Open sampling in a grounded theory study requires that the selection of interviewees be relevant to the research question (18, 35). Approval for the study was received from the University of Wisconsin-Madison Human Subjects Committee from 2002 through 2022. Participants received a $10 gift card (2002, 2005, 2010) or $20 gift card (2017, 2020) as a thank you gift.

Recruitment methods varied with the technologies available at the time and are listed in Table 2. Doulas were recruited through email announcements and social media, as well as word of mouth. Interested doulas contacted the researcher, were informed about the study, signed a consent form, and were interviewed (see Table 1 for participant description and Table 2 for sample recruitment.) Doulas needed to have attended over 25 births, to speak English fluently, and not use clinical skills in any capacity. (In 2002, it was unknown that 25 births would end up omitting novice doulas from the sample).

During each recruitment wave, efforts were made to ensure diversity among doulas. In 2002, the first wave of 30 doulas sought out doulas from different regions of the country and in different job types. In 2005, the focus was on hospital-based doulas who had attended hundreds of births without ever meeting a client before labor. This enabled labor support to be isolated from other doula functions. In 2010, the sample was expanded to include hospital-based doulas from four different programs in two different cities. This could serve to validate emerging concepts and ensure that they were not specific to one program. By 2017, training approaches and practice models for doulas had diversified, and doula agency owners were contacted and interviewed. This group had large numbers of births, a variety of doula experiences over time, and had become leaders. In 2020, I returned to hospital-based doulas to further refine skill development in the birth doula role. However, most had had a few clients they saw prenatally. In the last two waves, purposeful efforts were made to increase the racial diversity of the sample to reflect the changing workforce and to be more informed on how race or ethnicity made a difference.

A total of 65 birth doulas participated in the study. They ranged in age from 22 to 65 years and were recruited across 26 US states, three Canadian provinces, and the Netherlands. The majority identified as white (n = 55; 84.5%), with others identifying as Black (n = 4; 6%), Latina (n = 3; 5%), Asian (n = 2; 3%), and Arab-American (n = 1; 1.5%). Five participants were white immigrant doulas who had moved to the United States as adults. Participants represented a range of socioeconomic and religious backgrounds and practiced in a range of settings, including large cities, small towns, and rural areas. Births were supported in homes, freestanding birth centers, and hospitals.

Data were collected over a 20-year time period in five waves.

To minimize the impact of bias, multiple procedures were followed and are listed in Table 3. Some procedures changed over time. Rather than member checking with doulas who had been interviewed, concepts were cross-validated by discussion groups of doulas not in the original study. This was done for two reasons. First, in 2002–2006, member checking with the original group was a daunting task, as the sample of 30 was spread across the eastern United States and Canada. As a graduate student, I was discouraged from sharing research documents on paper with participants. Because of the technology at the time, that was the only option available. Second, since the transferability and generalizability of the concepts was paramount, it was considered appropriate to check the data with a discussion group of doulas who were not interviewed. If the data were valid, they would concur with the findings. Concepts were viewed as reflective of the doula's experience and skill levels by the discussion groups. To ensure that earlier data (2002–2005) were not outdated, excerpts were shared with contemporary doulas. They were identified as relevant and could not be distinguished from more recent excerpts. Although the data were not used here, a sample of 30 parents who received doula support expressed viewpoints consistent with those of the doulas. All participants were assigned pseudonyms.

Trustworthiness and the researcher's relationship to the topic are key. I had been a doula for 15 years in 2002 and attended births until 2015. A bidirectional relationship developed between data analysis and professional growth. My skill development progressed rapidly as I applied their suggestions with my own clients and to training new doulas. This directly impacted my ability to be an instrument of analysis and interpretation because my own doula skills improved. This process of insight and application deepened my understanding of doula skill growth, including intuition, which is often valued in qualitative methods (39, 40).

Birth doulas hold the fundamental belief that clients define their own ideal birth. Their role is to assist the client to discover and support them in their vision. At the novice stage, this ideal birth is often outcome-oriented. Most people enter the field with this mental mindset. As Bree said, “Earlier in my career, I probably nudged people to decline or accept things based on my own ideas.” Scout outlined her mindset at the time. “My first few clients didn't want an epidural, and one of them ended up getting one, and I felt like a failure, like I had not done enough to prevent this medication … I was sad for her and frustrated with myself.”

The newly trained doulas in Doris' program said they would be ready once they had attended a birth with someone else. Doris laughed, “It doesn't work like that. It's important to have the willingness to go into that territory … If everything you do is based on doing it before, you’re no good to her. Because every labor is a new one.”

Several doulas felt they needed to justify their presence. Bree shared, “Eight years ago I would have done everything I could to get into the place [the father] was in, to take over that role, because I would have felt like I needed to be doing that.” Riko says, “I've seen this with a lot of new doulas, you're not directing or calling the shots. That is what makes doctors and nurses very upset. You're not the birth planner … You are just there to support and encourage.”

Doulas quickly realized that there were a few rules that often brought overwhelm and uncertainty. With each birth they discovered how much they did not know. Part of transcending unpredictability and uncertainty is moving forward despite feeling unprepared. Scout spoke for most participants: “I was really starting to realize very early,” “Whoa, none of this is under my control, and there's a bigger bag of stuff out there than I realized.”

Novices rely on rules and guidelines learned in their training. In the advanced beginner stage, their performance increases in terms of reliability. Certain aspects of hospital routines or labors become familiar. Advanced beginners start to differentiate situations but still have difficulty distinguishing important cues (18). In unpredictable situations, they may not know where to put their attention.

Advanced beginner doulas have a shift in cognition described as chunking (41). Chunking is the process by which larger units of behavior or cognition come to be seen holistically as a single thought or action. The novice sees letters, and the advanced beginner sees syllables. Their concept of an ideal birth changes. Camille shares, “Even though I intellectually understood that it's not about my right kind of birth, it took a while to have enough experiences where you really see, ‘Wow. This person so benefited from that epidural,’ or, ‘Their labor really got better after they had that IV and were hydrated.’”

One of the markers of birth doulas who transcended this stage was confronting and discarding their own biases. They had to detach their clients' behavior from being anything personal. Doulas had to see birth as something that happened while they were accompanying their clients and not as something that had a universal ideal goal. Scout says, “I had to learn that birth wasn't about me. It's not about what I do for the family, it's about how the family feels.”

At this stage, doulas have experienced differences in staff behavior and concerns. They are surprised at how often the mother or baby's needs are not prioritized. The hospital system can be bewildering and uncaring. Sometimes, doulas are uncertain whether they are witnessing maltreatment.

The seasoned doula actively retrieves knowledge on aspects familiar to them but still looks outside for context, clues, and validation when uncertain. At this stage, feeling overwhelmed lessens. Overwhelm is the emotional feeling of the flooding of a person's neurological senses. They are coping with multiple sensory inputs simultaneously and do not know where to put their attention first. Seasoned doulas can prioritize and integrate information; they have now developed a mental schema to sort out what is important and manage their own responses. Confidence is key, as Riley states, “I can use things in that birth room in ways that you can't even imagine. But if I don't have the confidence to do it, all that information in the world doesn't help me.” Lani's confidence shows up in a different way. “I go to a birth with my birth ball, a hot sock, and some oil. And that's it. My heart and my hands and my voice are all I bring. Tea, my glasses … stuff for me. We just don't need a lot of stuff.”

The seasoned doula focuses on their role, what they do know and what they can influence in a situation. Uneven treatment of mothers and other people in labor is no longer new or novel. Some doulas reported they witnessed maltreatment of their client at every birth. Their mental process focuses on, “What is the priority here? What do my client and family need most? What can I do?” Serena says, “You’re there with a woman who happens to be part of a public health clinic system and you see her being treated like a guinea pig … You’re trying to keep her spirits and morale up and show some respect.” In a contrasting situation, Scout explained, “Because I had a relationship with the nurses, they felt comfortable asking me,” “Can you help us better care for this patient? We want her to have a good experience.”

At this stage, the doula is still evaluating their performance according to external metrics—their cesarean or epidural rate, or how many intended VBACs were successful. There is a burgeoning sense of relying on a more holistic sense of success: “Was the client 100% supported? Were the client's and family's needs met?” This shift is necessary to move on to the next stage. Bree illustrates her thinking. “Births weren't happening the way that I wanted them to happen. When I took it away from being about me, or what births should be like, or confirming my biases, I think that very much contributed to my sustainability.”

At the proficient level, birth doulas have begun the process of reflection in action: “a particular kind of mindfulness which involves an intense concentration on the task at hand” (37). Reflexive thinking relates all actions to the patient and situation without conscious thought. This intense focus is possible because the landscape of birth has become familiar to them. Ashley shares, “That's what was strange, I called every shot ten minutes, fifteen minutes before it happened. I’d explain it to them, and I’d say, “Look this might be what's coming next.”

Proficient birth doulas are very clear about their role and know where they have power and influence, even though none of the important decisions are theirs. As Scout outlines, “None of my perspective matters. I don't have to go home with the consequences … You have to make these really hard decisions sometimes, and your care provider has to make really hard decisions sometimes. I'm here to facilitate communication more than anything.”

In familiar situations, proficient doulas begin to act reflexively. When faced with novelty, it may take the doula a while to process and arrive at the best approach. Minal makes it clear. “You've got to learn when to give them some space … when a doctor has just come in and said, ‘I want to put Cesarean birth on the table’, maybe it's time for you to go get a coffee. You don't have to be right there in their face, ‘What do you think?’ Go. Give them a minute. Let them cry.’”

Proficient doulas have become savvy about their relationships with medical staff. Their biggest leverage is in how they set it up when the staff arrive.

They have established a separation between the outcomes of birth, the client's feelings, and their own performance. This is a boundary that did not exist in the previous stages.

By the time they reached this stage, doulas had found ways to cope with the treatment they witnessed in hospitals. Some moved away from doula work or hospital births. Tracy shared, “My supervisor at the hospital doulas at home births because that's the only way she can survive.” Lani says, “I’m doing less hospital births and teaching more classes. People need to learn how to just say ‘no’ and take responsibility for their own experiences. I’ve got to teach people how to do that.” Sonia stated, “In the city the more experienced doulas make boundaries: what hospitals they’ll go to, what doctors’ practices they’ll work with. There's a lot of doulas who only do birth center or home births, because they don't want to deal with anything else.”

Interestingly, several of the proficient doulas mentioned how they had broken through their internal taboos about touch. In every case, the birth doula followed their inner prompting or “intuition” rather than their social conditioning.

The expert doula claims not to think about labor support, instead they act. As Colleen said, “Sometimes there are things that I think about doing and yet I don't do them. I have to assume it's because I just don't feel that that's the right thing for her.” Alison now enters the labor room without any plan. You have to look and see what they’re doing. They’re going to do something instinctively. If they feel safe that will help them get there…That's why when people say, “What do you do in labor for pain coping?” I’m just like, “Oh dear, I don't know. Whatever pops into my head at the moment.”

Expert doulas freely talked about the negative aspects of their work, often with a sense of humor. They discussed the challenges along with successful solutions. In previous stages, these struggles may have felt overwhelming, but now they are part of the job. Bree shares, “I feel like I can anticipate how the birth will go and when it doesn't, I'm frustrated and I kick myself. I'm kind of jealous of new doulas because they're so excited and they love this work, and they just can't wait for the call.”

The Benner model emphasizes the importance of intuition in the expert stage. Intuition was a robust code with contributions from 12 participants. The expert may not even understand how it is that they know what to do but they have gotten over any impediments to following these inner prompts. Expert doulas provided their own explanations and descriptions of these experiences.

Expert doulas figure out what cues to pay attention to. Their cognitive intuition is so efficient that they often act without thinking, yet it is often the best response. The expert practitioner no longer follows rules but actively constructs knowledge (37). Their actions have become embodied (23, 38, 42, 43). Mia's words echo those of many expert doulas: “I have a very strong intuitive side. The more you get to know women in labor the more you develop that … I trust my instincts to know what to do.”

The expert doula's approach to client relationships has shifted. Their approach is much more relaxed. They seem much less driven to share information than doulas in the earlier stages and more interested in listening. They are more invested in empowering the client than in being the person who gives the answers.

Expert doulas mentioned the importance of self-care more often than any other group. Years of doing the hard physical work of labor support and healing from injuries led them to be more cautious. Eve says, “Just recently I thought, Why don't I raise the bed and look at her face-to-face? Why am I bending over? This is dumb. I know better.”

One of the hallmarks of the expert stage was how often birth doulas mentioned “letting go.” Letting go is a process that is ongoing; it is not a single act. It required going through the first four developmental stages to reach this sense of freedom and confidence in all aspects of doula work. Almost all expert doulas mentioned this in one way or another and often without elaborate explanations. Brione says, “The knowledge that you don't make anything happen. The only thing that you can do is inform, and support, and letting all of the rest of it go.” Char adds, “Now I'm kind of just going with the flow. I almost felt like I had to control it back then. Where now I know I'm not in control of anything. I'm along for the ride as well.”

Brione summarizes another expert skill: “To be able to see somebody's discomfort and be okay with it and not try to fix it is not something everybody can do. I think it's something that the doulas learn over time. I think a big part of us early on do want to fix it and part of the lasting aspect of it is having to learn that you can't fix it and that it's okay.”

Birth doulas demonstrate the three components of the Dreyfus model: moving from abstract principles to concrete past experiences; from seeing situations as discrete parts to seeing them as part of a whole; and from being a detached observer to an involved performer. The patterns of development of doulas align with Dreyfus' model and Benner's nursing framework, including shifts from rules to intuition, fragmented cues to holistic schemas, and detached to embodied practice.

Trends in the number of births are shown in Figure 1. First, with each phase, the number of births required to progress was significantly higher. Two, being challenged by a variety of support experiences mattered. Doulas who served homogeneous communities or one hospital progressed more slowly out of the advanced beginner phase. Variety stimulated the internal processes of reflection and finding meaning, which were integral parts of skill acquisition for birth doulas. Three, additional career and life experiences likely contributed to how quickly birth doulas progressed through the stages. For example, typically doulas did not reach the expert stage until several hundred births. However, one participant, retired after a 30-year career in counseling, expressed a proficient to expert perspective after supporting 85 families (Table 4). Therefore, the number of births attended can be used only as a reflection of general progress at this time.

While healthcare systems, policies, trends, and cultural context changed over the 20-year time period, labor support itself as described by participants did not. As the interviews were analyzed, they were compared across participants with similar and contrasting characteristics. None of the extraneous factors that changed over the 20-year period had a discoverable bearing on the doula's professional development. It was similar no matter where or when they were. Documented changes included but were not limited to the following: baseline health in clients; eligibility for homebirth; need for education; healthcare provider access; education access; access to birth control and abortion; availability of water immersion (i.e., pool, tub) for labor and birth; pain medication practices; policy initiatives in facilities; provider practice style; protocols for cardiovascular conditions; new technologies; cesarean birth rates; COVID-19; hospital obstetric unit closures; public health strategies; delayed cord clamping; infant “skin to skin” policies; and the value placed on the doula. While these factors certainly influenced how birth is managed, what doulas experienced, and the availability of clients, it did not change how the doulas developed their skills over time.

Doulas in the fifth wave in 2020/2021 were more likely to identify maltreatment compared with the first wave in 2002. Out of 30 doulas in 2002, only a third mentioned maltreatment, although all doulas described incidents that could be classified as such (44). In contrast, all 14 doulas interviewed in 2020/2021 identified patient maltreatment consistent with Vedam's definition (44), including vaginal examinations conducted without permission; loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused care, or receiving no response to requests for help. In the immediate postpartum, mothers sometimes did not hold their newborns despite repeated requests, often because of power struggles with nursing staff. The incidents described in 2002, however, were more egregious and included overt coercion and manipulation. Doulas recounted providers performing artificial rupture of membranes without consent during a biophysical profile visit, lying to clients about medication effects, skewing test result interpretations to pressure clients into cesarean births, and chastising a client for hiring a doula. In sum, doulas reported witnessing maltreatment throughout the study period; however, the forms it took were described differently over time.

Salient factors relevant to each stage of birth doula development are summarized in Table 5. What they considered to be an ideal birth changed over time as did their sense of purpose. In the first two stages, their purpose was outcome-oriented; success was defined by whether goals were met. In the seasoned stage, this emphasis shifted to whether the client's needs were met in the moment. By the time they reached the proficient and expert stages, doulas had learned to trust and rely on themselves, and whatever they did in the moment constituted the best support for their clients. Outcomes were much less important. As a doula's sense of identity shifted, so did the language they used to describe themselves. As they grew in the level of experience, participants claimed the title of doula as their professional identity. The novice might say they were going to births as a doula but not yet internalize the role. Advanced beginners might see themselves as doulas but not with confidence. By the time they reached the seasoned stage, an appreciation for the professional skills they had acquired added an additional layer to their identity. By the time they reached the proficient stage, their doula perspective had permeated every aspect of their lives. At the expert stage, doulas were applying their mastery in other professional roles or pursuits.

This study demonstrates that birth doulas develop skills along a continuum with five stages of expertise: novice, advanced beginner, seasoned, proficient, and expert. While growth was influenced by the number of births attended, variation in settings and the capacity for reflection and adaptation were equally important. These findings extend the Dreyfus Model of Skill Acquisition and Benner's nursing adaptation by emphasizing that doula expertise depends as much on emotional presence and relational skill as on hands-on techniques.

A hallmark of doula development is reflective practice. Reflection and mindfulness shape how doulas adapt to new situations, turning experience into actionable knowledge (30). This iterative process of testing, modifying, and reapplying informal theories in practice closes the gap between theory and practice and makes professional growth sustainable (37).

Another key developmental transition is the shift in attribution—recognizing the doula's own role as a primary influence in the birth environment. Similar to research on expert teachers (45), who attribute classroom outcomes to the quality of teacher–student interactions, experienced doulas increasingly identified themselves as central actors shaping dynamics among clients, partners, and healthcare staff. This shift represents a move from externalized explanations of outcomes to an internalized sense of agency.

Progression from the novice to advanced beginner stages aligns with what Peña has called “pre-confident” practice, characterized by uncertainty and reliance on rules (37). As doulas gain experience, they develop individualized guidelines and begin to integrate more sophisticated emotional support strategies. Prior research has shown that doulas employ nine such strategies; in our data, early-stage practitioners most often used reassurance, encouragement, praise, and explanation, while more experienced doulas employed reframing, reinforcing, acceptance, mirroring, and debriefing. These latter strategies require greater foresight, empathy, and emotional intelligence—capacities that increase with experience.

The expert stage is marked by the emergence of intuition, a skill described in both nursing and educational literatures as the capacity to integrate conscious reasoning with tacit knowledge. Expert doulas, like expert nurses, move beyond rule-based responses to anticipate likely scenarios and flexibly shift strategies as conditions change. Intuition at this stage is not naïve guesswork but an embodied trust in accumulated experience, pattern recognition, and relational sensitivity. The expert no longer needs to refer to the rules of practice as they have themselves become the rule makers of practice (38, 41).

Taken together, these developmental patterns suggest that doula expertise is not simply a matter of attending a certain number of births, but rather a process of reflective practice, increasing self-awareness, and growing ability to anticipate and influence complex social dynamics. This highlights the importance of training and mentorship approaches that deliberately cultivate reflection, relational attunement, and situational forecasting in addition to technical skills.

Recent nursing studies have continued to validate the Benner model. Healy emphasizes the role of internal engagement in developing expert practice (46). As Rosander observed in midwifery education, embodied learning and situational sensitivity grow over time, especially in unpredictable environments (47). These developments underscore how experiential, reflective, and systemic factors converge in professional growth—paralleling what was observed in doulas.

In the Dehn (30) study, nurses used a patient-centered model. Skills that were key in their development were mastering unpredictability, complexity, meaningfulness of the work, and self-reflection and awareness. These same themes were present in the excerpts from birth doulas as they grew in each stage. In a study of novice and expert nurses given patient care scenarios, novice nurses collected 49 different cues (48). They tended to be more reactive and then tried to collect cues in response to the emerging problem. The expert nurses collected 89 different cues, using a greater number and broader range of cues. These nurses were proactive in planning ahead and anticipating what would happen. For birth doulas, this shift from reaction to anticipation was seen by the time they reached the proficient stage. Expert intuition can be explained as the ability to utilize metacognitive strategies from a highly organized knowledge base to recognize patterns and then select, monitor, and modify a strategy as needed (48, 49). In their stories, the expert doulas in this study actively shifted between different possible scenarios as labor progressed and collected more cues from the person laboring and the environment.

Similar to birth doula skills, the Benner model revealed the non-clinical skills used by emergency room nurses (50). First was the ability to form compassionate connections that support their emotional availability to patients. The second cluster concerned the nurse's growing awareness that the patient needed to be protected from harm. The third cluster pertained to self-assuredness in their judgment and decision-making. The fourth cluster was communication skills. In order to flourish as emergency room nurses, they needed to become skilled in all four domains. Birth doulas need to grow in these same areas in order to succeed. These themes were represented in the findings, including awareness of patient harm.

The finding that doulas consistently described maltreatment reflects a broader reality. Maltreatment of people in labor is widespread, with an estimated 1 in 6 patients experiencing medical abuse during labor, including being yelled at and physically violated (51). It is considered a global health challenge (51–53). All doulas in the study described incidents of maltreatment, some at every birth they had attended. Doulas in the first wave of data collection described more egregious incidents of patient abuse. The last wave of doulas described maltreatment as commonplace. Patients of color are likely to experience racism in their treatment and care (54–56). One reason for having a doula is to prevent being manipulated or pushed into interventions.

All birth doulas in the study described some negative treatment (i.e., ignoring the doula, disparaging comments) from providers and clients' family members. Some experienced racism. Students who experience microaggressions have additional cognitive load and are distracted from the learning task (57). Thus, negative treatment puts an additional burden on skill development. Instead of reflecting solely on what happened at a birth, doulas go through an additional coping and debriefing process. If it also involved their client, even tangentially, that is an extra burden. Thus, skill development is a complex social process shaped by social hierarchy, culture, and unconscious bias (52).

The strength of this study is the large and diverse sample of 65 doulas and the 20-year time span. Interviews were lengthy and open-ended, with line-by-line coding that allowed for subtle themes to emerge. The researcher's depth of experience allowed for a detailed understanding of the connection between the inner world of doulas and outer behaviors. Multiple rigor and reflexivity strategies were implemented to involve participation from other doulas to validate emerging concepts. The limitations of this study included the following: there was only one coder; novice doula data were obtained by more experienced doulas rather than directly from this group; and efforts were made to increase the racial diversity to reflect the more current doula workforce. The context in which doula support occurs and how it is experienced may depend on race as well as other factors (i.e., ethnicity, immigrant status, and disability status). However, the actions of labor support may be a human activity that occurs similarly despite the context, making race or other socially constructed factors less influential. Determining what actions of labor support and caregiving are affected by race (or other socially constructed factors) and how they affect the process of professional development in birth doulas is a topic for future research. These efforts would be best received if they emerged from the Black doula community to encourage participation and relevance. Other areas for exploration are novice doulas and their emerging development, whether growth in these stages is linear or looping, and how particular skills progress across the stages from novice to expert.

Effective labor support by a birth doula is a sophisticated activity deserving of compensation commensurate with the skill set of doulas. Like beginning nurses, beginning doulas are competent enough to earn a living wage with benefits. Rather than continually training new people, programs should concentrate on removing barriers to continuing birth doula work. Doula programs should address the challenges of each stage, thus encouraging greater expertise and proliferation of an experienced workforce. Seasoned, proficient, and expert doulas have much to offer as mentors and trainers to emerging doulas and deserve career pathways that recognize their expertise. Higher-level doulas are essential to any perinatal healthcare strategy that desires to improve maternal or infant outcomes; it is time they are recognized as skilled professionals.