at the same time” (2). Increasing the doula workforce from within marginalized communities is imperative and training all doulas how to provide culturally sensitive care is important for ensuring doulas are prepared to serve a wide variety of clients.

Cultural sensitivity and awareness were viewed as essential for serving rural communities as well as Indigenous populations. One mental health practitioner emphasized, “Rural homes do not look like you said, the upper white class homes that most doulas were going into to start with. Not judging that family for that is huge” (18). This acknowledgment underscores the importance of understanding and respecting diverse cultural backgrounds and living environments when providing doula support, which should be reflected in trainings. In discussing rural populations, participants suggested increasing accessibility through telehealth services to reach individuals in rural areas or with limited access to consistent in-person support. One maternal healthcare participant highlighted the potential benefits of telemedicine doula services, saying, “I think being able to use Zoom to offer telemedicine doula services, so you at least have that verbal support with someone and then you don’t actually have to go to the rural spot until the time of the birth and you’re able to even through” (16.) The suggestion of telehealth services aligns with participants’ discussions regarding the value of extending doulas’ reach to diverse communities, but also necessitates additional training of doulas in provide care in a virtual format.

Discussion

Participants emphasized the importance of improving doula training programs to better equip doulas with the skills to address PMADS and support diverse communities. The results shed light on successful elements of existing training programs, gaps in PMAD training for doulas, barriers to accessing doula trainings, and the need to birthing people of various cultural backgrounds. Participants provided valuable insights into both the challenges and opportunities for doula training, offering pathways for improvement and advancement in the field.

The results highlight the distinct benefits and challenges of standardized doula training programs and community-based training approaches. Standardized training programs provide a structured curriculum and certification process, ensuring consistency for participants. Conversely, community-based trainings were reported to emphasize local knowledge, fostering a sense of relevance within communities (Gilliland, 2016). Existing doula trainings were recognized for their valuable insights, but participants highlighted gaps in coverage, particularly concerning birth trauma, triggers, and the impact of birthing on mental health, and emphasized the need for training programs to go beyond generic or standardized approaches to tailor content to the specific needs of doulas and the individuals they are caring for. These findings reveal tension between the desire for standardization of doula trainings and certification to ensure reimbursement, and the necessity for flexibility in meeting diverse individual and community needs.

Cost was identified as a significant barrier to engaging doula trainings, especially supplemental trainings. Participants also highlighted time constraints as a barrier, noting the difficulty of balancing training commitments with family responsibilities and other obligations. Additionally, issues related to diversity and accessibility were raised, including the lack of training options tailored to different cultural backgrounds and locations. Travel requirements and costs further compound these challenges, particularly for individuals living in rural areas.

Many participants stressed the immediate need for doulas to possess a complete understanding of mental health issues, particularly after birth. This involves expanding existing trainings, supplementing them with additional content, and incorporating hands-on experiences, including scenariobased learning and case studies to better prepare doulas for real-world situations. By equipping doulas with specialized knowledge and skills in perinatal mental health, which include understanding symptoms and risks, implementing trauma-informed care, and connecting individuals to appropriate resources, doulas can effectively support those experiencing PMADs (Fleischman, 2019). This not only enhances the quality of doula care but also contributes to improved maternal mental health outcomes and better birthing experiences overall (Hall et al., 2021; Liddell & Glover, 2021–2023).

Establishing guidelines and certification requirements for doula training can help ensure consistency and quality across training programs and is necessary for gaining Medicaid coverage of doula care (Henley, 2016). While standardization may not be universally desired among all doulas, there is widespread recognition of the importance of insurance reimbursement for doula care. States that have been successful in pursuing insurance reimbursement have included specific standards of care and accreditation for doula training (Gilliland, 2016). Establishing guidelines and certification requirements for doula training can help ensure consistency and quality across training programs but may also lead to less customized and local-led doula content, and there is a pressing need for additional research into the impact of standardization and accreditation of doula training, particularly regarding perinatal mental health content (Henley, 2016).

This is consistent with recommendations for tailoring training approaches to specific demographics to better help doulas serve a broader range of individuals and families, ensuring that their care is inclusive and culturally sensitive. This emphasis on customization within training programs promotes greater accessibility and relevance within communities ((Thurston et al., 2019). Emphasizing customization within training programs could offer a beneficial compromise compared to making all doula training standardized to be accredited. Oregon and Rhode Island are two states that have successfully balanced flexibility with standardization in setting requirements for doula certification. Both states have implemented Medicaid coverage for doula care and have taken steps to accommodate an array of training programs for doula certification. Oregon’s approach, beginning with legislation mandating exploring doula benefits, has now expanded to include multiple State Plan amendments, allowing for various training programs to be recognized. Similarly, Rhode Island’s comprehensive doula coverage, mandated for both Medicaid and private insurance, allows doulas to tailor their education to the needs of the communities they serve. Other states like Massachusetts, Connecticut, and Illinois have adopted policies accommodating diverse doula training backgrounds. Massachusetts has pursued the integration of doula services into Medicaid coverage through legislation and a pilot program, reflecting a commitment to inclusivity. Meanwhile, Connecticut and Illinois have established formal committees to provide recommendations on doula certification and training, signaling a recognition of the importance of flexibility in training requirements (Chen, 2024).

Cultural awareness emerged as a recurrent theme, with participants emphasizing the importance of diversity among doulas and tailored training programs for marginalized populations. Ensuring inclusivity and respect for diverse cultural backgrounds in doula training is crucial in providing equitable care. Participants suggested bolstering supplemental trainings, specifically in addressing the unique needs of rural communities and Indigenous populations. Leveraging telehealth services to increase accessibility to doula support in rural areas is a promising option for expanding doula services to underserved populations, but requires doulas to receive training in how to provide care in this format (Gjerdingen et al., 2013; Nguyen et al., 2022). Implementing these potential solutions can help overcome barriers in doula training for rural populations specifically, and practice to create more inclusive and accessible perinatal care for all individuals, regardless of their location or cultural background.

Implications

Implications of the study include enhancing training accessibility, incorporating PMAD-specific training, emphasizing cultural sensitivity and diversity, building the doula workforce from local communities, and adding supplemental training for marginalized communities. Doula training programs need to be flexible, financially supported, and widely accessible to ensure inclusivity, which could be done by offering online options and scholarship opportunities (Howard & Low, 2020). By removing financial and logistical barriers to training, individuals from diverse backgrounds can pursue doula certification. This recommendation echoes existing research emphasizing the importance of accessible and diverse training formats to increase representation in the doula workforce (Black et al., 2024; Thomas et al., 2017).

Addressing perinatal mood and anxiety disorders (PMADs) and trauma-informed care should be central to doula training programs to better support individuals after birth (Black et al., 2024; Shklarski & Kalogridis, 2022). This includes providing comprehensive education on recognizing the signs and symptoms of PMADs, equipping doulas with effective strategies to provide empathetic and supportive care to individuals experiencing any form of birth trauma, and offering appropriate support and resources for individuals (Black et al., 2024; E. M. Hall, 2021; McKee et al., 2020; Mosley & Lanning, 2020). In enhancing their knowledge and skills in this area, doulas can play a vital role in early identification and intervention (Shklarski & Kalogridis, 2022).

Cultural sensitivity and diversity are imperative to address disparities in access and outcomes, as emphasized in existing literature (Kozhimannil et al., 2016). This includes recruiting and training doulas from different cultural backgrounds to better meet the needs of diverse populations (Ireland et al., 2019). Further, it is important to address the inherent biases in the current landscape of doula training, which predominantly caters to white, middle-to-upper class women, who have another form of income in their household (Black et al., 2024; Campbell-Voytal et al., 2011; Gilliland, 2016; (Howard & Low, 2020). This highlights the need for diversification within doula training programs to ensure inclusivity from all socioeconomic backgrounds and cultural identities to make doula training more representative and equitable.

Another important implication highlighted by the study is the significance of building the doula workforce from the communities they serve. This approach emphasizes the importance of community relevance in doula services (Black et al., 2024; Thurston et al., 2019). There is a need to lower barriers to training for people from marginalized communities who aim to support their communities as doulas to improve the inclusivity and responsiveness of doula care (Hardeman & Kozhimannil, 2016; Howard et al., 2020).

Specialized training addressing cultural awareness, trauma-informed care, and rural community needs is essential (Statz & Evers, 2020). This includes providing additional resources and support for doulas working with marginalized communities to address disparities in maternal and infant health outcomes (Black et al., 2024; Thurston et al., 2019). In addition, the integration of telehealth services could be explored, particularly to address the unique needs of rural communities and enhance accessibility (Statz & Evers, 2020). Telehealth platforms offer a promising avenue to bridge geographical barriers and provide continuous support to pregnant individuals in remote locations who face limited access to in-person care (Nguyen et al., 2022; Thomas et al., 2017). This approach aligns with recommendations from existing literature to enhance accessibility and widen access to doula support services (Thurston et al., 2019).

Limitations

The study is subject to several limitations that warrant consideration. The sample size of participants included in the study may affect the generalizability of the findings to broader doula populations or those with different training programs. Recruitment took place through a combination of purposeful and snowball methods. Targeted sampling to ensure a broad range of participants were reached would strengthen these results. Additionally, these results may not be generalizable to other states in which doulas are reimbursed for their services or states with different demographics.

Future research

Future research should include larger and more diverse samples of doulas to capture a wider range of perspectives and experiences. Additionally, research examining the impact of geographical factors on doula trainings could provide valuable insights into unique regional variations and disparities in doula care. Longitudinal studies are also needed to assess the long-term outcomes and overall effectiveness of doula trainings, including their impact on maternal health, birthing experiences, and postpartum well-being. Investigating the influence of doula training on healthcare disparities and access to culturally sensitive care is essential for promoting equitable healthcare practices and improving birth experiences and outcomes for all individuals across different communities.

Conclusion

Overall, this paper highlights the role of doula training in shaping the accessibility and quality of doula care for birthing individuals. In examining the existing challenges for training, the need for comprehensive, culturally sensitive training emerges to better address the unique experiences of birth. In doing so, the competency and diversity of the doula workforce can be enhanced, improving access to care and ultimately contributing to positive birth experiences and outcomes for birthing individuals across diverse settings. Despite its growing recognition, the scarcity of literature on doula training highlights the need for further research and attention on doula training programs, as well as their effectiveness in preparing doulas to serve as essential support figures throughout the birthing journey. This research emphasizes the significance of doula training in improving birth outcomes and promoting equitable care during pregnancy and birth.