Promotion and Prevention of Perinatal Mood and Anxiety Disorders: Doulas’ Roles and Challenges

Abstract

Doulas are uniquely positioned to support women during birth and the postpartum period and can serve as a great asset to identify symptoms of perinatal mood and anxiety disorders (PMADs) and refer women to treatment. The goal of this study is to increase knowledge of doulas’ training on PMADs and their work with women who experienced symptoms. Results from a survey of 156 doulas and interviews with 27 doulas indicate that they felt ill-prepared to identify PMAD symptoms. They struggled in referring patients to the appropriate services and finding professional support related to supporting clients with PMADs. The study concludes that there is a need to develop a standardized model for postpartum doula care that explicitly addresses PMADs.

Doulas, whose primary role is to meet the woman’s emotional needs instead of their physical needs, have a unique opportunity to assess and provide perinatal mental health interventions. Furthermore, the doula’s professional values of educating and empowering women, and the doula’s ability to provide support by being present and listening, are important when considering the helplessness and social isolation experienced by women with poor maternal mental health (Campbell-Voytal et al., 2011; Deitrick & Draves, 2008). Doulas also provide important culturally competent support to low-income women and those with limited English proficiency as they navigate the complex health-care system (Kang, 2014).

Doulas are trained professionals who provide nonmedical physical, emotional, and informational support to pregnant and childbearing individuals. The scope of doula work ranges from the prenatal to postpartum periods. Generally, “birth doulas” meet prenatally with clients to establish a trusting relationship during the pregnancy before providing continuous labor support during the birth and immediate postpartum period. During their visits, doulas support their clients as they develop a birth plan based on the mother’s expectations, fears, and goals. The birth doula remains available to the client throughout the entire birth process as a source of affirmation, encouragement, and emotional and physical support. Doulas also promote communication between their clients and their clients’ medical providers regarding their hopes and preferences for their births, as well as their individual care needs. Typically, birth doulas also provide one or two visits within the first few weeks following childbirth. During these visits, the doula observes how the baby has been integrated into the family. The doula again listens to any concerns from the parents and provides them with resources and emotional support as necessary.

Doulas offer support throughout an extended period of time after the birth by providing information about breastfeeding and newborn care, as well as assisting in the emotional processing of the birth and navigating the client’s transition to parenthood. Given that the scope of practice for doulas centers on providing continuous and individualized emotional support, they are ideally positioned to assess for potential perinatal mood and anxiety disorders (PMADs) symptomology and to make referrals to mental health treatment.

Little research has been done on the doula population, doulas’ role in mental health assessment and prevention, and doulas’ training to identify components related to PMADs (McComish et al., 2013). This mixed-method study was designed to expand on the existing literature on the role of doulas in identifying and referring women to mental health services by focusing on three research questions: (1) What are doulas’ perceptions of their role in identifying the symptoms of PMADs? (2) Does doula training include sufficient knowledge on how to identify PMADs and how to support women with PMADs? (3) What are doulas’ field experiences of working with clients with PMADs, and do they practice a collaborative approach?

REVIEW OF THE LITERATURE

Up to 80% of women who give birth report feeling postpartum “baby blues” as a normative response to this immense transition (Stewart et al., 2003). According to Newport et al. (2002), women are more likely to develop depression and anxiety symptoms during the first year after childbirth than at any other time in their lives. Approximately 20%–25% of women suffer from PMADs (Fairbrother et al., 2015). Specifically, estimates of the prevalence of prenatal anxiety range from 13% to 21% of all new mothers, with the prevalence of postpartum anxiety estimated as between 11% and 17% (Fairbrother et al., 2015; Field et al., 2005).

PMADs are one of the most common complications of pregnancy, and it is critical that efforts are made to educate parents and providers about them. The wide spectrum of symptoms and diagnoses related to PMADs includes depression, anxiety, post-traumatic stress disorder, and obsessive-compulsive disorder. PMADs have a quite significant adverse impact on the mental, physical, and emotional health of not only the women who experience them but also their children and families (Challacombe et al., 2016; Giannandrea et al., 2013; Mulder et al., 2002). PMADs are associated with adverse pregnancy outcomes, miscarriage, pre-eclampsia, preterm birth, and low birth weight (Field et al., 2005). Moreover, PMADs can compromise parenting, impair effect, and behavior regulation, and lead to insecure attachment with the infant (DiPietro et al., 2006).

Particularly concerning is that up to 50% of mothers with symptoms will not seek mental health treatment (Martin et al., 2014; Woolhouse et al., 2015). As a result, in recent years, there has been a push for medical providers—including midwives, obstetricians and gynecologists, and pediatricians—to implement streamlined procedures for the assessment of these conditions.

WHO CAN HELP?

During and following pregnancy, women often work with a range of health-care professionals such as doulas, midwives, obstetricians and gynecologists, pediatricians, and other support staff. In order to increase the number of women identified and referred to mental health specialists, many public health policies advocate for these professionals to assess and speak with women about PMADs. The American College of Obstetricians and Gynecologists’ (ACOG) (McKinney et al., 2018), 2018 guidelines encourage providers to screen women at least once during the perinatal period and complete a full mood assessment, including for postpartum depression (PPD), in the postpartum appointment (thereby optimizing postpartum care). Prior to the issuance of these guidelines, screening was neither consistent or universal. For example, a 2011 survey of ACOG members found that routine PPD screening was completed by only 72% of respondents (Leddy et al., 2011).

Health-care professionals vary in their levels of comfort, confidence, and practice in terms of assessing and providing resources for maternal depression. A study comparing pediatricians, obstetricians, and family medicine physicians identified key differences between them despite all professionals recognizing their responsibility for and the importance of assessing and supporting mothers with perinatal mental health challenges. In particular, obstetricians were most likely, and pediatricians were least likely, to assess women for PMADs. In addition, nearly 40% of primary care providers rarely or never assessed women for PMADs. Obstetricians are most likely to provide counseling or referrals for maternal depression; but only one-third of family medicine practitioners and less than 10% of pediatricians reported providing similar referrals (Leiferman et al., 2008).

Further understanding the perspectives and attitudes of these professionals, in particular doulas, can provide insights about their experiences and indicate which potential systemic changes are needed to improve outcomes for women with PMADs. For example, midwives, who provide prenatal care to women with low-risk pregnancies, have the opportunity to provide psychoeducation interventions and assess for perinatal mental health challenges. Despite recognizing the importance of screening and assessing for PMADs, both are inconsistently provided (Viveiros & Darling, 2018). Some midwives have reported the specific challenge of separating mental health symptoms from the physical symptoms of early pregnancy (e.g., nausea, which is most prevalent in the first trimester) during the first prenatal care appointment since these physical symptoms tend to manifest around the same time that midwives most frequently ask about perinatal mental health (Baker et al., 2020; Williams et al., 2016). Midwives also described the challenge of women themselves holding different views on depression and finding screening questions invasive.

Studies that explore the attitudes and perspectives of midwives have shown mixed results about their knowledge of perinatal mental health disorders and their confidence in assessing them (Baker et al., 2020; Noonan et al., 2018; Williams et al., 2016). Despite this challenge, pregnant women and midwives agree that initial screening questions could be helpful as a way to introduce mental health-related topics. It should be noted that some midwives consider maternal mental health as outside of the scope of midwifery care, which may suggest an underlying bias or hesitation to discuss mental health (Baker et al., 2020). This perspective could pose a challenge to collaboration in multidisciplinary teams or convey a sense of disinterest in their patients’ mental health.

Many pediatricians and other support staff shared these perspectives and challenges. Pediatricians in particular have a unique opportunity to assess for maternal mental health given their frequent contact with mothers at well-child visits. Although research has suggested that maternal depression screening practices increased from 2004 to 2013, recent surveys have indicated a continued need to increase the screening rate, with around half of pediatricians screening for PMAD during well-child visits (Kerker et al., 2016; Yu & Sampson, 2019). Pediatricians identified limited time, limited or no information about mental health referrals, and the difficulty of assessing family members when the child is the primary patient as challenges to screening for maternal mental health (Glasser et al., 2016; Yu & Sampson, 2019). Many women also commented on this focus and explained that sensing that a pediatrician is only concerned about their child’s wellbeing and not their own is a barrier to them seeking information on mental health services from this resource (Byatt et al., 2013; Byrnes, 2019; Young et al., 2019). Pediatricians have reported receiving little or inadequate education about PPD, although pediatricians with more years of experience and/or recent training about PPD reported a higher level of confidence in their assessment ability (Wiley et al., 2004; Yu & Sampson, 2019).

Family practitioners and other primary care providers reported having similar perspectives. Family practitioners were found to be inconsistent in assessing maternal mental health challenges, mostly focusing on PPD rather than anxiety or other disorders (Noonan et al., 2018). Fortunately, studies have indicated that primary care providers are open to using screening tools and that they recognize their responsibility in diagnosing and supporting patients with managing perinatal depression (Gaynes et al. 2005; Kallem et al. 2019). Multiple barriers complicate the provision of such treatment from primary care providers such as their lack of time, high caseloads, and difficulty providing follow-up care (Glasser et al., 2016; Leiferman et al., 2008; Noonan et al., 2018).

Several studies have found that having continuous support during labor and birth by doulas and others improves maternal health outcomes and strengthens the mother’s connection with the infant (Corrigan et al., 2015; McComish et al., 2013; McComish & Visger, 2009). McComish and Visger (2009) qualitatively studied postpartum doula supportive care with four doulas and 13 new mothers. They found that in the postpartum period, doulas mainly provided emotional support, infant care, information, advocacy, referral, resolution of infant feeding, integration of infants into the family, and support for developmental care and attachment. The authors highlighted the immense emotional support that the doula participants in their study provided to women.

Steel et al. (2015) conducted a systematic review of 48 articles related to the training and work experiences of doulas. In their review, they found that doulas help women in four main ways through: (1) physical support: such as birth positioning and light touch; (2) emotional support: including listening, encouragement, and affirmation; (3) empowerment: meaning advocacy, referrals, and information; and (4) information provision: such as offering education and multiple perspectives pertaining to pregnancy. The researchers highlighted that while doulas carry out all four duties, they need better guidance to improve their practice with pregnant and birthing women. Furthermore, they recommended developing more rigorous (particularly quantitative) research to establish evidence-based doula training in order to guide policy and practice.

In a more recent qualitative study conducted in England, McLeish and Redshaw (2018) found that the support from doulas was very important and complementary to the role of their midwives. In this study, 19 volunteer doulas and 16 mothers who had received doula support during birth were interviewed. Findings show that the doulas were motivated to support their clients by advocating on their behalf to the degree that sometimes there was a conflict with midwives. The participants’ doulas highlighted their role in easing women’s transitions to motherhood and empowering them by providing emotional and physical support.

Finally, a relatively small qualitative study with 12 doulas explored the participants’ insights into their training requirements and experiences with women suffering from PMADs. The results showed that while all 12 doulas reported assisting women with PMADs, nine of them felt that the training they had received on PMADs in their doula certification program was inadequate to deal with the situations they had faced with women in practice (Jensen, 2018). Findings from this study highlight the need to develop more research to inform better practices for doulas training.

METHOD

Study Design

A convenience sample of 156 (non)certified birth and/or postpartum doulas from across the country participated in a 57-question online survey. The survey was based on review of the literature (Campbell-Voytal, 2011; McComish et al., 2013; Pascali-Bonaro, 2003) and conversations with doulas. It included an electronic informed consent form, demographic questions, questions regarding participants’ perceptions of their training, professional education, work experience, personal and professional beliefs about PMADs, and assessment of and interventions for PMADs. In the survey, participants could leave their email address if they wished to be interviewed. Following the survey, we contacted the participants who had volunteered and conducted semi-structured phone interviews with 27 doulas to learn more about their experiences of working with women who had experienced PMADs symptoms.

The study was approved by the Institutional Review Board of Long Island University (protocol ID: 19/11-153) and conducted over a five-month period from October 2019 to March 2020. We recruited participants for the study by sending the online survey to the personal email addresses of doulas with profiles on the DONA International website and those with profiles on the Childbirth and Postpartum Professional Association; we also used listservs and Facebook groups for doulas to recruit participants.

Participants

The majority of the participants (n = 150) identified as women between the ages of 25 and 40. Twenty percent of the participants were from the Western United States, 17.4% were from the Midwestern United States, 32.3% were from the Northeastern United States, and 30.3% were from the Southeastern and Southwestern United States.

The majority of the participants identified as White (64.1%); 14.7% identified as Black or African American, and 9% identified as Hispanic, 7.1% identified as Asian, and 5.1% identified as Native. Seventy-five percent of the participants had a minimum of two years of experience working as a doula. About 59 were certified doulas through a US doula organization and the rest were trained through a doula organization but not certified. Sixty percent of the participants were full-spectrum doulas (encompassing the birth and postpartum period and trained in other reproductive experiences, such as abortion, IUD procedures, adoption, etc.); the rest of the sample was birth and labor doulas (working during pregnancy, birth, and into the immediate postpartum period). For a detailed overview of the participants who participated in the survey, see Table 1.

TABLE 1. Quantitative Participants: Demographic Characteristics, Means, and Standard Deviation.

Characteristic	Number	Mean	(SD)
Gender
Female	150	96.2
Non-binary	6	3.8
Race
White	100	64.1
Black	23	14.7
Hispanic	14	9
Asian	11	7.1
Native	8	5.1
Age		36.6 years	1.173
25–34	63	40.4%
35–44	55	35.2%
45–54	17	10.9%
55–64	14	9%
65 and above	7	4.5%
Highest level of education
No degree	38	24.3%
Associate degree	15	9.6%
BA/BS	69	44.3%
Master’s degree	31	19.8%
PhD/PsychD	3	2%
Certified doula	92	58.9%
Non-certified doula	64	41.1%
Birth doula	66	42.3%
Full-spectrum doula	60	38.4%
Postpartum doula	30	19.3%

Procedures for Analyzing the Quantitative Data

Statistical Package for the Social Sciences (version 27) was used to analyze the quantitative data. We descriptively analyzed the data in order to demonstrate the shape, central tendency, and variability within the dataset. The results reflect the valid percentage of the responses. We used bivariate Pearson correlations to assess the associations among continuous variables. A p-value of less than .05 was considered to be statistically significant. In addition, multiple linear regressions were conducted to assess the associations between variables of interest while controlling for potential confounding variables.

Procedures for Analyzing the Qualitative Data

Thematic analysis was undertaken (Braun & Clarke, 2006) to analyze the qualitative data. In this process, we transcribed the recorded interviews and read them to identify concepts. After repeating these steps across all the transcripts, emerging codes and categories were compared by two reviewers (the researchers), connected as appropriate, and organized into key concepts.

RESULTS

Research Question One: What Are Doulas’ Perceptions of Their Role in Identifying the Symptoms of PMADs?

Nearly all of the participants agreed that it is within the scope of the role of the doula to watch for PMADs symptoms and refer clients to mental health treatment (96.8%, n = 151, M = 4.92, SD = 401). Similarly, 93.5% of participants (n = 146) agreed with the statement: “It is important for doulas to assess for PMADs symptoms, risk factors, and protective factors in their work with clients” (M = 4.57, SD = 976). Furthermore, 90.4% (n = 141) agreed with the statement: “Doulas are in an ideal position to assess for symptoms of PMADs due to the nature, setting, and scope of their work” (M = 4.51, SD = 998).

We examined associations between doulas’ perceptions of their need to learn about PMADs and their perceptions of their role in assessing symptoms. Table 2 presents the statistically significant associations between their beliefs regarding the need to learn about PMADs and their perceptions of their role in the field. For example, there was a positive association between the belief that doulas need to be educated and the position they took on their fieldwork as it related to assessment and referral (r =.386, p <.001). There was a positive association between participants’ agreement with the statement: “It is important for doulas to assess for PMADs symptoms, risk factors, and protective factors in their work with clients” and their perception of themselves as being in an ideal position to assess symptoms of PMADs (r =.518, p <.001). A similarly positive association was found between their agreement that it is within the scope of doula practice to assess for PMADs symptoms and that assessing for PMADs symptoms in all clients is a best practice (r =.252, p <.001).

TABLE 2. Statistically Significant Correlations: Doulas’ Perceptions of Their Role.

Independent variables	Dependent variables	Sig.
Q14. It is important for doulas to be educated about the symptoms, risk factors, and protective factors of PMADs.	Q16. Assessing for PMADs symptoms in all clients is a best practice.	.252*
	Q18. If a doula recognizes signs of PMADs in their work with a client, it is their ethical responsibility to recommend the client seek additional support or mental health services.	.299*
	Q19. Doulas are in an ideal position to assess symptoms of PMADs due to the nature, setting, and scope of their work.	.386*
Q15. It is important for doulas to assess for PMADs symptoms, risk factors, and protective factors in their work with clients.	Q19. Doulas are in an ideal position to assess symptoms of PMADs due to the nature, setting, and scope of their work.	.518*
Q17. It is within the scope of doula practice to assess for PMADs symptoms when working with clients.	Q16. Assessing for PMADs symptoms in all clients is a best practice.	.252*

^*Indicates that correlation is significant at the 0.001 level (2-tailed).

In addition, linear regression was conducted to assess the association between the participant’s level of education and their agreement with the following statement: “It is important for doulas to assess for PMADs symptoms, risk factors, and protective factors in their work with clients.” The findings showed that after controlling for age and years of practice, as a doula’s education level increased, their agreement with the statement significantly decreased (B = –.208, SE =.065, p =.002). This finding reveals that the more educated the doula, the less they agreed that doulas should assess their clients for PMADs. Finally, there was an association between the participants’ perceptions of their education (“It is important for doulas to be educated about the symptoms, risk factors, and protective factors of PMADs”) and their fieldwork (“I feel comfortable talking to clients about their emotions and difficult feelings”) (r =.289, p <.001).

Research Question Two: Does Doula Training Include Sufficient Knowledge on How to Identify PMADs and How to Support Women with PMADs?

The findings show that 80.1% of the participants reported that their doula training touched upon PMADs as part of the baby blues symptoms category (n = 125). For example, 73% of participants (n = 114) agreed with the statement: “My doula training addressed signs and symptoms of PMADs such as anger, sadness, irritability, lack of interest in the baby, changes in eating and sleeping habits, trouble concentrating, thoughts of hopelessness, and thoughts of harming themselves or the baby”. However, only 57% (n = 89) reported that their training addressed multiple PMADs symptoms and made a clear distinction between PPD and PMADs.

Most participants believed that doula training should incorporate a focus on PMADs. Participant 12 explained:

We talked about postpartum depression in my training, I think, they went in depth in regards to that. I do most definitely recall them talking a lot about things like postpartum depression and, you know, catching postpartum, depression symptoms and stuff like that.

The participants highlighted that PMADs and PPD are terms that are often used interchangeably because of a lack of sufficient knowledge about the differences between them. While it is a common source of confusion, in doula training, there is a great need to make a clear distinction between the two as well as the symptoms that may overlap but are often different. Participant 4 explained that oftentimes she does not know how to speak about PMADs, what terminology to use to address changes in moods or anxiety, or how to discuss depression symptoms.

We need more education, we need more opportunities to learn about this stuff. I don’t even have the language, I can’t even tell you the information or the skills we need because it’s so far out of what I know, but I know I need to know more. I think training should go over specific types of perinatal mood and anxiety disorders in training. I don’t know how to frame the questions with clients, so I think that would be helpful too. Sometimes I don’t know how to address it.

Here, the participant expressed her confusion regarding the different types of disorders and emphasized her need to learn more about them so she can link this knowledge to her fieldwork. Another important point that was brought up by participants was their need to learn not just about PMADs but also about related issues such as trauma, stress, and adjustment. Participant 23 explained:

I think we definitely should know more about trauma, I need to know more than I do. I don’t even know the words to talk about it. I took a trauma-informed class in midwifery school and it talked about it. Sometimes it feels like that’s the doula’s job, to try to prevent someone from being traumatized. I’ve been reading these articles lately about how some doulas are brushing trauma under the rug, like if they don’t say something. But I’m not so sure what to do about it. I think part of our jobs is mitigating trauma, but we just got three days of training and because we don’t do medical stuff our job isn’t seen as important, and we don’t get any respect.

PMADs and perinatal depression can be understood in the context of trauma and post-trauma experiences. As a result, it is important to cover the topic from a broader approach to cover a range of symptoms and triggers and train doulas to identify the symptoms or teach them how to articulate mental health symptoms. Considering the amount of stigma associated with mental health, a doula who interacts with her clients should be comfortable addressing the issue.

The findings also show that participants had to increase their knowledge independently through continued education classes. Sixty-four percent reported that they had engaged in continuing education or other professional development opportunities that were specifically about PMADs (n = 100).

PMADs Assessment and Best Practices

The participants agreed that doula training should include education about PMADs and the recommended best practices (strategies, tools, skills, etc.) to support clients who are experiencing PMADs symptoms (n = 149, 95.5%). However, the findings show that only 58.3% of participants (n = 91) reported that their training actually addressed the role of doulas in assessing PMADs, and only 47.5% reported that their training offered information on best practices, recommended strategies, tools, and skills for supporting clients who are experiencing symptoms of PMADs (n = 74). For example, when asked if their training had addressed the risk factors for PMADs (e.g., the lack of a support system, a personal or family history of mental health issues, a difficult or traumatic pregnancy or labor, a history of trauma, challenges breastfeeding, recent life crises, financial stress, or environmental stressors), only 69.8% of the participants agreed with the statement (n = 109). Similar results were recorded for the statement: “My doula training addressed protective factors for PMADs (e.g., family support, financial security, access to mental health treatment),” with which 62.1% agreed (n = 97).

Finally, the participants were asked if their training had included any recommendations on how and what specific screening tools could be used to identify symptoms of PMADs (e.g., the Edinburgh Postnatal Depression Scale - EPDS, the PPD Screening Scale, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder Scale-7, the Perinatal Anxiety Screening Scale), with 41% reporting that their training had provided information about a screening tool (n = 64). These participants also reported that the recommended screening tool was the EPDS.

Participant 29 confirmed that her training had “touched upon” perinatal mood disorders but had not gone into detail to teach her how to identify the symptoms:

In my training, there was a recommended book list; however, none of the books were about PMADs… I wish I knew how to have a real-life conversation, how to work these questions, how to work them into normal conversations specifically because the clients are usually around other family members. We are not therapists, but we need ‘tricks’ to learn how to identify the symptoms… I don’t know how to frame the questions with clients, so I think that would be helpful too.

This reveals that doula training often provides limited insight into PMADs but rarely gives doulas the tools they need to address the topic with their clients or assess the symptoms. The findings show positive associations between the statement: “My doula training addressed multiple PMADs, rather than focusing only on ‘postpartum depression’” and the statements that explore the depth of the training related to PMADs. For example, participants who reported that their training had addressed multiple PMADs, rather than focusing only on PPD, also reported that their training had addressed the risk factors (r =.259, p <.001), the protective factors (r =.277, p <.001), the role of doulas in assessing for PMADs (r =.374, p <.001), and offered best practices (r =.315, p <.001).

There was a statistically significant negative association between the age of the participants and their agreement with the statement: “Doula training discussed the role of doulas in assessing for PMADs” (r = –.208, p <.001). As the age of the participants increased, their reports of having received a PMADs-related education decreased.

Research Question Three: What Are Doulas’ Field Experiences of Working with Clients with PMADs, and Do They Practice a Collaborative Approach?

The results show that 85.9% of the participants (n = 134) had worked with clients who had exhibited symptoms of PMADS. Different from the participants’ experiences of their training, 87.1% of the participants (n = 136) reported that they felt competent in recognizing the signs and symptoms of PMADS in clients, and 97.4% stated that they felt comfortable talking to clients about their emotions and difficult feelings (n = 152). Nevertheless, only 69.2% of the participants (n = 108) reported that they asked clients about the stressors they experience (e.g., environmental, personal, family, relationships, financial, health, etc.), and 60.9% reported (n = 95) that when they notice that their client is looking sad, upset, unhappy, or has a “flat affect,” they discuss it with them. Finally, 39.7% of participants (n = 62) stated that they share information with clients about the symptoms, risk factors, and protective factors of PMADs preventively. The results show that 54.4% stated that they know how best to support clients when they are exhibiting signs of PMADs (n = 85).

The findings show a negative association between the age of the participants (r = –.227, p <.001), their seniority in the field (r = –.210, p <.001), and their agreement with the statement: “I have worked with clients who exhibit symptoms of PMADs.” This result shows that the more experience the participant has and the older they are, the less likely it is that they have worked with women who had PMADs. This may be because they were trained before PMAD received the relevant attention.

Use of Screening Tools

The most commonly used self-report instrument for the assessment of PMADs is the EPDS. However, the EPDS does not contain items specific to mood disorders and anxiety. In addition, PMAD screening tools are limited in their ability to account for racial, ethnic, financial, familial, and support factors. In our study, only 31.4% of the participants (n = 49) consistently used a structured screening tool to assess for PMADs symptoms, and the participants had mixed opinions on whether it was appropriate for doulas to administer screening tools (e.g., the EPDS). As participant 11 explained:

I started carrying an Edinburgh scale with me. I had no idea there were other kinds of forms like that until I took your survey, and I’m looking forward to learning about some of the others. I think the scale is helpful if you have postpartum depression, but maybe not if you don’t. I took it myself recently, and the questions are so specific. I was like, well I’m not experiencing that, but what about all these other things I am experiencing? There was nowhere to put them on the survey.

In addition to the limitations of the EPDS, there is a cultural component that is not fully represented in the scale. As participant 28 explained:

We have a large Latinx community in my town. So, I am familiar with Edinburgh and I know that’s like the most widely used, but there’s some problems with it; it’s just very clinical. And it doesn’t take into account cultural things a lot of times. So, um, I would hesitate to use it. Um, I find that I get more information from people and when I just have a conversation with them and ask gentle, leading questions about how someone’s really doing, and then just the fact that I have a relationship with these people and they know that I’m safe.

This quote supports our findings showing that the participants are more comfortable speaking with their clients about their feelings rather than using a standardized scale. In some cases, the participants did not feel confident using a standardized tool to assess mental health symptoms. Instead, they based their assessments on conversations they had with their clients and their partners. It is interesting to note that 35.7% of the participants (n = 56) reported that they would like to use a screening tool but are not sure how to do so.

Coordination of Care between Doulas and Medical Providers

In this study, 35.9% of the participants (n = 57) reported that there are reputable mental health providers in their community to whom they feel comfortable referring clients who need access to additional support. Participant 3 expressed her thoughts about the need to transform the doula profession into a regulated profession in order to increase the coordination of care and connections with other health-care professionals: “I feel like because it’s not a regulated profession that people question our ability to give referrals if we’re seeing something.”

Doula’s lack of regulatory oversight was brought up by many participants and was perceived as a barrier to their ability to support women. The participants discussed their lack of coordination with other health-care professionals, explaining that even when doulas try to be proactive and advocate on behalf of their clients, they are often dismissed by other professionals in the health-care field, mainly because they are seen as supportive services but not as health-care professionals.

Peer-to-Peer Mentorship

Since the majority of the participants worked freelance, they agreed that they would benefit from additional education, mentorship, and peer-to-peer support opportunities in order to better support clients with symptoms of mental health challenges and also bolster doulas’ mental health and prevent burnout. Participant 5 explained her experience in the field:

I had to find my own mentorship with other doulas, you just take the training and then you go out on your own. I have built relationships with other doulas in town, I think there are like 16 of them. I don’t think there are more than one or two doulas that are gender-nonconforming or not white. There isn’t a lot of conversation amongst us about mental health, although maybe I should be bringing it up more. If I have a question about mental health and a client, that’s why I’d want to ask a therapist not one of the doulas. But it is very helpful to talk about births. We don’t complain about “that client was so hard,” instead, we talk about “wow, that provider was so abusive.” It’s helpful to have people to talk with about the providers in the area.

The participants felt the need to surround themselves with other doulas in order to process their own professional experiences and to develop professional support and a network of referrals as well. Even the doulas who practiced in areas where there were many other doulas still expressed the need for additional support in their work—particularly, a safe space in which to consult other doulas and discuss the problems that sometimes arise.

DISCUSSION

Most of the time, the doula’s role is to be a professional support to their client and their client’s family during the most personal and intimate moments in a woman’s life: pregnancy and childbirth. As such, the doula develops a trusting relationship with clients during a very vulnerable time to which others, aside from family members, do not bear witness. Due to their proximity to their clients during the perinatal period’ doulas have the opportunity to identify mental health signs that may be alarming and which require intervention.

This study revealed that the training that doulas receive is not always sufficient because it does not provide them with enough information about mental health assessment, particularly as it applies to identifying PMADs symptoms. This carried over into the participants’ fieldwork and negatively affected it as well. While they all felt comfortable with providing support to women who have mental health symptoms, they encountered some obstacles in assessing and referring women to treatment. We found the negative association between seniority in the field and work with women with PMADs to be surprising. This may be explained by the fact that PMADs is a relatively new term and awareness of mental health symptoms among women during the perinatal period is a more recent development.

In the United States, there is not currently a nationally standardized protocol for becoming certified as a doula. Rather, doulas can choose to certify with one of a number of organizations that often have similar but independently determined criteria which may or may not encompass education about PMADs. The findings emphasize the need for systematic doula training that will allow for a more specific and thorough exploration of each of the symptoms of PMADs and will offer doulas the tools they need to assess PMADs. After all, it has been shown that the EPDS is the most common tool used to screen for changes in mental health during the postpartum period, yet it is limited to assessing depression and less effective in assessing anxiety and mood disorders. Many of the participants did not use a screening tool at all, mainly because they were either uncomfortable using one or did not know how to administer such a tool correctly. While it may not be the responsibility of the doula to use a clinical inventory, doulas do have a professional and unique relationship with the women they work with, and this special relationship allows them to identify issues that other professionals (such as the obstetrician or pediatrician) might not necessarily observe. As a result, a protocol specially designed for doulas should be developed in order to help them identify the symptoms of PMADs and refer their clients for treatment.

This study identified a systematic barrier related to medical providers’ perceptions of doulas, and to some degree some conflicted opinions related to their role and their part in an interdisciplinary team. It seems that doulas’ voices are not always being heard, and as a result, this affects the coordination of care which in turn directly and negatively affects the women they work with and their families. The participants shared that their experiences of interacting with other health professionals were not always comfortable, mainly because the doula profession was not always recognized as legitimate. In addition, health-care providers do not often coordinate care with doulas because they do not understand their role or know doulas with whom they can connect their clients. Consequently, doulas encounter a lot of resistance and have to go the extra mile and take the initiative to build relationships with health-care providers in the community.

LIMITATIONS

Our sample was a convenience sample. As a result, the sample lacks the randomization and accuracy that is so important when conducting research. Moreover, we recognize that our analysis did not include variation between groups. Specifically, since close to 40% of our sample was comprised of birth doulas and 30% was comprised of postpartum doulas, we wonder if their experiences differed based on their specialized roles. Similarly, we did not assess the differences between certified and noncertified doulas.

CONCLUSIONS

Little research has been done on the role of doulas in supporting women’s mental health. The current study identified the need of doulas’ organizations to develop standardized training protocols related to understanding PMADs and identifying their symptoms. It is recommended that doula organizations revise their curricula to include PMADs and teach doulas about the different tools that could be used to identify PMADs so they can refer their clients to treatment.

The study indicates that doulas confidently support women with PMADs, but they feel ill-prepared to use screening tools and refer their clients to the appropriate services. The main finding is that there is a need to develop a standardized model for postpartum doula care for women with PMADs and learn more about the best practices to coordinate care between doulas and other providers, as well as understand the mechanisms that enable and hinder the coordination of care with doulas.

Biographies

LIAT SHKLARSKI is an assistant professor at Ramapo College of New Jersey School of Social Work and an adjunct professor at Smith College, School of Social Work. Her academic research focuses on women’s access to mental health and psychiatric services during and after pregnancy. Liat holds a Master of Social Work from the University of Washington, Seattle, WA, and is an active clinical practitioner, providing psychodynamic psychotherapy to youth and adults as a licensed clinical social worker in New York City.

LAUREN KALOGRIDIS received her Master of Social Work from Smith College School for Social work, and is certified as a Full-Spectrum Doula through Doula Trainings International. She currently lives in Reno, Nevada, where she works as a psychotherapist and as the Program Manager of an intensive outpatient program specializing in the treatment of perinatal mood and anxiety disorders. Lauren additionally works as a doula with multiple community-based doula organizations locally.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.