Doula and Community Health Worker Support for Perinatal Intimate Partner Violence Survivors: Current Practices,Desired Resources,and Self-Care: A Qualitative Study

Abstract

Introduction:

The perinatal period is a dangerous time for survivors of intimate partner violence (IPV). Doulas and community health workers (CHWs) serving perinatal people and their infants provide resources and support for survivors experiencing IPV. This study aimed to explore (1) current practices of doulas and CHWs for addressing IPV among their clients, (2) barriers and facilitators to supporting survivors, and (3) needed resources.

Methods:

We conducted virtual semistructured interviews with doulas and CHWs. Participants were recruited through local- and statewide organizations focused on violence prevention, doula care, and perinatal support. Interview recordings were transcribed verbatim and coded using a deductive-inductive thematic analysis approach. Team members coded the transcripts separately and then met to resolve discrepancies.

Results:

We conducted interviews with 15 doulas and 9 CHWs. Participants reported that structural inequities shape survivors’ experiences with their perinatal care providers. Participants described how these inequities caused harm to survivors’ health, well-being, and quality of care and support for IPV. Both doulas and CHWs shared self-care practices that allow them to care for IPV survivors, including setting boundaries, mindfulness, and spirituality.

Discussion:

Doulas and CHWs offer essential support for perinatal survivors and their infants. This study suggests that doulas and CHWs require additional training and support to care for IPV survivors. Future research and interventions should prioritize integrating institutional supports for doulas and CHWs to prioritize their well-being.

Keywords

intimate partner violence domestic violence doula community health worker birth center health care disparities

Introduction

Intimate partner violence (IPV) includes physical and sexual violence, stalking, and psychological aggression.¹ Perinatal IPV is defined as experiences of violence in the 12 months before pregnancy, during pregnancy, and the 12 months after pregnancy.² Nationally, an estimated 3–9% of birthing people report physical IPV during pregnancy, though prevalence varies widely by region and population subgroup.² Clinic-based samples often document substantially higher rates, with up to 16.4% reporting physical IPV and 73% reporting psychological IPV.² However, these figures likely underestimate the true burden, given persistent barriers to disclosure and safety concerns that limit reporting.² IPV has profound health consequences, including pregnancy complications, preterm birth, and postpartum depression.^3,4 Pregnancy and postpartum are dangerous times for survivors, with increased risk of physical violence and homicide.⁴ Marginalized groups often face barriers to IPV disclosure and support, including fear of surveillance, systemic discrimination, and biases in service provision related to race, gender, class, disability, and cultural background.^5–7 Specifically, partners may use immigration status to limit access to social support, threaten deportation, or prevent access to language-concordant information to gain power and control over survivors and prevent disclosures.⁸

The United States has one of the highest maternal mortality rates when compared with other high-income countries.⁸ Maternal mortality rates include pregnancy-associated deaths while pregnant or within 1 year postpartum.⁸ Racial and ethnic disparities exist in maternal mortality within the United States, with Black pregnant people being three to four times more likely to die of pregnancy-related causes than white pregnant people.⁸ A significant contributor to the maternal mortality crisis within the United States is high rates of homicide during pregnancy and the postpartum period.⁸ Black pregnant people are also at a higher risk of homicide than white pregnant people, with Black pregnant people having a sevenfold pregnancy-associated homicide ratio.⁸

One proposed solution to increasing support and access to community-based resources for perinatal IPV survivors is expanding access to members of the community health care team who are trained in trauma-informed support.⁹ Doulas and community health workers (CHWs) are essential members of the community health care team, providing emotional and practical support to birthing people throughout the perinatal period.^9–11 Doulas are trained nonmedical professionals who provide physical, emotional, and informational support to their clients and support system before, during, and shortly after childbirth.¹⁰ CHWs work with clients both within and outside the perinatal period, serving as a link between their communities and health care and social services, providing health education, and facilitating care coordination.^11,12 Although many aspects of doulas’ and CHWs’ responsibilities overlap, the key distinction between the two roles is that doulas focus on the perinatal period and spend the most time with clients during active labor.^10,12 On the other hand, CHWs have less training specifically around birthing but have a broader scope in terms of population and health conditions.¹² While doulas and CHWs have slightly different roles, studies have shown that perinatal care from CHWs and doulas is associated with better birth outcomes, including lower cesarean rates, preterm birth, and low birth weight; positive infant care behaviors, such as safe sleep practices and car seat use; and referrals to community-based organizations to support unmet basic needs such as food and housing.^10,13,14

Due to their extended relationships with their clients, doulas and CHWs have a unique opportunity to provide ongoing support to IPV survivors.^12,13 As trusted members of the survivors’ care team, doulas and CHWs have the opportunity to provide emotional support and connect survivors with community resources, such as shelters, advocates, and other support services.⁹ Research and practice have identified the importance of trauma-informed doula and CHW services for survivors in preventing retraumatization in the birthing experience.⁹ Recent research has examined CHWs’ readiness and capacity to support IPV survivors.¹¹ A two-phase cross-sectional study found that over half of CHWs lacked formal training on IPV, half reported not being aware of their institution’s policies on IPV, and more than half indicated that they did not know IPV referral resources.¹¹ However, CHWs with greater knowledge reported higher perceived readiness to provide support to clients experiencing IPV.¹¹ Although perinatal and violence prevention organizations, including Futures Without Violence and National Research Center on Domestic Violence, call for trauma-informed doula, research has yet to explore doula perspectives on their current practices supporting IPV survivors.¹⁴ These findings highlight not only gaps in CHW and doula perceived readiness to support IPV survivors but also opportunities to improve training and support for both CHWs and doulas in delivering trauma-informed care.¹¹ Moreover, the barriers and facilitators to supporting IPV survivors are not well understood from the perspectives of doulas and CHWs.

One such barrier to supporting IPV survivors may be the profound mental health consequences for doulas and CHWs, including experiencing vicarious trauma, burnout, and compassion fatigue.¹⁵ Part of responding to IPV in a trauma-informed way is recognizing that self-care practices are essential to building sustainable supports for IPV survivors and preventing such adverse mental health outcomes among professionals supporting IPV survivors.¹⁵ Concepts such as trauma stewardship, a framework focused on sustaining one’s own well-being while caring for trauma survivors, offer guidance for doulas and CHWs by emphasizing practices such as recognizing personal limits, pursuing ongoing professional development, maintaining supportive networks, engaging in grounding or reflective rituals, and developing long-term self-care plans that promote physical and mental health.¹⁶ Several of these individual and organization-level self-care practices are associated with better mental health outcomes and lower levels of stress related to the occupational stress of supporting IPV survivors.¹⁵ For example, individual-level self-care practices such as engaging in physical activity, mindfulness, prayer, and connecting with social support networks were cited by professionals working with IPV survivors as crucial for promoting their own well-being.¹⁵ Moreover, at the organizational level, peer support groups, debriefings after cases with supervisors, and training on how to set boundaries between professionals’ work and personal lives decreased stress associated with supporting IPV survivors.¹⁵ Additional work is needed to understand the specific self-care practices of doulas and CHWs supporting IPV survivors and what resources they need to promote their well-being.

Therefore, the goal of this study is to examine doulas’ and CHWs’ perspectives on how they currently support IPV survivors and practice self-care, needed resources, and recommendations regarding what training is needed for them to support IPV survivors in a trauma-informed way. Our specific objectives were to explore (1) how doulas and CHWs see IPV manifest during the perinatal period; (2) how doulas and CHWs currently support IPV survivors; (3) what barriers and facilitators doulas and CHWs experience in supporting IPV survivors; (4) how doulas and CHWs currently practice self-care; and (5) recommendations for training and resources for doulas and CHWs to optimally support IPV survivors.

Methods

Study design

We conducted semistructured interviews with doulas and CHWs in Western Pennsylvania to explore how they support IPV survivors. We employed a descriptive qualitative inquiry, a hypothesis-generating qualitative approach that is ideal for gaining a deeper understanding of phenomena from participants’ experiences and ideal for a study focused on capturing doula and CHW experiences and perspectives.¹⁷ We convened a community-academic team with expertise in perinatal health, IPV, and doula care.

Measures

We developed interview guides for doulas and CHWs aligned with our study objectives. We asked questions focused on (1) how doulas and CHWs have seen IPV manifest in their clients’ relationships; (2) how systems of oppression impact survivors; (3) what services or resources doulas and CHWs recommend to survivors; (4) how they support IPV survivors during the prenatal, birth, and postpartum periods; and (5) how doulas and CHWs practice self-care while caring for IPV survivors. The complete interview guide is available in Supplementary Data. The University of Pittsburgh Institutional Review Board approved this study. Questions were developed by the research team, aligned with our core research objectives. The interview guide was reviewed by the full community-academic team, which included doulas and IPV advocates, and then revised based on their feedback.

Participants’ recruitment

Eligibility criteria for doulas and CHWs included (1) age 18 or older, (2) identifies as a doula or CHW who serves perinatal survivors, and (3) speaks English. Doulas and CHWs were recruited through emails, flyers, and Pitt+Me, an online research registry. Local- and statewide organizations serving perinatal clients and IPV survivors shared flyers on behalf of the study to their listservs of doulas and CHWs. The flyer and email contained a link to a presurvey, which participants completed to check eligibility and sign up for an interview. Interviewees were selected via convenience sampling from those who expressed interest in participating after receiving information about the study. Forty participants expressed interest; eight were ineligible, seven consented but were lost to follow-up or did not attend the interview, and one whose call back number was not working. Twenty-four participants (65%) completed the interview.

Data collection

Virtual interviews were conducted from May to August 2024. Interviews lasted 45–60 min, were conducted via Zoom, and were audio-recorded. Before each interview, verbal consent was obtained, and participants completed a demographic survey. Interview audio recordings were transcribed verbatim. Interview participants were provided a $50 gift card and a resource sheet about local IPV resources. The study team continued conducting interviews until thematic saturation was achieved, where no new themes were heard.¹⁸

Data analysis

The study team used a deductive-inductive thematic analysis approach.¹⁹ Two study team members individually coded each transcript on the Dedoose qualitative software package.²⁰ The codebook began with a list of a priori codes that matched the interview guide. Inductive codes were added to the codebook during the coding process. The coders met biweekly to resolve discrepancies in coding. The research team met monthly to review emerging codes, consolidate codes into themes and domains, and make iterative changes to the interview guide.

Results

Twenty-four participants took part in the study: 15 doulas and 9 CHWs. Participants primarily identified as cisgender women (83%) and as Black (38%), White (29%), Asian (8%), and Hispanic (4%) (Table 1). We identified three domains. Additional quotes are presented in Table 2. We did not observe differences between the experiences of CHWs and doulas; therefore, we presented their results together.

Table 1.

Demographics

n = 24	n (%)
Gender
Woman	20 (83%)
Man	0
Nonbinary	0
Prefer not to answer	1 (4%)
No data	3 (13%)
Race and ethnicity
White	7 (29%)
Black or African American	9 (38%)
Hispanic	1 (4%)
Asian or Pacific Islander	2 (8%)
Prefer not to answer	3 (13%)
No data	3 (13%)
Age
25–34	7 (29%)
35–44	2 (8%)
45–54	10 (42%)
55–64	1 (4%)
65–74	1 (4%)
No data	3 (13%)
Occupation
Doula/In-training doula	13 (54%)
Community health worker	7 (29%)
Experience in both	4 (17%)
Years worked as doula/CHW
<1 year	3 (13%)
1–2 years	3 (13%)
3–5 years	8 (33%)
6–10 years	2 (8%)
11–15 years	3 (13%)
16–20 years	1 (4%)
20+ years	1 (4%)
No data	3 (13%)
Practice setting
Urban	18 (75%)
Rural	1 (4%)
Suburban	1 (4%)
Prefer not to answer	1 (4%)
No data	3 (13%)

CHW, community health worker.

Table 2.

Representative Themes and Quotes

Domain 1: Experiences supporting intimate partner violence survivors
Theme 1: Doulas and CHWs report that perinatal people experience multiple types of behaviors and violence throughout the perinatal period.	“Taking control of the finances. You know taking the EBT card you know and using it for their own personal good. Which pushed that mom you know put that mom in a challenging situation because you know she needed to buy diapers you know and things for the home.” Participant 6 “Their partner would use her vulnerability against her later. Like making disparaging remarks about her body to other people and about her... a partner who is present, who is abusive, could take all of that, her nakedness, her primal instincts, and totally use that against her with her family and friends, and then shame her. I’ve seen that. I have seen that, not with abusers who are physically violent, but with abusers who are psychologically abusing.” Participant 7 “There was this one woman where she said she couldn’t even sleep because she feared that he might be able to strangle her. And she had to sleep with the children as well. And whenever she would sleep with her kids... the chair would be like kind of blocking the doorknob. So her partner wouldn’t come in the door.” Participant 8
Theme 2: Language and immigration-related inequities can increase the risk of IPV.	“I would say that language is another thing that abusers can use against their partners. Often, it’s the abusive partner that speaks English when a birthing person does it. And so, they take advantage of that of not allowing birthing person to be heard.” Participant 23 “Two cases with a mom that doesn’t know how to read or to write. So, it’s, it’s hard because the partner or husband is always controlling everything because he knows how to read or to write. So all the services, the doctors, you know, all the connections are speaking with him.” Participant 5 “I think it was that too because a lot of shelters, they don’t have translation. Yeah. A lot of them don’t. And they use a telephone translation. But a lot of times, you don’t have that same interaction as a person face-to-face as over the phone, right?” Participant 8
Theme 3: IPV experiences are profoundly shaped by the intersections of race, age, and culture, which affect survivors’ access to resources and the harms they face within institutional systems.	“Oh, yeah. It’s systematic. They’re not given the same treatment. They’re not given the same, you know they have to do more to prove more. Some women go into the shelter and just say that they’re being abused. Some centers make you prove that you’re being abused, possibly PFA, possibly you know records showing pictures. And sometimes women go in and they have none of that that are non-color. You know Women who are minorities are asked to prove that they have suffered abused by the hands of their abuser.” Participant 10 “What I see is in different cultures and communities that domestic violence, I mean, intimate partner violence just looks different to different cultures... I’ve learned to just still address it but find the time unless the person is at you know their safety is at risk and things like that.” Participant 16
Theme 4: Survivors demonstrate resilience through the support provided by doulas and CHWs.	“Just their will, just their will to have the baby and to just want something better for their baby. Like even if they’re in the situations, I’ve heard like even if they’re not out of it completely, they know that it’s unhealthy and the resilience that they have is like, “I’m not going to let him keep doing this to me. I’m going to make plans, just trying to get out of the situation and just move forward.” Participant 16“I have a story to where the woman was ready to get out. She had three babies, and then she had one more on the way. So he went to work. I was able to load up you know some of her things. She was able to save a little money, put some back. And I was able to get her to an amazing women’s shelter. And since I got her into that women’s shelter, you know of course, I stayed with them until I think the baby was I’d say two. We were able to they were able to provide housing through you know Section 8 in a totally different county.” Participant 14

Domain 2: Supporting IPV survivors: current practices and challenges
Theme 1: Doulas and CHWs provide validation and emotional support to IPV survivors.	“We talk to them. So, you know the woman that I had, I would talk to her, give her space, a private room because a lot of times they don’t want to speak when they see a lot of people.” Participant 8 “So just trying to break up that isolation of he’s totally in charge of everything when he shouldn’t be. You know you should have friends. You should have family. You know try to connect with the people that you can connect with while possibly he’s at work or you know try to still maintain some signs of healthiness, healthy relationships with others until you’re able to remove yourself from that situation. Safety Planning” Participant 10 “Active listener, being transparent, being able to relate, being able to share my strength and hope, being able to sit where they sit, being able to build trust, doing whatever it take to help this person get to where they want to be.” Participant 17
Theme 2: CHWs and doulas describe receiving training on IPV and perinatal health; however, not all individuals received IPV training, and some noted that accessibility of training was a barrier to their practice.	“So there have been some trauma-informed parts of doula trainings. But I have been through a ton of them because I enjoy it. And I like to check them out and see what people are talking about and what’s changing because I’ve been doing this for quite some time. And I often think that that is something that is lacking in doula trainings because I think that they can be violent as well. And I hear about it often. I’m like, “Oh, that behavior is so harmful. Like What are you talking about? That’s dangerous.” So I do think like the trauma-informed piece and the cultural appropriate piece, I think a lot of that is missing from a lot of the doula trainings.” Participant 15
Theme 3: CHWs and doulas navigate the tension between mandated reporting requirements and maintaining client trust, balancing legal obligations with the risk of escalating harm or disrupting care relationships.	“Oh, they highlighted a lot of things to look out for when people are experiencing things and not really outward saying that they’re having this experience. Some things that are signals to maybe things are happening in the home that client might not be disclosing, you know warning signs. Just different things to show you that a client might need more resources than they let on to say. Yeah But sometimes your clients are afraid to ask you because they think you’re going to call CYF [Office of Children, Youth, and Families] or call someone on them yeah because they need help. But oftentimes it’s just help getting you know from this week to next week. Small amount.” Participant 10

Domain 3: Doula and CHW self-care practices
Theme 1: Setting boundaries and seeking support helps doulas and CHWs manage emotional demands.	“But I’ve spent a lot of time sort of accepting that I can’t control things. And I think not that I feel ready to deal with an IPV situation, but I feel very comfortable knowing that seven-time statistic and knowing that there’s only so many limits that I can’t force a change in the situation, and I can only do so much, but I can be ready to do and take the steps to support someone as soon as it’s as soon as they ask for it, if that makes sense.” Participant 4 “And then for my own well-being, like definitely therapy, I kind of kept myself in therapy all the time.” Participant 7
Theme 2: Mindfulness, creativity, and spirituality support long-term sustainability.	“Accountability. Honestly, I want you to give people a ton of education. You teach them every single thing in the whole wide world, right? But if we are not holding ourselves accountable about the behaviors that we’re expressing in these situations, we’re just as violent as the people that are abusing the people that are surviving or right in the middle of the crisis. We are no better than the systems that are consistently being violent to our clients. We have to be accountable and consistently check in on ourselves, which is something that takes time.” Participant 25 “So, if that’s food, if it’s alcohol, if it’s cigarettes, whatever that is, just you’re like, “Oh, my gosh.” you know And I had to learn better coping skills around that. And so therapy was helpful. But also, I started doing more physical walking, swimming, etc., because I knew that that would help keep my mental health in check, so.” Participant 7

Domain 3: Doula and CHW self-care practices

Theme 1: Setting boundaries and seeking support helps doulas and CHWs manage emotional demands.

“But I’ve spent a lot of time sort of accepting that I can’t control things. And I think not that I feel ready to deal with an IPV situation, but I feel very comfortable knowing that seven-time statistic and knowing that there’s only so many limits that I can’t force a change in the situation, and I can only do so much, but I can be ready to do and take the steps to support someone as soon as it’s as soon as they ask for it, if that makes sense.” Participant 4 “And then for my own well-being, like definitely therapy, I kind of kept myself in therapy all the time.” Participant 7

Theme 2: Mindfulness, creativity, and spirituality support long-term sustainability.

“Accountability. Honestly, I want you to give people a ton of education. You teach them every single thing in the whole wide world, right? But if we are not holding ourselves accountable about the behaviors that we’re expressing in these situations, we’re just as violent as the people that are abusing the people that are surviving or right in the middle of the crisis. We are no better than the systems that are consistently being violent to our clients. We have to be accountable and consistently check in on ourselves, which is something that takes time.” Participant 25 “So, if that’s food, if it’s alcohol, if it’s cigarettes, whatever that is, just you’re like, “Oh, my gosh.” you know And I had to learn better coping skills around that. And so therapy was helpful. But also, I started doing more physical walking, swimming, etc., because I knew that that would help keep my mental health in check, so.” Participant 7

EBT, Electronic Benefit Transfer.

IPV, intimate partner violence.

Domain 1: Experiences supporting IPV survivors

Theme 1: Doulas and CHWs report that perinatal people experience multiple types of behaviors and violence throughout the perinatal period

Practitioners described how emotional, psychological, economic, and physical abuse can limit a survivor’s ability to make empowered decisions about their prenatal, birthing, or postpartum planning. One doula reflected: “I’ve had a handful of birth clients…not [able to breastfeed] because of IPV… one who had significant scarring on their chest” (P20). Participants also explained how partners control survivors’ birth plans: “But if their partner is present, then usually they [survivors] will defer to their partner a lot, which is usually my first sign that there is something not right with their relationship if they’re the ones who are pregnant and going to have to give birth. But their partner is the one who is kind of calling all of the shots on how it’s going to happen is a pretty big red flag” (P21).

Theme 2: Language and immigration-related inequities can increase the risk of IPV

Doulas and CHWs discussed that systemic inequities impact the care they can provide. When language services are limited, IPV survivors who use languages other than English (LOEs)²¹ may face greater isolation and fewer avenues to seek support. Participants emphasized that trust-building, continuity of care, and shared language can reduce isolation and create safer spaces for accessing resources. One doula said: “Often, it’s the abusive partner that speaks English when a birthing person doesn’t… not allowing the birthing person to be heard.” (P23). This control is intensified when interpretation services are unavailable, and the client must rely on their partner to communicate even in health care settings: “One of the things that is scary to me is sometimes people will use the husband as the interpreter.” (P4). Participants shared that abusers may also weaponize immigration status, threatening deportation, or visa loss to maintain control. One participant said: “If they report their partner… they could also lose their visa.” (P23).

Theme 3: IPV experiences are profoundly shaped by the intersections of race, age, and culture, which affect survivors’ access to resources and the harms they face within institutional systems

Participants described how birthing people of color frequently encounter skepticism and unequal access to resources compared with their white peers. One CHW explained, “[racial discrimination] has an impact… people [practitioners] don’t believe them [survivors]… They don’t have anywhere to go. They don’t have the resources.” (P2). Doulas highlighted the experiences of marginalized survivors, noting that systemic inequities fuel mistrust: “sometimes people who’ve … grown up in marginalized communities … don’t have the best relationships with authority figures either. So, like doctors, social workers, police, and things like that. So, there’s a mistrust that they already have. And it’s like, ‘I am in trouble, and I can’t go to you.’ So that’s another thing that I’ve seen and witnessed. And I know that happens a lot.” (P1). Participants emphasized that the legacy of institutional violence continues to shape how support systems are experienced by communities of color, often reinforcing distrust and reducing access to care.

Theme 4: Survivors demonstrate resilience through the support provided by doulas and CHWs

Despite these challenges, participants emphasized the resilience of survivors, particularly in their roles as parents. They described how survivors draw strength from their children and use that motivation to pursue safety and stability. Participant 14 shared how a client with three children and another on the way managed to save money and, with the doula’s support, move into a women’s shelter before eventually securing long-term housing. As participant 21 explained, “Usually, the people that do end up leaving are the people that realize they need to leave for their own children.”

Domain 2: Supporting IPV survivors: current practices and challenges

Theme 1: Doulas and CHWs provide validation and emotional support to IPV survivors

Participants described the importance of creating safe, empowering spaces where survivors can access resources without needing to disclose IPV. As one doula noted, “First, just listening… letting them share what they do want to share, letting them withhold what they do want to withhold” (P1). Participants emphasized that their support is built on trust, not disclosure. Another doula shared, “Letting them know they can speak to me confidentially… I will use the resources and tools to get them out of that situation” (P3). Doula and CHWs’ long-term relationships with clients allow for deeper support. One participant shared that: “Going to appointments with [clients]… making sure they have their next doctor’s appointment set up, moms need help too, not just the babies” (P3).

Theme 2: CHWs and doulas describe receiving training on IPV and perinatal health; however, not all individuals received IPV training, and some noted that accessibility of training was a barrier to their practice

Training experiences related to supporting IPV survivors varied widely among doulas and CHWs. Many reported that IPV was not addressed in their initial training: “I trained through [training organization] originally. And I have taken continuing ed… But honestly, they don’t really touch on trauma that is oddly enough, trauma that’s currently happening. It’s more just like they were abused previously. And how does that affect their mind and body going into pregnancy and labor… And with [initial training organization], not at all, did not touch on it at all” (P21). Some doulas sought additional training on their own. Another participant shared: “There have been some trauma-informed parts of doula training… that is something lacking… the trauma-informed piece and culturally appropriate piece are missing from a lot of the doula trainings” (P15). Participants emphasized that inconsistent training leads to uncertainty in high-stress situations and advocated for clearer protocols and continuing education: “It would be nice knowing the exact places to call on behalf of someone… I would love to have more training on exactly what to do and what not to do as a doula” (P4). Training in cultural humility was also considered essential for providing respectful, informed care. As another doula explained, “Every home is different. I feel like we need more training when it comes to other cultures” (P14).

Theme 3: CHWs and doulas navigate the tension between mandated reporting requirements and maintaining client trust, balancing legal obligations with the risk of escalating harm or disrupting care relationships

Participants emphasized the importance of being transparent about their role as mandated reporters to Child Protective Services (CPS). One doula shared that they inform clients of their duty to report concerns, but try to avoid reporting when possible, knowing it can negatively impact the survivor and their children. Instead, they focus on helping clients safely navigate complex situations. Participants described varied experiences with CPS. While some saw CPS as a necessary intervention to protect children: “Me calling CPS gets baby protected” (P2), others noted the strain it can place on their relationship with clients. As one doula explained, “Sometimes your clients are afraid to ask for help because they think you’re going to call CPS on them… often they just need support to get through the week” (P10).

Domain 3: Doula and CHW self-care practices

Theme 1: Setting boundaries and seeking support helps doulas and CHWs manage emotional demands

Participants emphasized the importance of maintaining boundaries while offering empathetic care. As one doula explained, “I have to remind myself that I’m not talking to a friend or family member… my role usually is just to listen and offer resources” (P1). Other participants also described seeking therapy to process trauma, especially those with lived experience of IPV: “We are not exempt from experiencing domestic violence… [and need] space to process our own internal traumas.” (P6). Peer debriefs and regular team check-ins were cited as essential sources of emotional resilience: “There are times I need to debrief with a fellow doula… our team [has meetings] to share the doula’s own trauma.” (P19).

Theme 2: Mindfulness, creativity, and spirituality support long-term sustainability

Practitioners used various strategies to manage stress and avoid burnout. One practitioner shared, “I use art. That’s my self-care… we support each other in the same way that we support our clients” (P13). Others relied on spiritual or meditative practices: “Prayer… significant religious support for self-care and strength.” (P17). Another shared: “I’ve learned affirmations, meditation, self-care… and it’s been really effective.” (P14).

Discussion

To our knowledge, this is one of the first studies to explore how doulas and CHWs currently support IPV survivors, their current self-care practices, and recommendations for improving care. IPV has serious consequences for perinatal people and their infants.^2,22 Because doulas and CHWs have long-standing relationships and provide both emotional and tangible support to their clients, they can support survivors in an ongoing manner by validating their experiences, providing referrals to community-based organizations, and connecting them to resources that address other social determinants of health.⁹

In this study, participants specifically described their clients’ experiences with racism and xenophobia and noted that IPV and structural violence intersect and compound stress experienced by perinatal IPV services. They particularly described the role of language coercion, noting that partners often act as interpreters, thereby gaining control and decision-making power.^23,24 This finding aligns with prior literature, which shows that partners of IPV survivors who use LOE often control hospital and clinic visits by interpreting, thereby influencing the flow of information between clinicians and survivors.^7,25,26 Several studies examining language access in health care settings highlight the critical role of professional interpreters (spoken communication) and translators (written communication) in reducing health disparities.^27–29 Language services are required by law through the National Standards for Culturally and Linguistically Appropriate Services (CLAS), Title VI of the Civil Rights Act, and Section 1557 of the Affordable Care Act.^30–32 Use of ad hoc interpreters, including family members, has been shown to worsen health outcomes and can make it challenging for IPV survivors to access help-seeking services.^26,30 Our study extends this work by highlighting that language coercion is also present outside the health care system and by describing the need for training for doulas and CHWs in the provision of language services.

Participants also identified mandating reporting requirements as a barrier to providing trauma-informed care. Participants felt that they could hinder trust-building with clients and feared that CPS involvement would further harm the survivor. However, some doulas viewed CPS as an essential pathway for resource provision for IPV survivors. Exposure to IPV alone is not considered a reason to file a mandated report, although laws vary by state, and many experts in pediatric IPV differ in terms of their thoughts on when a CPS report should be filed in the setting of caregiver IPV.^33,34 Past work has also shown that IPV survivors have well-justified fears of reporting IPV, as they are concerned about CPS reports; in addition, the majority of IPV survivors do not believe that a mandated report was helpful or made their situation better.³⁴ Our study extends this work by showing that fears around reporting are also shared by community care team members, including CHWs and doulas, who voiced concerns about reporting to CPS. Our study also found that training and support are needed for doulas and CHWs on when to file and, more importantly, which services and resources should be offered to IPV survivors when a report is filed.

One important finding that emerged from this study is the need for standardized requirements for trauma-informed training specifically for doulas and CHWs around supporting IPV survivors. Training experiences related to supporting IPV survivors varied widely among participants. Many reported that IPV was not addressed in their initial training, while others sought additional training on their own. Some participants pointed to the training they received on sexual assault or trauma in general as being helpful to them when supporting survivors. Our study shows that even though doulas and CHWs are supporting IPV survivors in their practices, they do not feel they have had adequate training to fully support a survivor through pregnancy, childbirth, and postpartum.³⁵

Despite participants’ lack of knowledge and utilization of IPV trainings for doulas and CHWs, trauma-informed and IPV-specific trainings do exist for both doulas and CHWs, including those provided by community organizations and by individual doula trainers.³⁶ Although some CHW and doula training programs include elements of trauma-informed care and, in some instances, IPV education, the scope and depth of these components vary widely.⁹ For example, the community doula model by Healthy Start integrates training on how to recognize IPV, how best to support survivors, and how to screen and refer mothers experiencing IPV.³⁶ However, DONA (Doulas of North America) International does not currently require IPV or trauma to be covered during their approved trainings.⁹ While most doula trainings include a brief mention of trauma-informed care, it is up to the individual trainer to include these topics.⁹ Effective IPV training moves beyond an introduction to trauma and IPV to equipping doulas and CHWs with the skills they need to recognize signs of IPV, respond in an empathetic and affirming way to disclosure of IPV, and support survivors with referrals to community organizations.^37,38 Trauma-informed perinatal care requires more than learning how to screen for IPV; it requires a foundational shift in perspective from “What is wrong with you?” to “What has happened to you, and how can I support you?”.⁸ Effective training equips doulas and CHWs to support survivors across the continuum of care, recognizing trauma responses, resisting retraumatization during pregnancy and birth, and grounding care in principles such as safety, trustworthiness, mutuality, and cultural and historical humility.⁹ Results from our study demonstrate that while trainings on supporting IPV survivors currently exist, they are not required for all certification programs, and it is up to individual doula and CHWs to seek out and integrate these trainings into their practice. Doula and CHW certification and training programs should integrate education on supporting perinatal IPV survivors into their curriculum requirements. Moreover, additional research should examine how the existing IPV trainings can be disseminated to both community-based and independent doulas and CHWs.

Participants emphasized the importance of self-care practices for doulas and CHWs working with IPV survivors.^39,40 While participants shared that they had developed self-care practices for themselves, such as setting boundaries and practicing mindfulness, they notably did not mention organizational practices or policies that improved their well-being or facilitated their self-care practices. Historically, self-care recommendations have focused on individual behaviors rather than structural supports.⁴¹ While these strategies provide a structured approach to supporting oneself, they primarily place responsibility on individuals rather than on organizations or systems.¹⁶ Existing models offer limited guidance on how institutions can create sustained structures that protect doulas’ and CHWs’ well-being.¹⁶ As a result, the presence or absence of meaningful support is often tied to a doula’s or CHW’s employing organization, access to benefits, and personal resources rather than standardized, field-wide policies.¹⁶ Advocates have suggested several organizational policies to facilitate self-care practices, such as providing paid leave to seek mental health care or support for IPV, building dedicated time into the organization’s schedule for peer debriefs and team check-ins, and providing stipends for therapeutic services like one-on-one therapy or meditation classes.⁴¹ Our study extends this work by showing that doulas and CHWs currently utilize self-care, such as seeking therapy and participating in spiritual practices, to cope with the stress of caring for IPV survivors. Moreover, doulas and CHWs may benefit from integrating organization-level self-care policies and practices into hospitals, clinics, birth centers, and community organizations. Employing both individual-level practices and organizational-level policies would support doulas and CHWs as they seek to sustainably incorporate care for IPV survivors into their practice.

The results of this study should be interpreted in consideration of its limitations. Doulas and CHWs were primarily recruited from community-based organizations in a midsize city in the Northeast. Due to differences in practices, policies, and culture, the results may not accurately reflect the experiences of doulas and CHWs from outside the northeastern United States. Almost all participants identified as female, which is not atypical for other studies on doulas and CHWs working in urban regions, a finding that may be attributed to the study’s location.^42,43 Future studies should aim to include doulas and CHWs with varied identities, backgrounds, and work settings to ensure broader representation beyond urban, female-dominated samples.

Health Equity Implications

Similar work should elucidate the perspectives of IPV survivors, health care providers, and other key partners. Experimental studies assessing the impact of doula care on IPV survivors are also needed. Findings from this study reinforce the importance of equipping doulas and CHWs with training, resources, and organizational policies to be able to support survivors. Certification programs for doulas and CHWs should incorporate training on how to provide resources and respond to disclosures of IPV using a survivor-centered approach. Given the potential of doulas and CHWs to support survivors and improve maternal health outcomes, Medicaid and commercial insurance should expand access and coverage of doula services. Doulas and CHWs provide essential emotional and practical support to survivors throughout their pregnancy and postpartum; future interventions should equip doulas and CHWs with the skills, resources, and support they need to care for IPV survivors.

Footnotes

Authors’ Contributions

H.E.W.: Writing—original draft and writing—reviewing and editing. E.M., C.L., N.S., and E.O.: Investigation and formal analysis, and writing—reviewing and editing. M.C.A.S., S.G., A.E., C.C., A.B., D.D.M., and C.S.: Writing—reviewing and editing and conceptualization. M.I.R.: Conceptualization, methodology, investigation, resources, funding acquisition, supervision, and writing—review and editing. S.E.S.: Conceptualization, methodology, writing—original draft, writing—review and editing, visualization, and funding acquisition.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was funded by the American Association of Birth Centers Foundation, the Perinatal Health and Behavior Research Center through The Pittsburgh Foundation and the UPMC Department of Psychiatry, and the National Institutes of Health (R01NR021484: Principal Investigators, Ragavan, Mendez). S.E.S. is supported by the Children’s Hospital of Pittsburgh Research Advisory Committee Fellowship and the HRSA NRSA T32 Primary Care Research Fellowship.

Supplemental Material

Abbreviations Used

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