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 established¹and 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, models of care have the following key elements:

Quality care—promotes safe, high-quality care
Patient-centric—focus is on the patient/family
Integrated care—supports collaboration among all team members
Cost-effective—promotes efficient use of resources
Adaptability—localized flexibility; considers equity of access
Outcome evaluation—has a robust and standardized set of outcome measures and evaluation processes
Evidence-based—incorporates the best available evidence; links to local and national strategic plans and initiatives
Innovative—considers new ways of organizing and delivering care
Visionary—sets a vision for services in the future

A brief history of doulas

The word Doula has Greek origins and means “one 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 the early 1990s when professional doula training and certification emerged. A scope of practice for doulas was defined as the time-honored, informal role of the doula became professionalized. Today, there are numerous organizations training and certifying doulas across the globe.

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.

Each doula business is unique.

Because doulas remain, for the most part, an unregulated profession, 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 end-of-life arenas, 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.

How each doula manifests the doula model of care and delivers services to families will be uniquely her or his own. There is plenty of room for creative visionaries to adapt the doula model of care for a target demographic or specialized care setting. This freedom, entrepreneurship, and diversity benefit the variety of individuals and families with needs that are unmet by existing systems of care delivery. At the same time, while embracing our diversity, we must acknowledge what unites us as doulas and define the core, non-negotiable elements of the doula model of care.

CORE COMPONENTS OF THE DOULA MODEL OF CARE

Six Guiding Principles of Doula Support

NON-MEDICAL SUPPORT. Doulas refrain from giving medical advice or performing any clinical or medicalized tasks (e.g., monitoring vital signs, dispensing medications, wound care). This prohibition is fundamental to the role.

NON-JUDGMENTAL SUPPORT. The doula does not impose her/his values on the client such as acting on biases in favor of one method of giving birth or pre-conceived notions of what constitutes a “good death.” Care is based on the client’s values and goals, even if those differ from values cherished by the doula.

FAMILY-CENTERED APPROACH. The individual and their family are the focus of support. Doulas do not take the place of partners, family members, or other care providers but rather, work in a spirit of collaboration.

HOLISTIC CARE. Doulas recognize the bio-psycho-social and spiritual aspects of the whole person and provide services in the context of this understanding. Holistic care may can also include information and referrals for complementary healthcare modalities if the client is interested in alternative approaches beyond those embraced by the medical model.

EMPOWERMENT. Doulas promote informed decision-making and foster maximum self-determination for the individual and family. They encourage self-efficacy and self-advocacy rather than dependency. Doulas are not advocates per se and do not speak for their clients. Their role is better understood as that of a mediator who facilitates effective communication between all parties.

TEAM MEMBERS. Doulas are collaborators. The doula’s areas of expertise may overlap with that of other professionals involved with the client’s care, for example, a labor and delivery nurse, lactation consultant, or member of the hospice team. These overlaps are to be expected and need not lead to conflicts provided doulas stay in their lane and defer to medical experts for concerns outside their scope. Doulas often have a better grasp of the full continuum of care providers involved in the client’s care, as well as where gaps exist that create stress for the client and family. In this way, doulas provide much needed continuity of care.

Support provided by doulas:

Presence. Good listener, witness, calming influence, nurturing, support for troubleshooting challenges.
Emotional support. An essential aspect of doula care.
Information sharing. Education as needed and desired (e.g., how to care for a newborn or what to expect during the dying process). Information provided is non-biased and evidence-based. While encouraging informed decision-making, doulas refrain from giving advice to their clients or promoting a specific choice or course of action.
Proactive guidance. Doulas help their clients to anticipate pending needs and provide guidance for making a plan to address them (e.g., birth plan or vigil plan).
Resources and referrals. Doulas are generalists rather than specialists, though some may have additional training in specialty areas such as massage therapy or spiritual care. When client needs/requests are outside of the doula’s scope of practice, professional boundaries, or area of expertise, the doula is prepared to make referrals to appropriate community resources and care providers.
Comfort measures and physical support. Can include hands-on comfort techniques, help with positioning, visualization, use of the breath, and so on. Personal care at the end of life (e.g., helping to keep the person clean and dry) may be offered by some end-of-life doulas.
Logistical support. Can include household help, running errands, transportation to medical appointments, and so on. Services provided by individual doulas will vary in this area as each establishes her/his own professional boundaries.

Adapting the doula model of care for end of life

If we reconsider the definition and key elements of a “model of care” discussed earlier, 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 critical phases of the lifespan—as we expect they do—then a strong case can be made for expanding third party reimbursement for doulas so 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”⁵ 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)⁶ 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

SUMMARY

The emerging field of the end-of-life doula has benefitted 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.

¹Knocke, K., Chappel, A., Sugar, S., De Lew, N., and Sommers, B. (2022). Doula Care and Maternal Health: An Evidence Review. Retrieved from https://aspe.hhs.gov/sites/default/files/documents/dfcd768f1caf6fabf3d281f762e8d068/ASPE-Doula-Issue-Brief-12-13-22.pdf.

²Agency for Clinical Innovation (2013). Understanding the process to develop a model of care: An ACI framework. Retrieved from https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/181935/HS13-034_Framework-DevelopMoC_D7.pdf.

³DONA International (2020). 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 https://www.nedalliance.org/scope-of-practice.html.

⁵Librada-Flores, S., Nabal-Vicuña, M. Forero-Vega, D., Muñoz-Mayorga, I., and Guerra-Martin, M. (2020). Implementation models of compassionate communities and compassionate cities at the end of life: A systematic review. Int J Environ Res Public Health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7504622/.

⁶Institute of Medicine (2015). Dying in America. Improving quality and honoring individual preferences near the end of life. Retrieved from https://nap.nationalacademies.org/catalog/18748/dying-in-america-improving-quality-and-honoring-individual-preferences-near.