It’s no secret that a chasm exists between doulas and providers. accessHealth News is exploring this divide by interviewing clinical staff at area health systems and community doulas to understand the challenges, gauge their willingness to find common ground, and identify actions that foster the strongest collaboration to improve maternal and infant health outcomes.
According to the CDC, one in five pregnant women report mistreatment during a doctor’s visit. For Black women, that number rises to one in three. Full-spectrum community doulas serve as essential advocates on the front lines, bridging this critical gap in trust, safety, and culturally competent care.
They provide physical, emotional, and informational support before, during, and after childbirth. Doulas serve as advocates, helping pregnant women and birthing people navigate systemic biases that too often negate bodily autonomy and patient voice. To foster effective collaboration, healthcare providers should understand how to address resistance from clinical staff who may see doulas as adversaries rather than allies, which is essential for improving maternal health outcomes.
Organizations like the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) advocate a team-based approach that respects both roles. Nurses broadly agree that the best birth experiences happen when the nurse manages clinical safety, and the doula provides continuous psychosocial comfort, working together seamlessly to support the laboring patient.
Acknowledging the rift
But where does the breakdown happen, and what causes the divisiveness that erodes trust and heightens tension? One area nurse we interviewed said both parties sometimes come in with expectations that become self-fulfilling prophecies. “I know sometimes there is an expectation that hospital staff will be unresponsive and that the patient and doula will be a problem,” she said.
But when it comes to Black maternal health, she said it’s important for health systems to recognize and teach staff that women of color too often have poorer outcomes, a higher risk of missed diagnoses, a higher risk of ignored symptoms, and a higher risk of getting to a more advanced negative state before they’re treated.
“I think a lot of us don’t realize the bias that we carry,” she said, “expecting that a person who presents a certain way is going to be overreacting. That even relates to women in general: ‘Oh, well, that’s a normal symptom of pregnancy. You don’t need to worry about that.’
“We tend to normalize things that shouldn’t be normalized. There’s a big piece of that that is related to women’s health in general, that’s related to language, background, income, a lot of the socioeconomic factors; this is also specifically tied in with Black maternal health.”
For Black women, who have a three times higher mortality rate than white women, doulas have proven instrumental in improving maternal health outcomes. Doulas help bridge communication gaps between patients and medical providers and advocate for accountability and better care. Evidence-based research links doulas with lower rates of C-sections, fewer preterm births, reduced low birth-weight babies, and a lower likelihood of postpartum depression.
Community-based doulas who share the lived experiences and cultural values of Black mothers build essential trust, providing trauma-informed and culturally specific care that traditional medical systems are not always equipped to deliver.
One full-spectrum community doula we spoke with said in general terms, there seems to be three “camps” of providers: those who are open to doulas and make a conscious effort to foster collaboration, she said this is especially true when the patient faces a language barrier; providers who are indifferent to doulas, and see them as a regular family member or support person in the room but don’t make an effort to collaborate or acknowlege the doula’s role; and providers who aren’t comfortable with doulas and don’t acknowlege there is a doula in the room even after an introduction is made.
“This third type has been rare. Most fall into the first or second category equally,” said Jasmine James, a full-spectrum doula at Altruism, Inc. “I’ve had a couple of experiences where providers demonstrated prejudice, but usually after demonstrating my competence, calm pushback, and that I’m informed and educated, the prejudice resolves, or at least relinquishes to be expressed. I don’t like that it’s this way, but it is.”
James added that no matter which camp the provider falls into, she’s noticed a phenomenon: “When a doula is present, medical staff seem to practice due diligence to treat the patient with respect. There’s something about having a witness whose sole responsibility is to advocate and look out for the patient that seems to keep everyone a little more cautious and on their toes. Informed consent is honored, and providers slow down to make sure the patient understands procedures before proceeding. In a perfect world, all patients would be respected regardless of race, socioeconomic factors, language, etc. But we’re not there yet, and this is where a doula’s care and support help,” James said.
The Doula-Provider Narrative
When nurses were asked about their perceptions of doulas, responses varied. “I have not always been an advocate for doula services. I’ve been a nurse for 25 years, and when I first started in labor and delivery 20 years ago in California, doulas were unheard of. I had never experienced one. I worked at a hospital that felt like a baby factory. We had babies coming out 10, 20, 30 a day. If a patient at that point had brought in a doula who was trying to tell me to do things differently for my patient, I would have been very shocked, number one, because it never happened, and number two, I would have been very uncomfortable or frustrated. “
A move to another labor and delivery unit in Minnesota created a cultural shift. The patients came in educated, prepared, supported by family—and with a doula. “They came in with an unheard-of thing called a birth plan. And I was like, what in the world is this? In my mind, I was thinking, what are you bringing to me that I have to change my practice to accommodate stuff you got off the internet? You didn’t get these things from medical science, because if you had, I assumed I would know them. It was difficult, but I adjusted.”
She said she eventually learned that doulas played an important role in the patient-provider dynamic, and that as a nurse, she could learn from them because they had expertise she never encountered during her stint in California. Her experience in Minnesota taught her that the key was to collaborate with doulas, remove power plays, and make the culture patient focused.
She brought that mindset to her current role at an area health system. She admits that her early work in California may have caused PTSD for some of her patients.
“I started becoming much more aware through training, but more so through the personal relationships I built with doulas,” she said. “My perception has shifted from seeing doulas as an unnecessary challenge to them being a huge, integral part of providing patient support and helping them feel safe—which physically affects the patient’s birth outcomes. I recognize that doulas come in with an expertise and a capacity that I never developed as a nurse.”
Another area labor and delivery nurse we interviewed said she was surrounded by doulas while working in Texas. There, each patient had a doula. “Honestly, I think doulas are so, so helpful, and I think they give nurses a different perspective,” she said. “They have a lot of really good tools that we don’t always get as labor nurses.”
A champion of doulas, she admits a rift exists between them and clinical staff. She cites communication as one culprit. She’d like to see doulas and nurses listening more to each other and talking about their respective roles. She said something as simple as positioning techniques for the person laboring can cause friction. Another challenge she mentioned is distrust. And when it comes to Black patients, she believes the patients come in with a preconceived mindset that the medical staff will not be responsive.
“They come in expecting worse care than what I’ve seen them receive. I think they come in prepared not to be listened to and prepared for the worst outcomes. And I don’t think I’ve ever seen care given differently from one person to another. But I do think that they come in and they are anxious and nervous, and it takes a lot more love and care and time to sit with them because they’re so nervous. I do think there are probably places where they are treated differently. We have to work harder to bridge that gap.”
Another gap she mentions is nurses’ distrust of doulas, and the barriers that exist when it comes to arriving at a place of mutual respect. “I think that unfortunately, a lot of the nurses don’t have a lot of trust in the doulas because so much distrust has been formed over time because of specific situations. I think the biggest thing is going to be trying to get everybody to have that mutual respect. I think that’s going to take time.”
She adds that in her experience, nurses feel like they’ve advocated for a doula, but because of a perceived dislike of medical staff, the doula didn’t reciprocate. “It feels like the doula is just in there saying bad things about the nursing staff and saying bad things about the medical providers. I don’t know if that’s true, but that’s what I’ve heard: there is always animosity. ‘Oh great, we’re not going to be supported, and the patient isn’t going to listen to what we have to say or not trust what we have to say when we really do care, and we really want positive outcomes.’ That’s when it becomes a barrier when there shouldn’t be one.”
“The data doesn’t lie,” James said. “Black pregnant women are coming into the hospital with assumptions and biases because they are at a disproportionate disadvantage. The research and statistics back this up.”
James said patients who come in guarded and hesitant are exhibiting natural defensive mechanisms because too often they feel vulnerable and unsafe. “A doula’s role is to provide support during labor and delivery and advocate for her needs so that her autonomy is respected,” James said. “Oftentimes, Black women will go into the hospital to deliver and be treated by all-white staff. That, in itself, is jarring and scary, given our country’s history. Providers need to have this context in mind. Those defense mechanisms are deeply rooted in a dark past of racism. Having a doula present who has had the opportunity to get to know you personally–something medical staff doesn’t get to do–understands your cultural norms, and shares your racial and ethnic background can be comforting. I agree that there is room for improvement in approach for some doulas, but I think having standardized training and doula protocols will help.”
Bridging the Chasm
When asked how best to close this divide, the nurses we interviewed said doulas with clearly defined roles should be in the room as the norm. Another recommendation is that doulas and nurses get to know each other outside of the labor and delivery room. “A lot of doulas don’t come to the bedside until patients are in active labor. And then they’re stuck at the bedside. Things get really intense and nerve-wracking, and they get exponentially scarier and harder for the patient. Having doulas on the floor a little bit before then, or having them come out to the nurses’ station to discuss plans and converse about the patient helps to develop a united front,“ one nurse said.
James agreed and said doulas and providers should interact and have conversations before they step onto the labor and delivery floor. She added that by the time the doula arrives, things may be intense, making it harder to build rapport. “I always make it a point to introduce myself and let staff know who I am before stepping in to provide labor support,” James said. “I’ve noticed providers are usually much more receptive to my presence when I take time to introduce myself and ask about the patient’s care plan before stepping in.”
James believes clearly defined roles help doulas and providers, and that training should standardize how they communicate and interact. James also believes providers should better understand a doula’s role and be educated on the history of reproductive injustices in the U.S.
“Although obstetric racism and reproductive injustice are themes that we have a right to be angry about, bringing that energy into the labor and delivery room in most instances is not appropriate. However, there are situations that become outrageous, and we’ve all heard about them…” In those less extreme situations, there is a way to stand on principle, be firm, yet composed. I also think it would be helpful if providers were trained on doula care and the history of reproductive injustice in our country. This would provide them with much-needed context. Overall, doulas are becoming more accepted and integrated into patient care at the local and national levels. ACOG recently released a committee statement titled Partnering With Doulas in a Clinical Setting, which offers recommendations to providers. In my opinion, that’s a great sign,” James said.
