Ground Work | Blog 005 | The Doula's Mind: Mental Health, Vicarious Trauma, and What Sustainability Requires

I. Opening: The Year I Broke

In 2018, I had a mental health collapse.

I was a full-time doula in San Diego, California. I often asked potential clients what they could afford rather than stating my price.  My community needed access, and my heart wanted to be a space of refuge, even though my pockets were screaming for appreciation in the form of dollars. I was also a new student midwife and working part-time in a midwifery practice without pay because, as many of you know, that is often the cost of becoming a community midwife.  On top of that, I was paying for midwifery school out of pocket because most homebirth midwifery schools do not have the option of applying for school loans. So there I was, a full-time doula working birth and overnight postpartum shifts and an unpaid midwifery apprenticeship working for and with a community I was, and still am, committed to, with a body that was slowly running out of room to hold all of it.

The anxiety started quietly. My heart raced even at moments I used to find calming and enjoyable. Then the dissociation hit me like a ton of bricks. I remember having to go to the ER because I could barely stand up. My heart was racing, my body felt like it was miles away, and everything felt completely unstable. After a few of those experiences with dissociation, medication to help me stabilize, and a level of exhaustion that felt ancestral, I understood that if I did not change something, I was going to lose the ability to do this work entirely.

I left midwifery school, and I raised my prices. I stopped accepting what the market had decided my labor was worth and started asking what I needed to survive doing it. For The Village was built from that decision. A structure that could create access for my community without requiring my body and my mind to absorb the cost of that access. A redesign, a collective, without the hero complex I was carrying. A way of saying that sustainability and community care do not have to be in opposition if you are willing to build something different.

I am writing this essay from that experience and from the eleven years of understanding that followed it. Not from outside of it.

Something brings us to birth work. Some of us are called into this work by our lineage. Other times it is a birth that cracked something open. A loss that went unwitnessed or a community that had no one showing up for it. Oftentimes it is our own birth, our own loss, and our own experience of loneliness during a time of need. The thing that brought us in is often also the thing that makes us most susceptible to what the work costs because we cannot remove ourselves from this work. We are also the exact people needing to be served by this work.

We arrive carrying our own stories and walk directly into rooms full of other people's. Nobody teaches us what to do with the buildup we step into this work with.

II. What the Work Actually Costs

Compassion fatigue. Secondary traumatic stress. Vicarious trauma. These are not the same thing, and the differences matter.

Compassion fatigue is the gradual erosion of the capacity to care. When you have given so much for so long that the well runs dry and refilling it takes longer each time. Secondary traumatic stress is different. It appears suddenly rather than gradually; it is what happens when absorbing other people's trauma begins to produce symptoms in your own nervous system, such as helplessness, isolation, anxiety, numbness, and intrusive thoughts. Vicarious trauma goes deeper. Repeated exposure to suffering changes the way you see the world, relationships, safety, and meaning. It is not just a bad week; it is a shift in how you move through everything, and it can concern others around you as you present in a completely different way.

Doulas experience all three. Often simultaneously and without language for what is happening to them.

The 2 am calls when life only allowed you to get to sleep by midnight. The client whose birth plan was ignored and who looks at you afterward with a question you cannot answer. The loss at twenty weeks of your client who is several IVF rounds in and giving up on the idea of birthing their child. The abortion that saved a client's life alongside the grief they are not allowed to name out loud. The postpartum client you are worried about because they do not have a good support system and cannot afford postpartum doula care. You carry all of it home. You carry it into the next birth, even though you try your best to push it to the back of your mind while you are with a different client. You carry it into the next and the next, hoping the pressure you feel internally does not release itself at the wrong moment through yelling at your kids, isolating from your loved ones, or having an inappropriate reaction during a client experience.

Then there are the births that break something permanently. The stillbirth you were present for. The maternal death you witnessed. These are not experiences that resolve with time off or a good night's sleep. They are events that change a doula's relationship to the work, to their body, to their sense of what is possible in a birth room. Many of us carry these losses for years without ever having had a structured space to process them. The grief is real. The trauma is clinical. The support almost never exists.

Research on maternity care providers has found that a significant percentage experience secondary traumatic stress following a traumatic birth, with the stress appearing suddenly and catching practitioners off guard. A 2024 study found that nearly half of midwives surveyed, 47.1%, experienced burnout, with working more than 40 hours per week, job dissatisfaction, and depression symptoms among the most strongly associated factors. Studies on compassion fatigue in care workers estimate that between 36.8% and 78% of nurses are at risk, a range that reflects how much the conditions of practice shape the outcome.

These numbers are for midwives and nurses. Research specifically on doula mental health is sparse. That absence is not accidental, and we will return to it.

III. The Weight Nobody Names

The mental health burden of doula work is not only about what happens in the birth room.

The Medicaid reimbursement chaos is its own category of stress. Spending hours on unpaid administrative work that nobody trained us to do, in a system that was not built with us in mind, while also being on call and waiting months for payment. A 2025 report on New York City doulas documented what many practitioners across the country are experiencing: the city health department itself acknowledged the Medicaid reimbursement rate as low. In the report, one doula described the enrollment process for managed care plans plainly, "You feel bad telling people you have to turn them away because the process is not completed yet, but you are also not going to work for free."

That is the financial stress of practicing inside a system that needed us enough to integrate doulas into Medicaid, but not enough to build a nationwide system to make sure we get paid and resourced on time.

Then there is the broader entrepreneurship tax. The isolation of building a practice without a safety net. The absence of sick days, paid leave, and the uncertainty of care work that never fully resolves no matter how many years you have been doing this.

There are also the people closest to us who do not understand why we cannot leave it at work. Who wonder why we are tired when we love what we do. Who frame our exhaustion as a personal failure rather than a response to the physical, mental, and emotional work required to create positive client experiences.

The weight continues to increase as we also fight policies and understand precisely which bodies will pay for it in ways that most people in the room are still catching up to. We are educating communities whether we are on or off the clock, often because we are the only people a birthing person can access in times of intense worry or crisis. Birth work is nonstop.

For the doulas reading this who recognize this weight and have been trying to find the language to explain it to someone with a checkbook, there is a resource at the end of this essay that translates what you just read into a funding ask you can actually use. For the investors reading this who want to move differently than the system this essay is describing, there is a resource for that too. A practical guide to what real investment in doula sustainability looks like, with the numbers attached. Both are free. Both are waiting at the end. Keep reading.

IV. The Data Gap Is the Argument