An Australian doula program for socially disadvantaged women: Developing realist evaluation theories

Problem: Volunteer doula support has achieved favourable outcomes for socially disadvantaged women around the world. There is limited explanatory understanding of how, why and when doula support programs improve outcomes. 

Background: A community organisation is providing free doula support for women experiencing socioeconomic disadvantage in Melbourne, Australia. The program aims to complement the mainstream maternity care system, to promote equity in women's care, and experiences of pregnancy, birth and early parenting. This program is the first of its kind in Australia and has not previously been evaluated. 

Aim: To develop hypothesised program theories for the realist evaluation of an Australian doula program. 

Methods: As the first stage of a realist evaluation, three key informant interviews and rapid realist review of literature were conducted in December 2017 - January 2019. 

Findings: Seven theories were developed in four categories: critical elements of implementation (Attracting and activating the right doulas, and Good matching); outcomes for women (Being by her side, and Facilitating social connection), outcomes in maternity care system (Complementing or enhancing maternity care, and Doula as a witness — demanding accountability in others), and outcomes for doulas (Doulas as beneficiaries). These theories were framed in accordance with a realist understanding of causation, as Context – Mechanism – Outcome (CMO) configurations. 

Discussion and conclusion: The development of theories from multiple sources of evidence provides a strong theoretical base for program evaluation. The theories hypothesise how, why, for whom and when the doula program works. Subsequent stages of the evaluation will test and refine the theories.