THE DOULA MODEL OF CARE Guiding Principles & Best Practices for Doulas
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,2 models of care have the following key elements:
A brief history of doulas
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.
Each doula business is unique.
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.
Support provided by doulas:
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.
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 Doulas 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).
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.