As the anesthesiologist, you enter the delivery room and look around. The obstetrician is at the foot of the bed, the labor and delivery nurse is measuring the vital signs, the patient’s partner is holding her hand. And then your eyes land on another person: the doula. Who is this? Why is this person there? What should we know about them?
The doula concept originates from the ancient Greeks, where birthing mothers had helpers. Dana Raphael, a medical anthropologist, coined the term doula in 1969. She described a doula as a nonmedical support woman who assisted mothers through childbirth and post-partum. In 1992, the first training and certification program, Doulas of North America (DONA), was established. This organization defines the role and limitation of doulas, stating they will not perform clinical or medical tasks such as measuring blood pressure or temperature, monitoring the fetal heart rate, etc., nor diagnose or treat any abnormality (asamonitor.pub/3LFjhVV). They instead function as an advocate between multiple providers and the patient (J Midwifery Womens Health 2022;67:31-8). The doula model has assisted in decreasing cesarean sections and has improved the childbirth experience for mothers (Cochrane Database of Syst Rev 2017;7:CD003766). Access to doula services is somewhat obstructed by the medical payer system. Many insurance companies do not recognize doulas and do not cover their services. Although preterm birth, low birth weight infants, surgical delivery, and increased morbidity and mortality may be more common in minority women, a doula support person may be cost-prohibitive (Health Equity 2021;5:545-53). Recently, hospital and community-based doula programs have emerged, with many of the participants originating from underserved populations. A 2021 study by Kett et al. found community-based doulas assisted their clients in navigating and mitigating discriminatory practices by establishing a strong doula-patient connection, facilitating culturally appropriate birth practices, and empowering mothers to advocate for themselves and their infant (Perspect on Sex Reprod Health 2022;54:99-108). According to Ogunwole et al., between 2015 to 2020, there was a nearly threefold increase in various state bills related to doula care. Most of the bills were Medicaid-related, with the hopes of decreasing health disparities while improving maternal and fetal outcomes (Womens Health Issues 2022;32:440-9). Unfortunately, with the onset of the COVID pandemic, many doulas were unable to assist their clients during delivery. A study by Turner et al. performed in Atlanta, Georgia, between November 2020 to January 2021 showed that doulas were restricted from hospitals due to their nonmedical status (Sex Reprod Health Matters 2022;30:2133351). However, with restrictions lifted, doulas are making their way back into the delivery ward, and their status as patient advocates is being recognized. As of January 1, 2023, 10 states and the District of Columbia are actively providing Medicaid coverage for doula care – California, Michigan, Florida, Maryland, Minnesota, New Jersey, Nevada, Oregon, Virginia, and Rhode Island (asamonitor.pub/3ZYum95). One state, Rhode Island, allows doula coverage in both Medicaid and private insurance plans.
Because each Medicaid plan negotiates its own reimbursement terms, there is variability in payments to each doula, which subsequently affects access to doula care.
As anesthesia professionals, we will undoubtedly run across a doula. We should be knowledgeable about their function, role, training, and limitations (Birth 2019;46:355-61). As the medical and nursing team is providing cutting-edge obstetric and anesthesia care, the doula is providing a special form of emotional support and patient advocacy. So, just remember that the next time you’re in the obstetrics suite, that extra person just might be the doula!