# | Summary of review finding | Studies contributing to the review finding | Overall CERQual assessment | Explanation of overall assessment |
F1.0 | Continuous woman-centred support Community-based doulas provided individualised, woman-centred, continuous emotional, social and physical support for migrant women throughout their labour and birth. Community-based doulas may fill the gap in trained continuous emotional, social and physical support in labour and birth for migrant women in maternity settings. | 39–41 60–62 65 66 68 69 71 72 | High confidence | No or very minor concerns on coherence and adequacy, minor concerns on relevance (3 out of 9 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F2.0 | Knowledgeable in childbirth and navigating maternity systems Community-based doulas were perceived as knowledgeable sources of informational support, providing migrant women with childbirth education and guidance in accessing and navigating their new country’s maternity systems. | 39–41 60 65 66 68–71 | High confidence | No concerns on coherence, minor concerns on relevance (1 out of 6 studies may include non-migrant women’s perspectives), minor concerns on adequacy (6 out of 12 studies supported this finding) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F3.0 | Engaging partners Community-based doulas provided support to the partners of migrant women by enhancing their connection and involvement during labour and birth, particularly when there were differing cultural expectations of partners in providing birth support in high-income countries. | 39 41 60 62 65 66 69 | High confidence | Minor concerns on adequacy (6 out of 12 studies supported this finding), no or very minor concerns on coherence, minor concerns on relevance (2 out of 6 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F4.0 | Shared language and culture benefits Community-based doulas created a culturally safe space in labour and birth for migrant women, particularly if they were newly arrived or experiencing social isolation in their new countries. This was enhanced when community-based doulas shared the same language and/or culture as the woman, as this helped to reduce the barriers (eg, cultural or language) migrant women may experience when accessing and using maternity care. These community-based doulas were also perceived as cultural facilitators for both migrant women and healthcare providers. | 38–41 60–62 66–72 | High confidence | No or very minor concerns on coherence and adequacy, minor concerns on relevance (4 out of 12 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F5.0 | Respectful treatment and advocacy Community-based doulas’ presence and support enhanced respectful treatment of migrant women from healthcare providers. In circumstances where community-based doulas perceived mistreatment, they actively advocated for migrant women by communicating to healthcare providers (direct advocacy). | 38 40 41 61 62 66 67 69 | Moderate confidence | No concerns on coherence, minor concerns on relevance (4 out of 7 studies may include non-migrant women’s perspectives), moderate concerns on adequacy (7 out of 12 studies supported this finding, 3 moderate to thick data and 4 thin data) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F6.0 | Going above and beyond due to social justice work and volunteering Community-based doulas demonstrated high motivation and commitment to continuous support for migrant women in labour and birth where in some circumstances doulas went above and beyond their expected roles taking on added responsibilities, despite being unpaid volunteers. This was often driven by their motivation to advocate and support migrant women from their own communities due to a strong sense of social justice. | 40 41 60–62 65 66 68 69 71 72 | High confidence | No or very minor concerns on coherence, minor concerns on adequacy (6 moderate to thick data, 2 thin data), minor concerns on relevance (3 out of 8 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F7.0 | Considerations with non-matched community-based doulas Community-based doulas who were carefully matched with migrant women by a needs-based approach (eg, socio-economic hardship) rather than culturally or linguistically, were well received however, training into cultural backgrounds and having access to interpreters was recommended to ensure quality of care, positive relationships and rapport was established. | 40 66 67 72 | Moderate confidence | No or very minor concerns on coherence, minor concerns on relevance (2 out of 3 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, recruitment, reflexivity, data collection) and moderate concerns on adequacy (3 out of the 12 studies supported this finding). |
F8.0 | Role of community-based doula and position in maternity healthcare team Community-based doulas were perceived as different from interpreters and trusted members of the maternity healthcare team, particularly when healthcare providers understood and valued their roles—which was enhanced when they gained experience working together. The roles and expectations of community-based doulas in providing non-clinical support to migrant women (eg, emotional and social) in contrast to healthcare providers’ clinical care should be clearly defined to strengthen collaborative care opportunities and relationships. | 39–41 60 62 64 66–72 | High confidence | No or very minor concerns on coherence and adequacy, minor concerns on relevance (3 out of 9 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data analysis, support for findings, data collection and analysis). |
F9.0 | Communication, interpretation and informed decision making/consent Community-based doulas enhanced communication between both migrant women and their healthcare providers during labour and birth, through language interpretation or translating to plain language. They also validated and encouraged migrant women to communicate with healthcare providers (indirect advocacy) and enhanced migrant women’s understanding of informed consent in labour and birth. | 39–41 60 61 65 66 68 69 71 72 | High confidence | No or very minor concerns on coherence and adequacy, minor concerns on relevance (2 out of 8 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F10.0 | Difference from private practising doulas Some healthcare providers were often cautious when working with community-based doulas due to previous negative experiences with private-practicing doulas. However, community-based doulas were perceived as favourable and different by healthcare providers once they had more experience working with doulas and understood programmes were often not-for-profit volunteer organisations, supporting underserved communities such as migrant and refugee populations. | 40 64 69 | Low confidence | No concerns on coherence, minor concerns on relevance (1 out of 2 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, reflexivity, data collection and analysis) and serious concerns on adequacy (2 out of the 12 studies supported this finding). |
F11.0 | Social connectivity and emotional relationships Community-based doulas created emotional connections with migrant women similar to the intimate relationships shared with a family member or friend, which established a sense of trust. This relationship helped migrant women to feel a sense of community and social connectedness in their new country of residence. | 39–41 60–63 65 66 68 69 71 72 | High confidence | No or very minor concerns on coherence and adequacy, minor concerns on relevance (3 out of 9 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F12.0 | Empowerment Migrant women, community-based doulas and healthcare providers felt women were empowered during their labour and birth through the encouragement and reassurance that community-based doulas offered. Migrant women felt that the community-based doula’s belief in their abilities to labour and birth transformed their own beliefs of feeling fear, incompetence or self-doubt to confidence in their own capabilities. | 39 60–62 65 66 71 | High confidence | No or very minor concerns on coherence, minor concerns on relevance (3 out of 6 studies may include non-migrant women’s perspectives), minor concerns on adequacy (6 out of 12 studies supported this finding) and moderate concerns on methodological limitations (research design, recruitment, reflexivity, ethics, data collection, support for findings). |
F13.0 | Longer-term benefits for community-based doula support Migrant women and their families may experience long-term benefits to their health and well-being due to community-based doulas signposting migrant women to relevant support services or through health promotion of specific public health priorities. Community-based doula programmes may provide doulas and their local communities with educational or employment opportunities that may have been limited to them prior to their involvement with the programme. A database is recommended to record and demonstrate the possible long-term family-centred impacts of community-based doula programmes on underserved populations and to gain potential investment opportunities. | 40 41 62 64 68 73 | Moderate confidence | No concerns on coherence, minor concerns on relevance (3 out of 5 studies may include non-migrant women’s perspectives) moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings), moderate concerns on adequacy (5 out of 12 studies supported this finding). |
F14.0 | Impact of limited clarity of community-based doula role in the maternity care team When the purpose, roles and boundaries of community-based doulas within labour and birth were unclear among community-based doulas and healthcare providers, tension and conflict may result. Community-based doulas who engaged in clinical decision-making or roles outside of their scope of practice were negatively received by healthcare providers. Whereas healthcare providers either misperceived them as interpreters often rejecting their roles (ie, advocacy, birth support), delegated them clinical tasks, or perceived them as replacing providers' or women’s partners' roles. | 40 41 60 62 64 66 68–70 | High confidence | No or very minor concerns on coherence, minor concerns on adequacy (5 out of 12 studies supported this finding), minor concerns on relevance (2 out of 5 studies may include non-migrant women’s perspectives) and moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings). |
F15.0 | Impact of limited clarity of community-based doula role with being on-call Some community-based doulas were unable to provide on-call support for migrant women in labour and birth due to their own individual or cultural limitations working during night-time hours. Migrant women expressed disappointment in their doulas’ absence at their labour and birth as they had desired continuity of doula support. | 39 40 64 65 | Low confidence | No or very minor concerns on coherence and relevancy (1 out of 2 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, recruitment, reflexivity, ethics, data collection) and serious concerns on adequacy (2 out of 12 studies supported this data). |
F16.0 | Limited continuity due to meeting too late Some migrant women who first met their community-based doulas in labour and birth were disappointed in the limited continuity of support offered by their doulas and would have preferred to establish relationships with their doulas earlier in their pregnancy. | 39 40 65 | Low confidence | No or very minor concerns with coherence, minor concerns with relevance (1 out of 2 studies may include non-migrant women’s perspectives), moderate concerns for methodological limitations (research design, recruitment, reflexivity, ethics, data collection) and serious concerns with adequacy (2 out of 12 studies supported this finding). |
F17.0 | Limited childbirth knowledge Some migrant women expressed dissatisfaction and feeling unsupported during labour and birth when they perceived a gap in their community-based doulas’ training, specifically when doulas lacked specialised childbirth knowledge, birth support training and culturally competent care. Similarly, some doulas expressed inadequate knowledge and desired more education. | 39 40 68 71 | Moderate confidence | No or very minor concerns on coherence, minor concerns on relevance (1 out of 4 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, recruitment, reflexivity, ethics, data collection and analysis, support for findings) and moderate concerns for adequacy (4 out of 12 studies supported this finding). |
F18.0 | Establishing credibility and marketing of community-based doula programmes Community-based doula programmes implemented by a non-profit organisation external to maternity settings experienced concerns with networking opportunities and accountability that led to challenges in establishing credibility and receiving referrals to the programme. Similarly, volunteer programmes with doula-like support may limit recruitment and funding opportunities available for community-based doula programmes. Community-based doula programmes which engaged in community networking opportunities and advertised doula services to prospective clients and organisations outside of maternity settings may improve the credibility, marketing and uptake of programme services. | 40 41 64 | Low confidence | No concerns on coherence, minor concerns on relevance (1 out of 2 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings) and serious concerns on adequacy (2 out of 12 studies supported this finding). |
F19.0 | Funding and sustainability The impact of partially or unfunded community-based doula programmes meant that programme staff and local champions were tasked with sourcing alternative funding streams (eg, paid doula work) in the short-term. This included some non-profit organisations using fundraising or paid community-based doula models to sustain their programmes. Networking and establishing strategic partnerships may appear to be valuable in strengthening community-based doula programme funding applications and pursuing alternative collaborative funding streams. Community-based doula programmes may have to consider aligning their priorities to local public health priorities areas to be considered for funding opportunities and as a possible cost-effective measure. | 40 62 64 73 | Moderate confidence | No or very minor concerns on coherence, minor concerns on relevance (3 out of 3 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, reflexivity, ethics, data collection) and moderate concerns on adequacy (3 out of 12 studies supported this finding). |
F20.0 | Professionalisation and organisation of community-based doula programmes Community-based doula programmes may need to change current organisational processes to attract prospective clients and to motivate and retain volunteers. This may include flexibility among recruitment of clients (eg, broadening eligibility criteria) and volunteers (eg, alternative referee options, contracts) and including volunteers in strategic programme meetings and mandatory training opportunities. | 40 62 64 | Moderate confidence | No concerns on coherence, minor concerns on relevance (2 out of 2 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, reflexivity, ethics, data collection) and serious concerns with adequacy (2 out of 12 studies supported this finding). |
F21.0 | Challenges with the resource-intensiveness of community-based doula programmes Community-based doula programmes are resource intensive and are often faced with logistical and financial challenges, particularly if there are additional expenses associated with maintaining the programme. Programmes often required a dedicated team to run them, in which staff appeared to go beyond their role by volunteering their time to cover shortfalls in programme activities. | 40 64 | Low confidence | No concerns on coherence, minor concerns with relevance (the only included study may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research aims and design, recruitment, reflexivity, ethics, data collection and analysis, support for findings) and serious concerns on adequacy (1 out of 12 studies supported this finding). |
F22.0 | Motivation of community-based doulas and their engagement with the programme Community-based doula’s own motivation and time available to be a doula may impact how motivated and engaged they were in their role. Similarly, community-based doula programmes which had limited clients to support found doulas became unmotivated if they remained unmatched. | 40 64 67 | Low confidence | No concerns on coherence, minor concerns on relevance (2 out of 2 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, recruitment, reflexivity, data collection) and serious concerns on adequacy (2 out of 12 studies supported this finding). |
F23.0 | Challenges with receiving limited or no numeration and demanding work Some community-based doulas perceived being unpaid volunteers or receiving minimal reimbursement for their services as challenging especially if they were from the same communities as the migrant women they were supporting. Similarly, some women expressed feeling challenged knowing that their community-based doulas were unpaid volunteers. | 62 65 68 | Very low confidence | No concerns on coherence, minor concerns on relevance (2 out of 3 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, reflexivity, ethics, data collection) and serious concerns with adequacy (3 out of 12 studies supported this finding). |
F24.0 | Demanding nature of community-based doula work Community-based doulas expressed the demanding nature of being on-call through the physical and emotional toll on themselves, their partners and families. For some employed doulas, they found timekeeping their birth work hours challenging given the on-call nature of their work, and possibly are restricted in how much support they can provide, particularly when balancing other commitments (eg, paid work). | 62 68 73 | Moderate confidence | No or very minor concerns with coherence, minor concerns with relevance (2 of the 3 studies may include non-migrant women’s perspectives), moderate concerns with methodological limitations (reflexivity, ethics, data analysis) and moderate concerns with adequacy (3 out of 12 studies supported this finding). |
F25.0 | Mentorship and support opportunities may facilitate community-based doulas’ motivation and engagement with programme When programmes ensured that community-based doulas felt supported and valued within their organisation, a sense of community among doulas and programme staff ensued. Mentorship opportunities may be valuable in motivating and creating the sense of community among community-based doulas and programme staff, especially for newly recruited volunteer doulas. | 40 62 64 68 | Moderate confidence | No concerns on coherence, minor concerns on relevance (2 out of 3 studies may include non-migrant women’s perspectives), moderate concerns on methodological limitations (research design, reflexivity, ethics, data collection) and moderate concerns with adequacy (3 out of 12 studies supported this finding). |
F26.0 | Moving towards paid community-based doula models may sustain the workforce and provide financial and health benefit for doulas and their families Some community-based doulas working as employees of a community-based doula programme received hourly remuneration; a set number of hours per week; paid attendance to meetings and training, leave entitlements; and health insurance for both doulas and their families. Doulas felt this paid-model symbolically represented value and recognition of the importance of their birth work, particularly as they were supporting women from their communities. | 73 | Very low confidence | No concerns on coherence, minor concerns on relevance (the only included study may include non-migrant doulas' perspectives), minor concerns on methodological limitations (ethics) and serious concerns with adequacy (1 out of 12 studies supported this finding). |