Expanding the service: Goodwin Trust volunteer doula project

The Goodwin volunteer doulas prove the old adage that volunteers are unpaid not because they are worthless, but because they are priceless.

The Thornton Estate, in Hull, was hit hard after the collapse of the fishing industry in the 1980s. It is a community of 5000 people who, since that time, have experienced significant socioeconomic challenges but who have risen, including through the efforts of some determined women, to create a new and supportive community. The Goodwin Trust grew out of this, and has been developing and delivering a wide range of services in the community since 1994. The Trust's formal strategy states its priorities as fighting poverty in the community, caring for the health and wellbeing of the community and all the individuals within it, and to provide and support access to education, training and employment opportunities. One of these, born of necessity, is the thriving and fascinating project which provides volunteer doulas to women who need them.

Among midwives, there are varying views about the value of doulas. The Royal College of Midwives (RCM), for example, considers that they might be the ‘ultimate birth companion’ (RCM, 2015). Historically, women have been attended and supported by other women during labour, and the Cochrane review into continuous support for women during childbirth found that such support has clinically meaningful benefits for women and infants, and no known harm (Hodnett et al, 2013). The emphasis on birth suggests that doulas and midwives are likely to come into close contact during the intrapartum period. This may be for the first time, so there are some tripartite discussions to be had between doula, midwife and the woman being supported, about roles, responsibilities and expectations. The value of collaborative team-working and support is undeniable, and should extend for the whole maternity pathway, rather than being confined to the intrapartum period.

Working together to improve maternal and infant outcomes is the common purpose that unites midwives and doulas. It was for this reason that the volunteer doula project was conceived in Hull. Recognising that professional territorialism, working relationships and joint expectations would be key to successful design and implementation of the project, the starting point was clearly based on the evidence of where there were deficits in service provision and where the health outcomes of mothers and babies could be improved.

The genesis of the project was, therefore, a desire to address unmet needs. Two midwives started the project because they saw a need for additional, complementary support to vulnerable women during the late stages of pregnancy, birth and postnatally, which could not be met through the services available at that time. The initial doula project began 10 years ago as part of the Sure Start local programme (Department for Children, Schools and Families, 2009), which employed a community midwife seconded to the programme. Goodwin Development Trust, as lead and accountable body for Sure Start Newland and Avenues, was successful in applying for £89 000 from the European Social Fund (ESF) to deliver an 18-month pilot project within the Sure Start postcode area in Hull. The project aims were to:

The outputs were specifically to recruit, train and support a minimum of six volunteer doulas working with a maximum of 12 expectant mothers.

None of this could be achieved without attending to the relationships needed for effective working between midwives, the project team and ultimately the volunteers. Ten years on, the relationships between midwives and the doulas are constructive, symbiotic and mature. However, it did not start like that. Initially, the midwives were concerned that the doula volunteers would not be sufficiently skilled to undertake a safe and appropriate birth-partner role or understand, and therefore respect, professional boundaries, potentially undermining the midwife's role and putting the mother and baby at risk. The small doula project staff team met with midwifery teams and invited midwives onto the doula project steering group. The relationship-building and subsequent trust took time to develop, and was significantly enhanced when volunteer doulas gained places on the undergraduate midwifery degree at the University of Hull and became registered midwives.

Two important aspects of the project, which assure the quality of both the volunteers and the service they provide, are the way they are recruited and the way they are trained. Potential candidates are invited to an open day to meet the staff team, current volunteers and parents and children who have benefited from the service, and to gain an understanding of the commitment required. They are then required to submit a written application and invited to an interview. A total of 261 doulas have been recruited to volunteer and, to date, 53 have been unsuccessful at interview, with 20 of these reapplying successfully; there are stringent selection criteria and not everyone is suitable.

The 10-week, 61-hour training programme is crucial. It is very practical (Table 1) and results in a portfolio of evidence that is externally verified by Certa (the operating name for the Open College Network Yorkshire and Humber Region), a national awarding organisation committed to providing a high-quality and responsive accreditation service to recognised centres. Certa accredits the training at academic levels 2 and 3. The training is both accessible and rigorous. Many who undertake it are people who left school at the first opportunity, and they complete the training successfully. The result is that the volunteers have a confident base from which to offer their services that is not just based on experience—important though that is, not every volunteer doula is a mother, although the majority are. The interview process focuses on specific skills, and previous qualifications are not necessary. The successful volunteer is able to demonstrate significant empathy, problem-solving skills, commitment and personal development goals.

The volunteers come from a range of backgrounds. Some are starting out on a career, others are retired, while some are working and able to give the commitment required. The volunteers include those with postgraduate qualifications and those whose first accredited qualification is the doula training. They are local women who vary in age from 18 to 68 years. The majority of the volunteers live in Hull, with the remainder living locally in the East Riding apart from two who travel from Lincolnshire. They focus on one woman at a time and commit to give at least 1 hour per week to support her. However, many give time far beyond the minimum commitment and are extremely flexible, as they could be needed at any time—and, possibly, for a prolonged period if the woman wants them to be her birth partner. So far, there have been 261 doulas volunteering with the project, who have given a total of 10 316 hours between April 2009 and March 2015. Those who have left the project have often done so for positive reasons. They are often equipped with newly found confidence, experience and self-esteem, and access employment and education in a way that they did not think possible at the start of their volunteering. Up to July 2015, 28 volunteer doulas have become midwives, and the volunteer doula experience is increasingly viewed in Hull as an excellent basis for applying to the profession. Twenty of the volunteers have gained places on nursing degrees and 33 gained places on other health and social care training (ranging from academic level 2/3 programmes to graduating with first degrees). But crucially, the volunteers are not doing this for themselves; they have consistently improved outcomes for women and babies.

The intended outcomes for women and babies are summarised in Table 2. Over time, these outcomes have been achieved and exceeded, with additional targets included from August 2014 as part of the current 4-year contract commissioned by Hull City Council Public Health, Adult, Children and Families Services Directorate. Collecting this evidence is not only an important measure of success but has been crucial in securing the funding to sustain the project.

Replication of the project has been undertaken in five other urban sites: Bradford, Leeds, Liverpool, Sheffield and Tower Hamlets. The Sheffield replication has been particularly successful and is now mainstreamed within the local authority public health budget. Sheffield has recently recruited its ninth cohort of volunteers onto the training; it currently has 50 active volunteers, and nine are beginning midwifery degrees in 2015.

This model of service provision fits well with the plurality and flexibility envisioned for the future as expressed in the Five Year Forward View (NHS, 2014). It is clear the NHS will not be able to provide every aspect of personalised care and will be reliant on the third sector in a way that the Goodwin Trust exemplifies. It is also clear that midwives cannot satisfy every aspect of personalised care and women's choice of care and support, so collaborative and mutually beneficial working of this sort will be essential in the future.