How Doulas Took Over the Birth World
Are doulas part of a much needed birth revolution? Or an expensive bandaid for a broken public system?
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The Rise of the Doula
My Instagram algorithm knew I wanted a baby before I did. The creep was slow, but eventually I couldn’t ignore the change in my explore page. Gone were natural wine bars and ballet flats. Here were topless women cradling bumps in front of indoor ferns.
In this new part of the internet, pregnancy and birth seemed so different from the back-breaking ordeal I’d witnessed growing up. These mothers were’t harassed and exhausted, they were ethereal and serene. Floating in home birth pools, they resembled fertile pre-raphaelites. Across essay-length Instagram captions they spoke of birth as an ecstatic act. A bloody but triumphant merging of life, death, history, family and identity. Their bodies weren’t flesh and bone but gateways and sacred vessels. This was not What to Expect When You’re Expecting…
I’ll be honest, the cynic in me is reflexively weary of such earnestness. Even after having a baby I still sometimes roll my eyes at this near religious depiction of maternity. But the most devout sceptic can’t ignore that online and off a new culture around pregnancy and birth is emerging. One that exists outside of doctors, hospitals, blood tests and ultrasounds. But rather considers the full social, emotional and physical experience of parenthood. And at the centre of this all is a very distinct figure: the doula.
What Actually Is a Doula?
Across the past decade doulas have gone from hippy birth accessory to a must have item common enough to inspire celebrity listicles and Chris Pine movies. But if you’re new to this world, let me explain.
Doulas are non-medically trained childbirth companions. For Vaughne Geary, a doula and naturopath who has worked in this space for almost a decade, the job is that of “an educational and emotional support person”. Someone who's there to help parents “prepare for the practical, emotional and spiritual unfolding and transformation that occurs when a new baby enters the family.”
That might involve pre-birth classes, massages, meal preparation, mental health support, meditation, journaling, belly binding and closing of the bones ceremonies. Some doulas also provide bereavement care for individuals who have experienced miscarriage, abortion and premature or stillborn birth.
Unlike midwives, who are medically trained and whose practice is strictly defined by the nursing midwifery board of Australia, doulas are unregistered and require no regulated training or experience. As such, they don’t undertake procedures to do with client health–including performing deliveries.
A New Trend With an Ancient Past
The idea of non-medical birth companions is hardly new. For most of history births weren’t performed by doctors, but rather women with experience delivering babies. In fact, the word doula comes from ancient Greek and means "a woman who serves". But the formalised, paid role we recognise today really took form in the 1980s. It was a response to growing concerns about the state of mainstream maternal healthcare. In particular, distress over rising rates of caesarean sections.
Then, as now, families were drawn to alternative approaches to birth. But despite that swell of interest, doulas were still largely seen as an “alternative” birth practice until fairly recently. While there’s no formal data tracking doula participation, career birth workers are quick to confirm the sense that they really are everywhere. “Interest in increasing access to doula support has gone up exponentially in the last few years,” says Carol Sakala, a long-time maternity care advocate, researcher, policy analyst and director of Childbirth Connection programs at the National Partnership for Women & Families. “We have never before received so many inquiries into doula support,” echoes Claire Wyborn, the president of Doula Network Australia.
So, what gives?
Why Everyone You Know Has a Doula
The case for doulas is easy to make. As Katy Backes Kozhimannil, a professor at the University of Minnesota School of Public Health, explained to CBS News in 2020, doula support has been linked to: “higher levels of satisfaction, shorter labours, more spontaneous vaginal births, fewer caesarean deliveries, fewer unnecessary caesarean births, fewer preterm births, fewer epidurals, higher rates of breastfeeding initiation, reduced racial disparities in breastfeeding initiation and higher maternal confidence and satisfaction."
With that context, the central question of our obsession isn’t really, why do people use them? But rather, why are people using them so much now?
It’s not a shock to hear that escalating pressures on Australian maternity services are leaving parents feeling lost and overwhelmed. Anyone who has given birth in a public hospital can tell you that despite the best efforts of staff, support is limited. You’re shuffled between midwives, rushed through appointments, often pushed into procedures and left with little time to ask questions or engage meaningfully with your care providers.
This churn has led to significant issues around the services available. In 2021, a shocking Fairfax investigation reported “a ‘huge’ increase in women and their babies being readmitted to hospital for wound infection treatment after having been sent home on day two rather than day three after caesareans, or suffering mastitis.” With a shortage of beds in maternity wards (owing to a rise in birth rates and private insurance costs forcing more people into the public system) birth parents are regularly sent home before they’re ready, often before they’re even chestfeeding comfortably.
That lack of continued assistance is leaving people anxious and seeking help. June* is a high school teacher who looked into using a doula for the birth of her first child. She reflects, “People I know are going down the doula route because the public health system is so overrun that what they say they can offer is not what’s happening...Women aren’t feeling supported so they’re getting someone else in to help them.”
With resources strained–barely covering physical needs–additionally emotional care is rarely an option. That was the situation Maggie faced when preparing for the birth of her daughter two years ago. She was weary of the limitations placed on the hospital-focused birth system. Observing friends and family she noticed “a heavy preoccupation with the medical aspect of the pregnancy, and not so much consideration for the spiritual or emotional aspect.”
Understanding these weren’t concerns that mainstream health workers had room to unpack with her, she engaged a private birth worker who “works as an intuitive healer, and that brings a whole level of spirituality to the birth scene.”
June and Maggie saw doulas as a way to plug gaps in public services. But they can also bridge social divides. Feeding, holding and even bathing new parents is noble work, but feels like a role family or friends would traditionally play. The reality is though, in a post nuclear-family world, that help is becoming more fractured. And while we tend to think of pregnancy as a time for community, for many it can be intensely isolating.
Vaughne observes that doulas can give less emotionally complex comfort for those estranged from social networks. Having worked in a paid and volunteer capacity, assisting unhoused and refugee individuals during pregnancy and birth, she’s sensitive that, “Some people are triggered by the idea of a family member coming into the birth space.”
Even if relationships aren’t frayed, many still need additional help navigating the challenges ahead of them. Taylah had only been dating her partner for two months when she found out she was pregnant with her son. She was the first person in her friendship group to have a child, and employed a doula as a source of information and solace. “Until you’ve been through pregnancy and birth you don’t really know how to support other people properly,” she remembers. “The doula was great because it’s support that you know you’re going to get, you don’t have to ask for it”.
Decolonising Birth
It should be stressed that issues of limited and worsening physical and cultural assistance are even more pronounced in regional and Indigenous communities. For context, reviewing maternal deaths in Australia between 2015 and 2017, The Australian Institute of Health and Welfare reported that: “The incidence of maternal death in Aboriginal and Torres Strait Islander women was more than 3 times as high as that for non-Indigenous women.”
But doula projects like Charles Darwin University’s Caring for Mum on Country are working to address these discrepancies. Led by research fellow Dr Sarah Ireland, they’re exploring how maternal health outcomes can be improved through the work of Indigenous doulas (called djäkamirr). Additionally the program aims to address the ways colonisation and racism interact with the birth experience.
Again, these doulas’ scope of work moves beyond anything available through regular health services. In a joint statement, Sara’s co-researcher Dr Elaine Läwurrpa Maypilama, herself a Yolŋu woman, and Caring for Mum on Country project research assistant Raisa Brozalevskaia explained: “The djäkamirr role supports woman by sharing Yolŋu knowledges about healthy childbearing, including hunting, cooking healthy bush foods, bush medicine and involvement in ceremonies that support pregnancy, childbirth and postpartum.”
Not Everyone Is a Fan
Speaking to doulas and the people who they work with, it’s clear this is a life changing job. But in many ways, it’s also a bandaid: a paid role employed to make a public service feel more whole. One could argue that in a perfect world, with a fair and functional health system, doulas wouldn’t need to exist.
Not surprisingly, the collision of the highly regulated medical world and doula culture can create tension. Joanne Gray is the president of the Australian college of midwives and a professor of midwifery at the University of Technology Sydney. She’s worked as a midwife for over 30 years, and while she’s aware and respectful of doula work, she champions continuity of care midwifery models as the “gold standard”.
Speaking of doulas, she cautions: “The risk is that these are untrained, unregistered [people working in the health space]. So there is no mechanism of ensuring the skills a doula can provide”
Still, the appeal isn’t lost on her: “What a lot of people accessing a doula are looking for is just someone who knows them. So they have their person the whole way through the birthing experience. That says to me women need this person, but it would be so much better if this person was a midwife.”
Although she admits that right now that’s not an option for most families–unless they can pay for private care. “We have shortages of midwives...Fewer than 10 percent of women in Australia have access to a midwife for continuity of midwifery care throughout their pregnancy and into their birth period.”
With that understanding, she concedes that “when the system isn’t providing that, they do then seek a doula”. But also worries: “If we are using unregulated and unregistered people in a space where we know we have people with those skills but women simply can’t access them like they should, that’s a problem.”
The Price of a Good Birth
As established, doulas are a private, out of pocket expense that people turn to when public services fail. Because they’re non-regulated, they’re not covered by Medicare or health insurance. There are free and volunteer programs, but they’re limited. In Australia groups like Birth for Humankind offer pro bono support to parents experiencing social and financial disadvantage, but as the demand for doulas increases lone organisations can’t keep up.
In most cases doulas charge between $1,500 to $10,000 depending on the length and level of care.
This need to pay up front creates an ironic conflict where a role that plugs gaps in public health care is largely only available to those with money to access it. This was the barrier that eventually saw June choose to not hire a doula. “I was kind of put off by the cost...They’re so expensive it’s like paying for a private hospital bill.”
While the financial restrictions are significant, it’s worth pointing out that being a doula is a physically and emotionally demanding job. No one is saying they should charge less or work for free. Researching this piece, many doulas talked about the need for their work to be covered by Medicare and private insurance, or to be more formally integrated into the hospital maternity flow. Especially if they’re delivering services that hospitals aren’t currently equipped to supply –no matter how much midwides like Joanna would like to.
What Our Doula Obsession Can Tell Us
It’s easy to make jokes about doulas. Hell, I started this article doing it. We’re conditioned to roll our eyes at woolly feelings and effusive talk of community and connectedness (especially online). But there’s no doubt doula work is transformative and vital. Their increased popularity tells us that the way we consider our bodies, our births, our stories are changing. Birth parents are feeling empowered to advocate for a different experience, one that is personal and specific. That speaks to their unique needs and dreams for what a family could and should look like.
But sadly, it’s an experience our healthcare structure isn’t set up to handle. As a result, their rise is a flashing warning for how the current system fails families. And while doulas make a difference on an individual level they can't serve as a permanent solution for greater problems around access to ongoing, high quality care. Because a safe, respectful and supported birth and postpartum shouldn’t be a luxury product.
*Names have been changed.
Thank you for reading my first real post! I’d love to hear what you think about doulas and their place in the birth system. Feel free to comment or even shoot me an email. And if you like what you’ve read, please share this article or tell a mate!