INTRODUCTION

A doula is a trained, unregulated layperson who provides emotional, physical, and informational support for pregnant people and their families throughout the perinatal period.¹ Evidence shows that doula support can improve neonatal and maternal health outcomes and reduce health system costs.^2-4 Evidence also shows that doula support may be especially beneficial for clients who are at a higher risk of poor health outcomes due to racism, poverty, and gender discrimination.⁵ In the last decade, doulas have expanded their scope to support people seeking abortion care.⁶ This work may be advertised under the umbrella of “full spectrum” doula practice - referring to doula care that supports all outcomes of pregnancy, including abortion, miscarriage, and abortion. Like birth doulas, abortion doulas provide emotional, physical, and informational support, as well as navigating sometimes complex healthcare and socio-legal systems to facilitate access for their clients.⁷

Doula practice is widespread in Canada.^8,9 Many provinces have non-governmental non-profit provincial doula associations that list doulas who have paid association member fees.^10–12 Recent years have seen an increase in Black and Indigenous doula training and doula collectives.^13–17 Research on the role, scope, and efficacy of doulas in Canada is limited. A 2017 scoping review on doulas in Canada identified seventeen relevant studies, with most studies focusing on physicians’, registered nurses’, and midwives’ attitudes toward doulas.¹⁸ Despite a growing interest in and demand for doula services, to date there is no comprehensive directory of doulas in Canada, making it difficult to identify the numbers of and distribution of doulas.

Wellness Within, a Nova Scotia-based non-profit organization supporting women, trans, and nonbinary people who have experienced incarceration, has provided doula support in Nova Scotia institutions of incarceration, including the provincial jail, federal prison for women, and youth detention centre, since 2014. Wellness Within has offered abortion support workshops for doulas, published free resources on accessing abortion,¹⁹ and collaborated on an interprofessional health education course on abortion offered to all health professional students at a large university.^20,21 In Spring 2023, with funding from Health Canada, Wellness Within partnered with the Contraception and Abortion Research Team (UBC) to research the challenges and opportunities to enhance abortion doula support. The need to recruit abortion doulas for qualitative research identified the lack of a broad national directory of doulas. The objective of this study was to conduct an environmental scan of all doulas with publicly available and searchable information in Canada, and to analyze the results for key trends in doula practice, including the number of doulas supporting abortion. The resulting directory of doulas is not available to the public and was assembled solely for analysis of key trends and as part of a larger research study exploring the role of abortion doulas in Canada. Abortion doulas identified through the environmental scan were contacted and invited to participate in qualitative interviews, which we report on elsewhere.²²

METHODS

Design

In Spring 2023, we met as a team and with abortion doula experts and interest holders to determine how best to search for doulas online systematically. This work was a part of a larger research study exploring the role of abortion doulas in Canada.²² The inclusion criteria included anyone with publicly available information of any kind (e.g., personal website, information listed on provincial association site, Facebook page) indicating that they provide doula services anywhere in Canada, with at least one method of contact. We excluded people with no contact method (e.g. no email, direct message, phone, or organizational contact listed). The reason for these exclusions was twofold; the environmental scan was a part of our qualitative study which involved contacting abortion doulas, and we aimed only to collect information on doulas that prospective clients could easily access and contact through online searching.

The search strategy was executed by province/territory. First, we consulted any and all relevant provincial associations and directories and imported all doulas that met our inclusion criteria. Then, we searched Google, Facebook, and Instagram using the search terms “doula + PROVINCE”. We did not search other social media platforms such as TikTok; this is a methodology limitation. As a final step, we shared the search strategy and environmental scan results with two abortion doula experts (one Anglophone and one Francophone expert) for review, noting that we could only add doulas that have publicly available information and not doulas that they knew of through word of mouth and professional connections, to stay consistent with our inclusion criteria. The abortion doula experts provided validation by identifying any missed directories or associations. Data was then cleaned for any missing information and for consistency in nomenclature.

For each entry we recorded the following information: Name; Type of Services (e.g., abortion, full-spectrum, birth, postpartum); Province; City/Town/Area; Rural or Urban; Specific Communities Served (e.g., Indigenous clients); Phone; Email; Website; Affiliations (e.g. Nova Scotia Doula Association); Training; Languages Spoken; and any other relevant information.

We performed descriptive analysis to determine the regional distribution of doulas and percentages of doulas self-reporting online as supporting abortion clients or serving a specific community.

Ethical Considerations

The environmental scan and basic descriptive analysis of results were approved by the University of New Brunswick Research Ethics Board as part of our qualitative study interviewing abortion doulas. Although we only collected publicly available information, the doulas in the directory were not contacted at any point about inclusion in a public directory. We did contact doulas who explicitly stated that they support abortion or termination of pregnancy to invite them to participate in a qualitative interview as part of a larger study. The directory remains private and is held on a password-protected hard drive with other materials associated with the larger study interviewing abortion doulas for up to 7 years post-publication.

RESULTS

Geographic Distribution

We identified 699 doulas with publicly available information in Canada, with the highest concentration of doulas in Ontario, Alberta, and British Columbia. See Table 1 for full geographic distribution and distribution by population size. Doulas are concentrated in urban areas: 60.4% of doulas serve urban areas (n=422); 20.5 % of doulas serve rural areas (n=143); and 16.2% percent of doulas serve both rural and urban through a wide regional catchment area (n=113). The remaining 3% of doulas did not specify a region beyond the province on their online materials (n=21).

Communities of Focus

Some doulas listed their identities on their online materials to facilitate clients seeking culturally appropriate and relevant care. This data should be interpreted with caution, as we only collected what was publicly listed on their online materials, however it does provide some insight into the prevalence of doulas serving Indigenous, Black, and queer communities. Approximately 7% of doulas identified as Indigenous, and 4% of doulas identified as Black. Approximately 4% identified as BIPOC broadly. Approximately 4% of doulas identified as queer. Eighteen percent of doulas identified themselves as speaking French. Languages spoken in addition to English and French included Cantonese, Danish, Dene Bangla, Hindi, Amharic, Italian, Portuguese, Hebrew, Spanish, Japanese, Turkish, Russian and Ukrainian. Several doulas self-identified as providing adjacent services, such as herbalism or lactation consultancy.

Abortion support

Out of 699 doulas, approximately ten percent (n=73) explicitly states that they support abortion or termination of pregnancy, and an additional approximately five percent (n=31) explicitly stated that they provide full-spectrum services. Almost half of doulas providing abortion support are located in British Columbia. We did not identify any abortion doulas in Prince Edward Island, Yukon, or Nunavut. Approximately 58% of all abortion doulas are practicing in urban areas (n=60); twenty-six percent in rural areas (n=27); and sixteen percent in both rural and urban areas (n=17). See Table 2 for the geographic distribution of abortion doulas.

DISCUSSION

To our knowledge, we conducted the first environmental scan of doulas with publicly available and searchable information in Canada. We found there are doulas practicing in every province and territory, and doulas providing abortion support practicing in 10 provinces and 1 territory. Overall, doulas are most prevalent in urban areas. However, doulas disproportionately serve rural areas compared to Canada’s overall rural population. Approximately 17.8% of Canadians live in rural areas.¹⁹ 23% of doulas serve rural areas exclusively. Including doulas who serve both rural and urban areas, approximately 37% of all doulas practice in rural areas. The proportion is slightly higher for abortion doulas, with 42% practicing in rural areas. This could suggest a heightened need for navigational support to access abortion services in rural areas. Doulas are concentrated in the most populous provinces; however, the Northwest Territories, Yukon, and Nova Scotia all report the highest per capita rate of doulas. These territories and province have a high proportion of people living in rural and remote communities.²³ Future work could examine the role and scope of doulas in rural and remote communities, which may lack access to the breadth of perinatal healthcare and abortion services available in urban areas.

Approximately 40% of all doulas providing abortion support are located in British Columbia; future research could examine possible reasons for this trend. Seven percent of doulas identify as Indigenous, while five percent of the population of Canada is Indigenous²⁴; this is consistent with recent research studying the growth of Indigenous doulas and doula collectives, many of which are responding to and concertedly working against client experiences of medical racism and obstetric violence.^14,25 Approximately four percent of doulas identified as queer, consistent with the most recent census data that reported four percent of Canadians identify as 2SLGBTQ+.²⁶ Approximately four percent of doulas identified as Black, also consistent with census data that reports 4.3% of Canadians are Black.²⁷

Although this scan provides a useful starting point for illustrating the landscape of doula practice in Canada, this study has significant challenges and limitations. We only included doulas with publicly available information. Abortion doula experts and interest holders we consulted in the planning stages of this project indicated that many people learn about abortion doulas through word of mouth, as doulas may hesitate to publicly list their abortion support services due to stigma and identifying themselves to online harassment.^28,29 We can assume we missed doulas who take clients only through community referral and do not advertise online, and doulas listing their services in a language other than English or French. This search strategy may have excluded doulas who are integrated into a health or community centre, and doulas working in rural and remote communities. There are several examples of community organizations with subsidized or sliding-scale community-based doula programs across Canada,^30–32 with one such program in PEI, a small, rural province where we identified only one doula. This is just one example of how the limitations of the inclusion criteria can result in a potentially inaccurate snapshot of the landscape of doula practice in Canada. The results are likely skewed towards privately operating doulas, and a future environmental scan is needed to identify the range and scope of community and hospital-based low-barrier doula programs. The resulting directory of such a scan could be made public for the benefit of both families and researchers, as publishing organizational names and contact information does not have the same ethical and confidentiality concerns as publishing individual names and information.

Another major limitation of the scan is using the term “doula.” Our recent international scoping review of the doula role in abortion and contraception found that people filling a non-clinical support person role may refer to themselves by a range of different terms. However, all identified studies conducted in North America used the term doula.⁷ This is consistent with other research indicating that support people, particularly in Indigenous and Black communities, have been acting in these roles for pregnant people long before the term doula gained popularity, and continue to provide support without defining themselves as “doulas.”^13,33,34 While the environmental scan may have met its intended goal of collecting information on “doulas,” the term doula limits the ability to see the full scope of people supporting all pregnancy outcomes in Canada. This may be especially true for people providing abortion support, with alternative support models such as hotlines, abortion funds, and accompaniment.⁷ Future efforts to identify supports for all pregnancy outcomes could include other search terms, such as community birth-worker. Finally, the search strategy itself is a limitation. Although we made all efforts to extract data in a thorough and systematic way and kept detailed audit trails of each search, searching using Google, Facebook, and Instagram is highly imperfect and relies on the search engine optimization (SEO) of doulas’ online materials.

Given these limitations, we do not suggest that the results of this scan provide a definitive count or analysis of doulas in Canada. The results do indicate that, at a minimum, there are at least 699 doulas practicing in Canada, with at least 104 of those providing abortion support. The limitations of this study illustrate the difficulty in collecting this data. Although a Google search is a flawed strategy, it is a prospective client’s strategy. We cannot say definitively that there is nobody providing abortion doula support in the Yukon, for example. Still, a person seeking support would also not be able to find someone with ease. This is consistent with findings from our qualitative research with abortion doulas, who felt that people were not aware that they could access doula support,²² and with research on doulas broadly indicating a low understanding of the role and scope of doulas.^35,36 Future research can examine pathways³⁶ and barriers to accessing doula support in regions under-represented in the environmental scan, including rural and remote provinces and territories.

Finally, we cannot publish the resulting directory of doulas in Canada publicly. Although their information is publicly available, the 699 individuals identified by the environmental scan have not been asked to consent to inclusion in a public directory, and the directory will inevitably be rapidly outdated.

CONCLUSION

Using publicly available information, we conducted an environmental scan of doulas in Canada, identifying 699 distributed across all provinces and territories, with concentrations in Ontario, British Columbia and Alberta. Of these, 10% of doulas indicated they provide abortion support and 37% serve rural clients. Of provinces with doulas providing abortion support, per population, British Columbia has the most doulas providing abortion support and Manitoba has the least. PEI, Yukon and Nunavut have none. There are doulas specifically indicating support for Black, Indigenous, BIPOC and queer communities, and multiple languages. Greater detail and diversity among doulas may improve client comfort, safety, and satisfaction with support. Efforts by governments, community organizations, and the general public to destigmatize abortion care may enhance doulas’ feelings of safety in publicly disclosing their support for abortion clients. The myriad ways in which people both provide and seek support for all outcomes of pregnancy require further investigation, particularly in rural and remote communities, through non-profit organizations, health center-based programs, and through pathways of community referral.