Purpose

In light of inequities in maternal and infant health in the United States (U.S.) (Howell, 2018; MacDorman et al., 2016; MacDorman & Mathews, 2011), doula care has often been cited as a cost-effective intervention (Kozhimannil et al., 2013; Kozhimannil, Hardeman, Kozhimannil et al., 2016) to improve health and health care experiences (Gruber et al., 2013; Kozhimannil, Vogelsang, Kozhimannil et al., 2016; Mallick et al., 2022; Thomas et al., 2017). Birth doulas are non-clinical, trained professionals who provide one-on-one educational, informational, physical, and spiritual support before, during, and after childbirth (Bey et al., 2019). Doulas can also provide support during miscarriage, stillbirth, and abortion (Goodman & Arora, 2022). Notably, doula support is associated with higher levels of respectful care in hospital settings, particularly for individuals who are Black, Asian/Pacific Islander, or insured by Medicaid (Mallick et al., 2022). This finding is particularly important given that Black women, who are disproportionately impacted by maternal mortality and morbidity, face structural racism and implicit bias in pregnancy-related care (Crear-Perry et al., 2021; Njoku et al., 2023).

Various models of doula care exist, including volunteer and/or paid hospital-based doula programs, doula collectives, community doula programs, and fee-based individual private doula care. Community doulas are members of the communities they serve and share the same backgrounds, cultures, and/or languages as their clients (Bey et al., 2019; Marshall et al., 2022). Community doulas often work with community-based doula programs, which mostly rely on public and private funding to provide low- or no-cost doula services to individuals who are more likely to experience adverse health outcomes (Bey et al., 2019; HealthConnect One, 2017). Community doulas may provide more home visits and referrals to social support services than traditional private doulas, who serve clients with more financial and social resources (Bey et al., 2019). The community-based model of doula care specifically focuses on reproductive justice and health inequities, making it a promising intervention to reduce racial disparities in maternal and infant health (Bey et al., 2019; Van Eijk et al., 2022). However, research that focuses on the community-based model of doula care is limited.

Nationwide, policymakers and advocates have pushed to expand access to doula care; several states now cover doula services through Medicaid (National Health Law Program, n.d.). California’s Medicaid program, Medi-Cal, covers nearly half of the 500,000 births each year in the state (Simon, 2020) and added doula services as a covered benefit in 2023 (Department of Health Care Services, n.d.). From 2019 to 2022, at least ten doula pilot programs launched in California to serve Black birthing people and Medi-Cal enrollees (Robles-Fradet & Chen, 2022). Health plans and the California Department of Public Health’s Perinatal Equity Initiative funded most pilots, many of which incorporated elements of community doula care (Robles-Fradet & Chen, 2022).

Research on the impact of doula care, including evaluations of different models, will likely increase as coverage of doula care increases. Recent reports have noted the need for future research on patient preferences for utilization of doula services, sustaining the doula workforce, and the impact of doula services on health outcomes and maternity care costs (Guenther et al., 2022; Knocke et al., 2022). To develop best practices for research, it is critical to engage community doulas, clients, and other key stakeholders. In this paper, we detail our stakeholder-engaged process to build capacity for client-centered, community-informed, and equity-focused research on doula care in California. Although our focus is California, we believe our process and the accompanying lessons learned provide important insights for conducting research on doula care more broadly.

Description

Our overarching goal was to build capacity for future doula- and client-centered research on community doula care. Three university-based researchers invited three leaders of community-based doula organizations or initiatives in California to join the project leadership team. This project leadership team collaboratively developed four project objectives. Below we describe the steps we took to achieve each objective.

Step 1: Establish and Engage Steering Committee

The leadership team identified seven relevant stakeholder groups as essential partners in future research on community doula care and, thus, to be engaged in the project. Stakeholder groups included community doulas, former or potential doula clients, clinicians (including physicians, midwives, and nurses), payers, advocates, researchers, and public health professionals. The leadership team established a Steering Committee with members from each stakeholder group to create infrastructure and help guide project activities by leveraging their professional networks to recruit members and inviting additional members based on suggestions from those initially selected. Community doulas and former doula clients were prioritized for membership given the importance of including their perspectives as individuals who have the lived experience of providing or receiving doula support.

The final Steering Committee included project leadership and consisted of community doulas (n = 4), former doula clients (n = 4), clinicians (n = 3), payers/health plan representatives (n = 2), advocates and policymakers (n = 2), researchers (n = 3), and public health professionals (n = 2). Members lived and worked in the San Francisco Bay Area, Fresno, Los Angeles, and the Inland Empire. Members met monthly via teleconference from July 2020 to February 2022 and were paid for their time and expertise. Meetings initially focused on building rapport, familiarizing members with the project objectives, and developing and adopting shared values and principles (Table 1). Later meetings focused on the activities described in Steps 2–4.

Table 1 Steering committee’s shared values and principles1
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Step 2: Conduct Needs Assessment to Understand Needs and Values around Research on Community Doula Care

In this step, we conducted a needs assessment to identify and understand stakeholders’ needs and values for research on community doula care. This was a particularly important step before engaging in future research because many community doulas and their clients are from groups that have a history of underrepresentation, exploitation, and exclusion in research (George et al., 2014).

We conducted semi-structured interviews with individuals from the seven stakeholder groups using an interview guide based on leadership team expertise and input from the Steering Committee. We used a purposive and snowball sampling strategy to recruit participants, leveraging the networks of our leadership team and Steering Committee. The Committee for the Protection of Human Subjects at the University of California, Berkeley approved the study protocol.

Interviews occurred from November 2020 to May 2021 and explored participants’ knowledge of, value for, and perceptions of gaps in research on community doula care, feelings about how research is typically conducted and should be used, and their willingness to participate in research. We used a Rapid Assessment Process (RAP) to analyze the interview data. To develop preliminary, actionable findings, RAP utilizes iterative analysis, additional data collection, and data triangulation (Beebe, 2008; Hamilton, 2013).

We conducted 29 interviews across the seven stakeholder groups: clinicians (n = 8), public health professionals (n = 8), doulas (n = 4), former doula clients (n = 3), researchers (n = 3), and policymakers or advocates (n = 3). Some participants represented multiple stakeholder types (e.g. a former doula client who works in advocacy). All but one participant lived and worked in California.

Overall, participants felt that research on community doula care was important and could be used positively to increase access to doula care by informing policy changes and helping doulas be more welcomed in medical settings (Table 2). Participants identified gaps in doula-related research on appropriate compensation models for doula care, interactions between doulas and hospital care teams, and racism in hospital settings and in the doula profession.

Table 2 Needs assessment findings
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Interviews surfaced concerns regarding research. One participant expressed a fear that increased research and attention to doula care may lead to regulation of the profession, which may make it inaccessible to community doulas. For example, some states require doulas be certified by specific doula organizations to enroll as Medicaid providers. However, obtaining certification can be costly and does not necessarily indicate relevance or competency in working with families at the intersection of racism and/or disadvantaging social determinants. Other participants expressed concerns about research being exploitative or extractive, biases affecting studies and results, and findings not being adequately disseminated to communities.

Participants suggested incorporating more community members into research from the start, creating funding opportunities for Black people to conduct their own research, and being transparent about who is conducting research. Participants also shared preferred research methodologies, including community-engaged research and qualitative methods such as focus groups, which give doula clients opportunities to share their experiences and can allow for community healing.

Step 3: Identify a Shared Research Agenda Related to Community Doula Care

Informed by important contextual information about how future research on community doula care should be conducted, we next focused on identifying specific research topics and questions to be prioritized. We adapted the Research Prioritization by Affected Communities (RPAC) protocol, which aims to initiate patient and public involvement in setting research agendas, to guide this process (Franck et al., 2018). We engaged the Steering Committee in three virtual RPAC sessions from July 2021 to September 2021, with intermediate activities between meetings.

Session 1 involved a guided discussion to generate potential research questions about community doula care, which were grouped into themes and then reviewed carefully in session 2. The first and second sessions generated a total of 178 questions. A visual scribe recorded the first two sessions by drawing illustrations and writing words in real time. This process created a visual representation of each session that we shared with the Steering Committee to facilitate discussion and to serve as a reminder of commonly discussed topics (Fig. 1). Prior to session 3, the Steering Committee voted on questions most important to include in a research agenda about community doula care and, in the final session, confirmed the prioritized list of questions.

Fig. 1
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Graphic recording of the Steering Committee’s discussion about community doula care during the first RPAC session by visual scribe Ashanti Gardner

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The final list of 21 priority research questions (Table 3) represented 10 themes: (1) scope of community doula care; (2) awareness of doula care; (3) doula training and certification; (4) workforce development; (5) policy and standardization; (6) ethics; (7) metrics, outcomes, and mechanisms; (8) COVID-19; (9) compensation and funding; and (10) integration and interactions with health systems. Notably, many questions focused on the implementation and sustainability of community-based doula programs and identification of appropriate metrics/measures of successes.

Table 3 Priority questions identified by steering committee through RPAC process
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Step 4: Increase Capacity among Community Doulas to Engage in Research on Community Doula Care

The final step of the project focused on a training to build skills relevant to answering research questions developed in step 3. With guidance from the Steering Committee, we decided to focus our training efforts on community doulas, as they are increasingly asked to collect data for evaluations of community-based doula programs and participate in research about their work. However, they are not often invited to develop evaluation methods or informed about research goals.

During the virtual, two-hour workshop, we disseminated the needs assessment and research prioritization findings, introduced research concepts, and provided a space for community doulas and other stakeholders to discuss the relevance and impact of research on their work. In a didactic portion of the workshop, we presented information about the research process and common research types, including community-engaged research (Key et al., 2019) and comparative effectiveness research (Sox, 2010). Project leaders, including doula leaders and a researcher, also shared their experiences with partnered research during a panel discussion.

Assessment

Below we discuss successes, challenges, and lessons learned while carrying out this project that are relevant for future research on doula care.

Research Prioritization Identified Important Understudied Questions that will Need to be Further Developed

While the list of priority research questions lays out important areas of inquiry for further exploration, we recognize that it is a starting point, and researchers will likely need to further develop the questions to be clearly defined, specific, and focused, which is important for successful research projects. By design, most Steering Committee members did not have a background conducting research, which we believe was a strength of the project. Our goal was not to produce perfected research questions, but, rather, to identify questions deemed to have shared importance across stakeholder groups and allow for partnered research.

We also hope that our list of questions can influence funders’ research priorities. Notably, none of the priority questions focused on clinical birth outcomes. Our Steering Committee and some needs assessment participants recognized that there is existing evidence that doula care improves clinical outcomes and, as such, felt there was a need for more research on the impact of community doulas on clients’ overall well-being, including social support, and birthing experiences. Further, funders, researchers, doulas, and community members measure success differently. As such, shared metrics must be holistically defined by those most affected.

Challenges and Benefits of Evolving Policy Related to Expansion of Doula Services in California

About halfway through the project, the 2021–2022 California state budget provided funding to add doula services as a covered Medi-Cal benefit (Department of Health Care Services, n.d.). As a result, our Steering Committee meetings evolved to serve not only as a time to discuss research-related matters, but a gathering space for members to engage in conversations related to upcoming policy. In many regards, this was a positive outcome of our capacity-building process and reflected the strong relationships members developed. At the same time, it was challenging to maintain focus on research when there were pressing policy considerations at hand. Many members were aware of the challenges that occurred with Medicaid coverage of doula care in other states and used our meetings to discuss how implementation in California could avoid these pitfalls.

Overlapping Findings Provide Direction for Future Research on Doula Care

Our findings provide direction for those interested in conducting research on doula care, as well as policymakers and funders. We observed overlapping findings across project phases, which indicates data triangulation and, thus, increases the validity of our results (Carter et al., 2014). First, regarding future research topics, we found in both the needs assessment and the research prioritization that there is a need to explore dignified compensation models for doula care and identify ways to build mutually respectful relationships between doulas and clinicians. Second, our needs assessment findings offer insight into acceptable research practices, which we also discussed during Steering Committee meetings and the research workshop. There was a desire for researchers to engage clients, community doulas, community-based doula organizations, and other stakeholders early in the research process and to center the voices of Black, Indigenous, and people of color (BIPOC) community members, who are most impacted by the maternal health crisis. This finding suggests that researchers should utilize community-engaged approaches for future research on doula care. Study designs like randomized controlled trials, in which one group receives the intervention and the other does not, would not be acceptable. Given existing evidence demonstrating the benefits of doula care, stakeholders perceived research involving withholding doula care from pregnant and birthing people as unethical. Lastly, throughout the project, stakeholders expressed a preference for qualitative data collection methods, which can create opportunities for storytelling and community healing. Stakeholders also noted that asking doulas to provide documentation and collect data for research purposes can be overly burdensome, especially when funders, including health plans, and researchers do not seek doula input.

Need to Increase Public Awareness about Community Doula Care

A key observation from Steering Committee members, needs assessment participants, and workshop attendees was a need to increase awareness about the community doula care model across the general public, health care providers, and health systems. As California rolls out its Medi-Cal doula benefit, increasing awareness will be a critical step to ensuring pregnant people utilize the benefit, if desired, while developing more support for doulas in clinical environments.

Limitations

While we believe our approach and findings have broad implications, we engaged stakeholders from a single state that was advancing Medicaid coverage of doula care. Additionally, although we attempted to engage all identified stakeholder groups, clients ended up having less representation on our Steering Committee due to some dropping out, potentially due to meetings occurring during working hours. Engagement, with respect to attendance at project meetings and events, was challenging overall due to the demands of the COVID-19 pandemic on our stakeholders, who mostly worked in health care or public health.

Conclusion

The increasing utilization of doula care, and specifically community-based models of doula care, to address inequities in maternal and infant health provides an opportunity to think critically about research. The findings of our stakeholder-engaged process provide a roadmap that will lead to equity-oriented research centering clients, doulas, and their communities. Collaboration is critical for future research on doula care; our project findings suggest there is a welcome opportunity for partnered research if approached carefully and thoughtfully.