By Birth & Baby University · Last updated: October 2026 · 8 min read
Compassion is the quality everyone names first when they describe a good doula, and it is rightly valued. But compassion alone does not tell you how a doula should speak up in a delivery room, explain a plan without giving medical advice, support someone who has experienced trauma, work alongside a nurse, or return the next day after a long birth and do it again. This article looks at the skills that standards, guidance and research point to when they describe good doula practice. One caution up front: no study defines or measures an “exceptional doula.” The skills below are drawn from professional standards, state program requirements and research on doulas’ work, not from a validated list.
Key takeaways
Quick answer: beyond warmth, the skills that recur in standards and research are communication that supports decision-making, strong boundaries and referral judgment, collaboration with the clinical team, trauma-informed and culturally responsive practice, emotional support skills, reliability, and the self-regulation to last in the work.
- DONA’s standards define advocacy as fostering client autonomy and supporting informed decision-making, not speaking for the client, and they pair it with a firm non-medical scope.
- Research on respectful care suggests that decision-making, support and communication are the components families value. An analysis of 1,977 California births found higher odds of reported respectful care with doula support (odds ratio 1.4), with larger associations for Black women and Medicaid recipients.
- A 2025 survey of 252 U.S. doulas found they overwhelmingly wanted more training in emotional support.
- Skills are only part of the picture. A randomized trial of community-based bilingual doula support for migrant women in Stockholm found no difference in care ratings or emotional well-being, a reminder that doula support is not a guaranteed effect.
1. Communication that supports a person’s own decisions
DONA’s Birth Doula Standards of Practice (revised September 2025) describe advocacy as fostering client autonomy and supporting informed decision-making, encouraging the client to express values, preferences and goals, and amplifying their voice within the care team. The Illinois Medicaid-Certified Doula Program’s guide adds that doulas make suggestions and respectfully ask questions based on their understanding of the client’s preferences, and do not interfere with the primary care provider’s care.
In practice this is a specific skill set: asking open questions, reflecting back what you heard, helping someone prepare questions for a clinician, using plain language, staying quiet when quiet is needed, and never steering a client toward your own preferences. A useful self-test is to ask whether a client would describe a decision afterward as “mine.”
The research on respectful care supports the importance of this. In an analysis of the 2018 Listening to Mothers in California survey (Mallick and colleagues, 2022), respondents with high levels of decision-making, support and communication were classified as having high respectful care. Women with doula support had higher odds of high respectful care (odds ratio 1.4, 95% CI 1.0 to 1.8), and the association was largest for non-Hispanic Black women and for women with Medicaid. It was a cross-sectional survey, so it shows association, not cause.
2. Boundaries and referral judgment
This is the skill that most distinguishes experienced doulas. The DONA standards state that doulas do not perform clinical tasks and will not diagnose or treat, and that referrals are made for needs beyond the doula’s training. The Illinois guide lists specific limits, such as not taking blood pressure, not listening to fetal heart tones, and not recommending medications or herbal remedies.
The skill is not only refusing. It is recognizing when something needs a clinician, saying so clearly and calmly, and helping the client act on it. The CDC’s Urgent Maternal Warning Signs (May 2024) are a good example of knowledge a doula should hold: signs such as a headache that will not go away, changes in vision, fever of 100.4 degrees Fahrenheit or higher, trouble breathing, chest pain, vaginal bleeding or discharge after pregnancy, and thoughts of harming oneself or the baby call for prompt medical care.
3. Working as part of a team
ACOG’s August 2026 Committee Statement, Partnering With Doulas in Clinical Settings, says that strong clinician-doula partnerships can benefit patients, clinicians and the workplace, and that barriers can be addressed with training, policy and approaches that promote collaboration, communication and accountability. The Illinois guide says doulas are guests of the medical facilities where they work and are expected to collaborate respectfully and productively with the healthcare team.
Collaboration skills include introducing yourself and your role, learning unit norms, staying out of the way during procedures, asking rather than telling, thanking staff, and handling disagreement privately and professionally. The standard is not deference to everything a clinician says, since DONA also describes speaking up when mistreatment is witnessed. The standard is clarity about role and respect for the people around you.
4. Trauma-informed and culturally responsive practice
A narrative review of trauma-informed doula care in Midwifery (Mosley and Lanning, 2020) describes six principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and attention to social, cultural and historical considerations. The authors noted that there is little formal evidence on how doulas provide trauma-informed care, so the review offers guidelines synthesized from the wider literature, not trial results.
Cultural responsiveness is likewise supported more by lived accounts than by trials. A qualitative study of Black community-based doulas in Los Angeles (Thomas and colleagues, 2023; five doulas and two program directors) described cultural concordance as integral to equitable care and described the barriers these doulas faced. That is a small study of a particular program. Meanwhile, the Swedish randomized trial of bilingual community doula support for migrant women (Schytt and colleagues, 2022; 164 women) found no differences in care experience ratings or emotional well-being at 6 to 8 weeks postpartum, and only about three quarters of those assigned to doula support actually received it during labor. The honest reading is that language and cultural alignment are important in many accounts, that outcomes depend on how and whether support is delivered, and that more research is needed.
5. Emotional support and mental health sensitivity
In the survey by Hall and colleagues (2025), 252 U.S. doulas overwhelmingly wanted more training in emotional support, nearly all perceived symptoms of emotional distress in their clients, and most preferred in-person training built into foundational workshops. The authors suggested such training should refine doulas’ sensitivity to mental health referral needs while remaining within scope. Skills here include listening without fixing, noticing change over time, asking gently about how a client is coping, knowing local mental health and crisis resources, and knowing that a doula does not diagnose or treat.
6. Reliability and continuity
DONA’s standards ask doulas to make reasonable efforts to provide the services in their contracts, to make back-up arrangements whenever possible, and to notify clients in writing and refer to replacements if they must discontinue service. The Illinois guide asks doulas to be punctual, dependable and transparent about planned absences. These are unglamorous skills, and they are often what a family remembers. Clear contracts, backup partnerships and honest communication about availability are part of excellent practice.
7. Self-regulation and sustainability
Doula work involves irregular hours, emotionally intense events, and exposure to other people’s difficult experiences. The World Health Organization’s description of burnout in the International Classification of Diseases (ICD-11) names three dimensions: feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism, and reduced professional efficacy. It is classified as an occupational phenomenon, not a medical condition. Recognizing those signals early, building real time off, using peer support, and seeking professional help when needed are professional skills, not indulgences.
Putting it into practice: a development plan
- Pick two or three skills to work on this year, not all of them.
- Get feedback. Ask clients, colleagues and, where appropriate, nurses or midwives what you do well and what to change. Certifying organizations often require evaluations for this reason.
- Practice out loud. Role-play a boundary conversation, a referral, a disagreement with a provider.
- Seek mentorship or peer review. Debrief births and visits with someone experienced.
- Study with sources. Read the standards you work under, state program guides if you serve Medicaid clients, and current clinical guidance.
- Protect your capacity. Design your on-call load and your time off before you are exhausted.
When this guidance may not apply
The skills described here come from U.S. standards, state program documents and research of mixed design and size. Communities, certifiers and employers define good practice differently, and no skill list guarantees outcomes for any client.
The bottom line
Compassion opens the door. What keeps a doula effective and trusted is the less visible work: listening in a way that strengthens someone’s own decisions, staying inside a clear scope, collaborating with a team, practicing with cultural humility and attention to trauma, being reliable, and looking after the person doing the work.
If you are building these skills, Birth & Baby University’s For Doulas page outlines its doula training, recertification and mentorship for doulas who want guidance as they develop their practice.
This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.
Sources and further reading
- DONA International. Birth Doula: Standards of Practice (revised September 2025). Read the source
- SIU School of Medicine. Illinois Medicaid-Certified Doula Guide (posted December 2024). Read the source
- American College of Obstetricians and Gynecologists. Partnering With Doulas in Clinical Settings, Committee Statement No. 31 (August 2026). Read the source
- Mallick LM, Thoma ME, Shenassa ED. The role of doulas in respectful care for communities of color and Medicaid recipients. Birth (2022). Read the source
- Mosley EA, Lanning RK. Evidence and guidelines for trauma-informed doula care. Midwifery (2020). Read the source
- Thomas K, et al. The experiences of Black community-based doulas as they mitigate systems of racism: a qualitative study. Journal of Midwifery & Women’s Health (2023). Read the source
- Schytt E, et al. Community-based bilingual doula support during labour and birth to improve migrant women’s intrapartum care experiences and emotional well-being: a randomised controlled trial in Stockholm, Sweden. PLOS ONE (2022). Read the source
- Hall EM, et al. Doula support for perinatal mental health needs: perspectives on training and practice. Midwifery (2025). Read the source
- World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases (May 2019). Read the source
- Centers for Disease Control and Prevention. Urgent Maternal Warning Signs (Hear Her). Read the source
More for professionals: the Professionals Blog.
Leave a Reply