A Systematic Review of the Use of Doulas to Support Rural Perinatal People in the United States

Abstract

Introduction

Maternal health outcomes are frequently worse for individuals living in rural and remote communities due to the distance people must travel for healthcare, higher rates of poverty, and higher risk factors for related health conditions, such as mental illness and substance use. Doulas, non-medical childbirth companions, provide emotional, informational, physical, and advocacy support to people during pregnancy, birth, and postpartum. Research has documented doulas’ positive impact on birth outcomes, including lower rates of induction and cesarean birth. The benefits of doulas may be especially important for marginalized and underserved populations who experience disparate health outcomes, including rural residents. This scoping review was conducted to describe and assess the landscape of doula-focused research that focuses on the unique contextual challenges faced by rural communities.

Methods

We conducted a scoping review of research exploring the use of doulas in rural contexts. Peer-reviewed articles presenting original research using both quantitative and qualitative methods were included. Target populations for the included studies were rural perinatal people receiving doula support or doulas in rural contexts. All definitions of rurality were included. Database index terms were searched as well as keyword search terms: “rural” AND “doula” OR “labor coach” OR “birthing coach” OR “childbirth coach” OR “birth attendant” AND “United States” OR “U.S.A.”12 peer-reviewed journal databases and Google Scholar were searched May 2022-September 2023. Data was synthesized using tabular and narrative methods to capture (a) study design and type, b) study purpose, c) population, d) study location, e) analysis, d) definition of rurality, and e) reported results and gaps in the literature.

Results

2,195 articles were identified. After removing duplicates and ineligible studies, 3 articles were included in the final results. These articles included quantitative (1), qualitative (1), and mixed methods (1) studies exploring access to and perceptions of doulas in rural areas.

Conclusion

Findings demonstrate limited scholarship on the use of doulas in rural settings. This area of research warrants further attention.

Introduction

People living in rural areas are particularly vulnerable to poor maternal and infant health outcomes in the perinatal period, such as increased maternal and infant mortality, higher rates of chronic illness, pre-eclampsia, eclampsia, pre-term birth, and hypertension (Collier & Molina, 2019; Ehrenthal et al., 2020; Ely et al., 2017; Rural Health Information Hub, 2023). Limited access to obstetric healthcare due to long distances, extreme weather conditions, hospital and obstetric unit closures, workforce shortages, as well as a lack of insurance coverage and transportation are compounded by factors such as poverty, housing insecurity, and others that contribute to these outcomes in rural areas (Collier & Molina, 2019; Kozhimannil et al., 2017). For example, an analysis of national birth cohort data (2014–2016) using NCHS urban-rural classification demonstrates 1.3 higher odds of mortality for infants living in rural areas (Ehrenthal et al., 2020).

Despite evidence that rural perinatal people experience worse health outcomes, there remain significant gaps in research and intervention development for this population. These gaps are particularly concerning in the context of the US maternal mortality rate, which exceeds that of all other high-income countries (Gunja et al., 2022). Approximately 13% of the US population lives in rural areas defined as “non-metro” by the U.S. Office of Management and Budget. Although not all people who live in rural areas, give birth in rural settings, those who give birth in non-metro counties experience a 9% higher likelihood of death or severe injury due to childbirth (Kozhimannil et al., 2019). Increased focus on rural maternal healthcare access and targeted interventions to lower rural maternal and infant health disparities is needed to address US maternal mortality broadly.

Doulas, trained professionals who support individuals and families in the perinatal period, have been advocated for as an intervention to improve maternal and infant health outcomes (Dekker, 2017; Kozhimannil et al., 2016). Doulas augment clinical obstetric care by providing informational, emotional, advocacy, and physical support during pregnancy, birth, and the postpartum period (Dekker, 2017). Doulas’ unique role, distinct from that of medical professionals (midwives and obstetricians), has been shown to have profound maternal and infant health benefits (Bohren et al., 2017). For example, doulas’ continuous support during labor is associated with a 39% reduction in the risk of birth by Cesarean section compared to births attended by medical professionals only (Bohren et al., 2017). Current evidence also indicates that doulas can improve infant Apgar scores and breastfeeding initiation, and shorten the length of labor (Bohren et al., 2017; Dekker, 2017; Fortier & Godwin, 2015; Kozhimannil et al., 2013).

Significant research suggests that doulas are well-positioned to support underserved and socially marginalized populations (Mallick et al., 2022; Kozhimannil et al., 2016). Support from a doula is associated with an increase in respectful maternity care for Black perinatal people and those who receive Medicaid assistance (Kozhimannil et al., 2013; Mallick et al., 2022). Qualitative data demonstrate that doulas improve healthcare quality and access in the perinatal context by supporting health literacy and facilitating patient-provider interactions (Kozhimannil et al., 2016). These advantages of doula care may also particularly benefit rural perinatal populations, who experience worse health outcomes.

The purpose of this scoping review was to identify and compile existing peer-reviewed literature on the use of doulas in rural settings. To our knowledge, no other scoping review has explicitly explored the use of doulas in rural contexts. Given the disproportionate maternal and infant health disparities experienced by rural populations and the US maternal mortality rate, research exploring innovative interventions like doulas to improve health equity in this context is needed. Our overarching research question is, “What is the current scope of literature exploring the use of doulas in rural contexts in the United States?” We also seek to identify what research gaps exist and what study designs are needed to fill these gaps.

Methods

Search Protocol

The review protocol was registered with Prospero (ID: CRD42022331570), an international prospective register of systematic reviews (National Institute for Health and Care Research, n.d.), before beginning the review. The research team for this study was comprised of two research assistants (RA), one an undergraduate and one a graduate student, and two faculty members, one in the School of Social Work, and one an Epidemiologist in Public Health. All team members have prior experience in conducting systematic reviews and prior experience conducting research on the topic of doulas, and two team members have been trained as doulas themselves. All team members are from rural states, and currently reside in rural states. One of the research assistants conducted a preliminary search of related literature to establish a list of potential search terms. This list was refined by the researchers with subject matter expertise, who also compiled a list of potential databases. The following search terms were used to conduct the search: “rural” AND “doula” OR “birth attendant” OR “labor coach” OR “childbirth coach” OR “birthing coach” AND “United States” OR “U.S.A.” Index terms were also used when relevant. The following sources were searched for articles: (1) Google Scholar, (2) PubMed, (3) SAGE, (4) EBSCO, (5) Global Health Archive, (6) CINAHL, (7) JSTOR, (8) Project MUSE, (9) PsycARTICLES, (10) PsycINFO, (11) SocINDEX with full text, and (12) ScienceDirect (Elsevier).

Eligibility Criteria

Articles were included if they met the following criteria:

• An original research study published in a peer-reviewed journal.

• Published in English.

• Study target population included people who received doula support during pregnancy, birth, or up to 12 months postpartum and/or doulas who provided support to perinatal people.

• Study took place in rural area or context, defined in any way, in the United States.

Our goal was to capture all research on the specified topic published up through the time of this review (September 2023), and we did not limit articles to a specific date range. There are a variety of methods used to geographically or culturally define “rural” including the use of data from the U.S. Census Bureau and the U.S. Office of Management and Budget (Ratcliffe, 2016). We included studies that explicitly stated the study location was rural, regardless of how the authors defined rurality. We excluded articles that did not have an explicit focus on rural areas or contexts.

As we are exploring this topic broadly, we are interested in both perinatal people’s experiences with doula support, outcomes associated with doula care, and doulas’ experiences providing that care. As such, we included articles in which the target population were perinatal people who received care from a doula and/or doulas who provided that care. We define “doula” as a person trained specifically to provide prenatal, birth, and/or postpartum support. Grey literature, systematic or scoping reviews, white papers, commentaries, theses, and dissertations were excluded. This is also in line with our goals of better understanding what peer-reviewed research has been conducted exploring the use of doulas in rural contexts and to determine which research gaps exist and what study designs are needed to further explore this topic.

Study Selection

Zotero and Microsoft Excel software were used to manage all references for this review. A RA conducted the initial search and removed articles that were not relevant or were duplicates. Following this step, the RA reviewed bibliographies to capture additional relevant studies. The full research team then reviewed the full text of the articles to determine eligibility. Each researcher independently reviewed the articles and provided feedback on whether to include or exclude the article. The research team then met to discuss any disagreement on inclusion. A PRISMA flow chart was used to document exclusion throughout the process (see Fig. 1).

Fig. 1.

Flow Chart of Article Review Process

Data Synthesis

We used a combination of tabular and narrative methods to synthesize data. Studies included in the final results were synthesized by: (a) author and year of publication; (b) title; (c) study design and type; d) study purpose; e) population; f) study location; g) analysis; h) definition of rurality; and i) reported results. Our narrative synthesis of data included study discussion/impact of rural settings on population or service provision, recommendations for future research, and best practices.

Results

The results of this scoping review reveal limited literature exploring the role of doulas in rural contexts in the United States. A total of 2,195 articles were identified in the initial search, of which three articles were included in the final results of this review. 2,104 articles were identified in the initial search conducted in 2021. Of these articles, 9 remained after screening for duplicates and initial eligibility. Another initial search was conducted in 2023 to ensure results were relevant, during which three more articles qualified for inclusion. Following a search of bibliographies, 12 more articles were added for full review. 24 full-text articles were sought for retrieval and one article was not accessible, leaving 23 total full-text articles screened for eligibility. 20 articles were excluded due to lack of focus on rurality or doulas, failing to meet eligibility criteria (Fig. 1).

Three articles were included in the final results. Study designs and sample sizes varied. Quantitative, qualitative, and mixed methods were represented, and sample sizes ranged from 52 – 1,711. All studies included in the final results were descriptive. Please see our tabular synthesis in Table 1 for a full list of study attributes.

Table 1.

Study characteristics

Author(s), Year	Title	Study Design and Type	Study Purpose	Population	Study Location	Analysis	Definition of Rurality	Reported Results
Horstman et al., 2017	Communicatively making sense of doulas within the U.S. master birth narrative: Doulas as liminal characters	Qualitative study using interviews and focus groups. Descriptive study.	To explore individual narratives about doulas within the context of birth in the U.S.	(N=52) Participants included perinatal people, doulas, and obstetric staff.	A community hospital in a rural Midwestern town.	Narrative theorizing and inductive analysis.	No geographic parameters were provided.	Doulas were described as liaisons, coaches, and advocates. Doulas conceptualized as facilitating communication between family/pregnant person and the medical team, providing guidance and suggestions, and acting helping pregnant person to them articulate their needs.
Ibrahim et al., 2022	Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents	Quantitative research using surveys. Descriptive.	To investigate rural availability of evidenced-based supports and services for maternal and infant health, including doulas	(N = 93) Individual rural hospitals, 31% in counties with majority BIPOC populations.	Rural hospitals in the Northeast, Midwest, South, and West U.S.	Logistical regression analysis to compare evidence-based birth supports among hospitals in counties with varied Social Vulnerability Index (SVI) scores and majority BIPOC populations.	Definition is unclear.	Rural hospitals with high SVI scores reported significantly less access to doula care (33.3% versus 59.7%). 86.2% of majority-BIPOC counties were represented in most vulnerable quartile compared with 14.1% of majority-White counties.
Ibrahim & Kozhimannil, 2023	Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States	Retrospective mixed methods study. Descriptive.	To investigate access to VBAC care, level of respectful maternity care, and autonomous decision making.	N = 1,711 Participants were recruited from online pregnancy and birth peer support forums from both urban and rural communities who had VBACs in the past 5 years.	U.S.	Bivariate statistical analysis and qualitative descriptive analysis.	Participants identified their residence as rural or metropolitan.	Residents of rural communities were 6.4% less likely to have doula care for their birth after cesarean section.

Study Outcomes

The final included studies assessed varied outcomes including perspectives and experiences of doula care as well as access to doula support. Utilizing semi-structured interviews and focus groups, Horstman et al. (2017) elicited the perspectives of doulas, obstetric staff, and perinatal people to explore the role of doulas. The authors hypothesized that doulas may not perfectly fit into the overarching narrative surrounding birth in the US. The results of this study indicated that doulas were viewed as “liminal”, occupying a middle space between families, medical staff, and people who gave birth and were considered beneficial. Horstman et al. (2017) note that this study took place at a small rural hospital in which volunteer doulas were an integrated into standard obstetric care, perhaps influencing participants perceptions of and experiences with doulas. No further description or measure of rurality was provided. Implications of this study included a need to expand integration of doulas into medical systems and develop methods of effectively communicating doulas’ liminal role.

The two additional studies included in the review utilized quantitative or mixed methods to investigate access to doulas in relation to access to healthcare, race and ethnicity, and social vulnerability. Ibrahim and Kozhimannil (2023) assessed rates of Vaginal Birth After Cesarean (VBAC) and utilization of birth supports including doulas, by surveying US women who had given birth by cesarean and had a subsequent birth. Analysis of these data indicated that women in rural areas used doulas less than women in metropolitan areas (33.8% compared to 40.2%, p =.03) though had higher usage than the national average (Ibrahim & Kozhimannil, 2023). Results also indicated that a larger ratio of rural women were insured through Medicaid (32.1% compare to 18.6%, p <.0001) or reported no insurance coverage (4.7% compared to 1.2%, p <.0001). Importantly, rural women expressed a similar level of desire for VBAC care but traveled 60 min or more to access that care more often than their urban counterparts (19.4% compared to 4.1%, p <.0001). Both quantitative and qualitative data revealed women from racialized groups in rural areas experienced disrespectful maternity care more frequently. Rural location was determined based on participant self-report. Implications of this study are need for increased local opportunities for rural woman to access VBAC care and support, of which doula support may be one resource.

Similarly, Ibrahim et al. (2022) investigated access to evidenced-based supports for rural and perinatal people from marginalized racial groups. However, unlike the prior study, Ibrahim et al. surveyed hospital sites in rural areas, not individuals. It was not clear how rurality was defined or determined. Analysis of these data entailed comparing the social vulnerability index and demographics of counties in which participating hospitals were located with reported access to evidenced based supports. The results indicated that BIPOC rural women were more likely to experience high social vulnerability and less to lactation specialists, midwives, doulas, and postpartum support groups. For example, this population was 70% lower odds of using a doula (OR 0.30, 95% CI 0.11–0.84) (Ibrahim et al., 2022).

Gaps and Needed Research

The studies identified by this scoping review utilized multiple methods, target populations, and outcome. Nonetheless, they were few in number and more research on the use of doulas in rural areas is needed. Descriptive quantitative research exploring the prevalence of doulas in rural areas would elucidate whether doulas are well represented in rural areas and can meet demand. While there is significant research documenting rural perinatal people’s experiences traveling to access care, less research explores doulas experiences with rurality. Qualitative research investigating doulas’ perspectives of providing care in rural and remote contexts could help inform efforts to support the doula workforce. This research could also explore potential differences in scope, characteristics, business models, and resources of rural doulas in comparison to doulas in urban contexts. Finally, experimental research investigating potential associations between doula support and specific perinatal health outcomes in rural contexts is needed. Considering the breadth of literature documenting rural disparities in maternal healthcare and outcomes, studies exploring the impact of doulas in these contexts is a significant gap in research.

Discussion

This scoping review indicates a dearth of literature specific to the use of doulas in rural contexts indicating a need for increased exploration of this topic. All study designs including quantitative and qualitative methods are needed to provide additional evidence of the role and impact of doulas in rural contexts. Studies included in the results were all descriptive in nature, suggesting that research about doulas in rural settings is still developing.

These articles further highlight social factors such as unstable housing, lack of transportation, lack of insurance, high incidence of intimate partner violence, and scarcity of mental health support as unique challenges to accessing quality rural perinatal care (Gregory-Davis, 2021; Ibrahim et al., 2022; Ibrahim & Kozhimannil, 2023). Consistent with previous literature (Collier & Molina, 2019; Ehrenthal et al., 2020; Ely et al., 2017; Rural Health Information Hub, 2023), these articles also highlighted the increased risk for poor maternal and child health outcomes for rural populations. People in rural areas are more likely to experience maternal mortality or morbidity, and over half of rural counties in the US lack access to an obstetric unit (March of Dimes, 2022). As of 2022, 2.2 million people of reproductive age live in what are defined as maternity care deserts (March of Dimes, 2022).

Findings also highlight the increased social vulnerability experienced by rural communities, which is deeply stratified by race (Ibrahim et al., 2022; Ibrahim & Kozhimannil, 2023). Rural communities with majority BIPOC populations have much higher levels of social vulnerability than do rural communities with majority White populations. They are also least likely to have access to evidence-based support. The trend towards rural hospital closures, and obstetric units in particular, is deeply alarming and will require a multi-pronged approach to ensure people living in rural areas have access to robust perinatal care (Ibrahim & Kozhimannil, 2023). Underscoring the need to include an analysis of race when exploring rural v. urban differences, Ibrahim & Kozhimannil note that there were not significant differences in the MORI (measure used to assess respectful maternity care) and MADM (measure used to assess autonomy in decision-making) responses between rural and metropolitan population, but large discrepancies between White populations and minority populations (2023).

All articles also described the additional barriers rural perinatal people experience when trying to access doula support. This literature underscores that those who have the highest level of social vulnerability also happen to have the least access to evidence based supports during the perinatal period. Those who would benefit the most from doulas are also those that have the most restricted access. All articles called for expanding doula care in rural areas and making it truly accessible, which is an important step towards rectifying health disparities. Ibrahim and Kozhimannil (2023) in particular explore how rural participants are less likely to have access to doula support, and face very significant barriers to accessing perinatal care, making them, in turn, less likely to obtain a desired VBAC. However, they also note that rural residents display tremendous motivation to achieve their desired birth experience, often traveling hundreds of miles to hospitals with the capacity and willingness to provide VBACs (Ibrahim & Kozhimannil, 2023).

These articles also describe the specific roles doulas playing in improving the perinatal experiences and outcomes for people in rural areas. Consistent with previous literature highlighting the roles that doulas play in supporting perinatal people (Dekker, 2017), doulas were described as providing each of the four main types of doula support. Providing social and emotional support that may ease the challenges and transitions of the perinatal period and provide much needed support was discussed by these articles.

Knocke et al. (2022) notes how rural communities that are majority Black or Indigenous, and who have historically and continue to experience systemic barriers to accessing care, as well as increased likelihood of developing severe complications or dying during the perinatal period, may particularly benefit from the support of doulas (2022). Doulas can assist in helping the birthing person navigate health systems that often dismiss, devalue, exclude, or discriminate against them (Ibrahim et al., 2022; Ibrahim & Kozhimannil, 2023; Knocke et al., 2022).

Despite the limited scope of literature on this topic, studies identified in this review provide important recommendations for improving health equity among rural perinatal people. These recommendations included making active efforts to integrate doulas into community health organizations and local hospitals (Horstman et al., 2017; Knocke et al., 2022). More education for providers is needed on the scope of doula services and their importance in improving outcomes in order to lessen friction between doulas and other providers (Horstman et al., 2017). Several of these articles also highlight the importance of doulas in promoting measures of maternity care quality that go beyond medical measures and integrate patient values and experiences into measures of quality, and the importance of non-medical support figures (doulas) in shaping patients’ experiences (Horstman et al., 2017; Ibrahim & Kozhimannil, 2023). Providing an emphasis on the shared interest in the patient’s well-being is an important strategy in reducing tensions between doulas and medical staff (Singer-Miller, 2023).

Additional recommendations provided in this literature include increased messaging about and awareness and visibility of doula services, including their availability, advantages, and the scope of their work (Horstman et al., 2017). Rural-serving programs and hospitals could also explore providing doula services specifically for high-risk patients (Ibrahim et al., 2022; Ibrahim & Kozhimannil, 2023; Knocke et al., 2022). Ability to pay for doula services is an additional important piece in expanding access to doula care for rural populations. Medicaid expansion, helping people enroll in Medicaid earlier in their pregnancies, and increasing reimbursement rates for hospitals who serve majority Medicaid enrolled patients and providing Medicaid reimbursement for evidence-based supports such as doulas are all important recommendations for improving access to care and health outcomes (Ibrahim et al., 2022; Knocke et al., 2022).

Even with funding to support doula care, many of the rural workforce gaps in healthcare also often extend to doulas (Guenther et al., 2022; Knocke et al., 2022). Efforts to increase the number of doulas trained should also include efforts in workforce retention, as burnout impacts the retention of doulas. It is important to note that none of these articles specifically described the type of training doulas may need to serve clients in rural areas. Knocke et al., 2022 discusses the importance of doula training, and the need for increased funding for doula trainings, but the specific types of trainings needed for doulas working in rural communities were not described by these articles. Considering the unique obstacles experienced by rural populations described by these articles, this is an important gap.

Limitations

Because the goal of this study was to explicitly investigate the published scholarly literature on the use of doulas in rural communities, we excluded any white papers or grey literature. Future studies should further investigate scholarship in this area that is occurring outside of published journal articles. For example, the final project by Gregory-Davis et al., (2021) offers important insight into the barriers facing rural populations and the role of doulas in mitigating these barriers. Community-based doula organizations and activists, and other doula programs doing important work to address health inequities may similarly be underrepresented in the academic literature.

Additionally, the focus of this article was on the United States context. Future research should explore the use of doulas outside of the United States, since rural health disparities that could be impacted by doulas most likely exist in other settings as well. Similarly, we excluded articles not written in English. Finally, rural communities throughout the US are extremely diverse. The needs of a rural community in Oklahoma for example may look very different from one located in rural Alaska. The unique needs of individual rural communities should drive doula training and interventions.

Conclusion

Although the literature identified in this study was limited in number and scope, it nonetheless provides important insight into the current use of doulas to specifically address the needs of rural perinatal people. This study is unique in being the first to systematically explore the use of doulas to support rural perinatal people. In addition to highlighting the gap in knowledge in this area, we also offer important calls to action and suggestions for policymakers. These findings suggest that those who are most in need of doula care currently have the least access. Expanded and holistic access to doula care in rural areas is a key step in improving health equity for rural populations.

Significance.

Rural populations experience perinatal health disparities at higher rates than their urban counterparts, yet few interventions focused on supporting rural perinatal populations exist.

Data Availability

All articles in the systematic review are publicly available.

Code Availability

Not applicable.