doi: 10.1111/hex.12290

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

Abstract 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

Background Training organizations as well as academic and popular literature provide ambiguous or ethically contentious characterizations 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 relational 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 exercising autonomy reduces the potential for the doula to seek to influence 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 organizations and academic and popular literature sometimes describe an ‘advocacy’ role for

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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

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a wide social context, not just within the confines 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 misunderstandings that have been reported.

What is a doula? The work doulas do descends from the age-old tradition of experienced female elders supporting labouring women during childbirth. As childbirth became medicalized in the 20th century 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 vocation emerged to fill this need, ‘professionalizing’ a role that was once occupied by laywomen.1 Although the occupation is largely unregulated, 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 considerable variation in their philosophy and methods. No single definition of the doula role exists. Academic research, trade associations, and consumer books and websites also contribute 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 positioning for pain relief or labour progress, use of the breath, sacral counterpressure, and application 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 encompass informational support and advocacy.2–7

Informational support may be described as explaining, answering questions, or giving ‘information about what’s happening during 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 questions the client may ask and help her communicate on her own behalf with medical staff.11,16,22–24 Another approach, offered primarily by academic articles and consumer materials, places the doula-as-advocate in an intermediary role, ‘communicating and interpreting the mother’s desires to care providers during labour’, ‘question[ing] a clinical intervention 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 organizations primarily define and inculcate the role of a doula, other sources may exert influence over how the role is understood. Certification organizations tend to avoid the more activist approach of advocacy, but ambiguity still arises in how this concept is or is not incorporated into the doula role. One scope-of-practice document noted, for example, that ‘the advocacy 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 professional contexts both can be understood to involve an active subjective role for the intermediary.27 Similarly ambiguous, another training 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 Meadow

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 boundaries of the support role. As doulas work within environments in which clinicians may routinely and legitimately share advice or opinions, the doula role in this context requires further elaboration and specification to differentiate it from existing educator or clinical roles. Lack of clarity over advocacy and advicegiving leaves the doula profession vulnerable to charges of inappropriate or unethical practice. 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 communicate 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 manipulated 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 communication, 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 influence 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 ‘behaving outside the circle of professional practice’33

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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 contentious 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 concept 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 autonomy when she acts with intention, with understanding, and without ‘controlling influences’.35 Acting autonomously in this standard conception means a woman is ‘competent’ (rational enough to make a choice), has enough information and comprehension and can make a ‘reasonable’ choice, free from explicit coercion.

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Susan Sherwin objects, however, that this understanding of autonomy goes too far in assuming we are each ‘independent, selfinterested 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 selfdetermination in a social world. The second is trust – trust in others to support our autonomy, 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 circumstances 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 shoulder 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 pregnant women (and everyone else). Relational autonomy therefore provides a framework in which to position doulas’ twin impulses to support 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 doula’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 recognize 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 decisionmaking 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 prospective client is ‘what sort of birth are you

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her family and social group, a doula can help her to decide whether to defend her boundaries, retreat in the interest of family harmony, or negotiate. Choice of caregiver/facility Part of empowerment is, perhaps counterintuitively, 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 questions 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 relational-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 pregnancy and childbirth is nearly always exercised in collaboration with others, and in a way tailored 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 interdependent 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 collaborative 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 appearance overstep their role and direct women or give advice. A framework that encourages doulas to use reflective practice both in training and in professional life and to examine the limits of their role and responsibility, demands

ª 2014 John Wiley & Sons Ltd Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow

intensive engagement, time and mentoring within supportive group-learning environments.60 Likewise, it takes time and experience to develop complex skills such as values clarification 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 decisionsupport skills, but many doulas are certified through weekend workshops. Because the ethical vulnerabilities of current doula practice are significant, some adaptation of the workshop model, for example to include a distancelearning follow-up component, could be advantageous. 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 primary role is to support the birthing woman in choosing her own path, and instead argue that the power imbalance between the medical system and vulnerable individual women is too great and that the social and political construction of health care limits autonomous choices. These doulas may regard medical staff with distrust. They may see the process of supporting a woman through claiming her own autonomy 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 fuller 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 opportunities may yield ‘transformative experiences’.36 Providing such opportunities requires doulas to navigate the porous line between

ª 2014 John Wiley & Sons Ltd Health Expectations, 18, pp.3057–3068

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 concerns 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 clinicians 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 pressing 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 autonomy 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 professionals 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 decisionmaking, as strategies to improve satisfaction and reliance on evidence-based care.

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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.

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.

Health education Doulas educate women and their partners, and sometimes family members, about the physiology 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 communication 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 consistently presenting a range of perspectives and encouraging clients to develop consumer skills, including honing a critical eye for the reliability of sources.

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 medicated labour benefits from physical support too.

Emotional support A cornerstone of doula work – emotional support – remains in an autonomy-building model. Doulas and their clients build a relationship 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 emotional support not only for the experience of labour, but for a woman’s efforts to empower herself with the skills she needs, such as negotiating, communicating, reflecting, reframing and placing trust in others. One concern about promoting autonomy is the potential for supporters (clinical or otherwise) to present a set of facts and then step back expecting the woman to decide for herself. This can leave women feeling abandoned and ill-equipped.38,63 With emotional 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

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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 autonomy, 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 second 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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her family and social group, a doula can help her to decide whether to defend her boundaries, retreat in the interest of family harmony, or negotiate. Choice of caregiver/facility Part of empowerment is, perhaps counterintuitively, 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 questions 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 relational-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 pregnancy and childbirth is nearly always exercised in collaboration with others, and in a way tailored 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 interdependent 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 collaborative 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 appearance overstep their role and direct women or give advice. A framework that encourages doulas to use reflective practice both in training and in professional life and to examine the limits of their role and responsibility, demands

ª 2014 John Wiley & Sons Ltd Health Expectations, 18, pp.3057–3068

Doulas: fostering relational autonomy, S L Meadow

intensive engagement, time and mentoring within supportive group-learning environments.60 Likewise, it takes time and experience to develop complex skills such as values clarification 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 decisionsupport skills, but many doulas are certified through weekend workshops. Because the ethical vulnerabilities of current doula practice are significant, some adaptation of the workshop model, for example to include a distancelearning follow-up component, could be advantageous. 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 primary role is to support the birthing woman in choosing her own path, and instead argue that the power imbalance between the medical system and vulnerable individual women is too great and that the social and political construction of health care limits autonomous choices. These doulas may regard medical staff with distrust. They may see the process of supporting a woman through claiming her own autonomy 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 fuller 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 opportunities may yield ‘transformative experiences’.36 Providing such opportunities requires doulas to navigate the porous line between

ª 2014 John Wiley & Sons Ltd Health Expectations, 18, pp.3057–3068

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 concerns 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 clinicians 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 pressing 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 autonomy 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 professionals 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 decisionmaking, as strategies to improve satisfaction and reliance on evidence-based care.

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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 second 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 engagement and shared decision-making could have benefits for health-care professionals and health organizations.

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