What is the “Doula Model of Care”?
Copyright 2018 by Patty Brennan, All Rights Reserved
Excerpted from The Doula Business Guide: How to Succeed as a Birth, Postpartum or End-of-Life Doula, 3rd Edition
What is the Doula Model of Care? Doulas are coming into the cultural mainstream and they are not just for birthing and postpartum mothers and their families. The emerging role of the end-of-life doula is gaining traction and helping transform how we approach end-of-life care in the United States and beyond. As training and certification programs for doulas of all kinds expand exponentially, there is a danger that each new player in the field will attempt to assert their brand by re-inventing and re-defining the role of the doula, potentially undermining evidence-based core principles of what it means to be a doula. Since current evidence for birth doulas is well established1 and based on a model of care that is gaining widespread recognition and acceptance by both consumers and medical care providers, it behooves the doula profession to unite in our understanding of the doula model of care, especially as it evolves to serve diverse needs of families throughout the lifespan.
Preliminary definitions are in order as a basis for understanding. A Model of Care broadly defines the way services are delivered. It outlines best practices for a person, population group or patient cohort as they progress through the stages of a condition or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place. According to the Agency for Clinical Innovation, models of care have the following key elements:
- Quality care—promotes safe, high-quality care
- Patient-centric—focus is on the patient/family
- Integrated care—supports collaboration among all team members
- Cost-effective—promotes efficient use of resources
- Adaptability—localized flexibility; considers equity of access
- Outcome evaluation—has a robust and standardized set of outcome measures and evaluation processes
- Evidence-based—incorporates the best available evidence; links to local and national strategic plans and initiatives
- Innovative—considers new ways of organizing and delivering care
- Visionary—sets a vision for services in the future2
The word Doula has Greek origins and means “woman who serves.” Service is at the heart of doula work. Throughout time and in cultures all over the world, there have always been those individuals—usually women—who tend to the needs of the mother in labor, nurture the family in the early weeks postpartum, and care for the sick and dying. The concept of the modern-day doula began in 1969, but the word did not come into widespread use until 1992 when Doulas of North America (now known as DONA International) was founded by five visionary maternal and infant health experts. The goal of this new organization was to train and certify doulas to support families in birth and during their early postpartum experiences. Standards of practice and a code of ethics for doulas3 were thoughtfully articulated to define the doula’s scope of practice, thereby professionalizing the time-honored, informal role of the doula. Today, DONA International is the largest doula training organization in the world, serving as the standard-bearer in the doula industry.
The emergence of the end-of-life doula is a 21st century development, and more men are being drawn into the field. With the “silver tsunami” of aging baby boomers upon us—many of whom are proponents of natural lifestyles and holistic approaches to health care—it makes sense that we are seeking new models of care to meet unmet needs at the end of life. Everyone benefits from dedicated support when major life transitions are underway.
Because doulas remain, for the most part, an unregulated profession (only Oregon and Minnesota have passed legislation licensing birth doulas and enabling Medicaid reimbursement for services), there is a great deal of autonomy for doulas to practice freely and evolve businesses that suit each individual doula’s interests, strengths and skill set. Today, doulas are working in solo practices, partnerships, collectives and doula agencies. A variety of doula programs have been established, in both the birth and the end-of-life fields of care, from community-based nonprofits to hospital-based or hospice-sponsored programs. Some doula programs use volunteer doulas only, while others engage doulas as employees or independent contractors. There is plenty of room for creative visionaries to adapt the doula model of care for a target demographic or specialized care setting. Furthermore, how each doula manifests the doula model of care and delivers services to families will be uniquely her or his own. This freedom, entrepreneurship and diversity benefit the variety of individuals and families with needs that are unmet in existing systems of care delivery. At the same time, we must acknowledge what unites us as doulas and define the core, non-negotiable elements of the doula model of care.
Core Components of the Doula Model of Care
Six Guiding Principles of Doula Support
- Non-medical support. Doulas refrain from performing any clinical or medicalized tasks (e.g., monitoring vital signs, dispensing medications, wound care, etc.). This prohibition is fundamental to the role. For example, a retired hospice nurse who has trained as a doula should not call herself a doula if she is also dispensing medications and providing clinical care; rather, she is a nurse with doula support skills.
- Non-judgmental support. The doula does not impose her/his values on the client such as acting on biases in favor of one method of giving birth or pre-conceived notions of what constitutes a “good death.” The doula does not presume that she/he knows best or somehow confers deeper meaning on the experience, but openly explores the emerging needs of the person/family, what is meaningful/important to them, and how the doula can best support them. Care is based on the client’s values and goals, even if those differ from values cherished by the doula.
- Family-centered approach. The individual and their family form the unit of care. Doulas do not take the place of partners, family members or other care providers. Rather, they seek to support the optimal involvement of loved ones and all available services.
- Holistic care. Doulas recognize the biopsychosocial and spiritual aspects of the whole person and provide services in the context of this understanding. Holistic care can also involve information and referrals for complementary healthcare modalities if the client is seeking alternative approaches beyond those embraced by the medical model.
- Empowerment. Doulas promote informed decision-making and foster maximum self-determination for the individual and family. They encourage self-efficacy and self-advocacy, based on identified values and preferences, rather than dependency. Doulas are not advocates per se and do not speak for their clients. Their role is better understood as that of a mediator who is facilitating good communication between all parties.
- Team members. Doulas are team players with a special role. The doula’s areas of expertise may overlap with that of other professionals involved with the client’s care, for example, a labor and delivery nurse, lactation consultant or hospice team member. These overlaps are to be expected and need not lead to conflicts provided doulas practice good communication and defer to medical experts for concerns outside their scope. Doulas often have a better grasp of the full continuum of care providers who might be involved, as well as where gaps exist that create stress for the client and family. They help provide much needed continuity of care.
Types of Support Provided by Doulas
- Presence. Good listener, witness, calming influence, nurturing, support for troubleshooting challenges.
- Emotional support (always part of the doula’s role).
- Information sharing. Education as needed and desired (e.g., how to care for a newborn or what to expect during the dying process). Information provided is non-biased and evidence-based. While encouraging informed decision-making, doulas refrain from giving advice to their clients or promoting a specific choice or course of action.
- Proactive guidance. Anticipating needs and making a plan (e.g., birth or vigil planning).
- Resources and referrals. Doulas are generalists rather than specialists, though some may have additional training in specialty areas such as massage therapy or spiritual care. When client needs/requests are outside of the doula’s scope of practice, personal/professional boundaries, or experience/expertise, the doula is prepared to make referrals to appropriate community resources and care providers, thereby increasing access to all available services.
- Comfort measures and physical support. Can include hands-on comfort techniques, help with positioning, visualization, use of the breath and so on. Personal care at the end of life (e.g., helping to keep the person clean, dry and comfortable) may be offered by some end-of-life doulas.
- Logistical support. Can include household help, running errands, transportation to medical appointments and so on. Services provided by individual doulas will vary in this area as each establishes her/his own professional boundaries.
Adapting the Doula Model of Care for End of Life
If we reconsider the definition and key elements of a “model of care” discussed above, the doula model of care readily meets the standards of being high quality, patient centric, collaborative, cost-effective, adaptable, innovative and visionary. While the body of literature establishing the benefits of birth doulas is extensive and compelling, standardized outcome measures to evaluate the efficacy of postpartum doulas and, especially, end-of-life doulas are scarce to non-existent. These are urgently-needed areas for research. If the health benefits and cost savings, now in evidence for birth doulas, extends to doulas involved during other phases of the lifespan—as we expect they do—then a strong case can be made for third party reimbursement for doulas and more families will benefit. The more unified the doula profession can be in agreeing on scope of practice, core competencies and guiding principles for doulas, the more successful we will become. In 2018, the National End-of-Life Doula Alliance (NEDA) was formed by a diverse group of trainers and leaders in the field for this very purpose.4
In terms of linking to national strategic plans and initiatives, the doula model of care synchronizes well with the public health approach to forming “compassionate communities” for folks at the end of life now being developed and implemented in Australia, the U.K, Canada and the U.S. And it is not a hard case to make that the following recommendations of the Institute of Medicine’s landmark report Dying in America (2015)5 are in alignment with the doula model of care:
- Deliver comprehensive end-of-life care by trained caregivers
- Meet Advance Care Planning standards
- Stronger knowledge and skills in palliative care
- Policies and payment systems to support high-quality care
- Public education and engagement
The emerging field of the end-of-life doula has benefitted greatly from the foundational work completed by leaders in the birth and postpartum doula arena. It would behoove practicing doulas, doula trainers, and hospice and palliative care organizations interested in adopting this new addition to end-of-life care to thoroughly understand and integrate the best of what the established doula model of care has to offer. Within the parameters described, doulas will retain great range for individual expression of their role and the services offered to families. The core principles can serve as a touchstone for the doula profession, helping us to better serve individuals and families while achieving greater recognition and acceptance worldwide.
1Dekker, R. (2017). Evidence Based Birth: Evidence on Doulas. Retrieved from https://evidencebasedbirth.com/the-evidence-for-doulas/.
2Agency for Clinical Innovation (2013). Understanding the process to develop a model of care: An ACI framework. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/181935/HS13-034_Framework-DevelopMoC_D7.pdf
3DONA International (2017). Birth (and Postpartum) Doula Standards of Practice and Code of Ethics. Retrieved from https://www.dona.org/what-is-a-doula/scope-and-ethics/.
4National End-of-Life Doula Alliance (NEDA) (2018). Our Scope of Practice. Retrieved from http://nedalliance.com/.
5Institute of Medicine (2015). Dying in America. Improving quality and honoring individual preferences near the end of life. Washington DC, The National Academies Press.
Patty Brennan has been a practicing doula since the early 1980s. She has trained birth and postpartum doulas for 20 years as an approved trainer through DONA International and has served as founder/executive director of two nonprofit community-based volunteer doula programs in Michigan. In 2016, Patty co-founded Lifespan Doula Association [LifespanDoulas.com] with Merilynne Rush, to offer end-of-life doula training, certification and professional development support. She is the author of The Doula Business Guide: How to Succeed as a Birth, Postpartum or End-of-Life Doula, 3rd Edition (Ann Arbor, MI: DreamStreet Press, 2019) and The Doula Business Guide Workbook: Tools to Create a Thriving Practice, 3rd Edition (2019).