DONA International (1992– )

In 1992, five maternal-infant health researchers founded Doulas of North America, later renamed DONA International to train certified birth attendants called doulas to provide care to pregnant women both before and after the birthing process. Annie Kennedy, John Kennell, Marshall Klaus, Phyllis Klaus, and Penny Simkin used the term doula, derived from the Greek word for woman servant, to describe a female birthing aide who provides non-medical emotional and physical support to laboring pregnant women. Eventually renamed DONA International, the organization has certified over 12,000 doulas as of 2017. Though the organization aims to provide a doula to everyone who wants one, there have been controversies surrounding the accessibility, affordability, and necessity of pregnant women using a doula before and after birth. DONA International is the largest doula-certifying program in the world and has created global awareness of the risks and benefits associated with using a doula during the birthing process.

Kennedy, Kennell, Simkin, Klaus, and Klaus founded Doulas of North America in 1992 to create a systematic means of licensing non-medical birthing aides called doulas. DONA International’s mission is to promote high quality birth and postpartum support by setting the standard for the doula profession through evidence-based training and certification for doulas of diverse backgrounds. Doulas are trained to provide emotional and physical support to laboring pregnant women through non-medical intervention techniques such as aromatherapy, acupuncture, and massage and meditation techniques. Before DONA International, there were no known professional affiliations for non-medical birthing aides in the United States. While some pregnant women in labor also use midwives, midwives differ from doulas in that midwives are typically trained medical professionals who specialize in pregnancy and labor.

Each of the cofounders specialized in an aspect of maternal-infant health and their individual specialties impacted the organization’s development and mission. In the 1960s, physicians Klaus and Kennell worked together at Case Western Reserve University in Cleveland, Ohio conducting research on maternal-infant bonding. Maternal-infant bonding is the study of the physical, chemical, and emotional dynamics shared by a pregnant woman and her infant. Researchers who studied maternal-infant bonding examined the relationships between mothers and their infants to understand the infant’s development and socialization. Klaus and Kennell discovered that the first three to five days following birth is a critical time for women who recently gave birth to create important bonds with their infants. Klaus and Kennell also discovered that a pregnant woman’s labor and delivery experience was positively impacted by the presence of another woman providing continuous emotional support. Klaus and Kennell founded DONA International alongside Klaus’s wife, Phyllis, who was a social worker. Also joining the project was Kennedy, a trained midwife, and Simkin, a physical therapist.

In the 1980s, Klaus and Kennell came together with Kennedy, Klaus, and Simkin to begin to discuss their findings that women experience better birthing outcomes with the support of a non-medical female birthing aide. Their findings led the researchers to conclude that those birthing aids needed training and certification. The group decided to use the word doula to identify the women who supported laboring pregnant women. Doula is derived from a Greek word meaning servant woman. The group was not the first to use the word doula. In 1969, breastfeeding and lactation researcher Dana Raphael used the term doula to describe the behaviors and actions of birthing aides in a study on how different mammals gave birth and cared for their offspring. The founders of DONA International used the word doula to describe women whose presence during childbirth positively affected the pregnant woman and infant.

In 1992, as stated by the founders, the purpose of Doulas of North America was to train and certify doulas in providing emotional and physical support for pregnant women before, during, and after labor as well as to provide certifications for doulas in Canada and the United States. The organization, originally named the Doulas of North America was renamed DONA International in 2004 after the organization developed an international presence outside of North America. As the organization grew, its purpose evolved to encompass specialized training for labor and delivery doulas, and postpartum doulas. Birthing doulas are used to assist the pregnant woman through labor, providing relaxation and calming exercises. Postpartum doulas work with women after birth, helping women acclimate to a new infant and providing guidance in breastfeeding and lactation. The organization also trains doulas in breastfeeding and lactation techniques and information. As of 2017, DONA International has certified doulas in over fifty-six countries and claims to have over 12,000 trained and active doulas around the world.

To become a labor doula, an applicant must participate in at least one in-person DONA certified workshop, and has four years to complete additional online classwork and paperwork. The applicant must also write an essay on the value and purpose of labor support and gain two letters of recommendation, one from a client and one from a healthcare professional before she receives certification. The process is similar to become a postpartum doula, except the applicant must complete an essay on the value of postpartum support. Throughout its training courses, DONA International emphasizes that doulas do not gain any medical training and are not expected to use any previous medical training they may have received.

DONA International’s doula training program is largely based on the research done by the original founders, who found that women experienced more positive births with the aid of a doula. A 2013 article published in the Journal of Perinatal Education summarized over ten studies performed in the 2000s that indicated doulas provided positive support to laboring women. Those researchers found that laboring women assisted with doulas throughout their pregnancies were four times less likely to have an infant with low birth weight, and were significantly more successful at initiating breastfeeding in the first twelve hours following birth. Because of those conclusions and those found by Klaus and Klauson the benefit of breastfeeding during the first few postpartum days, DONA International created an optional online breastfeeding course to better prepare doulas to assist women who recently gave birth in initiating breastfeeding.

The five original founders had a large influence in DONA International’s development as the first doula-certification organization. Simkin served as the original president of the organization, and contributed to the doula manuals and certification standards that the organization produced. The Klauses conducted research on new mothers and found that the three-to-four-day period following birth was a crucial time for women who recently gave birth to form attachments to their infants. The founders implemented those findings in the organization’s standards on the importance of immediate skin-to-skin contact and breastfeeding. Even after many of the original five founders stepped down, they continued to collaborate on research. In 2012, Klaus, Klaus, and Kennell published the book, The Doula Book: How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth, a guide on emotional and physical support during labor. DONA International recommends that all doulas pursuing certification read the book.

During the 2000s, leadership and organization at DONA International changed as it became an international agency. The management and structure of the organization evolved to encompass state-level affiliations, with a state director for each state in the United States and national directors for countries outside of North America. There is also a board of directors that are voted into office every year by members of DONA International, including the positions of president, president-elect, treasurer, director of education, intercultural director, and membership director. In addition to the United States and Canada, there is leadership present in Australia, Finland, Greece, Mexico, Puerto Rico, Slovenia, and New Zealand. As of 2018, DONA International outsources their general management and operations activities to a consulting company called Bostrom headquartered in Chicago, Illinois. Through Bostrum, DONA International employs an executive director, certification and education manager, and a membership manager, along with a full support staff of employees.

Throughout the 2000s, DONA International continued to claim that doulas were beneficial to a pregnant woman’s birthing process. However, some women and medical professionals voiced concerns about a doula’s overall involvement in labor and delivery. In a 2006 study of women using doulas in Alabama, over 44 percent of women who recently gave birth indicated a hostile relationship between their doulas and hospital nurse. According to the New York Times article, “And the Doula Makes Four,” many physicians and nurses agree that doulas have created conflict between healthcare professionals and pregnant women, and as a result, some hospitals have prohibited the presence of doulas. According to the physicians interviewed in that article, they encountered doulas who overstepped their boundaries and advised pregnant women to go against medical advice. The physicians also found that some doulas encouraged their own opinions on whether women should use medication or receive a cesarean section during labor, even when those options were unlikely to cause harm to the pregnant women, according to the physicians. Because of those reasons, the physicians interviewed in that article advised women against the use of a doula.

Though DONA makes it clear that it’s doulas are trained to be non-medical support aids, instances of conflict between health professionals and doulas have caused some to believe that doulas can interfere with the provision of medical care. Despite the existence of training and certification programs through organizations like DONA International, anyone can claim to be a doula regardless of whether they have received training. DONA International continues to indicate that doulas do not receive medical training and they should not be involved in any critical medical decisions.

As of 2017, DONA International continues to certify doulas around the world. DONA International continues to conduct research regarding the role of doulas in the birthing process, and contributed to the World Health Organization’s Baby Friendly Hospital Initiative by demonstrating the benefits of lactation consultants and birthing aids.