'I was in the delivery room and at my most vulnerable - then the doula arrived'

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Should you hire a doula?Hearst Owned

Non-medical birth workers are now supporting women with period pain, fertility and menopause. To some, the doula offers something the NHS can’t. To others, they represent an attempt to plug the gender healthcare gap with an unregulated profession. WH reports on an emerging industry…

Katryna Pitts was in her ninth hour of labour when a thought gripped her with striking clarity: ‘I can’t do this.’ As another contraction shuddered through her, a hand slipped into hers, a pair of eyes met her gaze and a voice spoke the words she needed to hear, ‘You’re safe.’ Her son, Myles, was born shortly after.

But those calming words that made all the difference to the 33-year-old supply teacher’s birthing experience weren’t delivered by a midwife or by her husband, James. They were spoken by her doula, Ellie – a professional hired by the Bristol-based couple to support them during the birth. After finding Ellie online, they paid around £1,000 for a package that included six hours of support during pregnancy, on-call availability for the birth and a debrief session afterwards.

Today, Katryna credits Ellie for facilitating her ‘really positive’ birth – it could have been otherwise. When Katryna’s waters broke two weeks before her due date, in April 2022, the couple arrived at the hospital to find the unit where they had planned to have their baby was closed due to staff shortages.

From a small, windowless room on the labour ward, Katryna began to panic. ‘The lights were blinding and all the stuff I’d planned to use, like a birthing ball, was in the midwife unit,’ Katryna recalls. ‘I was at my most vulnerable – and it felt like it was going wrong already.’

After James explained the situation on the phone, Ellie arrived, armed with a projector to soften the lighting, a birthing ball, a yoga mat and some essential oils. ‘I just remember an overwhelming feeling of relief,’ says Katryna. ‘She completely transformed the space. I don’t know what we would have done if she hadn’t been there.’

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Supporting role

Described variably as a ‘non-medical birth worker’ and a ‘modern Mary Poppins’, the doula’s job description includes offering emotional and practical support during pregnancy, labour and, in some cases, after the birth.

‘Their presence serves to complement, rather than replace, the role of midwives and members of the obstetric team,’ says Asma Khalil, a consultant obstetrician and vice president of the Royal College of Obstetricians and Gynaecologists, adding that doulas should never perform midwifery, do clinical tasks or offer medical advice or diagnoses.

‘Doula’ is an unprotected term, meaning anyone can call themselves one, so there’s no official data on how many practising doulas there are. But the not-for-profit membership organisation Doula UK told WH the number of births aided by their doulas has increased steadily in recent years, from 1,460 in 2020 to 2,047 in 2022; the number of enquiries from families looking to hire a doula has risen, too.

But if the doula’s job description was born in pregnancy, the role is expanding. A Google search for doulas now delivers results across the reproductive life cycle, with non-medical professionals offering to support you with everything from trying to conceive to managing your menopause.

To some, this development reveals a vibe shift that acknowledges the emotional toll these life stages take – and the limits of what our healthcare system can offer. To others, the rise of the doula represents an attempt to plug the gender healthcare gap with an unregulated profession. With demand for doulas set to rise again, is this is a shift we should welcome?

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Mend the gap

The celebrities who’ve used a doula read like the guest list for The Met Gala: Heidi Klum, Christy Turlington, Nicole Kidman. But if hiring a doula feels as ‘2024’ as employing a brand consultant, the role actually dates back centuries.

Derived from the ancient Greek word for ‘female servant’, the current iteration of the doula was popularised during feminism’s second wave and the natural childbirth movement of the 1970s. The term was coined by the American anthropologist Dana Raphael in 1973 in her book, The Tender Gift: Breastfeeding. In it, Raphael noted how other cultures had stronger traditions of ‘mothering the mother’.

‘Until relatively recently, it wasn’t always midwives who tended to women during labour,’ agrees Ellie Dunkley, a spokesperson for Doula UK. ‘It might have been Sandra from down the road, who’d had six babies, who would come to your home and observe how things were going.’ This normalisation of ‘mothering the mother’, she says, is what’s missing in western society, where birth is predominantly seen as a medical event. ‘But doulas can bridge that gap.’

Doulas’ rise in popularity is further explained by a growing perception that the gap between the pastoral and the medical is widening. In recent years, it’s become impossible to ignore the reality that an under-resourced NHS doesn’t always deliver, especially when it comes to women’s healthcare.

The Royal College of Midwives has warned that the NHS is short of 2,500 full-time midwives, while maternity scandals at NHS Trusts such as Nottingham University Hospitals and Shrewsbury and Telford Hospital have highlighted the devastating impact of a culture
in which women weren’t listened to.

For Julianne Boutaleb, a perinatal psychologist who has worked with NHS maternity services for 20 years, the spike in the demand for doulas is directly related to these headlines. ‘Women are finding that the system isn’t always able to meet their needs, so they’re resourcing that support for themselves, if they can afford to.’

In the past, it was a big ‘if’. But while the doula was once seen as the preserve of the wealthy, Dunkley points out that many doulas now offer payment plans to spread the cost. Doula UK also runs an access fund to provide support to those experiencing financial hardship. ‘For a long time, doulas seemed to be the preserve of white, middle-class women,’ adds Mars Lord of Abuela Doulas*, who’s been practising for 19 years. That there were so few Black doulas when she started was one reason she began training them herself.

Two decades on, in a healthcare system in which systemic racism has been shown to be at the root of inequities in maternity care – including the appalling statistic* that Black women are four times more likely to die during pregnancy and childbirth than white women – Lord believes Black doulas can act as both advocate and witness in a way that helps pregnant Black and brown women feel more safe in a hospital setting.

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Pastoral care

Of course, childbirth isn’t the only area of healthcare where women have been let down. Whether they’re waiting to start fertility treatment, waiting to see a doctor who specialises in menopause or waiting to see a gynaecologist, women are… waiting. NHS waiting lists for the latter have trebled in the past decade, and it’s into this landscape that the doula has landed, with non-medical specialists now offering their services supporting women experiencing painful periods, unexplained infertility and debilitating menopause symptoms.

Alex Bannard was reeling from a relationship breakdown, experiencing panic attacks and suffering memory loss that felt like ‘early-onset dementia’ when she booked some sessions with a menopause doula at the start of last year. Despite taking HRT, the 53-year-old yoga teacher felt ‘broken’. She found Kate Codrington after reading her book, Second Spring: The Self-Care Guide To Menopause. Today, Alex pays £35 a month for a 60-minute Zoom call with Kate.

Through these ‘empathetic’, ‘insightful’ conversations, Alex began to join the dots between the anxiety and low mood she experienced in her forties – symptoms brushed off by her GP – and perimenopause. That her doula operates outside of a medical setting was precisely the point. ‘It’s not counselling, it’s not coaching – it’s an entirely different kind of wisdom.’

The belief that there’s a place for this wisdom within our healthcare system isn’t a controversial one. Emerging evidence suggests non-medical professionals play a vital role. A 2017 review* involving more than 15,000 women concluded that continuous support during labour (be that from a partner, a known midwife or yes, a doula) had shorter labours, required less pain relief and were less likely to require forceps or an unplanned C-section.

And birth isn’t the only life event where professional hand-holding is being shown to be valuable. ‘There’sa wealth of evidence on how important it is for many different life events and conditions to have peer support and to hear the stories of people who’ve been through something similar,’ says Shema Tariq, a sexual health doctor and senior clinical research fellow at UCL’s Institute for Global Health, giving the example of antenatal classes. ‘But I do worry that there are so many myths that may get perpetuated in an unregulated space.’

Sage advice

You don’t have to look very hard to find the myths that Dr Tariq is referring to. WH has seen countless examples of doulas breaching the non-medical advice rule in their posts on social media. Anna Brady had been trying to have a baby for 18 months when she paid £100 for three one-on-one taster sessions of a ‘complete fertile lifestyle programme’ with a fertility doula.

Alongside tips that included tuning out ‘negative thoughts’ was nutrition and lifestyle advice that, as Anna puts it, ‘took the joy out of life’. ‘She talked about the things I shouldn’t eat – no gluten, no dairy, no caffeine,’ Anna recalls.‘I wasn’t supposed to drink tap water, so I bought a distiller. But then she also said I had to take certain supplements.’

It was only after undergoing medical investigations months later, which revealed her womb was divided by a wall of muscle, that Anna realised how unhelpful the advice had been. The full package, had she signed up for it, would have cost £3,000. ‘And that was with a discount,’ she adds.

While Doula UK offers training to its 700 members – and also has a code of conduct – there’s no obligation to join in order to practise, which means it can be difficult to make a complaint when things go wrong.

Back in April, the Healthcare Safety Investigation Branch (HSIB), which is funded by the Department of Health and Social Care, published a report reviewing the role that doulas play in maternity safety investigations. While it found many cases in which the care provided by doulas was ‘positive and beneficial’, there were other examples where doulas’ advice impinged on medical decisions.

In one case, midwives were excluded from the birth by the doula; in another, a woman in early labour at home was incorrectly informed that her baby moving less than usual was normal as they had ‘less room to move’. When the mother went to hospital the next day, she was told her baby had died.

And parents have little recourse; unlike an NHS trust or a private midwife, doulas aren’t responsible for a person’s medical care, meaning they’re not legally liable in the same way. (Doula UK does recommend that doulas take out professional insurance, though.)

Body politics

That doulas are supporting women with health concerns, while not being allowed to offer health advice, is the issue at the heart of this story. ‘It’s a really grey area,’ says Dr Tariq. Women’s bodies, she points out, have been chronically ignored in both education and research settings for decades – a reality that’s necessitated the sharing of information in community settings.

And unmet physical health needs are only part of this story. Sula Windgassen is a health psychologist specialising in chronic stress, illness and trauma. She tells WH that feeling ignored and sidelined in healthcare settings is an alienating experience.

‘We need replenishment when ill but, because of the gender gaps in our healthcare system, women are forced to take on additional roles of problem-solver, advocate and healthcare coordinator – which often surpass the capacity we have,’ she explains. ‘In the context of feeling isolated and unsupported, it makes sense that women turn to what help is accessible. Especially if it foregrounds the caring, personable approach their standard healthcare lacks.’

You might argue that the end result (women receiving compassionate support through isolating health challenges and life stages) is more important than the means (read: how they receive said support and who is delivering it).

And it’s a view for which Dr Tariq has much sympathy. ‘This doesn’t mean that only doctors and nurses should hold the keys to this sort of information,’ she explains – adding that she ‘welcomes’ anyone coming into this space wishing to offer support. ‘But I’d be very wary of anyone offering any kind of medical advice without being, not only medically qualified, but specifically qualified in that area.’

Dr Windgassen goes one step further: ‘There’s definitely a need for individuals who aren’t qualified healthcare professionals to provide additional support – the reduction in healthcare access necessitates it.’ But discernment is key. ‘Red flags include highly specific protocols that come with lots of restriction that are disruptive to your normal life. Also, if the issue you’re working on requires further support from another professional, try asking about the process. If dismissed, that’s another red flag,’ she says.

Finally, she urges caution around unsubstantiated premium pricing. ‘A whole industry coaches unqualified professionals on how to make the most money from their clients with a bit of marketing sparkle. I’d always advise starting with qualified practitioners in regulated professions.’

Anna, for one, doesn’t believe she would have sought out a fertility doula if she’d had Instagram at the time – a place where she later found support from people going through something similar, as well as balanced information from infertility doctors and registered nutritionists. (It’s worth noting that WH saw examples of fertility and menopause doulas on Instagram sharing non-medical advice, too).

Road ahead

As it stands, there are no active plans to institute a regulatory body for doulas, although the HSIB is holding discussions about possible national guidance in which Doula UK has been present. ‘We were able to tell HSIB about our membership requirements in terms of training and mentoring, that there is a resolution and accountability process and that we have a code of conduct that all members must adhere to,’ a spokesperson for the organisation tells WH.

But for Ellie Dunkley, mandatory professional registration isn’t the right approach. ‘It gives the wrong impression,’ she says. It’s important for doulas to understand that you’re never fully qualified, as so much of it is based on life experience.’

One route forward is a mandate for NHS Trusts to have clear policies on doulas, as some already do. For example, areas that have received funding to create a maternal mental health hub are much better at integrating different kinds of birth support, doulas included. ‘But that’s not the standard throughout the country,’ says Boutaleb, who’s an advocate for this approach. ‘Doulas often provide a really good service, but it’s still a precarious situation.’

Outside of maternity care, Dr Tariq believes doula culture could serve to exacerbate existing health inequity. Together with her colleague, UCL professor Joyce Harper, she’s in the process of designing a national menopause education and support programme ‘like NCT classes, but for menopause’. It’s a model that, in time, has the potential to be extended to other areas of reproductive health, perhaps alleviating the isolation and information gaps women currently face.

‘I’m a feminist,’ adds Dr Tariq. ‘I don’t want to say you have to be a healthcare professional to be able to support women – I believe women are perfectly able to know their own bodies. But at the same time, I want people to get evidence-based information.’

As for the doula question, clearly we shouldn’t underestimate the power of this supporting role – as long as it’s the mother who’s still running the show.

‘If I’d taken the doula’s advice, I’d have given birth in my hallway’

After her first labour ended with an unplanned C-section, Alisha, 27, from west London, was determined to make her second birth a much more positive experience – so, she hired a doula.

With my first birth, I felt like everything was decided for me. So for my second, I wanted someone with experience outside of the NHS to support me. After a couple of friends suggested a doula, I found one online.

After an initial phone call, she sent me her contract and price list. The £2,000 fee would cover two meetings before the birth, a postnatal session and her being on call 24/7 for two weeks before my due date.

She’d been a doula for seven years, which helped me trust her, and we clicked instantly. Before long, we were chatting on WhatsApp – and the emotional support she gave me was
the antithesis to my NHS appointments.

When I went into labour, I messaged her straight away. It was late, so she told me to try to rest – and to keep in touch. By morning, my contractions were closer together and, 10 hours since I thought my labour had started, it wasn’t clear if she was coming over.

Because of my previous birth experience, I wanted to stay home for as long as possible – something we’d discussed in our preparation session. But by mid-morning, my husband and I decided it was time to go to the hospital. Only, when we told the doula, she tried to persuade me otherwise. ‘Just try staying home for one more hour,’ she told me, via WhatsApp.

Feeling strongly that it was the right time, we went in, arriving at the birthing centre to discover I was 8cm dilated. My son was born just over an hour later. If I’d taken the doula’s advice, I’d have given birth in my hallway.

It wasn’t until we were at the hospital that she messaged to say she wouldn’t be able to make it, as she was in hospital herself, having medical treatment. It was no one’s fault – and she was apologetic. But at the same time, she didn’t offer a refund; my husband had to argue for it.

We eventually got back £1,000, half of what we paid. While we had drawn up a contract, it didn’t mention what would happen if she couldn’t make it, except for in exceptional circumstances, such as another national lockdown.

Before this happened to us, I’d not heard of anyone having a negative experience, but since then, I have. Ultimately, though, I wouldn’t advise someone against using a doula if you’re curious – just trust your instincts.

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