Listen mother

Defining the doula’s role: fostering relational autonomy

Sandra L. Meadow MA*†‡ *MSc Candidate in Public Health, London School of Hygiene and Tropical Medicine, London, UK, †MSc Candidate in Health

Communication, University of Illinois at Urbana-Champaign, Urbana, IL, USA and ‡Trainer and Curriculum Developer,

Childbirth International

Correspondence

Sandra L. Meadow MA

Graduate Student

1802 Belmont Avenue

Victoria, BC, V8R 3Z2

Canada

E-mail: [email protected]

Accepted for publication

29 September 2014

Keywords: doulas, patient

engagement, relational autonomy,

shared decision-making

Abstract

Background Training organizations as well as academic and popu-

lar literature provide ambiguous or ethically contentious character-

izations of the role of the birth doula, a non-clinical role assisting

women in pregnancy and birth with information and physical and

emotional support. Doulas have been criticized for attempting to

impose their own agendas on their clients and for interfering with

the relationship between women and their medical caregivers.

Objective To develop a theoretically grounded model of the birth

doula’s role to guide constructive practice and refute some training

organizations’ and doulas’ adoption of an active ‘advocacy’ role

with clients that can lead to inappropriate practices.

Design Apply the theoretical framework of relational autonomy to

the components of the work that doulas perform with their clients.

Discussion and Conclusions The conceptual framework of rela-

tional autonomy recognizes the social context in which women

make choices about their care in pregnancy and birth, instead of

assuming that autonomy is exercised in isolation. To support this

understanding of autonomy, a relational model emphasizes

women’s skills development, self-confidence and recognition of the

social context for decisions. Highlighting these aspects of exercis-

ing autonomy reduces the potential for the doula to seek to influ-

ence her client. The doula’s role is reframed as one of facilitating

patient engagement and shared decision-making.

Introduction

Birth doulas provide their clients with physical

and emotional support during labour, as well

as information and support for communication

and decision-making. Doula training organiza-

tions and academic and popular literature

sometimes describe an ‘advocacy’ role for

doulas, in ambiguous or ethically contentious

terms, potentially fostering misunderstanding

and conflict. Clinicians and parents describe

working with doulas who appear to impose

their own agendas and who interfere with the

relationship between women and their medical

caregivers. The bioethical concept of relational

autonomy recognizes that autonomy operates in

3057ª 2014 John Wiley & Sons Ltd

Health Expectations, 18, pp.3057–3068

doi: 10.1111/hex.12290

a wide social context, not just within the con-

fines of the mind of an individual. Grounding

the definition of the doula’s role in relational

autonomy gives coherence and guidance to the

work doulas do and has the potential to

resolve the kinds of conflicts and misunder-

standings that have been reported.

What is a doula?

The work doulas do descends from the age-old

tradition of experienced female elders support-

ing labouring women during childbirth. As

childbirth became medicalized in the 20th cen-

tury in many parts of the world, and women

spent labour in isolation from relatives or

neighbours, few women acquired the experience

to provide confident encouragement or practical

support to the next generation. The doula voca-

tion emerged to fill this need, ‘professionalizing’

a role that was once occupied by laywomen.1

Although the occupation is largely unregu-

lated, and anyone can call herself (or himself)

a doula, this article focuses on professional

doulas who are formally certified and paid for

their work. In this context, doula training

organizations are influential in defining the

role, but dozens of such organizations, large

and small, exist on six continents with consid-

erable variation in their philosophy and meth-

ods. No single definition of the doula role

exists. Academic research, trade associations,

and consumer books and websites also con-

tribute definitions. The doula role is almost

universally considered to feature physical and

emotional support,2–8 which Amy Gilliland calls

a ‘holding hands’ model,1 and which has often

been the subject of research on the effect of

supportive care in labour.9–13 Physical support

techniques include identifying helpful position-

ing for pain relief or labour progress, use of

the breath, sacral counterpressure, and applica-

tion of cold and heat. Doulas offer emotional

support through techniques such as reflective

listening, empathy, encouragement, mirroring

and protecting an atmosphere of quiet focus.14

Many definitions of the doula role also encom-

pass informational support and advocacy.2–7

Informational support may be described as

explaining, answering questions, or giving

‘information about what’s happening dur-

ing labour’8,15 as well as bringing the doula

into the process of preparing for informed

choice2,3,8,16–19 by discussing ‘options, risks and

benefits of the different approaches available in

maternity care’.20 The definition of advocacy is

more contested. One approach views advocacy

on the doula’s part as a way to support the client

in voicing her own intentions and increase her

involvement in decision-making. This approach

often emphasizes that doulas do not give advice

(especially medical advice)21 and do not speak

for their clients,6,17,19,22 but may identify ques-

tions the client may ask and help her communi-

cate on her own behalf with medical

staff.11,16,22–24 Another approach, offered pri-

marily by academic articles and consumer mate-

rials, places the doula-as-advocate in an

intermediary role, ‘communicating and inter-

preting the mother’s desires to care providers

during labour’, ‘question[ing] a clinical interven-

tion at the behest of the mother’,21 giving

‘advice’,8,16,21,25,26 or ‘add[ing] another opinion

to the mix when decisions need to be made

regarding the management of . . . labor’.15

Although arguably certification organiza-

tions primarily define and inculcate the role of

a doula, other sources may exert influence over

how the role is understood. Certification orga-

nizations tend to avoid the more activist

approach of advocacy, but ambiguity still

arises in how this concept is or is not incorpo-

rated into the doula role. One scope-of-practice

document noted, for example, that ‘the advo-

cacy role does not include the doula speaking

instead of the client or making decisions for

the client. The advocacy role is best described

as support, information and mediation or

negotiation’;6 ambiguity stems from the fact

that mediation and negotiation in other profes-

sional contexts both can be understood to

involve an active subjective role for the inter-

mediary.27 Similarly ambiguous, another train-

ing organization describes doulas as ‘assisting

in decision-making’7 and another as ‘guiding’28

their clients.

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Doulas: fostering relational autonomy, S L Meadow3058

Need for a theoretical framework

Doula training sessions may of course expand

on the phrases written into organizations’

documentation, but many doula training

courses consist of workshops with limited time

(typically 16–20 h over 2 days) to explore and

learn to apply in practice the ethical bound-

aries of the support role. As doulas work

within environments in which clinicians may

routinely and legitimately share advice or opin-

ions, the doula role in this context requires

further elaboration and specification to differ-

entiate it from existing educator or clinical

roles.

Lack of clarity over advocacy and advice-

giving leaves the doula profession vulnerable

to charges of inappropriate or unethical prac-

tice. One clinician questions the very need for

the doula’s role in communication: ‘to suggest

to any doctor – or nurse – that their patients

need a middleman just to help them commu-

nicate would ordinarily indicate a massive

failure in their practice’.29 Others assert that

doulas interfere. An Australian study reveals

that some midwives ‘felt that doulas manipu-

lated women into not trusting them, with the

purpose of protecting the woman from the

system’, quoting a doula who acknowledges

that she and her client ‘managed to lock the

doctor out of the room for 45 minutes’ to

avoid augmentation of labour with oxytocics

(drugs that intensify contractions).30 An

obstetrician complains that doulas are not

merely involved in doctor–client communica-

tion, but act as ‘intermediary’; ‘she has seen

doulas “all but refuse” to let her examine her

patients’.31

Even more troubling, doulas may at times

not only speak on behalf of clients, but influ-

ence or even attempt to coerce women.11,20 An

unhappy mother recalls that her doula ‘urged’

her to use a shower for pain relief; the client

reported that ‘I told her I didn’t want to, but

she was adamant’ and when she ‘ultimately

chose an epidural, her doula walked out’.32 It

is not only doulas acting as rogues by ‘behav-

ing outside the circle of professional practice’33

who might be tempted to direct their clients’

choices. A popular book on the benefits of

labour support advises doulas to ‘have the

mother stay home as long as possible’ and

notes that ‘several signs can help you and the

mother decide when to leave home to go to the

birth centre or hospital’34 [emphasis added].

These reports are anecdotal. No formal

research indicates how common such conten-

tious practices are. Without better clarity on

the limits of advocacy and advice-giving, some

doulas may plausibly yet erroneously believe it

is their responsibility to urge the client to take

steps the doula believes will help achieve the

client’s goals for birth.

A theoretical framework, based on the con-

cept of relational autonomy, would improve

the clarity and consistency of the doula’s role,

providing a rationale for why the doula does

not give advice or direction, or speak on behalf

of clients. Such a rationale may help guide the

doula training curriculum and assist doulas to

apply the ethical principles laid out in codes of

practice in their everyday working lives. As

well, this rationale may help position the doula

in the communication process so that all

involved in maternity care can collaborate

effectively to promote women’s autonomy and

well-being.

A new model of doula work: fostering relational autonomy

Why relational autonomy?

To assuage some of the criticisms of doulas’

practice and improve the consistency, integrity

and efficacy of the doula’s role in maternity

care, I propose a new model, framed in the

concept of relational autonomy. Beauchamp and

Childress explain that a person displays auton-

omy when she acts with intention, with under-

standing, and without ‘controlling influences’.35

Acting autonomously in this standard concep-

tion means a woman is ‘competent’ (rational

enough to make a choice), has enough infor-

mation and comprehension and can make a

‘reasonable’ choice, free from explicit coercion.

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Doulas: fostering relational autonomy, S L Meadow 3059

Susan Sherwin objects, however, that this

understanding of autonomy goes too far

in assuming we are each ‘independent, self-

interested and self-sufficient’,36 and John

Christman points out that it fails to recognize

our true social nature: that we, in fact, develop

autonomy in the context of the ‘relations of

care, interdependence and mutual support that

define our lives’37 which might at times

enhance and at other times conflict with our

desires. Women, then, do not make choices or

experience pregnancy and birth in a vacuum.

Their partners, families, peers and health-care

providers all influence the process of bringing a

child into the world.

Relational autonomy adapts the concept of

autonomy to incorporate this social view. A

relational understanding of autonomy rests on

three pillars.36,38,39 The first is a set of skills

and capacities that enable us to negotiate self-

determination in a social world. The second is

trust – trust in others to support our auton-

omy, trust in ourselves to be capable of good

judgment and trust in our ability to recognize

when trust in another is not warranted. The

third pillar is mindfulness that social circum-

stances not only enable autonomy but can

hinder it: our social worlds are filled with the

biases of the people and institutions we live

with; when we make choices within a biased

social system, we either overcome or coexist

with those biases.

Understanding autonomy in a relational way

does not mean expecting individuals to shoul-

der all the work of flexing their autonomy

through the ‘exercise of personal resources and

skills’.36 Autonomy must also be fostered from

the other direction: by expanding the social

and organizational options available for preg-

nant women (and everyone else). Relational

autonomy therefore provides a framework in

which to position doulas’ twin impulses to sup-

port individual women as well as promote

woman-centred and evidence-based care. It

provides a clear way to separate these two

activities so that doulas do not pursue political

aims by pressing individual women to make

certain choices. The danger of substituting the

doula’s judgment for the client’s would ideally

fade within a relational-autonomy model, in

which doulas would see the women they are

supporting, rather than themselves, as the

central actors in the drama of birth. The dou-

la’s role would then focus on helping women

to develop skills, strengthen appropriate trust

in their social networks and become mindful of

biases within those networks. Doulas would be

free to advocate – outside the birthing room – for evolution in maternity-care practices to

expand the prospect of autonomy for all

women.

Fostering women’s skills and capacities

Doulas’ support role, and their practice of

spending extended time with each client, mean

their most important contribution may be not

handholding in labour, but to help women rec-

ognize the skills and capacities they need to act

with autonomy. This can occur in five concrete

areas: values clarification, identification of

options, communication, decision-making and

reflection. These play out in an iterative cycle

throughout the doula–client interaction.

Values clarification

Values clarification provides a starting point

for the doula–client relationship in two ways: it

defines a context for making choices and

guides discrete choices as they arise, which may

lead the client to discover new goals.

Identifying core values can help women to

choose and foster a relationship with a midwife

or doctor,40 establish a framework for decision-

making with their partner and navigate social

and medical expectations of pregnant women’s

choices.41 Women may also clarify their values

about the very process of choice: in what

circumstances they prefer decision-making

that is paternalistic (clinician-directed), shared

(between patient and clinician) or informed

(patient-directed). Some women are not at first

aware that decisions may be made in anything

other than a clinician-directed way.42 One of

the first questions that many doulas ask a pro-

spective client is ‘what sort of birth are you

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looking for?’ This is a basic values clarification

exercise which can reveal priorities not only for

the actual birth, but for pregnancy and parent-

ing. Doulas can, for example, introduce the

concepts of expectant and active management

of labour so that women can locate their own

preferences.

Values clarification also informs particular

decisions. With core values in mind, doulas can

help women identify specific process or out-

come factors that are most important to them,

such as choosing a position for pushing or

avoiding a caesarean. In prenatal meetings, a

doula can offer to discuss common dilemmas

in pregnancy and birth, so women can apply

their core values and prepare to discuss options

with their health-care providers. Values clarifi-

cation exercises can help women to understand

the distinction between values and desires for

certain empirical outcomes. A woman cannot

completely control whether or not she has a

vaginal birth, for example – an empirical out-

come – but she can have a great deal of control

over selecting care that she is confident gives

her the best chance for a vaginal birth.

Identification of options

Many doulas are self-employed, and some pro-

mote this independence by advertising that

they provide information on pros and cons of

‘all’ the options, not just the ones that directly

conform to the policies or routine practices of

a woman’s health-care provider or birth facil-

ity. This can appeal to women and families

who strongly desire to take an informed-choice

approach to pregnancy and birth. Doulas

might, for example, offer information on topics

such as vaginal birth after caesarean (especially

where local hospitals do not offer this option)

or vaginal breech birth (where caesarean sec-

tion is routine for breech presentation). Given

the gap between some hospital policies and

principles of evidence-based care,43 it is possi-

ble that reasonable and competent clinicians

might exclude evidence-based options from

discussion.

The advantage of a relational-autonomy

model for this aspect of doula work lies in the

value of discussing not only factual aspects of

these topics, but in recognizing the subjective

context in which all choices are made. Doulas

promoting relational autonomy would avoid

urging their clients down a particular road.

Instead, where a client’s values spur her to

explore alternatives to the route recommended

to her, the doula may encourage her client to

consider the implications of her three basic

options: accepting the constraints of policy,

finding a mutually acceptable compromise or

seeking a more compatible care provider or

birth setting.

Communication

In a relational approach, exploring values and

options, and making decisions, require commu-

nication between a woman and her partner,

family, health-care providers and others, the

quality and substance of which shape a

woman’s identity and self-confidence.38

Communication skills. Doulas can model and

teach a host of communication skills, including

active and reflective listening;44 empathy for

the perspectives and concerns of others;45 ask-

ing effective questions;46,47 assertiveness (and

knowing the difference between assertiveness,

aggressiveness and passivity);48 expressing con-

cerns, feelings and expectations;46,48 and moti-

vational interviewing.49 Doulas can use these

skills to facilitate effective communication

between women and their medical caregivers,

especially where misunderstandings may arise.

Engagement. Engagement is not a specific skill.

It encompasses other communication skills to

enable the woman to contribute effort to her

own care and take a collaborative view of her

relationship with health professionals.50 Collab-

orating may require re-evaluating the health

professional’s role51 and regarding a clinician’s

input as a key resource rather than a set of

instructions. This might mean a woman asks

questions and explores options, makes explicit

her views and concerns (rather than hiding her

other sources of information)52 and partici-

pates in shared decision-making.53 Women

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need modelling and practice to learn the skills

of the engaged consumer,54 and a doula can

offer an example of respectful wording of a

question, roleplay and insight into the value

that many clinicians place on engagement.

Decision-making

Autonomous decision-making is more than

freely choosing from a menu. Drawing on the

values women have articulated, and the options

they have identified, decision-making in a rela-

tional world recognizes the importance of

framing and context for each individual.55

General decision tools. Doulas can help women

think explicitly about the type of deliberation

that most suits them. Whether a list of pros

and cons, a decision tree, or one of many

other tools, each woman may find a particular

style that appeals to her, from the very struc-

tured and empirical, to the more organic and

intuitive.

Decision aids. Doulas can point women to

decision aids that have been created to ‘prepare

people to participate in decisions that involve

weighing benefits, harms, and scientific uncer-

tainty’.56 The first review of decision aids for

pregnant women – exploring choices for giving

birth after caesarean, giving birth to a breech

baby, performing prenatal tests and using

drugs for labour pain relief – found that after

using them, women emerged with better knowl-

edge and more accurate risk perception, less

decisional conflict, less regret and less likeli-

hood of remaining undecided.57

Persuasion in decision-making. By moving

away from the false belief that women make

choices in ‘autonomous’ isolation, it is easier

to recognize that persuasion51 is legitimately

part of the process of decision-making, includ-

ing persuasion by clinicians. This dilutes the

assumption that a health professional is an

‘impediment to rather than a resource for deci-

sion making’.58 Instead of taking a ‘protective’

and polarizing approach,30 under a relational

model, doulas would recognize the processes

by which women can express their views, listen

and be listened to, and collaborate in making

choices. An important caveat is that women

and clinicians may interact across a power

imbalance of technical knowledge and social

status.59 Clinicians have a duty to support

women’s autonomy as well as to question their

own biases and assumptions that may be at

odds with best available evidence.36 Persuasion

does not, however, belong in the doula’s tool-

kit. That must be left to an activist role out-

side the birth room. Doulas’ professional

responsibility to their clients is to facilitate,

rather than to direct or shape, women’s capaci-

ties and choices.

Reflection

Reflective practice is promoted in many fields,

including the health professions,60,61 as ‘that

the form of practice which seeks to problema-

tise many situations of professional perfor-

mance so that they can become potential

learning situations, and so, the practitioners

can continue to learn, grow and develop in and

through their practice’.62 This relates to preg-

nant women in that if we think of them as

‘practicing’ engagement and relational auton-

omy, reflection is valuable. Doulas might sup-

port a woman to reflect on a sticking point

with her partner over whether to have a partic-

ular antenatal test or over her choice of routine

procedures. Reflection provides women with a

framework to value their own experience, espe-

cially from previous births; to become open

and curious about their ways of making

choices; to put their values into practice; and

to accept responsibility for their actions.62

Reflecting in a systematic, goal-oriented way

could help a woman see where past choices

yielded a gap between her expectations and

actual experience and illuminate how she might

change her actions to better align with her

goals.

Fostering trust and self-confidence

It may not be possible to teach trust or self-

confidence directly, but these qualities may

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emerge as side effects of some of the services

doulas routinely provide, such as childbirth

education, emotional support and decision

support.

Health education

Doulas educate women and their partners, and

sometimes family members, about the physiol-

ogy of pregnancy and birth, and post-natal

maternal adaptation and infant care. Sessions

typically aim to increase health literacy and

provide a foundation for developing commu-

nication skills. Topics covered might include

understanding the phases of labour, pain-coping

techniques and use of routine and indicated

interventions. All health education should be

evidence-based, or, where non-evidence-based

information is offered or requested – when

good evidence does not exist, for example – doulas should make clear the difference. Health

education can promote autonomy by consis-

tently presenting a range of perspectives and

encouraging clients to develop consumer skills,

including honing a critical eye for the reliability

of sources.

Emotional support

A cornerstone of doula work – emotional

support – remains in an autonomy-building

model. Doulas and their clients build a rela-

tionship and establish rapport, and doulas offer

generally continuous support in labour to both

the mother and her partner.

Fostering relational autonomy highlights

how important it is for doulas to offer emo-

tional support not only for the experience of

labour, but for a woman’s efforts to empower

herself with the skills she needs, such as negoti-

ating, communicating, reflecting, reframing and

placing trust in others. One concern about pro-

moting autonomy is the potential for support-

ers (clinical or otherwise) to present a set of

facts and then step back expecting the woman

to decide for herself. This can leave women feel-

ing abandoned and ill-equipped.38,63 With emo-

tional support, women may be less likely to feel

adrift and more able to identify what they need

to make a choice. Women (and partners) need

emotional support also when choice is restricted,

or absent, such as when they reluctantly choose

the only option paid for by their health

insurance, or in an emergent situation.

Physical support

Physical support has always been a bulwark

of the doula role. Many women describe great

satisfaction in managing an experience as

challenging as labour and liken it to crossing

a marathon finish line. A challenge for doulas

is to support coping without conveying the

impression that physical support is only for

‘natural birth’; the physical dimension is only

one aspect of a birth experience and medi-

cated labour benefits from physical support

too.

Recognizing context

The framework of relational autonomy hinges

on the notion that as much as a woman may

strive to apply her skills for maximum auton-

omy, her social relationships inevitably shape

her choices and her self-confidence. Doulas

work with clients in two areas in particular to

help navigate the influence of women’s social

worlds.

Family and social environment

Women face at least two forms of influence

from their families and social network. One

comes in the guise of predictions about how a

woman’s birth will unfold. This is often based

on a perceived pattern of experiences of other

women in the family and can set up fears or

false confidence while failing to recognize

individual circumstances and environment,

including local maternity care practice. A sec-

ond influence is the extent to which the

woman is expected to conform to notions of

‘acceptable’ choices within her social network.

Families develop ‘rules’ or expectations on

conformity to family norms and values.64 This

applies to families of origin as well as a

woman’s new family with her partner and also

to a woman’s social circle. When a woman

perceives a conflict with the expectations of

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Doulas: fostering relational autonomy, S L Meadow 3063

her family and social group, a doula can help

her to decide whether to defend her bound-

aries, retreat in the interest of family har-

mony, or negotiate.

Choice of caregiver/facility

Part of empowerment is, perhaps counter-

intuitively, learning to evaluate a person’s

words and actions to decide in whom to place

‘appropriate trust’.39,65 Clinicians’ beliefs and

values vary, and they influence the type of care

they provide.51,66 The lack of evidence base for

many routine practices in maternity care can

undermine the appropriateness of trust in the

clinician–client relationship. Doulas can help clients critically evaluate

whether they and their health-care provider

have compatible approaches to birth, which is

a critical component of a trusting relationship.

Doulas can help clients identify specific ques-

tions or discussion points, as well as explore

how their clinician may or may not support

women’s choices or preferences that are not in

line with his or her preferred recommendation.

Strengths of an autonomy-building model

Emphasis on non-directive support

The most serious problems with the prevailing

model of doula support are the potential for

the doula to speak for the client or to impose

her own, even well-meaning, agenda. Emphasis

on women’s autonomy keeps the focus of the

doula–client relationship on the mother. A rela-

tional-autonomy model of doulas’ work with

individual clients (as opposed to birth activism)

would abandon the role of ‘advocacy’, placing

more explicit emphasis on the choice-making

process rather than the outcome. When doulas

are seen by family, clinicians and women to

engage in relational autonomy-building, they

may be less likely to be perceived as exercising

unwarranted influence. As well, when doulas

focus on communication skills even more than

information-giving, this may lessen their own

self-image as ‘protector’. The doula role then

promotes what the client can do more than

what the doula has to offer.

Focus on engagement and control

A relational-autonomy–based model of doula

care highlights not just who is speaking but

who is in control. Although autonomy in preg-

nancy and childbirth is nearly always exercised

in collaboration with others, and in a way tai-

lored to each woman’s individual values and

intentions, autonomy is closely linked with

control.67 Recent surveys reveal a disconnect

between the engagement and control women

want to have during childbirth with their

actual experiences.68,69 In the same way that

third-party decision counsellors serve in other

areas of health care, doulas could facilitate the

education, communication and skills needed

for women to step into their full role to make

choices for themselves.70

Recognition of the social context for decisions

Pregnancy and childbirth unfold in an interde-

pendent social system that includes the woman,

her family and social network, her health-care

providers and her cultural environment. A

move in one part of the system – an opinion

expressed by a relative, a suggestion from a

nurse, a choice by the mother – ripples through

the entire system causing counter reaction,

accommodation or conflict.71,72 Doulas, with

their continuity of support and individualized

attention, are in an ideal position to help

women act autonomously within the context of

their relationships and contribute to a collabo-

rative environment in the labour room.

Challenges for an autonomy-building model

Complexity in training and professional skills

One of the biggest challenges for many doulas

is separating their passion to counter some of

the problems with maternity care from their

support role with an individual woman. Even

if they do not walk out if their client chooses

an epidural, they may in reality or in appear-

ance overstep their role and direct women or

give advice. A framework that encourages dou-

las to use reflective practice both in training

and in professional life and to examine the lim-

its of their role and responsibility, demands

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Doulas: fostering relational autonomy, S L Meadow3064

intensive engagement, time and mentoring

within supportive group-learning environ-

ments.60 Likewise, it takes time and experience

to develop complex skills such as values clarifi-

cation and decision support, especially applied

in the dynamic framework of relationships

between client, partner, family and health

professionals.

College-based training programmes or those

offered online may more easily accommodate

time to develop reflective practice and decision-

support skills, but many doulas are certified

through weekend workshops. Because the ethi-

cal vulnerabilities of current doula practice are

significant, some adaptation of the workshop

model, for example to include a distance-

learning follow-up component, could be advan-

tageous. However, more research is needed to

determine the best way to implement this

model across training methods.

Reframing advocacy and activism

Doulas who identify with an activist model of

doula work may resist the idea that their pri-

mary role is to support the birthing woman in

choosing her own path, and instead argue that

the power imbalance between the medical sys-

tem and vulnerable individual women is too

great and that the social and political construc-

tion of health care limits autonomous choices.

These doulas may regard medical staff with

distrust. They may see the process of support-

ing a woman through claiming her own auton-

omy as too slow – that she may make ‘poor’

choices in the interim, choices that the doula

might protect her from.

These worries, well-intentioned as they may

be, may focus too intently on the ‘moment of

medical decision making’36 and neglect the ful-

ler social context. Susan Sherwin proposes that

one way to foster relational autonomy is to

provide women with opportunities to develop

self-confidence and experience making choices

‘not influenced by the wishes of those who

dominate them’, and she suggests these oppor-

tunities may yield ‘transformative experi-

ences’.36 Providing such opportunities requires

doulas to navigate the porous line between

imposing their own views on the best way for

women to act autonomously – an imposition

which may ultimately undermine autonomy – and facilitating the choice process, regardless

of outcome.

Adversarial environment in maternity care

The impulses of those doulas who lean towards

an activist role are not without justification,

nor are they incompatible with a relational

view of autonomy. The influence of legal con-

cerns on clinical decision-making has produced

bans on vaginal birth after caesarean in many

US hospitals73 and non-evidence-based and

non-medically indicated interventions on the

increase in many areas of the world.74 Women

are not fully engaged in making choices about

their own pregnancies and births and their

preferences are often disregarded.53 As clini-

cians and women alike acclimatize to share

models of decision-making, welcoming a doula

to support this effort is a delicate proposition.

If a pregnant woman seeks support for a

choice that might still be perceived by some

clinicians as unconventional, even if supported

by evidence, and enlists a doula to support her,

the doula’s communication skills are tested to

continuously highlight that it is her client press-

ing for change, not the doula pushing her client

into the vanguard.

Conclusion and a research agenda

Organizing the birth doula’s role around the

concept of fostering women’s relational auton-

omy has three principle benefits. First, it could

contribute to resolving inconsistencies in the

definition of doulas’ roles and responsibilities.

Second, this organizing principle could dampen

frictions between doulas and health-care pro-

fessionals and between doulas and their own

clients around speaking for, influencing, or

even coercing women in their health-care

decisions. Third, doulas could contribute to

engagement of women in their maternity care

and to efforts to increase shared decision-

making, as strategies to improve satisfaction

and reliance on evidence-based care.

ª 2014 John Wiley & Sons Ltd

Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow 3065

Research is limited in these areas, but three

main avenues open up. One is empirical

research into how the components of relational

autonomy as practiced by pregnant women

could affect pregnancy outcomes, levels of

intervention and maternal satisfaction. A sec-

ond is to examine what strategies for doula

training and regulation would best support

the implementation of a relational-autonomy

model. A third area of research is the extent to

which employing doulas to support engage-

ment and shared decision-making could have

benefits for health-care professionals and

health organizations.

References

1 Gilliland AL. Beyond holding hands: the modern role

of the professional doula. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, 2002; 31: 762–769. 2 Australian Doula College. What is a Doula?

Australian Doula College, 2007. Available at: http://

www.australiandoulacollege.com.au/what_is_a_

doula_/, accessed 7 August 2014.

3 CAPPA. Scope of Practice. CAPPA, 2013. Available

at: http://www.cappa.net/about-cappa.php?scope-of-

practice, accessed 7 August 2014.

4 Childbirth International. Code of practice, 2010.

Available at: http://www.childbirthinternational.

com/code_practice.htm, accessed 15 August 2014.

5 Developing Doulas. What is a doula? 2014.

Available at: http://developingdoulas.co.uk/doula-

training-courses/about/what-is-a-doula/, accessed 7

August 2014.

6 DONA [Doulas of North America] International.

Standards of Practice: Birth Doula. DONA

International, 2008. Available at: http://www.dona.

org/PDF/Standards%20of%20Practice_Birth.pdf,

accessed August 7 2014.

7 Pacific Rim College. Holistic Doula Certificate

Program. Victoria, BC, Canada: Pacific Rim

College, 2014. Available at http://www.

pacificrimcollege.ca/holistic_doula_certificate.html,

accessed October 10 2014.

8 Kayne MA, Greulich MB, Albers LL. Doulas: an

alternative yet complementary addition to care

during childbirth. Clinical Obstetrics and

Gynecology, 2001; 44: 692–703. 9 Sosa R, Kennell J, Klaus M, Robertson S, Urrutia J.

The effect of a supportive companion on perinatal

problems, length of labor, and mother-infant

interaction. New England Journal of Medicine, 1980;

303: 597–600.

10 Kennell J, Klaus M, McGrath S, Robertson S,

Hinkley C. Continuous emotional support during

labor in a US hospital. A randomized controlled

trial. Journal of the American Medical Association,

1991; 265: 2197–2201. 11 Ballen LE, Fulcher AJ. Nurses and doulas:

complementary roles to provide optimal maternity

care. Journal of Obstetric, Gynecologic, and Neonatal

Nursing, 2006; 35: 304–311. 12 Kane LL, Moffat A, Brennan P. Doulas as

community health workers: lessons learned from a

volunteer program. The Journal of Perinatal

Education, 2006; 15 : 25–33. 13 Trueba G, Contreras C, Velazco MT, Lara EG,

Mart�ınez HB. Alternative strategy to decrease

cesarean section: support by doulas during labor.

The Journal of Perinatal Education, 2000; 9: 8–13. 14 Gilliland AL. After praise and encouragement:

emotional support strategies used by birth doulas in

the USA and Canada. Midwifery, 2011; 27:

525–531. 15 Harms RW. Labor and Delivery, Postpartum Care:

What are the Benefits of Having a Doula? Mayo

Clinic, 2013. Available at: http://www.mayoclinic.

com/health/doula/AN02118, accessed

28 February 2013.

16 Deitrick LM, Draves PR. Attitudes towards doula

support during pregnancy by clients, doulas, and

labor-and-delivery nurses: a case study from Tampa,

Florida. Human Organization, 2008; 67: 397–406. 17 Green J, Amis D, Hotelling BA. Care Practice #3:

continuous Labor Support. The Journal of Perinatal

Education, 2007; 16: 25–28. 18 Paterno MT, Van Zandt SE, Murphy J, Jordan ET.

Evaluation of a student-nurse doula program: an

analysis of doula interventions and their impact on

labor analgesia and cesarean birth. Journal of

Midwifery & Women’s Health, 2012; 57: 28–34. 19 Doula UK. Doula UK Code of Conduct. n.d.

Available at: http://doula.org.uk/content/doula-uk-

code-conduct, accessed 21 August 2014.

20 Eftekhary S, Klein MC, Xu SY. The life of a

Canadian doula: successes, confusion, and conflict.

Journal of Obstetrics and Gynaecology Canada, 2010;

32: 642–649. 21 Stockton A. Mother’s mouthpiece or clinician’s

curse: the doula debate continues. Midirs Midwifery

Digest, 2010; 20: 57–58. 22 Hodnett ED, Gates S, Hofmeyr GJ, Sakala C.

Continuous support for women during childbirth.

Cochrane Database Systematic Review, 2013; 7:

CD003766.

23 Papagni K, Buckner E. Doula support and attitudes

of intrapartum nurses: a qualitative study from the

patient’s perspective. The Journal of Perinatal

Education, 2006; 15: 11–18.

ª 2014 John Wiley & Sons Ltd

Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow3066

24 Simkin P. Doulas: nurturing and protecting

women’s memories of their birth experiences. The

International Journal of Childbirth Education, 2005;

19: 16–19. 25 Berg M, Terstad A. Swedish women’s experiences of

doula support during childbirth. Midwifery, 2006;

22: 330–338. 26 Gentry QM, Nolte KM, Gonzalez A, Pearson M,

Ivey S. “Going beyond the call of doula”: a

grounded theory analysis of the diverse roles

community-based doulas play in the lives of

pregnant and parenting adolescent mothers. The

Journal of Perinatal Education, 2010; 19: 24–40. 27 Waldman EA. Evaluative-facilitative debate in

mediation: applying the lens of therapeutic

jurisprudence. Marquette Law Review, 1998; 82:

155–170. 28 Birthing Wisdom. Birth and postpartum

fundamentals, 2010. Available at: http://www.

birthingwisdom.co.uk/training/training/practitioner/

page84/curriculum.html, accessed 8 August 2014.

29 Pannick S. How Doula do? Paying Patient Advocates

in Modern Healthcare. Medscape: Doctor’s Orders,

2012. Available at: http://boards.medscape.com/

forums/?128@@.2a31f55e!comment=1,

accessed 30 October 2013.

30 Stevens J, Dahlen H, Peters K, Jackson D.

Midwives’ and doulas’ perspectives of the role of

the doula in Australia: a qualitative study.

Midwifery, 2011; 27: 509–516. 31 Hwang S. As “doulas” enter delivery rooms,

conflicts arise. Wall Street Journal, 2004. Available

at: http://online.wsj.com/article/

SB107446888698004731.html.

32 Paul P. And the doula makes four. New York

Times, 2008 Mar 2. Available at: http://www.

nytimes.com/2008/03/02/fashion/02doula.html?

pagewanted=all&_r=1&

33 Gilliland AL. The doulas have arrived! Nurses,

what does this mean for you? Doulaing the Doula,

2014. Available at: http://doulaingthedoula.com/tag/

doula-ethics/, accessed 21 July 2014.

34 Klaus MH. The Doula Book: How a Trained Labor

Companion can Help you Have a Shorter, Easier,

and Healthier Birth. Cambridge, MA: Perseus Pub,

2002: 243.

35 Beauchamp TL, Childress JF. Principles of

Biomedical Ethics, 5th edn. New York: Oxford

University Press, 2001.

36 Sherwin S. A Relational Approach to Autonomy in

Health Care. The Politics of Women’s Health:

Exploring Agency and Autonomy. Philadelphia, PA:

Temple University Press, 1998.

37 Christman J. Relational autonomy, liberal

individualism, and the social constitution of selves.

Philosophical Studies, 2004; 117: 143–164.

38 Entwistle VA, Carter SM, Cribb A, McCaffery K.

Supporting patient autonomy: the importance of

clinician-patient relationships. Journal of General

Internal Medicine, 2010; 25: 741–745. 39 Goering S. Postnatal reproductive autonomy:

promoting relational autonomy and self-trust in new

parents. Bioethics, 2009; 23: 9–19. 40 McAlister BS. A case study of maternal response to

the implied antepartum diagnosis of inevitable labor

dystocia. Journal of Obstetric, Gynecologic, and

Neonatal Nursing, 2013; 42: 138–147. 41 Kukla R. Conscientious autonomy: displacing

decisions in health care. Hastings Center Report,

2005; 35: 34–44. 42 Fraenkel L, McGraw S. What are the essential

elements to enable patient participation in medical

decision making? Journal of General Internal

Medicine, 2007; 22: 614–619. 43 Sakala C, Corry MP, Milbank Memorial Fund.

Evidence-Based Maternity Care: What it is and What

it can Achieve. New York: Milbank Memorial

Fund, 2008.

44 Klagsbrun J. Listening and focusing: holistic health

care tools for nurses. Nursing Clinics of North

America, 2001; 36: 115–130. 45 Kunyk D, Olson JK. Clarification of

conceptualizations of empathy. Journal of Advanced

Nursing, 2001; 35: 317–325. 46 Rao JK, Anderson LA, Inui TS, Frankel RM.

Communication interventions make a difference in

conversations between physicians and patients: A

systematic review of the evidence. Medical Care,

2007; 45: 340–349. 47 Street RL Jr, Gordon HS, Ward MM, Krupat E,

Kravitz RL. Patient participation in medical

consultations: why some patients are more involved

than others. Medical Care, 2005; 43: 960–969. 48 Beisecker AE. Patient power in doctor-patient

communication: what do we know? Health

Communication, 1990; 2: 105–122. 49 Rollnick S, Butler CC, Kinnersley P, Gregory J,

Mash B. Motivational interviewing. British Medical

Journal, 2010;340:c1900–c1900. 50 Coulter A. Patient engagement–what works? The

Journal of Ambulatory Care Management, 2012; 35:

80–89. 51 Emanuel EJ, Emanuel LL. Four models of the

physician-patient relationship. Journal of the

American Medical Association, 1992; 267: 2221–2226. 52 Gualtieri LN. The Doctor as the Second Opinion and

the Internet as the First. ACM Press, 2009: 2489.

Available at: http://portal.acm.org/citation.cfm? doi:

10.1145/1520340.1520352, accessed 29 October 2013.

53 Gee RE, Corry MP. Patient engagement and shared

decision making in maternity care. Obstetrics and

Gynecology, 2012; 120: 995–997.

ª 2014 John Wiley & Sons Ltd

Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow 3067

54 Cegala DJ, Broz SL. Provider and patient

communication skills training. In: Thompson TL,

Dorsey AM, Miller KI, Parrott R (eds) Handbook

of Health Communication. Mahwah, NJ: Lawrence

Erlbaum Associates, 2003: 1137–1139. 55 Minkoff H, Lyerly AD. Doctor, what would you do?

Obstetrics and Gynecology, 2009; 113: 1137–1139. 56 Stacey D, Bennett CL, Barry MJ et al. Decision

aids for people facing health treatment or screening

decisions. Cochrane Database Systematic Review,

2011; 10: CD001431.

57 Vlemmix F, Warendorf JK, Rosman AN et al.

Decision aids to improve informed decision-making

in pregnancy care: a systematic review. British Journal

of Obstetrics and Gynaecology, 2013; 120: 257–266. 58 Quill TE, Brody H. Physician recommendations and

patient autonomy: finding a balance between

physician power and patient choice. Annals of

Internal Medicine, 1996; 125: 763–769. 59 Goodyear-Smith F, Buetow S. Power issues in the

doctor-patient relationship. Health Care Analysis,

2001; 9: 449–462. 60 Mann K, Gordon J, MacLeod A. Reflection and

reflective practice in health professions education: a

systematic review. Advances in Health Sciences

Education : Theory and Practice, 2009; 14: 595–621. 61 Johns C. The value of reflective practice for nursing.

Journal of Clinical Nursing, 1995; 4: 23–30. 62 Jarvis P. Reflective practice and nursing. Nurse

Education Today, 1992; 12: 174–181. 63 Sokol DK. What would you do, doctor? British

Medical Journal, 2007; 334: 853–853. 64 Fitzpatrick MA, Ritchie LD. Communication

schemata within the family: multiple perspectives on

family interaction. Human Communication Research,

1994; 20: 275–301. 65 Stirrat GM. Autonomy in medical ethics after

O’Neill. Journal of Medical Ethics, 2005; 31: 127–130.

66 Liva SJ, Hall WA, Klein MC, Wong ST. Factors

associated with differences in Canadian perinatal

nurses’ attitudes toward birth practices. Journal of

Obstetric, Gynecologic, and Neonatal Nursing, 2012;

41: 761–773. 67 Meyer S. Control in childbirth: a concept analysis

and synthesis. Journal of Advanced Nursing, 2013

Jan; 69: 218–228. 68 Declercq ER, Sakala C, Corry MP, Applebaum S.

Listening to Mothers II: report of the Second

National U.S. Survey of Women’s Childbearing

Experiences. The Journal of Perinatal Education,

2007; 16: 9–14. 69 Lantz PM, Low LK, Varkey S, Watson RL. Doulas

as childbirth paraprofessionals: results from a

national survey. Womens Health Issues, 2005; 15:

109–116. 70 Woolf SH, Chan ECY, Harris R et al. Promoting

informed choice: transforming health care to

dispense knowledge for decision making. Annals of

Internal Medicine, 2005; 143: 293–300. 71 Beach MC, Inui T; Relationship-Centered Care

Research Network. Relationship-centered care: a

constructive reframing. Journal of General Internal

Medicine, 2006; 21(Suppl 1): S3–S8. 72 Galvin KM, Dickson FC, Marrow SR. Systems

theory: patterns and (w)holes in family

communication. In: Braithwaite DO, Baxter LA

(eds) Engaging Theories in Family Communication:

Multiple Perspectives. Thousand Oaks, CA: Sage

Publications, 2006: 309–324. 73 Fineberg AE, Tilton ZA. VBAC in the trenches: a

community perspective. Clinical Obstetrics and

Gynecology, 2012; 55: 997–1004. 74 Johanson R, Newburn M, Macfarlane A. Has the

medicalisation of childbirth gone too far? British

Medical Journal, 2002; 324: 892–895.

ª 2014 John Wiley & Sons Ltd

Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow3068