Overreliance on cultural doulas: the paradox of entrusting the communication and care of high-risk migrant women to cultural doulas

BACKGROUND: It is widely recognized that migrant women from low-income countries are considered to be a group with increased obstetric challenges. To address these challenges, cultural doulas were introduced to provide continuous emotional and practical support during childbirth in Sweden. Leveraging their shared cultural background, language skills, and understanding, the idea behind these doulas was supposed to facilitate effective communication between the woman, her partner, and healthcare staff, with the assumption that this would lead to better maternity care for migrants. The aim of this study was to explore healthcare providers reflections on the role of cultural doulas and to explore their perceptions of cultural doulas' impact on childbirth.

METHODS: A qualitative study was conducted in 2022, involving semi-structured interviews with 18 healthcare providers; obstetricians and midwives from two Swedish counties. The data was analyzed using reflexive thematic analysis and discourse analysis, guided by Bacchi's 'What Is the Problem Represented to Be?'

RESULTS: Using Bacchi's 'What Is the Problem Represented to Be?' approach, the analysis highlights how healthcare providers interpreted cultural doulas as an asset in relation to problems in migrants' maternity care. Three key discourses that emerged were: underlying social and cultural factors, assumptions of improved outcomes and integration, and cultural doulas as informal interpreters. Instead of emphasizing medical risks, healthcare providers focused on social risks and overlooked the importance of professional training.

CONCLUSIONS: Cultural doulas are recognized as valuable in addressing gaps in migrant maternity care, yet their role presents a paradox. Entrusting the care of high-risk migrant women to minimally trained non-medical professionals paradoxically risks miscommunication and compromised care quality. Insufficient training, unclear roles, and the overextension of cultural doulas further exacerbate this issue, underscoring the need for systemic reforms. To resolve this paradox and improve maternal outcomes, the maternity care system must redefine the role of cultural doulas, prioritize professional interpretation services, and implement integrated care models tailored to the evidence based medical needs of migrant women.