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Abstract
Introduction In the USA, maternal morbidity and mortality is markedly higher for women of colour than for white women. The presence of a doula has been associated with positive birthing outcomes for white individuals, but the experiences of women of colour remain underexplored. The purpose of this qualitative paper is to understand the attitudes of black and Latinx communities towards doula-supported birthing practices.
Methods The perspectives of people of colour, both birthing women and doulas, were investigated through popular media sources, including blogs, magazine articles, podcasts and video interviews. Of 108 popular media sources identified in the initial search, 27 included direct accounts from birthing women or doulas and were therefore included in this paper. Thematic analysis was conducted by the grounded theory method.
Results Emerging themes reveal that doula presence allows for the experience of ancestral power, connection to the granny midwives, cultural translation in medical settings and physical protection of the birthing woman. When labouring with the support of a doula, women report the emotional and physical presence of their ancestors. Similarly, doulas recognise an ancestral presence within the birthing woman, and doulas experience their occupation as carrying on ancestral tradition and feel a strong vocational tie to the granny midwives of the American South. Lastly, doulas mediate communication between birthing women, their families and medical providers by emphasising the need for consent and patient autonomy.
Conclusion By connecting women of colour to historic and ancient spaces as well as providing comfort and familiarity in the birthing space, doulas grant their clients the self-advocacy and empowerment needed to survive the present. Doulas serve as protectors of women of colour and have become an important piece to bridging society from the current maternal health crisis to a more equitable future.
- patient narratives
- medical humanities
- popular media
- qualitative research
- women's health
Data availability statement
Data are available in a public, open access repository.
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Introduction
Women of colour in the USA experience poor health outcomes during and after pregnancy. Between 1979 and 1992, the Centers for Disease Control published maternal mortality ratios that demonstrated black and Latinx women were 4.2 times and 1.7 times more likely, respectively, to experience pregnancy-related death (Hopkins et al. 1999). More recently, the US Government Accountability Office published maternal mortality data that illustrates the persistence of these disparities, with black and Latinx women continuing to have higher maternal death rates than white women in 2021 (United States Government Accountability Office 2022). In addition to disparities in mortality, women of colour experience the greatest proportion of maternal morbidity (Leonard et al. 2019). Specifically, black women are more likely to develop pregnancy-related hypertension (Bryant et al. 2010), Latinx women are more likely to develop gestational diabetes and both groups are more likely to develop perinatal haemorrhage and infections when compared with white women (Cabacungan, Ngui, and McGinley 2012). The lack of recognition and treatment of mental health disorders in women of colour, such as postpartum depression, is common and further exacerbates poor outcomes for these populations (Kozhimannil et al. 2011). Ultimately, the impact of these maternal health disparities results in transgenerational harm because the children born to women of colour experience negative neonatal outcomes, including preterm birth and fetal demise (Bryant et al. 2010).
The causes of these health disparities are multifaceted and include individual, interpersonal and environmental components (Noursi, Saluja, and Richey 2021), such as systemic racism in healthcare. Research has already demonstrated the link between racism and poor health outcomes (Paradies et al. 2015), with chronic stress as a suggested underlying physiological mechanism (McEwen 2007). With the understanding that medical institutions are an extension of society and that racism permeates the healthcare environment (Bhugra 2014), it is necessary to consider the role of racism in maternal health outcomes. While one study found obstetricians contributed to the disempowerment of women of colour by selectively sharing and withholding medical information from patients (Altman et al. 2019), it is important to acknowledge that internalised and interpersonal racism are only minor contributors to the maternal health crisis. Obstetrics-gynaecology is the most diverse specialty in the USA, containing the highest proportion of physicians that identify as under-represented in medicine, comprising 11.1% black and 6.7% Hispanic physicians (Rayburn et al. 2016). Given that patient-physician racial/ethnic concordance is highest in this field, it is clear that systemic causes are fuelling the maternal health crisis. We must acknowledge that healthcare is an ‘institution of oppression… created by the privileged to benefit the privileged’ and is the source of oppressive power dynamics between patients and physicians (Savabi 2023).
The equilibration of this power dynamic can be aided by the utilisation of doula-supported birthing practices. Doulas are birth workers that act as companions for labouring women and as a liaison between patients and clinicians. While doulas have risen in popularity in recent years, they, along with midwives, are an essential component of obstetric history in the USA (Smithsonian: National Museum of African American History and Culture 2022). The original midwives in the USA were enslaved individuals who continued practising birth work after surviving the transatlantic slave trade. After emancipation, these midwives became known as the ‘granny midwives’, and they continued their work throughout rural Southern America. However, over the 20th century, birth became increasingly medicalised, and midwives were largely replaced by obstetricians (Papagni and Buckner 2006). As a result, the number of caesarean sections grew, and pregnant women began recruiting friends and colleagues to support them at the hospital during delivery (Papagni and Buckner 2006). This role later developed into the occupation of the doula, and by the 1970s, a natural birthing movement swept the USA with a focus on doulas performing home deliveries (Smithsonian: National Museum of African American History and Culture 2022). In 1992, the prominence of doulas prompted the creation of the Doulas of North America (later renamed DONA International), an organisation that serves to train and certify doulas (Smithsonian: National Museum of African American History and Culture 2022). While the modern doula may share a similar mission of patient-centred care with the midwife, the distinction between a doula and midwife remains an important one. In the modern medical era, a midwife is an advanced practice registered nurse that specialises in childbirth and is medically trained to manage low-risk pregnancies and deliveries (Turner 2020). On the other hand, doulas are people ‘trained to provide physical, emotional and educational support during pregnancy, labour and postpartum’ (Turner 2020). For instance, doulas may provide comfort to the labouring woman through breathing exercises, massage and modifying labour positions and have often spent time developing a relationship with the woman prior to delivery (Turner 2020).
Given the longstanding history of doulas, several studies have already explored the impacts of doulas on their patients. These studies demonstrate that doula care is associated with improved maternal health outcomes and that patients benefit from the social support doulas provide during labour and delivery (Berg and Terstad 2006; Biswas et al. 2021; Bohren et al. 2017; Darwin et al. 2017; Deichen Hansen et al. 2021; Gruber, Cupito, and Dobson 2013; Koumouitzes-Douvia and Carr 2006; Kozhimannil et al. 2016; Lunda, Minnie, and Benadé 2018; McLeish and Redshaw 2018; Mottl-Santiago et al. 2008; Sauls 2002). However, the majority of these studies focus on the experiences of white women, leaving the experiences of black and Latinx women underexplored. This study hopes to address the gaps in the literature by focusing on the experiences of black and Latinx women in the USA and demonstrate the potential for doulas to act as a tool in combating maternal health disparities.
The experiences of women of colour were collected from popular media sources, as opposed to formal interviews, because these platforms produce a massive collection of stories that is difficult to replicate with smaller scale qualitative interviews (Andreotta et al. 2019). The utilisation of popular media sources demonstrates the pervasiveness of the experiences of women of colour and normalises the birthing experiences of women of colour in the USA. Additionally, the utilisation of popular media allows for the identification of voices that may have otherwise been missed in a formal recruitment process and allows for the collection of data from a real-world social environment, unaffected by observer bias or researcher behaviours (Andreotta et al. 2019). Notably, studies also indicate popular media is heavily used by our population of interest. In a study investigating social media use for pregnancy-related health information, black women with low health literacy were found to use social media to a higher degree than other patient populations, and black women with a high degree of health literacy still used social media to give and receive support around pregnancy and childbirth (George et al. 2023). Because popular media can be shared and reshared within and across communities, these texts provide a unique insight into how communities of colour navigate the birthing experience in the USA.
Methods
We collected stories from popular media sources, including blogs, magazine articles, podcasts, and video interviews. The Google search engine was used to locate these sources, and the original search terms included “doula”, “women of color”, “Black”, “Latinx”, “ancestral power” and “ancestral strength”. After reviewing the initial articles, the search terms “granny midwife”, “legacy”, “translator”, “cultural translator”, “protector” and “bodyguard” were added. Of 108 popular media sources identified in the initial search, 27 sources included direct accounts from birthing women or doulas of colour and were selected for this paper. The sources on this topic focus on the perspectives of cis women of colour, so while our paper uses this language to describe the topic of interest, it does not encompass all people of colour who give birth, such as transgender and non-binary people. Sources were analysed by the grounded theory method.
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.
Results
Analysis of the collected sources reveals that women of colour experience several positive impacts from doula-supported labour and delivery. The themes that emerged include doulas as a source of ancestral connection, as legacies of the granny midwives, as cultural translators and as protectors of the body.
Doulas as ancestral connection
Women of colour describe ancestral presence filling the physical and emotional spaces around them throughout doula-supported labour and delivery (Allers and Tubbs 2021; Breakfast Club Power 2018). Some women simply acknowledge that doulas offer ancestral connection by allowing women of colour to reclaim ancestral birthing practices (Oduah 2011; Thompson 2022). Other women experience direct communication with their ancestors during labour and delivery and feel the presence of their ancestors in the birthing space (Allers and Tubbs 2021; Hutchinson and Jackson 2021). One woman reflects,
I had a lot of moments where I felt like I was sort of in a trance. I felt like I was speaking to my ancestors. If they could do this, you know, in some of the hardest conditions, I can do this. I was talking to myself, and my doula said later it was clear that [I was] somewhere else finding whatever strength and power that [I] needed (Allers and Tubbs 2021).
A few women even describe physically seeing their ancestors in the room (Breakfast Club Power 2018; Oduah 2011). One woman describes,
They asked me to get out of the tub and get in the bed…and that’s when I felt this like horseshoe shape around me and I looked up and then I saw…these ancestors cloaked. I didn’t recognize the faces but there was like this soul recognition (Breakfast Club Power 2018).
Similarly, doulas feel a connection to their ancestors when performing birth work (Allers and Tubbs 2021; Brown 2014; Hutchinson and Jackson 2021; Jones-Cooper and Cosgrove 2022; Little Mason 2020; Martinez 2020; Matos-Becerra 2024; Meurkens 2020; Oron 2022; Ratliff 2021; Reichard 2021; Swann-Quinn 2022). One doula describes,
[Being] in a room…supporting another woman of color was a powerful, powerful, powerful experience. We definitely felt our ancestors in that space, and we definitely felt like we were able to make that space very sacred for that mom (Hutchinson and Jackson 2021).
Some doulas describe their jobs as ‘sitting in a moment of ancestral remembrance’ (Jones-Cooper and Cosgrove 2022) and as a return to African and Indigenous practices (Martinez 2020; Oron 2022; Swann-Quinn 2022). Specifically, within the Latinx community, doulas use traditional postpartum care, such as sobadas (womb massages), baños (herb-infused baths) and caldos (broths) to decolonise healing and reclaim ancestral tradition (Reichard 2021). One doula remarks,
Even though caring for birthing people is an age-old tradition, slavery, white supremacy, and so many other policies disrupted our practices and took us away from our ancestral practices. That requires healing for grandma, great grandma, as well as the mother (Swann-Quinn 2022).
Additionally, doulas describe seeing their ancestors during deliveries because ‘every birth of a child is the return of an ancestor’ (Little Mason 2020), and each child is ‘encoded with [an ancestor’s] spiritual and physical DNA’ (Matos-Becerra 2024). Doulas also recognise the presence of their ancestors within the labouring woman (Breakfast Club Power 2018; Meurkens 2020; Swann-Quinn 2022) because each pregnant woman holds an ever-present ‘ancient song’ within her (Matos-Becerra 2024) and summons the strength of her ancestors during childbirth (Allers and Tubbs 2021). One doula describes,
I remember looking at her, and she was standing on the ground over the bed. She was mid contraction…and she looked like the goddess that she is in all of her power, summoning the strength of her ancestors in that moment… I could feel her ancestors there (Allers and Tubbs 2021).
Doulas as legacies of the granny midwives
Doulas feel a strong occupational tie to the granny midwives of the American South when they reflect on the obstetric history of the USA (Breakfast Club Power 2018; Cleo 2022; Doulas of Color Boston 2023; Nash 2021; Otis 2022; The National Association to Advance Black Birth 2018). Doulas describe how the granny midwives were paramount in establishing the early American population (Breakfast Club Power 2018; Nash 2021) and laid the foundation for the development of American birth work (Otis 2022; The National Association to Advance Black Birth 2018). One doula describes,
When we arrived on these shores in the 1600s the first black granny midwives arrived and they carried with them, in their hair, seed from the motherland that ended up in the soils here so that we have our medicine here. They delivered not only their babies, they delivered the master’s babies and even took care of the master when there was no doctor around, and these were women who birthed this entire nation—who breast fed and wet nursed this entire nation, and this is a legacy that we come from (Breakfast Club Power 2018).
Additionally, by continuing this legacy, doulas are granted access to the spirit of the granny midwives, equipping modern doulas with the resilience the granny midwives demonstrated while working in the antagonistic climate of the early American South (The National Association to Advance Black Birth 2018). The National Association to Advance Black Birth states,
Knowing the legacy of the black midwife creates resilience to rise above oppressive systems worldwide because it teaches the truth of the beauty, intelligence, spiritually, and skills of the African American midwife” (The National Association to Advance Black Birth 2018).
Doulas are also granted access to the skills of the granny midwives (Doulas of Color Boston 2023; Otis 2022), including innate knowledge of the pregnant body and of how to give birth (Breakfast Club Power 2018; Cleo 2022). With this knowledge, doulas constantly ‘pull on the thread left by black midwives…[and] are imprinted with the spirit of their granny predecessors’ (Cleo 2022).
Doulas as cultural translators
Doulas offer support during the labour process by mediating communication between women of colour, their families and providers (Bion 2019; Bobrow 2018; Dodson 2019; Syed 2022; Teixeira 2022). This launches doulas into the role of translating language and into positions that mediate cultural conflict, such as teaching patients and their families about current technology while navigating discussions about cultural needs (Teixeira 2022). One doula mentions,
It’s important to have the option of a provider who looks like you, who speaks your language, who understands things that another provider might not. Some of our clients go on to become doulas themselves because they see the impact we have. They felt valued and supported during this special, sacred time, and in turn wanted to do the same thing for others. That’s the best reward (Bobrow 2018).
Cultural translation is especially important if the patient is labouring without the support of a partner or when the patient is fatigued from the stress of childbirth (Bion 2019; Teixeira 2022). One woman describes how ‘doulas were [her] translators and [her] caretakers when [she] was confused, bleary-eyed and exhausted during [her] 15-hour labor” (Bion 2019). Additionally, cultural translation can become essential if the patient’s family imposes desires that conflict with the desires of the birthing woman (Gruber, Cupito, and Dobson 2013; Teixeira 2022) or when a patient’s cultural needs conflict with standard medical practice (Syed 2022; Teixeira 2022). For instance, doulas may advocate for cuarentenas on behalf of their Latinx patients, which entails a period of rest for 40 days postpartum that often conflict with medical visits for mother and child (Teixeira 2022). In addition to improving communication, doulas ‘may be able to identify culturally relevant, nutritious food for a client…[or] encourage a client to ask for an interpreter during labor’ due to the doula’s position between the world of the physician and the labouring woman (Syed 2022).
Doulas as protectors of the body
In addition to offering emotional support to women of colour, doulas also protect women of colour from physical violence in the medical setting (Bobrow 2018; Meurkens 2020; Nash 2021; Oduah 2011; Tucker 2018). For example, a patient who declined a vaginal exam due to a history of genital trauma was berated by her physician in an attempt to force consent (Bobrow 2018). In addition to these attempts at coercion, doulas describe witnessing physicians continue to perform vaginal exams after being refused consent (Tucker 2018). These experiences communicate,
Black birthing people… need…doulas as bodyguards to protect them from the violence that masquerades as medical care… The one solution that has been offered reveals how little investment in black maternal health there actually is: black women should save themselves (Nash 2021).
Given the potential for interpersonal violence in medical settings, doulas have strongly established their role in protecting patient consent. One doula describes successfully shielding a woman from being coerced into unnecessary medical procedures (Meurkens 2020), while another doula describes having their client purposefully taken away from them before the informed consent process (Bobrow 2018). One doula comments,
Her job could be better described as a bodyguard. Rather than offering comfort measures or encouragement at births, she felt she was really there to keep her clients safe, to protect their physical autonomy, to shield them from being victimized, and failing that, to stand as a witness to their abuse (Tucker 2018).
A woman, lamenting her previous birth experience without doula support, expresses how a doula would have helped her understand her rights prior to giving procedural consent (Orinda 2020). She states,
The doctors weren’t explaining anything to me… They didn’t give us enough information so we couldn’t even make an informed decision. I can imagine if I had a doula, then a doula would have been able to tell me ‘okay, you have rights and your rights are this’ (Oduah 2011).
Discussion
Doulas as portals to the past
By establishing doula presence as a connection to the ancestors and granny midwives, woman of colour can access the strength and power tied to the experiences and identities of these individuals. For instance, when women of colour acknowledge how their ancestors successfully bore children for generations before them, women regain trust in their bodies and approach the labour and delivery process with less fear. Additionally, doula-supported labour allows women to reclaim childbirth as a time of empowerment by rebalancing the power dynamic between the healthcare system and the birthing woman by increasing racially concordant support at the bedside. With the help of doulas, patients are also able to lean into the spirituality of birth by reconnecting with lost traditions. Furthermore, when doulas reflect on the societal contributions of the granny midwives despite the racist overtones of the early American South, modern-day doulas find the strength to advocate for patients in the midst of the maternal health crisis. Together, doulas and women of colour are reclaiming birthing spaces as a source of strength by reconnecting with the past.
The importance of connecting women of colour to this ancestral strength can be better understood by the works of Audre Lorde, a black American poet who dedicated her work to addressing racism, sexism, classism and homophobia in the late 20th century. In her collection of essays, Sister Outsider, she explains that society removes power from those ‘forged in the crucibles of difference’, including women of colour, and notes that ‘the master’s tools will never dismantle the master’s house’ (Lorde 1984). These words remain true in the midst of a maternal health crisis that has persisted despite decades-long attempts by historically white institutions to improve outcomes for women of colour. Doulas offer a path towards improving the maternal mortality crisis because an ancient tool, instead of a master’s tool, has the potential to dismantle society’s current predicament.
Audre Lorde’s work also contextualises the importance of doula support within an already racially and ethnically diversified obstetrician workforce. Based on several studies on the experiences of patients, racially/ethnically concordant patient-physician encounters increase patient satisfaction with their medical care due to improved patient-physician communication and decreased bias between patients and physicians (Blanchard, Nayar, and Lurie 2007; Okpa, Buxton, and O’Neill 2022; Takeshita et al. 2020). While it remains prudent to acknowledge the benefits that a diversified physician workforce already offers, the persistence of the maternal health crisis reveals it is insufficient to fully combat the structural racism embedded in the US healthcare system. The expectation is that doulas at the bedside would compound the positive effect of a diversified obstetrician workforce by bringing additional comfort and security to the bedside and facilitating ‘cultural sensitivity and trust‐building’ (Liese et al. 2022).
Doulas as keepers of the present
While doulas connect women of colour to historical sources of strength, doulas also connect women of colour to a safer present by providing cultural translation and physical protection. With 98.4% of women giving birth in hospitals in the USA (National Academies of Sciences Engineering and Medicine 2020), doulas offer additional support to women of colour entering oppressive spaces. The presence of a doula can prevent the miscommunications that take place between providers and patients unfamiliar with each other’s medical customs. For example, a Latinx patient hoping to begin her cuarentena or 40-day postpartum rest may face conflict with a medical team hoping to establish close follow-up for her and her newborn. The presence of a doula allows for improved communication of cultural expectations and may allow for compromises, such as home visits, to be established. Additionally, doulas increase the number of voices acting on behalf of the patient and have the ability to call attention to injustice due to their training and their understanding of patient rights. Whether through cultural translation or protecting women of colour from unconsented medical practices, doulas mitigate some of the threats that medical institutions and providers pose to women of colour.
The utilisation of doulas as a way to safely navigate medical institutions is not a modern intervention, and a historic example of the importance of supporting women of colour through birth work can be seen in Durham, North Carolina throughout the 20th century. In 1901, Lincoln Hospital was founded by Durham’s first black physician, Dr Aaron Moore, to serve the needs of the black community (Baker 2022). Although it lacked the funding of the nearby Duke Hospital, who served black and white patients on segregated wards, Lincoln was considered ‘hallowed ground’ for its patients, offering gentle care that brought people back despite its lack of resources (Baker 2022). Retired Lincoln nurse, Ann Mulligan Barnes, recalled that mothers could have faith that ‘somebody would’ have been there’ during the delivery and that they would have ‘made over’ both the mother and the newborn (Baker 2022). Lincoln Hospital was such a pillar of the community that many local black leaders opposed integration, and it remained in operation until Durham County Hospital opened in 1976 (Baker 2022). Although integration of the hospital system brought resources to patients, health disparities persisted, and it was understood by the community that disempowerment in the clinical setting was something financial resources could not sufficiently counter. While doulas were not directly mentioned within this example, the social support that the black community lost due to integration is the role that doulas would later come to fill. Regardless of the time period, communities return to practices that increase physical and emotional safety during labour (Sauls 2002).
Limitations
Limitations of this study include the lack of non-binary and transgender perspectives on doula-supported labour and delivery. This requires further investigation because doulas may provide varying degrees of impact on the care of other marginalised communities. Furthermore, the popular media sources in this study were intended for use by women of colour in the general population considering the use of a doula. The sources were removed from their original context, interpreted by authors with medical backgrounds and presented for an academic audience. Although authors of qualitative studies attempt to interpret sources within their original context, the sources remain subject to the implicit biases of the authors and impact the general trustworthiness of qualitative studies.
Conclusion: doulas as a bridge to an equitable future
Given the themes that arose throughout these popular media sources, doulas empower women of colour through connections to historic spaces and by increasing the safety of the present. By improving the self-advocacy of women of colour, doulas have become an important tool for combatting maternal health disparities. It is essential that doulas are prioritised as a facet of the healthcare system moving forward and made accessible to underserved populations. Next steps for the integration of doula care into modern obstetrics includes the proper compensation of doulas for their work by reimbursing their services through Medicaid, as exemplified in the law recently passed by the Washington state legislature (Oron 2022). Next steps for research include exploring the prevalence of doula-supported practices across the USA and the experiences of non-binary and transgender people using doula care.
Data availability statement
Data are available in a public, open access repository.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Bibliography
Footnotes
Contributors VRG acquired, analysed and interpreted the data and drafted the manuscript. SM made substantial contributions to the conception of the work and revised the manuscript for important intellectual content. SM is the guarantor of the project, accepting responsibility for the work and conduct of the study, had access to the data, and controlled the decision to publish. Both VRG and SM give final approval of the version to be published and agreed to be accountable.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.