Motivations for entering the doula profession: Perspectives from women of color

Abstract

Introduction

The imperative to diversify the healthcare workforce is evident: increased diversity contributes to the overall health of the nation. Given persistent racial and ethnic disparities in birth outcomes, workforce diversity is particularly urgent in the context of clinical and supportive care during pregnancy and childbirth. The goal of this analysis was to characterize the intentions and motivations of racially and ethnically diverse women who chose to become doulas (maternal support professionals) and to describe their early doula careers, including the experiences that sustain their work.

Methods

In 2014, 12 women of color in the Minneapolis, MN metropolitan area (eg, African-American, Somali, Hmong, Latina, and American Indian) applied and were selected (from a pool of 58) to receive doula training and certification. In January and February of 2015, we conducted semi-structured interviews (30–90 minutes) with the newly-trained doulas. We used an inductive qualitative approach to analyze key themes related to motivation and satisfaction with doula work.

Results

For many of the women of color we interviewed, the underlying motivation for becoming a doula was related directly to a desire to support women from the doula’s own racial, ethnic, and cultural community. Other key themes related to both motivation and satisfaction included: perceiving birth work as a “calling;” easing women’s transitions to motherhood by “holding space;” honoring the ritual and ceremony of childbirth; and providing culturally-competent support, often as the sole source of cultural knowledge during labor and delivery.

Discussion

Doulas of color have a strong commitment to supporting women from their communities. Given the evidence linking doula support to improved birth outcomes, successful recruitment and retention of women of color as doulas may support broader efforts to reduce longstanding disparities in birth outcomes.

Precis

Women of color become doulas to support women from their communities. Their experiences offering culturally-competent support motivate and sustain their work.

INTRODUCTION

There is a significant racial imbalance in the US health care workforce.^1–3 More than half of all women who gave birth in 2014 were women of color⁴, but there is little racial and ethnic diversity among midwives^{5, 6} and obstetricians^{2, 7} in the United States. There is a need for healthcare systems and providers that can reflect and respond to an increasingly heterogeneous and diverse patient population. Additionally, a lack of diversity in the healthcare workforce has been cited as one of many contributors to the persistent disparities in health status and limited access to health care for underserved populations.^{1, 2, 8} More broadly, a wide range of social determinants of health, which also influence the diversity of the healthcare workforce,⁹ directly affect birth outcomes. Given persistent racial and ethnic disparities in birth outcomes¹⁰, increasing workforce diversity is one of many potential policy levers that may disrupt the pathways between social determinants and health outcomes;¹¹ such efforts are particularly urgently needed in the context of care during pregnancy and childbirth. Efforts to diversify the healthcare workforce must occur among clinical professionals (physicians, midwives, nurses) and non-medical supportive roles (administrators, assistants, interpreters, community health workers and doulas).¹²

In addition to the clinical care provided by physicians, midwives, nurses and other professionals during pregnancy and childbirth, women benefit from access to non-medical doula support.^13–15 A doula is a trained professional who provides physical, emotional, and educational support to mothers before, during, and after childbirth.^{16, 17} Studies demonstrate that continuous support from a doula during labor and delivery is associated with positive birth outcomes, increased satisfaction, and no known harms.^{14, 18–20} Doula support shows also potential for reducing disparities in breastfeeding initiation.¹³ In addition to support during labor and delivery, the scope of a doula’s work often includes prenatal psychosocial support, education, and health promotion as well as attending to women’s personal and cultural expectations for childbirth and the transition to motherhood.²¹ Prenatal doula support is associated with lower rates of preterm and cesarean birth.²²

The concept of women who specialize in providing support during pregnancy childbirth is not new. Indeed, there is a long history of such support that spans many cultures and communities.²³ What is new, however, is the emergence of a specialized, professional, named role for women who provide this type of service for a fee.^{14, 24, 25} A doula is no longer simply a female friend or community member, an “auntie” who volunteers her knowledge and experience. Rather, doulas have become a type of provider within the healthcare system, with a specialized nonmedical role.^{18, 23, 26} There are myriad options for specific training and credentialing to become a doula.^{14, 24, 25} While only about 6% of US women who gave birth in 2011–2012 reported having doula support during childbirth, doulas are increasingly considered important members of maternity care teams.²⁶

When considering the striking lack of diversity in the maternity workforce alongside longstanding racial and ethnic disparities in birth outcomes, there is a particular salience to the potentially transformative role of nonmedical support from a doula. Disparities in adverse birth outcomes are pervasive.²⁷ Women of color (those who self-identify with a racial, ethnic, or cultural group that is non-white) in general, and African American women in particular, are at greater risk for adverse birth outcomes such as low birth weight,²⁸ preterm birth²⁹ and infant and maternal mortality.⁷ A growing body of literature has suggested that doulas may play an important role in mitigating some of these outcomes for women of color.^{13, 14, 18, 22} These same studies indicate that pregnant women of color face particular barriers to accessing doula care (eg, financial, geographic and cultural access).^{13, 18} Cultural barriers to access are substantial: namely, there is a paucity of doulas of color. Across the US, doulas are predominantly white, well-educated married women with children, living in urban areas, in upper-middle income households.²⁶

Several prior studies have explored the intentions and motivations of women who chose to become doulas.^{21, 26, 30, 31} Most doulas cite their desire to support and enhance the childbirth experience of women.³¹ Nearly 30% of doulas in one study reported plans to become either a direct entry or certified nurse midwife in the future, suggesting a pathway between becoming a doula and a career in midwifery.²⁶ An important limitation of these studies is the very small percentage of women of color in the samples, ranging from 0 to 2.6%.^{26, 27, 31} This study aims to examine what motivates women of color to become doulas. The goal was to characterize the intentions and motivations of racially and ethnically diverse women who chose to become doulas and to describe their early doula careers, and the experiences that sustain their work.

METHODS

This study used a prospective design to identify women of color who successfully applied and were selected to become doulas. It reports results from one key aim of a larger research endeavor, called the Doula Access Project.³³ Data came from in-depth interviews with doulas and were analyzed using a critical social theoretical framework in an inductive qualitative approach.

Theoretical Framework

Critical social theoretical frameworks purport the need to go beyond understanding the status quo to examine the alternative explanations for behavior and social phenomena.^34,35 In this study, we build upon prior research, which established the status quo that women are motivated to become doulas because they want to support and enhance the childbirth experience for other women.²⁶ The critical social theoretical framework we utilized allowed exploration of the motivations behind this desire to enhance the childbirth experience. In this way, this framework allowed us to identify, highlight, and understand the cognition and behavior of the doulas through a historical, cultural and social lens.³⁵ Finally, critical social theory suggests that the role of community must be at the forefront of the inquiry.³⁶ This study is based on a unique partnership formed between the co-authors and a community organization. Everyday Miracles is a Minnesota-based non-profit community-based doula program that aims to reduce health disparities by providing perinatal education and doula services to low-income women. The co-authors and Everyday Miracles have collaborated since 2011.

Study Participants

The Doula Access Project

The Doula Access Project (DAP) was a research project conducted from July 2014 through December 2015, aimed at documenting the challenges, opportunities, and effectiveness of Minnesota’s 2013 law extending Medicaid coverage to include doula care.³³ The Doula Access Project had four aims: 1) Assess demand for and barriers to doula care for diverse women through focus group discussions; 2) Train 12 new culturally-competent doulas from under-represented communities (eg, African-American, Somali, Hmong, Latina, American Indian) and administratively support these doulas in obtaining certification and registration to increase the diversity of the doula workforce; 3) Document the challenges and opportunities presented by Medicaid reimbursement from the perspective of community- and hospital-based doula programs; 4) Assess the effects of Medicaid reimbursement in the year following policy implementation. This paper draws on data collected to fulfill the second aim of training doulas from under-represented communities in an effort to increase the diversity of the doula workforce.

Sample and participation

In August 2014, the Doula Access Project released a call for applications, inviting women with an interest in becoming a doula to apply to the program. We used a snowball method of recruitment focused on communities of color, circulating the announcement via email, social media, and list-serves related to childbirth education, childbirth support, doula services, and birth equity.

There were 58 applications received for the 12 available spots. In their application materials, women indicated the languages they spoke fluently and described why they wanted to be a doula, any past experience working with pregnant women and birth, the communities with whom they would like to work, and described their financial need for support for the cost of training. Members of the research team interviewed 20 applicants before selecting 12 women to participate in the program; these 12 represent the sample discussed in this study. The application materials were in English and all interviews were conducted in English.

A diverse applicant pool allowed for selection of 3 African American, 3 American Indian, 2 Latin American, 2 African, 1 Karen (an Asian ethnic group from the mountainous border regions of Burma and Thailand), and 1 Yemeni doulas to be trained (Table 1). During the interview, all women self-identified their racial and ethnic background. While not directly proportionate, the selected doulas were representative of many of the racial and ethnic minority groups present in Minneapolis/St.Paul area. The doula training was conducted in October of 2014 with a certified trainer from DONA International.

Table 1.

Descriptive Characteristics of Doulas

Characteristics	N (%)
Race/Ethnicity
African American	3 (25.0)
African	2 (16.6)
American Indian	3 (25.0)
Latin American	2 (16.6)
Yemeni	1 (8.3)
Karena	1 (8.3)
Bilingual
Yes	6 (50.0)
Nob	6 (50.0)
Prior experience helping women through birth
Yes	9 (75.0)
No	3 (25.0)
Number of Births attended at time of interview
2–3	4 (33.3)
4–6	3 (25.0)
More than 5	1 (8.3)

^aThe Karen (pronounced Ka-REN) are an ethnic group from the mountainous border regions of Burma and Thailand, where they are the second largest ethnic group in each country. There are approximately 6,500 Karen living in Minnesota.

^bFor those who were not bilingual, English was their first language

By January or February of 2015, most doulas had attended between 2–6 births since they had completed their training. Data on client race and ethnicity was not universally available, but Everyday Miracles attempts to match each pregnant woman with a doula from the same racial or ethnic background. All of the doulas in this study had supported other women of color at the time of the interviews.

All participants consented to participate using a human subjects protection process approved by the University of Minnesota Institutional Review Board.

Data Sources

Data came from two sources. The first was the application for participation in the Doula Access Project. This application included a series of open-ended questions that candidates responded to including: (1) why do you want to be a doula? (2) What are three goals you hope to achieve as a doula? (3) What in particular attracted you to this training opportunity through the Doula Access Project? (4) Are there any specific ethnic groups or women of a specific culture that you wish to work with and why? Responses to these four questions from the application were extracted from the application and paired with the respondent’s interview notes.

Second, we conducted semi-structured interviews, lasting between 30 and 90 minutes (average interview was 60 minutes), with the newly trained doulas. An interview guide was created and used to conduct semi-structured interviews (Table 2). These questions were shared with community partners for input and feedback and revised before interviews were conducted. These interviews focused on motivations for becoming a doula; sustainability of doula work as a career; and relationship between doula care and positive birth outcomes.

Table 2.

Semi-structured interview questions

Motivation and training for a career as a doula	Why did you decide to become a doula? What were the most useful skills you learned in training? What skills do you think are most important for future doulas to learn about working with women from your community or women like those you’ve supported? How many births have you supported to date? How many prenatal visits did you do with each mother? How many postpartum visits did you do with each mother Has anything surprised you about being a doula?
How doula care can improve outcomes	There is a documented relationship between doula care and positive birth outcomes (lower rates of cesarean delivery, lower rates of preterm birth, higher breastfeeding, more satisfaction), How have you seen this work for the women you have worked with?   Women’s health (healthy pregnancy, preterm)   Women’s health care/procedures/intervention (cesarean, induction, epidural, etc)   A good birth/satisfaction (respect, agency, connectedness, security, knowledge)
Career plans and trajectory	Tell me about how you foresee your work as a doula. How do you see this working for you over the next 5 years? Have you made changes or special arrangements with family, friends or other jobs to accommodate your doula work? Do you think being a doula is a good career option for other women in your community? Why or why not?
Financial aspects of a doula career	Do you see doula work as a viable career financially? How much money do you need to make a month/year to make this work for you on either a full time or part time basis?
Participation in Doula Access Project	How have things been going with your participation in the Doula Access Project? What kind of feedback would you give us about the program (e.g. how its structured, requirements, etc)? Finally, is there anything else you would like to share or anything you’d like to clarify?

Interviews were conducted either by the first author (R.H.) or a trained research assistant and held at community locations selected by the doulas as most convenient for them. Each interview was recorded using a hand-recording device. The interviewer also took detailed notes of participant responses during the interview. The interviewers also noted participant demeanor and tone in the notes. The audio-recordings of the interviews were not transcribed in full; instead, recordings were used for clarification to support the detailed notes when needed and to confirm specific quotations. Notes from each interview were written within 24 hours of completion of the interview.

Analysis and Coding

We used an inductive approach to qualitative data analyses³⁷ to identify emergent themes around respondents’ motivations to become a doula.

A co-analysis method³⁷ was used by two research assistants and the co-authors. This methodology allowed for both co-authors and the research assistants to code individually, thus ensuring that initial coding was separately and independently validated. This method also provides a check on selective perception and illuminates blind spots in an interpretive analysis.³⁸ All co-authors had experience coding and analyzing qualitative data. Coding was conducted in a shared spreadsheet document. After the first round of coding, the team met to agree upon the initial codes, to refine codes and definitions for clarity, and to discuss differences between coders. Then, the lead author (R.H.) led a second round of coding; grouping each of the codes to identify which themes emerged as patterns across each of the interviews. This process was used first to code the open-ended responses on the Doula Access Project applications and repeated to code the responses to interview questions. While the two pieces of data were paired for each participant, they were coded separately. Coders were instructed to note changes in motivation that may have occurred in the 6 months between data collection points. Prolonged engagement allowed us to confirm credibility of our data. Both co-authors participated in the applicant interviews for selection into the Doula Access Project. Both also participated in the entire doula training, which allowed for a deep understanding of the backgrounds and motivations of the participants. Data saturation was achieved among interviews and open-ended application responses.

RESULTS

For women in this study, the underlying motivation for becoming a doula related directly to feeling called to support women from the doula’s own racial, ethnic, or cultural community. This overarching theme (“being a doula is my calling”) and 3 major sub-themes emerged from the interviews and responses to the Doula Access Project application as the motivations to become a doula for this diverse group of women. The key overall theme and each of the 3 sub-themes are described in detail below.

Being a doula is my calling

The overarching theme that emerged from these analyses was “being a doula is my calling,” meaning that the women felt very strongly, almost as a gut instinct, that they were called to the work of supporting women in childbirth and were motivated to integrate doula work into their lives because of this calling. The sentiment most often expressed among the participants was “I feel called to do this work and honored to be able to support someone on such a beautiful and special journey.” This key theme and motivation, when voiced by women of color, is particularly salient within the historical, cultural and social context of their lives and lived experiences.

For many women, this calling stemmed from a deeply historical understanding of childbirth in their respective communities, cultures, and families: “It’s in my family—part of my lineage so it’s always been a calling.” This strong connection to one’s history appears to be intertwined with culture. “Being a Doula allows me to carry on the legacy and knowledge of the women in my own family ....I relish the opportunity to honor the work that has been done before me.” Simultaneously, doulas felt a calling to protect women culturally and emotionally during a liminal transitional life moment. They felt strongly that culture is a significant and important aspect of pregnancy and childbirth and that women who are vulnerable or disadvantaged deserve the opportunity to reconnect with and have support from someone who understands their cultural beliefs and values: “Because I am an Indigenous woman I think it makes sense for me to help support other American Indian women because I can also support them culturally.” Ultimately, they felt they possessed knowledge to offer women from their own communities, and their own identity included this “calling” to confer support and share knowledge with women from their communities.

The doulas also acknowledged their personal calling within a social context. In particular, doulas felt a “calling” that was linked to a desire to personally take part in efforts to ameliorate the birth-related challenges faced by women of color and from marginalized communities. “…the women don’t have capacity or time to do research, go to prenatal classes, they deal with too much. I’m the only sounding board or fountain of information outside of their doctor.” Another doula explained that women in her community need this type of individualized social support that comes from the knowledge she gained through lived experience, “I was attracted to this opportunity [becoming a doula] because I am was on public assistance during all of my pregnancies and births. I feel that I have a unique perspective being a minority as well as below poverty level.”

Taken together, these historical, cultural and social elements shaped the overarching notion of a calling. However, there are important elements that highlight in greater detail what that calling entails and are described below as three sub-themes.

Holding the space

This sub-theme refers to the birthing space as something doulas hold so that the birth experience unfolds safely and powerfully within that space.²¹ This “space” for doulas may be physical in some aspects (eg, home, clinic, hospital). However, the space more frequently embodies the emotional interactions that occur between doula and client, in which a doula is empowering a birthing woman.²¹ In this way, it represents an emotional presence during the laboring process that non-verbally communicates a felt-message of trust and empowerment in the mother and the process.³⁹ Our findings suggest that women were drawn to or motivated to doula work for the opportunity to, hold the space for women of color, inherently recognizing and acknowledging the historical and structural factors that shape this space differently for women of color:

We [women of color] are given such a negative narrative of birth by popular culture and I think its critical to empower women to take back our births! I think support is needed for women of color that don’t necessarily have the means to get support. It’s incredibly important work and I want to be a part of it.”

In general, respondents described holding the space as a desire to create and maintain an intimate relationship before and throughout the birth experience that empowers women to have the kind of birth they want. The doulas recognized and were motivated by the notion that attending to childbirth is an intimate experience manifesting a particular sense of care and connection.

In the particular context of women of color, doulas were very aware of the potential for negative experiences to occur when pregnant women, with few resources and limited power, are accessing a health care system replete with structural racism.⁴⁰ Therefore, holding the space did not just refer to the labor and delivery process but holding the space during prenatal appointments. One doula explained that “[I want to] impact healthy pregnancy, help them [pregnant women] ask questions of their doctors or I will ask providers questions in a non-threatening way.” The idea of holding space in clinical settings is less explored, but may be an important aspect of how women from marginalized communities interact with their health care providers.

The doulas also expressed the notion that the ability to hold space may be strengthened if the doula and client share their racial, ethnic, or cultural background. These doulas, who self-identified as women of color, felt it was their calling to serve in this role and foster these connections “…I can offer the cultural piece—make that connection.”

Others explained the emotional connections “[I have] the ability to empathize and put myself in their shoes, being able to make an emotional connection,” or the desire to make connections through sharing similar stories “The ways that we can make connections with people by sharing similar stories…we establish I’m here for you and on this journey with you and now the connection is established.”

Honoring the ceremony of birth

When asked why they wanted to become a doula, many of the women discussed the desire to honor birth as a ceremony. “Waiting for life to come... The honor of sharing space in the ceremony of birth, in these important moments is huge.” For most of the women in the study, becoming a doula was an important way to acknowledge traditional and ceremonial aspects of this important life transition, especially for women of color, and many expressed this as “bringing back” or “giving back” the power related to the ritualistic or ceremonial aspects of birth.

I still feel passionate about opportunities to give people back their power and birth is ceremony for women and that aspect has been taken from us and with medicalization of birth we have lost our power. When I saw the opportunity to get trained [as a doula], I ran with it.

Many referred to birth as a ritual and talked about the loss of that ritual for women of color, noting their own motivation to help women “claim” this sacred power.

Birth is a ceremony and a time for women to claim their power. In our communities we have lost that connection to the sacredness of birth and as a result have forgotten our power as women. I want to be a part of reclaiming that.

The sole source of culturally-competent support during birth

One of the key aspects of the “calling” that doulas in our study reported was being the sole source of culturally-competent support during childbirth. They saw their role as providing the cultural support necessary, for women and for clinicians, to improve the quality of the birth experience. In many instances, the doula felt as though she was the sole source of culturally-competent support for diverse women during pregnancy and birth.

[I will] work with communities of color, and immigrant/displaced/migrant communities…. Why do I want to work with these communities? There are very few like them as OBs and midwives. They need to have someone who knows them culturally. I feel this quote sums it up best- ‘No one is free when others are oppressed’.”

Doulas voiced a strong connection between their desire to provide culturally competent care and a commitment to social justice issues. Many viewed becoming a doula as a means of impacting broader social determinants of health by providing support to one woman at a time, to transform the experience of childbirth more broadly for women of color: “I would like to not only be a doula for folks thru a social justice lens but also to advocate within these systems we navigate as people who give birth.” Overall there was a strong sense of social justice and a feeling of responsibility to take care of one’s cultural community, even (and especially) when the doula saw herself as the “only one” present at a birth who was equipped to provide this support.

Doulas also expressed the need to fill the gap around cultural practices and birth. They noted that often times, women are unable to access important cultural aspects of birth without a doula present “…we need to be there for these women spiritually and in the way they want.”. Another took this a step further explaining that she had a significant calling to ensure that she provides each woman with the “cultural stuff” that is important to her “I did a lot of cultural stuff; smudging the room, etc being the buffer and be comfortable with dealing with that and taking care of the mom, etc.”.

DISCUSSION

The goal of this study was to characterize the intentions and motivations of racially and ethnically diverse women who chose to become doulas through analysis of their program application materials and interview questions. Prolonged engagement between the research team and the program participants deepened both trust and shared understanding, allowing for a unique contribution of community-based voices to the academic and clinical understanding of the doula workforce and its potential for supporting women of color during pregnancy and birth.

For many of the doulas of color that we interviewed, the underlying motivation related directly to a desire to support women from their own racial, ethnic, and/or cultural community. The key theme was perceiving birth work as a “calling;” while sub-themes were easing women’s transitions to motherhood by “holding space;” honoring the ritual and ceremony of childbirth; and providing culturally-competent support, often as the sole source of cultural knowledge. The insights provided by the women of color in our study helps advance an understanding of how doulas of color view their role in pregnancy and birth, and also offer insights into strategies to effectively recruit and retain a diverse doula workforce.

Motivations for becoming a doula among the women of color in our sample were broadly consistent with Lantz and colleague’s earlier study, which found that most women in their sample (predominantly white women) wanted to become doulas in order to support and empower women and ensure that women have the birth they desire.²⁶ What was different is that the women in the Lantz study also describe a number of specific intrinsic motivators that were driving their desire to be a doula. For example, nearly half of the women in the Lantz study reported that being part of and witnessing the birth process (often described as “a miracle”) was important to them as is receiving gratitude, appreciation, and positive feedback from clients. On the other hand, the doulas in our sample tended to have more altruistic and extrinsic reasons for entering a doula career. Indeed, the women in our study viewed their specific role and identity as women of color as crucial to understanding the struggles that women in their communities are facing and supporting their peers during pregnancy and birth.

None of the doulas of color in this study indicated a desire to become a doula as a stepping-stone to another career such as becoming a midwife or physician. On the other hand, the Lantz study found that nearly 30% of the sample viewed their doula work as part of a trajectory towards a clinical or medical career.²⁶

The doulas in this study spoke of their desire to enhance women’s empowerment in the context of childbirth and more broadly in their lives. They recognized the importance of racial, ethnic, and cultural identity in their motivation to become a doula and in the ongoing work they do. Our findings corroborate recent studies of African American and other under-represented minority physicians which suggest that for these populations, there is an underlying sense of social justice and desire to improve one's community, which exists simultaneously with their obligations as health care providers.³² The term used to describe this phenomenon is “race-conscious professionalism”.³² The motivations articulated by the doulas in our study in many ways reflected race-conscious professionalism.

Implications for policy, practice, and future research

Given the strong evidence base linking doula support with improved birth outcomes,^10,11,14,15 successful recruitment and retention of women of color as doulas may support broader efforts to improve access to doula care and address longstanding disparities in birth outcomes. These findings have several implications for practice. First, the racial concordance literature in clinical medicine suggests that having a diverse care team (which may include a doula) can improve patient outcomes. When minority patients have a racially and/or culturally concordant patient-provider encounter, there is improvement in the quality of communication, comfort level, partnership, and decision-making in patient-practitioner relationships,^{12, 41, 42} thereby increasing use of appropriate health care and adherence to effective programs, ultimately resulting in improved health outcomes.^{12, 43}

Second, the trust in health care hypothesis¹² suggests that greater diversity in the health care workforce will increase trust in the health care delivery system among minority and socioeconomically disadvantaged populations, and will thereby increase their propensity to use health services that lead to improved health outcomes. The results of this study suggest exploring this notion further within the context of doula support, particularly given findings that providing culturally competent care for women of color is an important motivation for the doulas in our study.

Third, the professional advocacy hypothesis, outlined in a report by the US Department of Health and Human Services,¹² suggests that health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds will be more likely than others to provide leadership and advocacy for policies and programs aimed at improving health care for vulnerable populations.¹² Future studies that seek to understand how the calling to become a doula is related to professional advocacy will be important given the underlying desire to promote social justice that was evident among participants in this study.

Finally, a more comprehensive understanding of the motivations that lead women of color to pursue and sustain a career as a doula suggests the need for policy strategies that reflect this understanding to ensure successful recruitment and retention of women of color as doulas. In the state of Minnesota, an evaluation of the first year of Medicaid coverage for doula services offered several relevant recommendations that merit consideration in this context: 1) reducing financial barriers to entry (training and registration) possibly through grant or subsidy programs that allow women of color to train as a cohort, 2) ensuring adequate reimbursement of services to allow low-income women to maintain doula careers serving women in their own communities, and 3) professionalization and formalization of existing networks of doulas of color.³³ To date, doula participants in this study have been involved in advocating for policy change and likely will continue to do so.³³

Limitations

This study was not without limitations. First, the sample size was small (n=12). The sample used for this study was a convenience sample from one metropolitan area of the United States; thus broad generalizations cannot be made. To that end, these data represent the experiences and thoughts of doulas from specific racial, ethnic, or cultural communities and therefore are not fully generalizable to all experiences. A majority of participants had attended between 2 and 6 births at the time of the interview. Our focus was on early perceptions and we do not expect that what intrinsically motivated these women to become doulas will shift as the number of births that they attend increases; although, future studies could follow experienced doulas of color over time to better understand their career trajectories. Finally, this exploratory study has helped generate new knowledge about motivations for entering the doula workforce, but does not establish a causal pathway between doula support and birth outcomes, as this is beyond the scope of the analysis.

CONCLUSION

A strong desire to support women from their own racial, or ethnic, cultural communities during pregnancy and childbirth, motivates doulas of color to enter this profession. Additionally, doulas of color feel a “calling” to their work and report gaining satisfaction from honoring a woman’s cultural beliefs, preferences, and rituals or practices during pregnancy and childbirth. Given the evidence linking doula support to improved birth outcomes, successful recruitment and retention of women of color as doulas may support broader efforts to reduce longstanding disparities in birth outcomes.

Quick Points.

Many women of color have a strong desire to support birthing women from their communities, which motivated their entrance into the doula profession.

Additionally, doulas of color feel a “calling” to their work and report that they place value and gain satisfaction from honoring a woman’s cultural beliefs, preferences, and rituals or practices during pregnancy and childbirth.

Given the evidence linking doula support to improved birth outcomes, successful recruitment and retention of women of color as doulas may support broader efforts to reduce longstanding disparities in birth outcomes.

Biographies

Rachel R. Hardeman, PhD, MPH, is an Assistant Professor of Health Services Research Division of Health Care Policy & Research at the Mayo Clinic.

Katy B. Kozhimannil, PhD, MPA, is an Associate Professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health.