“It takes a village and we are the village”: A qualitative community-engaged study of doulas serving migrants and refugees in Georgia

Abstract

Background:

There is growing evidence that doulas may buffer poor birth outcomes for marginalized groups by providing social support, health education and advocacy between patients and their medical team.

Objective:

This study aims to examine the current environment and scope of work for doulas serving immigrants and refugees.

Design:

This study is an extension of the on-going mixed methods, community-engaged Georgia Doula Study. From June to November 2022, researchers conducted in-depth interviews with 22 doulas serving immigrants and refugees in and outside of Metropolitan Atlanta.

Methods:

Semi-structured in-depth interviews were conducted. Interviews were recorded and transcribed. Two research assistants independently coded the interviews using Dedoose. Data were examined using thematic analysis.

Results:

Four themes emerged for immigrant-serving doulas including: doulas fill the gap of care and societal navigation, doulas are asked to integrate themselves into their client’s communities, the relationship between doulas and their clients is mutually empowering, and the landscape included both doula-centered and systems-centered frictions. Doulas reported a high level of desire for their services among immigrants, with positive experiences for both clients and them. However, doulas were frequently the only source of support for immigrant clients and were tasked with navigating the complexities of both new arrival experiences and the complex U.S. healthcare system.

Conclusion:

Doulas provide critical support in the navigation of immigrant experiences in the United States—including and beyond pregnancy. Their work with immigrant communities enriches the lives of their clients and improves maternal and child health outcomes. However, revised policies and programming for more holistic perinatal services are needed to facilitate their expansive scope of work.

Introduction

Maternal health, specifically maternal mortality, is of critical concern in the United States which persistently has the highest maternal mortality rate among the highest income countries. ¹ Furthermore, there is conclusive evidence of disparities by race/ethnicity, socioeconomic status, state residency and citizenship.^1,2 Non-Hispanic Black women experience mortality rates 10-fold higher than their counterparts of other backgrounds.^3–7 Recent data have highlighted growing maternal health issues in immigrants and refugees and critical gaps in existing literature. ⁸

Immigrants and refugees, though distinct categories of legal designation for migrants, experience similar maternal health needs and persistent disparities relative to the general population. These populations initiate prenatal care later in pregnancy even when insurance status is controlled, and migrant populations have less optimal care than native-born populations due to factors such as poor communication from caregivers or delays in receiving information on diagnosis and treatment.^9,10 Furthermore, psychosocial risk factors and systemic issues interact to create vulnerabilities unique to different immigrant subpopulations and can be aggravated by intersecting identities such as race, language spoken, and documentation status. ¹⁰ This prompts a need to investigate ways to support pregnant immigrants.

Georgia ranks among the worst states in the country for maternal mortality, with a rate of 35.69 deaths per 100,000 live births. ¹¹ This is especially true for Black birthing people in Georgia, who experience two times the maternal mortality rate of White Georgians. ¹¹ Moreover, the maternal mortality rate for Black Georgians is increasing: comparing 2010–2019 data to 1999–2009, there was an over 93% increase. ¹² Georgia is also unique for the number of immigrants who call it home. Over half of the population of Clarkson, Georgia was born outside of the United States, and Georgia resettles approximately 2500–3500 refugees each year.^13,14 However, data on maternal health in Dekalb County, where Clarkston is located, is not disaggregated by immigration status, making it difficult to understand the health needs and disparities of the immigrant population of the area. Still, previous research has shown that the intersection of identities such as race and legal status can make immigrant populations uniquely vulnerable. ¹⁰ Taken together these data highlight the complex interplay of social determinants that underly persistent disparities in maternal health, especially for immigrant communities.

Doulas provide a promising path to non-clinical interventions to support these populations. Doulas are non-medical professionals who provide emotional, physical, and educational support for individuals before, during and after their birth.^15,16 Doulas have been shown to improve birth outcomes and decrease unnecessary interventions during labor, such as Cesarean. ¹⁷ Previous research has also shown promise for community-based doula programs that provide culturally responsive care to migrant and refugee communities. ¹⁸ Researchers have also documented how doulas both witness and mitigate against racism their clients of color experience within the health system.^17,19 Still, there exist barriers to connecting doulas and pregnant people. Doulas have typically been seen as an option that can only be afforded by those who can pay out of pocket. ²⁰ While more than half of all states are actively providing Medicaid coverage or in the process of some related action, differences between states means that barriers still exist. ²¹ Notably, Georgia has not implemented these benefits and are still in an exploratory phase. ²² Immigrants with legal residency have two options for public insurance in the state of Georgia. Refugees are eligible for Georgia’s Refugee Health Program, provided that they do not qualify for Medicaid, and legal residents who are non-citizens are eligible for Medicaid including the 6-month post-partum extension.^23–25 Still, not everyone qualifies for these programs and private insurance does not typically cover doula services.^17,20,26,27 Despite this, community-based doulas are interested in providing care for those populations, even when they cannot afford to pay. ²⁸ This paper aims to examine the experiences of doulas serving immigrant and refugee communities in Georgia, focusing on the benefits, facilitators, and barriers they face.

Methods

Since 2019, the Georgia Doula Study^19,28,29 has been a mixed-methods, community-engaged study about full spectrum doula care conducted by Emory University and community-based organization Healthy Mothers, Healthy Babies Coalition of Georgia (HMHBGA) using community-based participatory research principles.^30,31 The study is overseen by the Georgia Doula Access Working Group, a statewide steering community of doulas and stakeholders such as clinicians, hospital administrators, and advocates. The current phase of the Georgia Doula Study focuses on understanding the experiences of doulas serving rural, immigrant, and refugee communities in the state, and this analysis focuses on their perceptions of doula care for immigrant and refugee communities, specifically. In this phase of the study, we used a screening survey to find doulas who would qualify for the study, followed by a survey and semi-structured interviews. Study procedures were reviewed by the Emory University Institutional Review Board, and the study was deemed exempt due to minimal risk for participants. This manuscript was prepared in consultation with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Table 1). ³²

Table 1.

Positionality statements for research team members.

Research team member	Roles and identities
Ileana López-Martínez, MPH	Graduate research assistant. U.S.-born daughter of Mexican and Puerto Rican immigrants
Elizabeth A. Mosley, PhD, MPH	Co-principal investigator, White woman, U.S.-born full spectrum doula and academic, community-engaged researcher from Georgia who volunteers for and serves on the Advisory Council of Embrace Refugee Birth Support, a community-based organization serving immigrants and refugees
Sydney Comstock, MPH	Graduate research assistant, White U.S.-born woman of Jewish ancestry and a labor support volunteer
Tiffany Hailstorks, MD	Co-investigator, Black woman, OBGYN and academic community-engaged researcher.
Muzhda Oriakhil	Community member, immigrant mother from Afghanistan, who works as the Community Engagement Manager and a Community Liaison at Embrace, and is a certified child-birth educator and certified post-partum doula
Aku Dogbe	Community member, immigrant, midwife, and mother from Togo, who works as the Health Education Manager and as a Community Liaison at Embrace, and is a certified child-birth educator and certified post-partum doula
Mu Naw Naw	Community member, refugee mother from the Karen state in Burma, who works as the Client Services Manager and as a Community Liaison at Embrace, and is a certified child-birth educator and certified post-partum doula
Virginia Tester	Community member, White women, U.S.-born certified nurse-midwife and Director of Embrace Refugee Birth Support
Heidi Copeland	Community member, White women, U.S.-born doula and former Volunteering and Training Manager at Embrace
Madison Scott, JD	Co-principal investigator, U.S.-born White woman and the Director of Policy and Research at HMHBGA
Ky Lindberg	Co-principal investigator, U.S.-born Black mother and former Chief Executive Officer of Healthy Mothers, Health Babies of Georgia, the largest maternal and child health education and advocacy organization in the state
Subasri Narasimhan, MPH	Co-investigator, U.S.-born daughter of South Asian immigrant parents, and an academic community-engaged researcher

HMHBGA: Healthy Mothers, Healthy Babies Coalition of Georgia.

Participants, recruitment, and sample

Participants (N = 22) of phase 3 of the GDS were doulas, who serve rural, immigrant, or refugee communities in Georgia. The unique nature of Georgia— and Clarkston as a place with high resettlement of immigrants and refugees—makes it highly suitable for this investigation. Participants were purposively sampled and recruited from June to November 2022 through emails to the Georgia Doula Access Working Group, doulas in the HMHBGA online doula registry, reproductive health and justice organizations, rural health organizations, rural hospitals, and a community-based organization serving pregnant refugees. Participants completed a screening survey to determine eligibility. To be eligible, respondents had to have practiced in Georgia for at least 6 months; over the age of 18; spoke and understood written and spoken English; and who served rural, immigrant or refugee communities in Georgia. Exclusion criteria were respondents who did not understand or speak English; have not practiced in Georgia for at least 6 months; and did not meet the age requirement. Twenty-two doulas actively serving rural, immigrant, and/or refugee populations in Georgia were verbally consented and interviewed. Participants did not have a prior relationship with the graduate student researchers conducting phase 3 of the GDS. All participants were informed of the study goals prior to the interviews. Study participants were compensated with a $100 gift card upon completion of the interview.

Instruments

Demographics survey

Quantitative data was collected using a web-based online survey in Qualtrics. ³³ The survey included questions about demographics, specifically gender, race/ethnicity, age, economic status, level of education, current employment, and sexual orientation. Doula participants serving immigrant and refugees were identified through self-determination and were asked to estimate the percentage of their clients that were refugees, first-generation immigrants, second-generation (born in the United States to at least one foreign-born parent), or none of the former categories. We also asked about their doula work including length of time practicing, their training and certifications, services they provide, pricing, and experiences of discrimination. The survey also included questions about their clientele such as volume of clients and client demographics. The survey measured participants’ opinions on the current landscape of doula care using 5-point Likert scales. Items focused on pricing (e.g., “I believe current pricing of private doula services limits access to doula services”), insurance coverage (e.g., “I believe current insurance coverage of doula services limits access to doula services”), and training (e.g., “I believe the doula training I received prepared me to provide doula services”). Finally, the survey measured level of interest in two possible strategies for doula care in Georgia—Medicaid reimbursement and community health worker models—using 5-point Likert scales.

In-depth interview guide

We used a semi-structured in-depth interview guide, which was tailored to each doula depending on their answers to the demographics survey questions. The interview guide included the following domains: motivation for being a doula, training and certification experiences, stories about their services, how they built their doula practice, payment structures, interaction with clinicians and hospitals, experiences of discrimination, and unique challenges for rural areas and immigrant or refugee communities.

Validation and piloting of instruments

The original survey and interview guide were developed in partnership with the HMHBGA Doula Access Working Group, and therefore received significant input, revisions, and testing from Georgia-based doulas in that group. The original survey was not formally pilot tested, but the original interview guide was pilot tested with three doulas. The additional survey items and interview questions on immigrant doula care were developed in partnership with Embrace Refugee Birth Support and therefore received significant input from immigrant- and refugee-serving doulas.

Procedures

Participants were screened using a brief Qualtrics ³³ screening survey that ensured eligibility criteria were met. After enrollment, potential participants read information about the study and provided verbal consent and completed the demographics survey. The Emory University IRB approved the use of verbal consent for this study. Two Master of Public Health graduate student researchers would then schedule an in-depth interview with the participant via email. Interviews were conducted using an Emory University Zoom account. At the start of the interview, all participants were asked to consent to be audio recorded and were reacquainted with the study’s goals. Interviews lasted on average 50 min, ranging from 45 to 75 min. No non-participants were present. No repeat interviews were carried out. Post-interview, the interviewer completed a debrief interview memo to highlight important information and new topics that emerged. Interviews were transcribed verbatim, then uploaded to an encrypted and password-protected, private study SharePoint folder. This study utilized a constant comparison method to compare new interviews to the data we had already collected. Saturation was reached when there were no longer learning new findings.

Data analysis

Survey data were cleaned and analyzed using descriptive and bivariate statistics in Stata v.14. ³⁴ Qualitative analysis began with the debrief of the interview memos, when interviews started in June 2022. A codebook had already been developed from a previous iteration of the Georgia Doula Study and was used as the basis for this analysis. New and important topics identified on the debrief interview memos were added or used to modify existing codes to reflect the experiences of rural, immigrant, and refugee doulas. Using Dedoose, ³⁵ formal coding of the 22 interviews began in October 2022 and continued until January 2023. Two research assistants (ILM and SC) coded the first five interviews together, meeting to discuss their coding and to reach consensus. They then completed the coding on the remaining transcripts individually. The final codebook contained both deductive and inductive codes. Code memos were developed for each code to identify patterns within each topic and cross-cutting themes that emerged across topics. Themes were further refined in conversations as a research team and with our community partners. The resulting codebook can be found in the supplemental materials. Our analysis focuses on the doulas who reported serving immigrant and refugee communities.

Results

Demographic information

In total, 22 doulas were interviewed and 64% (n = 14) reported serving immigrant or refugee clients. Doulas were female-identifying (93%, n = 13), between 25 and 35 years old (57%, n = 8), U.S.-born (86%, n = 12), college educated (58%, n = 8), and their services focused on prenatal support (86%, n = 12) (Table 2).

Table 2.

Demographic information for doula sample (n = 22) and subsample (n = 14).

	Sample (n = 22)		Subsample (n = 14)
Variable	Frequency	Percent	Frequency	Percent
Race/ethnicity a
Black or African American	8	37	6	43
White	9	41	3	21
Hispanic or Latinx	1	4	1	7
Biracial or Multiracial	2	9	1	7
Asian or Pacific Islander	1	4	1	7
Other	1	4	2	14
Gender identity
Female/woman	20	91	13	93
Non-binary or genderqueer	1	4	0	0
Female/woman and nonbinary	1	4	1	7
Age
Under 25	1	5	0	0
25–35	12	55	8	57
36–45	7	32	6	43
46–55	1	5	0	0
Over 55	1	5	0	0
Immigration status a
I was born outside of the United States	5	11	5	36
One or both parents were born outside the United States, but I was born inside the United States	1	4	1	7
My parents, grandparents, and I were all born in the United States	19	76	12	86
Prefer not to answer	0	0	0	0
Education
High school	1	5	1	7
Some college/technical degree	4	18	2	14
Graduated college	12	55	8	57
Clinical professional degree	2	9	2	14
Graduate degree	2	9	1	7
Missing	1	5	0	0
Employment
Yes, full-time	11	50	8	57
Yes, part-time	6	27	4	29
No, not looking for employment	5	23	2	14
Doula scope of work a
Prenatal	14	64	12	86
Birth/labor	19	86	8	57
Postpartum	12	55	2	14
Full spectrum or abortion	5	23	5	36

^aParticipants selected multiple options; data does not add to 100%.

Four key themes emerged for immigrant-serving doulas: their role in filling gaps in care navigation, their provision of social and cultural support to their clients, the relationship between doulas and their clients was mutually empowering, and the landscape includes both doula-centered and systems-centered frictions.

Doulas serving immigrant and refugee communities fill a gap in care and societal navigation

The doula participants reported addressing the immediate needs of their clients and helping them with navigating a complex healthcare system. This support was in addition to providing education and prenatal support to their clients. Doulas from a one community organization with many immigrant and refugee clients guided their clients through an unfamiliar and cumbersome healthcare system. These doulas helped with Medicaid registration, setting up prenatal appointments and transportation arrangements, and even serving as an interpreter. Some of the doulas at this organization were refugees themselves, bringing a unique and keen understanding of the complexity of these new systems. One doula who primarily coordinated and managed other doulas identified the need for peer-support:

I mean, honestly, [mothers are] like begging for it, usually asking our interpreters to be there. . .One of our major goals is to keep training people from our community to not only teach our childbirth classes but also be the people that offer the labor support, offer the postpartum support, all of that, because I think that’s probably like the most ideal situation for culturally sensitive care.

They desired training for more compensated community-based doulas who are culturally humble is a response to the community’s needs. Bringing first-hand knowledge and a command of the language of refugee communities in Georgia, these doula participants described how they fill in the gaps refugee women experience. One doula participant serving Central Asian mothers shared: “I have moms who this is their fifth time [pregnant], but they still have lots of questions that [are] basic. . .it’s very important for me that [I] just give them the trust, give that support that no question is wrong.” She noted that, in addition to navigating the U.S. healthcare system, these mothers also have gaps in knowledge from prior pregnancies in their countries of origin that the doulas help with understanding. The expansiveness of doulas’ scope of work was also described by doula participants who weren’t refugees or immigrants themselves. One such doula with a background in social work saw her doula certification as “another piece to the puzzle.” She explained that her certification in providing birth support as a doula complemented the support she gave through her social and therapeutic work. Doula participants shared that they were able to expand the possibilities of holistic care for refugee and immigrant communities. Moving beyond the education and prenatal support typically associated with doulas, doulas participants serving these communities also described how they helped with systems navigation.

The relationship between doulas and their clients is mutually empowering

The benefits of doula care for immigrants and refugees are not limited to the clients alone. Doula participants, especially those who were refugees or migrants themselves, shared that the relationship to be mutually empowering. Doula participants described the feeling of having a valuable social role in their communities. Furthermore, participants shared that their experiences with providing support to their clients motivated their career goals.

The social empowerment of doulas gave them a sense of success and purpose in their communities. In retelling stories of impactful clients or birth stories, several participants reiterated the personal fulfillment made possible by helping their clients. In explaining her journey, one doula participant admitted that when she began providing services, she was fearful and nervous that she was not communicating well with her clients. However, the process of becoming a doula allowed her to build confidence—and clients affirmed her by expressing their trust in her: “. . .nowadays, I feel so proud and so honor[ed] that I got their trust. . .they know that I can help them, I can support them the way they want.” The mutual relationship between the client and the doula—one where the client felt supported, and the doula felt pride in her work—resulted in positive feelings for both.

Other participants expressed pride in the scope of social support they provided for the people they served. One doula shared: “We do all roles like actually, the family, the doula, the Uber, everything. . .it takes a village, and we are the village.” While this participant noted that there was a growing level of responsibility expected of doulas, this doula also noted the importance of her role for these communities. Another doula described this expansive role:

“[Advocacy] is where sometimes the doula’s scope of practice can get a bit blurred. A lot of the times it’s asking questions that the mom may not think to ask. Usually, it’s asking to get interpretation for them at the appointment. If they don’t have interpretation, it’s trying to secure it through our own resources.”

In addition to securing interpretation and driving clients to appointments, doula participants shared how they helped eligible clients register for Medicare, and securing necessary supplies such as diapers and car seats. However, not all participants included this level of support in their definition of what their scope of work was.

The experience of providing doula care empowered some to seek more professional development. One participant shared that her experiences solidified her desire to seek family planning training in the United States to build upon her midwifery education in her country of origin. However, she noted that a barrier to her pursuit of this training was education or professional requirements that she could not fulfill despite her earlier education. The lack of available training for doulas with immigrant or refugee backgrounds was identified by several participants as a roadblock. Participants noted that despite the desire for doulas with these backgrounds, the current opportunities for doula certifications and additional training are limited to those with native fluency in English, income to pay for the trainings. Unfortunately, doula participants also disclosed that there are few opportunities to utilize the transferrable education they had received before resettling in the United States.

Still, some doula participants shared how they were able to access this knowledge and education. One such participant was completing her nursing degree. She shared, “I want to be more involved in birth, so I’m in nursing school. After I got the doula training, I [went to] nursing school. I want to continue [my] education to be a midwife. This is what I can do so far.” Knowing that there was a limit to her involvement in the birthing experience as a doula, this doula participant chose to pursue nursing, and eventually midwifery, to increase her active role in the birthing process. She shared that the knowledge she gained from her coursework was informing the doula care she provided and advocacy even before she achieved her nursing certification. This doula participant believed that the education she received had strengthened the services she could provide to her clients, allowing her to provide accurate information on medications offered and encouraging patients to advocate for themselves.

For participants who were themselves immigrants or refugees, providing this service was mutually empowering. Doula participants shared that they had been inspired to pursue higher education and aspire for further training. They believed this training allowed them to be better doulas. Furthermore, participants noted being a doula promoted self-confidence and gave them a sense of value and purpose in their communities.

The current landscape includes both doula-centered and systems-centered frictions

Existing frictions for doulas serving immigrants and refugees can be distinguished in two ways: doula-centered frictions and systems-centered frictions. Doula-centered frictions focus on doulas’ scope of work, specifically the current trend of services going beyond what we typically associate with doulas. System-centered frictions encompass hospital policies, racism by physicians and other hospital personnel, and other conventions that undermine doulas and prevent birthing people from receiving the care they are entitled to. Addressing both types of friction is necessary to assess the benefits of doula care.

The expansive nature of participants’ scope of work frequently resulted in internal conflict for doulas. Doula participants disclosed that they are asked to fulfill social roles outside their scope of work, and U.S. care conventions sometimes conflicts with cultural expectations of care. Participants noted that the populations they worked with sometimes asked them to integrate themselves into their communities and presented an issue with boundary setting. One doula explained the difference between her practice and one client’s expectations:

“With my clients, I provide a prenatal initial consult. Then I provide any kind of consultation in between as well as a 37-week in-home give you an idea of what birth is going to be like, what labor is going to be like. It’s hands-on but distanced. It’s a very American style of practice. What she was expecting was very familial— food sharing is a big part of their culture and literally like, ‘Here’s my plate, take some food.’ It was a very intimate relationship that she wanted.”

This participant continued by explaining that this relationship was impossible for her to provide within the boundaries of U.S. care culture and the scope of her work. She noted the need for familial support for this client—once again indicating that while doulas can help with bridging some social support gaps, they can only do so much. Other doulas shared similar experiences and expressed fear of burnout. Another doula explained, “we get burnt out as practitioners, not only as a doula. I’m a social worker, a therapist, and those roles become exhausting.” She shared that she wanted to figure out a way to incorporate the additional support her clients needed into their communities. She noted that her intention was to make clearer the boundary between the support a doula could and could not provide. However, these boundaries differed between participants. In fact, doula participants who were themselves immigrants or refugees disclosed that they were willing to have a more expansive scope of work. One doula expressed that she had developed a friendship with a client from Africa, sharing that, “she went through the [birthing class] but beyond that, we became [friends]. Whatever she needed, [she’d] call me. Even if it’s not for the pregnancy. . .. I became part of her family.” This participant’s experience is a contrast to the doula participant who felt that the familial experience was outside of the scope of work; this doula participant—herself a refugee from Africa—explained that she embraced this close relationship. Doula participants who themselves are refugees or immigrants, shared that their integration into their client’s community may be seen as a natural responsibility of their work in providing care. Still, many participants doubted that doulas in Georgia had the capacity provide this wraparound support even if the need exists.

Doula participants also reported that systems-centered frictions at hospitals were limiting the support they could provide. Seven participants whom hospital personnel disregarded both doulas and their clients. One doula shared: “I think some [doctors] honor the plan of the moms, but some don’t. I remember supporting a mom at the hospital with her birth plan, but the team didn’t actually consider the plan. They just picked maybe one or two things and then that was it.” She continued, saying that she noticed that the services provided were subpar when her clients did not speak English, and doctors would proceed without bringing in an interpreter. Participants viewed this issue in two ways: first, that hospitals in their area of Georgia do not have staff who are reflective of the population they serve or sensitive to their needs and this results in decreased patient autonomy. Second, participants shared the belief that even when doulas are available to act as support for their clients, they are undermined. Participants identified these hospital conventions as barriers to providing care that could improve health outcomes.

Participants were most concerned about situations where hospital conventions directly conflicted with clients receiving care they are entitled to. Six of the doula participants providing care to immigrant and refugee communities explicitly mentioned witnessing discrimination against their clients. This included racist language, dismissal of the pregnant person’s birthing plans, and language-based discrimination. When asked what improvements in care would look like, one doula responded: “What does [improved care] look like? It’s people who actually get interpretation services.” Her experience was echoed by other doulas, who shared that hospitals would either avoid the use of translation lines or ask doulas to translate—something many refused because of their lack of knowledge around medical terminology in their languages.

Furthermore, participants described how they witnessed doctors used the religious needs and desires of women to proceed with unnecessary birth interventions. One doula shared:

Many providers, they play on this [desire for a female provider]. They say, ‘If you want to guarantee a female provider, come next Wednesday for induced labor.’ I can tell you 100% I don’t have any case in the last five years for people, like, they not offer (sic) to have induced labor. I don’t have any case I can remember of, they are not asked to induce labor.

This participant emphasized that, in her experience, doctors and hospital personnel recognize the needs of this population and choose to provide options that result in unnecessary interventions. Doula participants described this experience as their immigrant and refugee clients being stripped of their autonomy during birth, with multiple participants expressing frustration that their clients would come in with birth plans only to have them dismissed. Participants felt that their services were limited and so were the benefits of their care.

Discussion

The themes that emerged from these interviews provide insight into the unique role that doulas play in the lives of immigrant and refugee communities, especially their crucial role in navigating both pregnancy experience and broader life experiences for newly arrived U.S. individuals in Georgia, a state that welcomes a large proportion of U.S. immigrants and refugees.^13,14 Our examination of doulas serving these populations explores the integration of these groups and the support provided to care workers who choose to focus on these populations and who might also be immigrants and refugees themselves. Most doula respondents highlighted that their scope of practice was broader than the traditional perinatal support associated with doulas and shared that they were expected to integrate themselves into the personal lives of the women they served. However, some doulas who were immigrants or refugees themselves reported embracing this integration into the lives of their clients. This presents the possibility that the scope of work for a doula is influenced by U.S. or Western concepts of what doula work entails. An exclusively clinical or Western perspective of doulas’ scope of work might see it reflect the roles of doctors and nurses—that is, providing perinatal support, but not integrating themselves into the lives of clients. The results of this study are consistent with prior research on doulas for migrant populations in Sweden, which found that doulas were often expected to be personally and emotionally invested in the lives of their clients. ³⁶ This is in contrast to the current formal healthcare system, which requires providers to keep a degree of distance from their patients. In contrast, individually tailored personal and emotional investment in clients is central to the work of doulas, which can cause barriers when there are attempts to formalize or standardize doula care. ³⁷

Furthermore, doulas in this study helped their clients with navigating much more than the pregnancy experience, providing them with knowledge of the U.S. healthcare system, transportation, and more, acting as cultural and social support partners. This too follows prior research done with a diverse group of immigrant women in the Pacific Northwest and Hispanic immigrants in Utah, showing that having a doula with shared culture and language can help immigrant women with accessing information and resources.^38,39 These studies also highlighted that immigrant women’s communication with their care team improved with doula support, subsequently bolstering women’s feelings of autonomy and overall perception of care quality.^38–40 With previous research clearly documenting that social factors increase vulnerability and worsen maternal health outcomes for migrants, this conclusion suggests that with proper support, doulas can support immigrant women by aiding them in accessing both medical and non-medical information and providing a strong socio-emotional bond for their client.^{18,38,41–43}

This sample included doulas who are immigrants and refugees; these interviews were also helpful in illuminating how this community-based role can be fulfilling for this group. These doulas find that their work is a mutually enriching experience. Research primarily focuses on the benefits of doulas for direct clients, especially Black women’s success with doulas,^41,43–46 while other studies have focused on the rewarding and positive experiences of acting as a doula.^17,47 However, little research has been conducted on the mutually beneficial relationship between doulas and their clients. There are limited studies that indicate that doulas also benefit from the education and experience gained from participating in community-based doula programs. ¹⁸ Less is known about how the role of a doula can be especially powerful in giving immigrant women a valued role in their communities as they build new lives in the United States. Previous research has indicated the potential for occupations to improve the post-migration experience, especially when they provide meaning and purpose. ⁴⁸ This analysis of doulas is unique in part because it suggests that being a doula can be important for promoting a sense of belonging and purpose for new immigrants and refugees who choose this career. This presents an opportunity for meeting demand for doulas with specific cultural knowledge or backgrounds, while also providing refugees and immigrants with a valuable role in their communities. A few participants highlighted their inability to use training from their home countries to augment their current doula practice due to U.S. regulations, for example, needing licensure to provide certain types of family planning care. This is consistent with existing research suggesting that Western countries have institutional barriers that prevent immigrants from using their existing credentials and qualifications from their countries of origin. ⁴⁹ Thus, future research should examine immigrant or refugee-specific barriers as it relates to acquiring doula training or carrying out doula responsibilities in these groups.

Despite doulas highlighting that there were positive experiences, there are also negative experiences that occurred when integrating into the care team. COVID-19 brought restrictive visitor policies that forced pregnant people to choose between having a family member or a doula present.^28,29,50 Even prior to COVID-19, tension between doulas and the medical system was present. Biomedical care teams are unsure of how to integrate doulas into the care team and are unsure of the doula’s role on the team in relation to themselves. Studies found different points of contention between doulas and providers, including midwives’ worry that doulas overstep boundaries, ⁵¹ a perceived conflict between mainstream biomedical culture and a natural birth “counterculture,” ⁵² dismissal of the expertise of doulas, ⁵³ and personal attitudes toward doulas.^28,54 The exclusion of doulas from the hospital room, both before and after COVID-19, and beliefs that doulas are overstepping or less informed, is indicative of a view of doulas as extraneous people who might cause tension during birth as opposed to a knowledgeable member of the care team. The antagonistic relationship between doulas and hospital staff is concerning when considering reports of medical racism and dismissal of patient concerns found in this study and consistent with previous studies.^28,29,55 Inclusion of doulas and a positive, mutually respectful relationship between doulas and other members of the care team is important for ensuring patient advocacy among immigrant and refugee populations. Opportunities exist for improving this relationship and allowing the benefits of doulas to be fully realized. Education of doctors and nurses on the roles of doulas, bidirectional learning, increasing opportunities for medical staff to interact with doulas throughout their training, and viewing doulas as a part of the birthing team can result in a more positive relationship.^{29,52,56–58}

Finally, the support provided by doulas is not enough to overcome systemic issues. Increasing access to doulas has increased popularity and favor, with 18 states currently reimbursing doulas through Medicaid. ²² Expansion of Medicaid reimbursement for doulas can support eligible immigrants in seeking care, while also giving doulas the ability to sustain their work. Focusing on increasing access to doulas is a bandage on the much larger wound of maternal health, however. Previous studies have shown that working as a doula is not always a financially secure career path, and programs for community-based doulas with shared language and cultural backgrounds for clients face the same shortfalls as the non-profit sector.^18,28 The doulas interviewed for this study were also acting as unofficial social workers, navigating the Medicaid enrollment process, scheduling appointments, obtaining or acting as an interpreter, and figuring out transportation for their clients. While doulas can circumvent some of these systems-centered frictions, they can do only so much, and it would be incorrect to lean on them to fill the gaps that the U.S. and Georgia’s social systems create. Improved maternity care coordination can be a vital tool in supporting pregnant people and can lessen expectations of doulas that fall outside of their scope of work. Maternity care coordination, often associated with Medicaid, has been shown to improve birth outcomes, though less is known about maternal health outcomes, and still less about specific racial outcomes.^59–61 Current models of reimbursement focus on access to doulas and reimbursement of hospital care, but do not include all of the work doulas, including those in this study, are engaging in, such as transportation management, interpretation, and managing social needs for their immigrant and refugee clients. Building a comprehensive system of support for expectant mothers can help with the role definition of doulas, allowing them to maintain important boundaries around their scope of work. Until the medical system decides to be patient-centered and to provide culturally humble care, however, none of these interventions will be as successful as they can be.

Limitations

This study is limited to doulas in the Atlanta metropolitan area and thus may not be transferrable to other areas. Though this is a diverse area that includes a city with significant ethnic diversity, it may not be indicative of the experiences of doulas serving immigrants and refugees in other areas of the state or nationally. We were also limited to English-speaking doulas. Non-English-speaking doulas exist, but this study was unable to access them. Future studies must be completed with doulas who have limited English-speaking ability to achieve a comprehensive understanding of their work. Further, distinguishing between the immigrant and refugee status of both doulas and the clients they served proved difficult. The designation of immigrant and refugee is primarily a legal one, and motivations for migration can also play a significant role in the ability to access and navigate U.S. systems and healthcare. Additionally, categories such as first-generation, or second-generation immigrants are not clearly defined, and despite best intentions to be clear in the survey, each participant had their own perspective on who was or was not an immigrant. Doulas self-reported working with immigrant and refugee groups and we could not certify whether they had experiences with both groups or only one. Therefore, drawing conclusions between differences in service for the two groups was outside the scope of this study. Future research may consider focusing on different categories of migrants, including refugees, undocumented immigrants, and immigrants who have residency status but are not considered refugees and comparing differences in service among these groups. Finally, much of the existing literature on doulas supporting immigrants focuses on the benefits of their services and the barriers that exist for accessing them. Far less is known about training doulas to serve diverse migrant populations, including availability of training in other languages. There is an opportunity to survey the landscape of doula trainings with a focus on non-English trainings and trainings for immigrant populations in the United States.

Conclusions

Previous research has illustrated the potential for doulas in improving birth outcomes among the U.S. population. However, existing research on doulas who serve immigrant and refugee communities is limited. This research highlights the experiences of doulas serving immigrant and refugee communities in Georgia and is unique in its observations of the experiences of doulas who are themselves refugees or immigrants. Interviews found several existing successes, in addition to identifying frictions experiences by these doulas. Successes include the care navigation gap that doulas fill, the social and cultural support provided, and the mutually empowering nature of the doula-client relationship. Still, doula- and systems-centered frictions exist, which limit the potential benefits of doula care. These frictions are not entirely unique to the population studied and are reflective of other trends of racism and doula discrimination found by other studies. As doulas become more central to reducing maternal mortality in the United States, we must consider the heterogeneity of the doula work and the social support needs of doulas.