Anne Wallen is a respected figure in women’s health with over 30 years of experience and is a leading voice on global change in maternity care – particularly for those at greatest risk.
By now, you have probably heard of doulas. What you might still not know is their exact role in maternal care. The word doula (pronounced DOO-luh) is actually Greek. Historically, it referred to the female servant in a household that specifically cared for the woman in the family with whatever she needed regarding fertility, pregnancy, childbirth, breastfeeding and postnatal care. Today, this word refers to a support person (usually female) who is providing emotional, informational and physical support to a birthing or postnatal mother* throughout the maternity experience. Doulas are not medically responsible for the outcomes of care the way that a midwife or doctor would be. They don’t “catch” babies or do any clinical care, but their contribution to the well-being of the mother is undeniable and so important.
*While gender identities can be fluid, we will refer to the birthing person as “mother” for the sake of this article.
You might be wondering why someone would want to hire a doula or what all the buzz is about. Well, for the past 50 years or so, birthing practices around the world have been changing. Specifically in the United States, births have transitioned from being in the safety of the home with a familiar caregiver called a midwife, to being in hospitals with staff who are usually strangers or barely acquaintances, where complications and deaths caused by hospital borne infections, procedural mistakes, injuries and maternity related illnesses have risen from 17.4 in the year 2000, to 23.8 in 2020 (calculated per 100,000 births).
While that might not seem like a big jump, please keep in mind that other countries’ maternal mortality rates (average of 4.7 among developed countries) are going down, while ours continues to go up even though we spend more money on healthcare than any nation on the planet. This makes the critical thinker begin to wonder: Perhaps the fact that we are a profit driven healthcare system in comparison to those other countries, has a role to play in this disparity.
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Not only do we have an overall crisis of care when it comes to pregnancy and postnatal death rates, but the color of your skin in the United States apparently puts you at an even greater risk of death as well. Depending on where you give birth, black mothers have 5-9x greater risk of death (like in New York City) when comparing to their white counterparts. In my personal and professional experience, death is not the only increased risk factor for mothers of color; as trauma, injury and other complications aren’t statistically followed but have a great impact on the experiences that these women face when entering a medical system built on white patriarchal “good business” structures and mindsets.
Black women have a much greater risk of death during their maternal care experiences:
When you think about how abysmal our maternal care outcomes are compared with the rest of the world, we need to look at the differences in mindset, belief systems, practices and how can we turn things around. The first thing to delve into more deeply is the lack of education and understanding of self-health. The average person does not have even basic understanding of the anatomy and physiology of female bodies and the reproductive system. Compound that with traditional beliefs where sex and reproductive health is taboo, “sinful” subject matter that make people uncomfortable to talk about. When you have a lack of knowledge and a shame-based mentality around a topic, you leave it to an elite group who become the experts – the possessors of this mysterious information and anyone not in that group will be easily manipulated by “experts”.
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So, we don’t hesitate to say that Doulas save lives! That is a pretty bold claim. However when you think about what a doula’s role is, and when you encounter a doula who is well-trained and understands how to stay within their Scope of Practice, abide by a Code of Ethics, and knows how to professionally and compassionately support families while they navigate the medical system, it makes sense – especially when we are talking about a profit driven medical system like we have in the United States. Not only does having a doula by your side help with the emotional journey, but it can also help you to wisely navigate choices without feeling pressure from providers who often lack the ability to provide quality time or may have other conflicts of interest such as constraints by insurance companies, etc.
Let’s dig deeper into what all of this means. To start, we have to look at where Maternal Care has been over the past century, because major changes have happened and the general public (while overwhelmingly dissatisfied with the state of all medical practice at this point) has no idea why it’s gotten so bad. History shows that maternal outcomes are affected by a number of complicated factors but in the end, the top 3 appear to be: healthy lifestyle choices, educational access, and the choices made by patients under the advice of medical practitioners.
Less than 100 years ago, the majority of women gave birth where they conceived – in the safety and privacy of their own homes, with skilled, experienced maternal health specialists called midwives attending them. When a medical emergency came up, the mother was transferred to hospital care where surgery and other interventions were utilized to protect the well-being of mom and baby. This model of care is still used for the majority of patients in most places around the world where birth outcomes are best.
Times have changed, and not for the better
Homebirth was the norm.
Birth was seen as a rite of passage and the challenge of the experience was desirable.
Mindsets about birth were healthy and excited vs fearful and dependent.
Midwives were the main caregivers for pregnant and birthing families.
Complications were lower.
Hemorrhages were fewer.
Infections were fewer.
Maternal satisfaction was higher.
Resulting in
Higher breastfeeding rates
Healthier infants and children
Depression and other PMADs were significantly lower
Autism, ADHD, Allergies and other childhood issues were rare
At this point in history, what’s been established is that a major contributing factor for all of these bad outcomes is the lack of truly personalized care. Patients are not listened to or sometimes simply not believed when they present a symptom and this points to a much larger problem with sexism and the control of women’s bodies that we won’t get into (at least not today haha)! However, if we know that women are not being listened to, and this leads to poor outcomes, this sound like a simple problem to fix. Right? Except that it’s not. Have you ever tried turning an entire profit-based system on its head? In order to affect outcomes, we need to change mindsets of not just caregivers, but also society as a whole because within just a few generations, we have lost all the positive mindsets that accompany birth and replaced them with fear and dependency on others. We are too comfortable with giving our autonomy away.
Let’s look at the players in the game
There is a major difference between hospital caregivers – who are trained to maintain an authoritarian position at all times with their patients, with the goal to gain compliance (in the name of safety and litigation avoidance), and that of the core meaning and role of a doula – as servant and support. Whether it’s an Obstetrician or a Midwife, if they are employed by the hospital, they must obey protocols put into place by their employers. With a doula, her employer should always and only be the birthing person themselves – with no others dictating her role, telling her what skills she’s allowed to utilize, and her sole focus and interest is the birthing family. If this dynamic gets muddied by any outside interest, the (purity, clarity, dedication, commitment) of the doula relationship is hindered and becomes less effective.
Let’s imagine that you’re in a position where you are a doctor and you went to school a long time. You know a lot more than the patients in front of you all day, and that knowledge is meant to provide care of their health. They came to you for this care, right? Now, compound that with the expectation that you get things perfectly right every time or bad things will happen to you personally: being sued, having your license taken, your livelihood taken, even the possibility of prison… When you were in school, you were told that you have all the answers and that life and death is in your hands every day. You were taught that you must gain compliance from your uneducated patients (who might make demands on your limited time and require explanations, and give you push back before they say yes to what you believe is the right path for them) or things will surely go very wrong. Patients like that are joked about and groaned about, as an annoyance because they get in the way of you “doing your job”. You were taught that birth is dangerous, that “normal” is a very small container of traits that everyone must fit into or interventions must be used to control the process. You were taught and convinced that birthing bodies always “malfunction” in some way, no matter how small and there’s a crisis just waiting to happen at any given moment because of it. This is confirmed by the stories you have heard of tragedies and people just like you who suffered the consequences both personally and professionally from bad outcomes.
Add to all of this, the constraints by insurance companies who limit the amount of time you’re allowed to bill for so you can’t give more time to patients to educate and help them understand what you’re seeing and recommending and why, and hospitals boards (chaired by more financiers than caregivers) who tell you what your job should look like in order to provide profitable, efficient care. On top of all of that, if you don’t operate within this box, you face potential employment insecurity. You likely owe huge amounts of school debt for years, maybe decades beyond residency and the liability insurance you’re required to have continues to skyrocket as obstetric litigation becomes more and more common.
In school, doctors, nurse-midwives and even registered nurses are taught the answer is compliance and how to appear trustworthy, so patients will do what you say with less questions, saving time and irritation. You’re taught skills on how to gain this compliance with body language, words and tone, and it’s very effective, so you continue to use it.
In the mind and psyche of most birth practitioners, there is a war going on between fear and arrogance. Fear, because they really do care – about their patients and about their own consequences, but also a learned arrogance that they believe they know more than the person sitting in front of them and if a patient doesn’t agree or doesn’t want to comply, it will cause problems, which leads to feeling like they are in an adversarial position, creating more fear and to cover the fear, they step up higher into the authority attitude, which requires more arrogance. Do you see how this upward spiral keeps caregivers from taking time, seeing all the information, and actually listening to their patients?
The answer is to slow this process down, recognize humans as individuals, respect their bodily autonomy and really listen to them. This is at the heart of good doula work and it’s why we see better outcomes when doulas are involved in maternal care before, during and after the birth. Doulas should never see medical providers as the problem. They should never create or foster an adversarial mindset around medical practitioners. If their client is choosing to birth in a hospital, a well-trained doula will understand the demands put on hospitals practitioners, as well as the protocols in place to keep everyone safe, and a well-trained doula will know how to navigate this complex experience with their clients to get the best outcome possible in this “artificial” setting.
With all the demands put on medical providers, and the sometimes very challenging work environments they find themselves in, doulas can fill in the gaps. Doulas can and should be spending several hours cumulatively with their clients during pregnancy, to prepare, educate and support the birthing family as they navigate the healthcare system as well as the transformation of their personal lives while they look forward to welcoming their baby. Doulas are not just for people who want to go all natural with no pain meds! Doulas are for any and every pregnancy and delivery path. For example, in a hospital setting, you will find that more than 90% of patients are choosing epidural pain relief. However, while that can be useful for preparing a patient for eventual surgery, it has a number of other caveats to it’s use, including actually increasing the need for surgical birth for a variety of reasons, including maternal-fetal positioning among others. Maternity Wise International is a doula certification organization that also provides the premier educational program for doulas who want to reduce the complications that come along with epidural use. It is called the EpiDoula course and it is part of their Labor Doula Certification program. While other doula training programs focused on the natural, unmedicated birth narrative, MaternityWise looked at the reality of what was happening in hospitals and decided to create change by supporting the choices of birthing people to utilize epidural pain relief while also helping them to avoid unnecessary complications whenever possible, by teaching doulas how to address the many (and often unnecessary) complications that can arise and require additional interventions which can snowball into a true medical emergency.
According to Harvard Health, a 2023 analysis found that doula support was linked with better birth outcomes, such as fewer c-sections and premature deliveries, and shorter length of labor. Additionally, researchers found that the emotional support provided by doulas was associated with less anxiety and stress in the birthing family. It is important to note that the scope of a doula’s impact is not limited to the birthing event alone. Among low-income women especially, doula support was shown to improve breastfeeding success. When you have fewer c-sections, you will automatically have lower numbers of other risk factors and bad outcomes like infection, hemorrhage, trauma, even death.
So yes, while it is a bold claim, doulas do save lives. These are doulas who are well-trained and able to understand the complex system of human interaction, racial disparities, systemic prejudice and sexism, industrialized narcissism, the anatomy and physiology of a birthing body as well as how to walk the labyrinth of becoming parents with their clients. How? In summary, it is because they care and their investment is in the family they serve and no one else. Knowledge is power, but knowledge takes time to share and doulas don’t have the same constraints on their time. For doulas, time is a powerful tool they use to prepare and encourage and reassure their clients. For doulas, that quality time and getting to know their clients helps them to walk through the rite of passage with them. For doulas, time and loving care along with listening, validating and opening up resources and education are the most powerful and impactful things they can do for and with a client. As doulas, we don’t speak for the client. We make sure her wishes are heard and her choices about her body and her baby and her process are respected. Well-trained doulas are the ultimate body autonomy warriors and this makes all the difference!
MaternityWise Institute provides international board certification for Labor and Postpartum Doulas as well as Lactation Support, Childbirth Educators, Infant Sleep Specialists among many other modalities that make a difference for families in the childbearing year. You can find online or in-person doula training and certification, please go to here and choose the path you’d like to take, for a well-rounded education that will save lives and help to change the birthing world along the way.
Anne Wallen, Director and Founder of MaternityWise Intl
Anne Wallen is a respected figure in women’s health with over 30 years of experience and is a leading voice on global change in maternity care – particularly for those at greatest risk. She continues to educate and empower birth professionals in more than 20 countries, contribute to a variety of curriculums, and shape the future of maternal health through her impactful role as a speaker and mentor. Anne is the Director and co-Founder of MaternityWise International and her legacy lies in inspiring generational changes around, and elevating women's healthcare worldwide.
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