Doulas as Agents of Reproductive Justice Who Promote of Women’s International Human Rights: An Evidence-Based Review and Comparative Case Study Between Brazil and the United States

  • Kathryn MishkinEmail author
  • Luisa Fernandes
Conference paper


Increasingly, women’s health is improving, and women’s rights are being realized. In spite of this, women’s healthcare experiences and internationally recognized health indicators suggest that the quality of maternal healthcare is inadequate for many women. Reproductive justice serves as a platform to both improve reproductive health and reproductive rights. We argue that doulas serve as agents of reproductive justice because their work advances maternal health and women’s empowerment through three means: improving health outcomes, promoting women’s control over their health, and reducing cost-related health disparities. Using a reproductive justice lens, this paper explores the ways in which doula work supports the goals of the international human rights community through various human rights declarations and goals of the United Nations that focus on women’s health, maternal health, child health, and women’s empowerment. Specifically, the Universal Declaration of Human Rights, the Convention on the Elimination of All Forms of Discrimination Against Women, and the Sustainable Development Goals are analyzed to identify how doula services may be incorporated to complement strategies to improve maternal health. This paper also provides a cross-cultural comparison of how doula work is promoted and challenged through national policies and programs in two case example countries representing different health systems, cultures, and stages of development: Brazil and the United States. This comparison provides a practical application of our hypothesis that countries adopting doula-friendly policies may better promote reproductive justice and engage in the promotion of international human rights.


Doula Reproductive justice Human rights 


  1. ACOG. Approaches to limit intervention during labor and birth. Committee Opinion; 2017.Google Scholar
  2. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). US Department of Health and Human Services. 2017. Available at:
  3. Almeida LM, Caldas J, Ayres-De-Campos D, Salcedo-Barrientos D, Dias S. Maternal healthcare in migrants: a systematic review. Matern Child Health J. 2013;17:1346–54.CrossRefPubMedGoogle Scholar
  4. Asian Communities for Reproductive Justice. A new vision for advancing our movement for reproductive health, reproductive rights, and reproductive justice, Oakland; 2005.Google Scholar
  5. Bakken KS, Skjeldal OH, Stray-Pedersen B. Higher risk for adverse obstetric outcomes among immigrants of African and Asian descent: a comparison study at a low-risk maternity hospital in Norway. Birth. 2015;42:132–40.CrossRefPubMedGoogle Scholar
  6. Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol. 2008;199:445–54.CrossRefPubMedGoogle Scholar
  7. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One. 2016;11:e0148343.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Boerma T, Mathers C, Abouzahr C, Chatterji S, Hogan D, Stevens G, assisted by Wahyu, Mahanani R, Ho J, Rusciano F, Humphrey G. Health in 2015: from MDGs to SDGs. Geneva: WHO; 2015.Google Scholar
  9. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Coneglian FS, Diniz ALA, Tunçalp Ö. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015;12:e1001847.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Bowser DHK. Exploring evidence for disrespect and abuse in facility-based childbirth: report of a landscape analysis. Washington, DC: United States Agency for International Development; 2010.Google Scholar
  11. Brasil Ministério da Saúde. Política nacional de práticas integrativas e complementares no SUS. Brasília; 2006.Google Scholar
  12. Brasil Ministério do Trabalho e Emprego 2013 Classificação Brasileira de Ocupações.Google Scholar
  13. Brazil DD. Quem Somos. 2017. Available at:
  14. Bunch C. Women’s rights as human rights: toward a re-vision of human rights. Hum Rts Q. 1990;12:486.CrossRefGoogle Scholar
  15. Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. J Obstet Gynecol Neonatal Nurs. 2006;35:456–64.CrossRefPubMedGoogle Scholar
  16. Campero L, Garcia C, Diaz C, Ortiz O, Reynoso S, Langer A. “Alone, I wouldn’t have known what to do”: a qualitative study on social support during labor and delivery in Mexico. Soc Sci Med. 1998;47:395–403.Google Scholar
  17. Cavassini ACM, Lima SAM, Calderon IMP, Rudge MVC. Cost-benefit of hospitalization compared with outpatient care for pregnant women with pregestational and gestational diabetes or with mild hyperglycemia, in Brazil. Sao Paulo Med J. 2012;130:17–26.CrossRefPubMedGoogle Scholar
  18. CDC. Births: final data for 2008. National Vital Statistics Reports. CDC; 2015.Google Scholar
  19. Centers for Medicare & Medicaid Services. Improving maternal and infant health outcomes: CMCS crosswalk of current activities and identified potential strategies provider resources. Baltimore; 2013. Cited 08/03/2017.
  20. Cheyney MJ. Homebirth as systems-challenging praxis: knowledge, power, and intimacy in the birthplace. Qual Health Res. 2008;18:254–67.CrossRefPubMedGoogle Scholar
  21. Childbirth Connection. Overdue: medicaid and private insurance coverage of doula care to strengthen maternal and infant health. Issue Brief; 2016.Google Scholar
  22. da Gama SGN, Viellas EF, Torres JA, Bastos MH, Brüggemann OM, Filha MMT, Schilithz AOC, do Carmo Leal M. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health. 2016;13:123.CrossRefPubMedPubMedCentralGoogle Scholar
  23. de Castro Leão MR, Bastos MAR. Doulas apoiando mulheres durante o trabalho de parto: experiência do Hospital Sofia Feldman. Rev Lat Am Enfermagem. 2001;9:90–4.CrossRefGoogle Scholar
  24. Declercq ESC, Corry M, Applebaum S, Herrlich A. Listening to mothers III: pregnancy and birth: listening to mothers II: report of the third national survey of women’s childbearing experiences. New York: Childbirth Connection; 2013.Google Scholar
  25. Dias MAB, Domingues RMSM, Schilithz AOC, Nakamura-Pereira M, do Carmo Leal M. Factors associated with cesarean delivery during labor in primiparous women assisted in the Brazilian Public Health System: data from a National Survey. Reprod Health. 2016;13:114.CrossRefPubMedPubMedCentralGoogle Scholar
  26. DONA International. About DONA International. 2017. Available at:
  27. Elias PE, Cohn A. Health reform in Brazil: lessons to consider. Am J Public Health. 2003;93:44–8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Fertonani HP, de Pires DE, Biff D, Scherer MD. The health care model: concepts and challenges for primary health care in Brazil. Cien Saude Colet. 2015;20:1869–78.CrossRefPubMedGoogle Scholar
  29. Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012;29:7–18.CrossRefPubMedGoogle Scholar
  30. Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on healthy birth outcomes. J Perinat Educ. 2013;22:49–58.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Hayes I, Enohumah K, McCaul C. Care of the migrant obstetric population. Int J Obstet Anesth. 2011;20:321–9.CrossRefPubMedGoogle Scholar
  32. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7:CD003766.PubMedGoogle Scholar
  33. Human Rights Watch. “Stop making excuses”: accountability for maternal health care in South Africa. New York: Human Rights Watch; 2011.Google Scholar
  34. Kane Low L, Moffat A, Brennan P. Doulas as community health workers: lessons learned from a volunteer program. J Perinat Educ. 2006;15:25–33.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a us hospital: a randomized controlled trial. JAMA. 1991;265:2197–201.CrossRefPubMedGoogle Scholar
  36. Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OM, Feigl AB, Graham WJ, Hatt L, Hodgins S, Matthews Z, McDougall L, Moran AC, Nandakumar AK, Langer A. Quality maternity care for every woman, everywhere: a call to action. Lancet. 2016;388:2307–20.CrossRefPubMedGoogle Scholar
  37. Kozhimannil KB, Hardeman RR. Coverage for doula services: how state Medicaid programs can address concerns about maternity care costs and quality. Birth. 2016;43:97–9.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O’Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013a;103:e113–21.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood). 2013b;32:527–35.CrossRefGoogle Scholar
  40. Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery. Birth. 2016;43:20–7.CrossRefPubMedPubMedCentralGoogle Scholar
  41. Lalonde AB, Miller S. Mother-baby friendly birthing facilities initiative. Int J Gynaecol Obstet. 2015;128:93–4.CrossRefPubMedGoogle Scholar
  42. Le HH, Connolly MP, Bahamondes L, Cecatti JG, Yu J, Hu HX. The burden of unintended pregnancies in Brazil: a social and public health system cost analysis. Int J Womens Health. 2014;6:663–70.PubMedPubMedCentralGoogle Scholar
  43. Lothian JA. Safe, healthy birth: what every pregnant woman needs to know. J Perinat Educ. 2009;18:48–54.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Macinko J, Harris MJ. Brazil’s family health strategy. N Engl J Med. 2015;373:1278.PubMedGoogle Scholar
  45. Maher S, Crawford-Carr A, Neidigh K. The role of the interpreter/doula in the maternity setting. Nurs Womens Health. 2012;16:472–81.CrossRefPubMedGoogle Scholar
  46. Martinez M, Zammitti E, Cohen R. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–September 2016. National Health Interview Survey Early Release Program. CDC; 2017.Google Scholar
  47. McGrath SK, Kennell JH. A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth. 2008;35:92–7.CrossRefPubMedGoogle Scholar
  48. Meyer B, Arnold J, Pascali-Bonaro D. Social support by doulas during labor and the early postpartum period. Hosp Physician. 2001;37:57–65.Google Scholar
  49. Miller S, Lalonde A. The global epidemic of abuse and disrespect during childbirth: history, evidence, interventions, and FIGO’s mother-baby friendly birthing facilities initiative. Int J Gynaecol Obstet. 2015;131(Suppl 1):S49–52.CrossRefPubMedGoogle Scholar
  50. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, Diaz V, Geller S, Hanson C, Langer A, Manuelli V, Millar K, Morhason-Bello I, Castro CP, Pileggi VN, Robinson N, Skaer M, Souza JP, Vogel JP, Althabe F. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388:2176–92.CrossRefPubMedGoogle Scholar
  51. Minnesota State Senate. Doula services medical assistance (MA) coverage requirement. Minnesota Senate Bill 699; 2013.Google Scholar
  52. Nakamura-Pereira M, Do M, Leal C, Esteves-Pereira AP, Soares RM, Domingues M, Moreira ME. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13:245–56.CrossRefGoogle Scholar
  53. Oregon Health Authority. Billing for doula services. 2015.Google Scholar
  54. Redshaw M, Hockley C. Institutional processes and individual responses: women’s experiences of care in relation to cesarean birth. Birth. 2010;37:150–9.CrossRefPubMedGoogle Scholar
  55. Rosenfield A, Maine D. Maternal mortality – a neglected tragedy. Where is the M in MCH? Lancet. 1985;2:83–5.CrossRefPubMedGoogle Scholar
  56. Ross L. Understanding reproductive justice: transforming the pro-choice movement. Off Our Backs. 2006;36(4):1419.Google Scholar
  57. Sartori Fernandes RZ, de Gouveia Vilela MF. Estratégias de integração das práticas assistenciais de saúde e de vigilância sanitária no contexto de implementação da Rede Cegonha. Cien Saude Colet. 2014;19(11):4457–66.CrossRefGoogle Scholar
  58. Sauls DJ. Effects of labor support on mothers, babies, and birth outcomes. J Obstet Gynecol Neonatal Nurs. 2002;31:733–41.CrossRefPubMedGoogle Scholar
  59. Shaw D, Guise J-M, Shah N, Gemzell-Danielsson K, Joseph K, Levy B, Wong F, Woodd S, Main EK. Drivers of maternity care in high-income countries: can health systems support woman-centred care? Lancet. 2016;388:2282–95.CrossRefPubMedGoogle Scholar
  60. Silva RMD, Jorge HMF, Matsue RY, Ferreira Junior AR, Barros NFD. Uso de práticas integrativas e complementares por doulas em maternidades de Fortaleza (CE) e Campinas (SP). Saúde e Sociedade. 2016;25:108–20.CrossRefGoogle Scholar
  61. 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. N Engl J Med. 1980;303:597–600.CrossRefPubMedGoogle Scholar
  62. Strauss N, Giessler K, McAllister E. How doula care can advance the goals of the affordable care act: a snapshot from New York City. J Perinat Educ. 2015;24:8–15.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Swedish Government Initiative. A call to action: Swedish Government initiative High-Level Group to ensure Global Goals and 2030 Agenda are implemented. 2017. Available at:
  64. UN (United Nations). Goal 3. Sustainable development goals. 2015.Google Scholar
  65. UN. Sustainable development goals. 2017a.Google Scholar
  66. UN General Assembly. Universal declaration of human rights. 217 A (III). 1948.Google Scholar
  67. UN General Assembly. Convention on the elimination of all forms of discrimination against women, 18 Dec 1979. United Nations, Treaty Series, vol. 1249.Google Scholar
  68. United Nations. Review of the implementation of the Beijing declaration and platform for action and the outcome of the twenty-third special session of the general assembly in Latin American and Caribbean countries Division for Gender Affairs. Economic Commission for Latin America and the Caribbean. 2010.Google Scholar
  69. United Nations. Official documents system. 2017. Available at:
  70. WHO. Sexual health, human rights and the law. World Health Organization; 2015a.Google Scholar
  71. WHO. WHO statement on caesarean section rates. 2015b.Google Scholar
  72. WHO. World health statistics 2017. Monitoring health for the SDGs. 2017.Google Scholar
  73. WHO, UNFPA, The World Bank, and UN Population Division. Trends in maternal mortality: 1990 to 2013. 2014.Google Scholar
  74. World Bank. Health expenditure. 2017a. Available at:
  75. World Bank. Infanct mortality ratio. 2017b. Available at: 4-
  76. World Bank. Maternal mortality ratio. 2017c. Available at:

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Health Policy, Management, and BehaviorUniversity at Albany School of Public Health, State University at New YorkNew YorkUSA

Personalised recommendations