It’s clear that the growing number of doulas in the United States have begun to significantly change the maternity care landscape. While many doulas still have struggles with doctors and hospitals and the medical system’s acceptance of their role, many more are finding providers to be willing partners who understand through patient demands and a growing body of scientific research that doulas improve the birth experience. But a question that came up at a recent university talk, and one I’ve been thinking about for years now, is: What is the end goal of the doula movement? What are we working toward? Many doulas would likely say—and I would have been among them just a few years ago—that the end goal is to have a doula at every birth. But I no longer believe that’s the right goal.

Last week I was invited to speak to a group of nursing and medical students at the University of Pennsylvania about my work as a doula and its connections to reproductive justice. The fact that I was invited alone shows how far the doula movement has come. Doctors and nurses, two groups historically (and presently) at conflict with the doula community, invited a doula to address them. Furthermore, when I asked if anyone in the room had also been trained as a doula, about half of the nursing students in the room raised their hands.

Though the formal concept of a doula was introduced in the 1970s, it’s seen tremendous growth in the last two decades. Doulas of North America (DONA), the largest doula training and certifying organization, grew from just 750 doulas trained in 1994 to more than 5,800 in 2004. And I would guess that in the years since then, we’ve seen tens of thousands more trained doulas.

Given that there are so many more doulas today than ever before, why do I no longer believe that having a doula at every birth should be the goal of the doula movement? For one thing, logistically, it’s still a pretty daunting task. We’d need to increase the number of doulas in this country exponentially to keep up with the demand—to be able to match each pregnant person with a doula for support during labor. Even if we could grow the doula ranks enough to meet this demand, what would be the cost? The majority of doulas who do this work professionally do it on a fee-for-service basis, charging anywhere from $300 to $3,000 per birth, depending on their experience, what services they offer, and where they live. In a system with already incredibly high health-care costs, especially in the arena of pregnancy and birth, where are these fees going to come from?

Insurance reimbursement is increasing becoming an option, and some doulas hope that it will solve the question of fees. Last year a bill passed by the Oregon legislature recommended that the Oregon Health Plan include a waiver allowing doulas to be reimbursed for their services. From a cost/benefit standpoint, this could actually decrease costs for insurers because research has shown that the presence of a doula decreases the likelihood of interventions like cesarean sections, which increase costs.

The downside, though, is that insurance reimbursement will likely come with increased regulation and professionalization of doulas—more rules about what training is required and more standards about what doulas can and cannot do. I fear that these changes could dilute the power doulas have to fundamentally alter the pregnancy and childbirth experience. It’s a power I believe comes from being outsiders in the medical system, from being interveners, and from being independently trained.

This is where my biggest concern about the goal of a doula for every birth lies. It’s clear that the only way to reach everyone giving birth would be through institutional support, whether it’s insurance reimbursement or doulas being employed by hospitals, birth centers, and obstetrician practices (something we’re starting to see in the United States). We’ll never reach everyone if individuals are required to pay for doula care out-of-pocket, because in that scenario doula care will always be out of reach for low-income people.

What would institutionalization of doulas mean for our ability to make the radical change that doulas work to make, the change that could actually bring our maternity care system back toward patient-centered and non-interventionist care? I know there are other professions that at their inception saw themselves as actors with the ability to make radical change. I think about nurses, and how much of what doulas do was was at one time seen as part of the role of the nurse. Nurses are meant to be focused on patient needs, to be a more consistent presence during hospital stays. But the reality of nursing today, particularly in hospitals, is very different. Nurses attend to many patients at once, and at least in labor and delivery wards, do so more from the nurses’ station monitors than from the patients’ actual rooms. Social workers are another example of a well-intentioned profession whose ability to make major systemic change has been mediated by the institutions that support the profession.

I recently had a conversation about this with Jennie Joseph, a midwife and leader in the movement to address race-based maternal health disparities. In particular, we discussed how, despite the existence of Healthy Start, a decades-old government-funded program with millions of dollars in funding, infant mortality and low infant birth weight among African Americans in the United States remains extremely high. What is it about these institutional solutions that renders them ineffective, or at least keeps them from achieving their goals?

There is no easy answer to the question of where the doula movement is headed. It’s clear to me that doulas provide an important and potentially transformative intervention for our maternal health system. But it’s also clear to me that institutionalization and professionalization threaten the very model we’ve developed, a model that, because it is outside the medical system, allows us to shift the dynamic and improve outcomes.

An alternative that I think may be more feasible is working to bring the doula model of care to existing participants in the health-care system. How could the doula model transform the way current providers, like doctors and nurses, care for their patients? Rather than creating a vast doula profession, could we transform maternity care by turning everyone into doulas? Could family members, for example, be trained or shown how to provide the kind of support that doulas provide?

I think doula work is valuable and important, and I also don’t believe the essence of doula work—non-judgmental and unconditional support for pregnant and parenting people—needs to be locked away in a system that says only a certain amount of training, certificates, or other paperwork bestows upon someone the right to provide this support. We run the risk of replicating the model we’re trying to revolutionize. And I don’t think that is where real social change happens.

Joseph, for example, is trying to bring doula-like training to people already working in Healthy Start programs as community health workers. These folks are already working with at-risk pregnant and parenting people, tasked with improving their outcomes through education and support and navigating systems like Medicaid. Joseph’s educational program, called Community Outreach Perinatal Education, provides these community health workers with additional skill sets, based on the doula model, to transform their existing work. As Joseph explains, these people already have jobs, so she’s not trying to pull them out of the system and find work for them as doulas. Instead, she’s trying to give them skills to do better within the existing infrastructure.

If our goal is really to have doula support for every person who gives birth, we’re going to have to accept doulas in lots of different forms: nurse doulas, doctor doulas, family member doulas. We’ll need to tap into the existing networks of support and see what doulas have to teach everyone about supporting people through the journey of pregnancy and beyond. This doesn’t mean that professional doulas need not exist—they can and should continue to provide doula support. Rather, we need to look toward more flexible ways of bringing doula care to a larger number of people.