Doulas Make a Difference: Optimizing Doulas’ Education to Improve Perinatal Mental Health Outcomes

Approximately 21% of birthing people in the United States each year experience perinatal mental health disorders, which disproportionately affect individuals from low socioeconomic environments.¹ Additionally, Black women are more likely to die from preventable pregnancy-related complications and experience severe comorbidities during birth.² Fortunately, the involvement of doulas in the birthing experience has been shown to improve maternal-infant health outcomes.³ However, there is limited literature on the impact of doulas on mental health outcomes in underresourced birthing populations. Therefore, we were pleased to read the study by Dr Nigeda et al, which explored the role of doulas in improving the birth experiences of Black women by decreasing perceived racism and creating a more positive birthing experience.² While doulas improve the birthing experience, their lack of substantial mental health training is a barrier to improving the mental health outcomes of birthing people from disadvantaged communities. Therefore, there is a need for increased clinical education in perinatal mood disorders for doulas to improve screening, awareness, and earlier intervention and referrals in birthing people.

Studies have shown that race has a direct impact on the psychological well-being of birthing individuals. The COVID-19 pandemic subsequently heightened perinatal mood disorders.² Nigeda et al found that 70.9% of Black birthing women were afraid of a pregnancy complication and 54.9% were afraid of dying due to a pregnancy-related issue due to their skin color.² The role of the doula is imperative as they are advocates for birthing people and provide emotional and physical support during the prenatal period, pregnancy, labor and delivery, and postpartum.⁴ However, doulas are encountering patients with an increased amount of mental health concerns, particularly with symptoms of depression and anxiety.⁴ Consequently, birthing individuals who identify as American Indians or Alaskan Natives were more likely to die by suicide or overdose during pregnancy, or the postpartum period, followed by non-Hispanic Whites, Blacks, or Asian or Pacific Islanders.³ Poorer perinatal mental health outcomes in underresourced groups indicate the necessity for increased clinical education in doulas, as they can address disproportionate mental health outcomes.

Trauma-informed mental health doula training that emphasizes cultural awareness and sensitivity can mitigate the gaps in perinatal health disparities.⁵ Two recent qualitative studies of doulas support this recommendation. In the first study, doulas explicitly stated that they wanted more training in emotional support to improve their abilities to address perinatal mental health concerns.⁵ In another study, there was a consensus on the need for more thorough education in perinatal mood and anxiety disorders (PMAD) and training in trauma-informed care.⁵ There was an overemphasis on postpartum psychosis in the limited PMAD training, but doulas did not feel adequately trained to know the signs of depression, anxiety, and obsessive-compulsive disorder.⁵ This confirms the necessity for a more rigorous clinical education in perinatal mental health. Conversely, the medical education system in the United States would benefit from incorporating education on the role of the doula, and their positive impact on perinatal outcomes.² For instance, Nigeda and colleagues demonstrated that the simple presence of a doula decreased perceived racism during the pregnancy and improved the birthing experience.²

The disparities in perinatal mental health outcomes require reform within medical education and doula training.² With adequate clinical training in PMAD, doulas would have the opportunity to create a greater impact on their communities and allow for earlier psychiatric intervention and access to care. Doulas are trusted members of the community, and investing in their education is critical to increasing perinatal mental health outcomes and closing the gaps in care, specifically in underresourced birthing populations.