Birth doulas play a vital role in improving pregnancy and birth outcomes, especially for birthing people of color, by advocating for and empowering their patients. Birth Doulas Addressing Systemic Racism in Underserved Communities, a webinar from the Health Workforce Technical Assistance Center (HWTAC), explored recent studies detailing the essential role of birth doulas in improving perinatal health disparities and ideas for supporting doulas through the expansion of services and system-level changes.

The webinar featured Paula Kett, Ph.D., MPH, BSN, IBCL and Grace Guenther, MPA — two research scientists for the Center for Health Workforce Studies at the University of Washington. The discussion also included Amy Chen, J.D., a senior attorney for the National Health Law Program who oversees the Doula Medicaid Project, which launched in 2019.

Racism Drives Maternal Health Disparities

Significant health disparities exist in birth outcomes in the U.S. with maternal mortality rates typically two to three times higher among Black, Brown, and Indigenous people compared to white populations. According to Guenther, stress associated with exposure to racism is a major underlying factor in these disparities, contributing to higher rates of preterm births and low birth weight in infants, depression and PTSD in birthing parents, and lower odds of breastfeeding.

Patients of color specifically have reported greater instances of delayed care, gaps in communication with providers, shorter encounters with their providers, and extended wait times for appointments, compared to white patients.

Birth doulas, particularly doulas who can address and relate to the effects of structural racism on pregnant and birthing people, are proven to have a positive impact on birth outcomes by helping decrease maternal stress, reduce rates of C-sections and unnecessary interventions, and increase overall satisfaction with the birth experience.

“Having access to doulas who understand and have experienced the effects of systemic racism increases the patient’s trust and engagement with care and strengthens their agency and decision-making processes,” Guenther said. This trust then builds a foundation for patients to be more transparent about their health history, needs, and concerns, thus better informing doulas on how to provide support most effectively.

Though research shows doulas are effective in improving birth outcomes, policymakers are still in the dark regarding how to expand access to doula services due to two major challenges:

  •  Identifying how to best provide training and compensation support for doulas working in underserved communities.
  • Providing doula training that is specific to the needs of underserved communities, to replace current training that has historically focused on the experiences of upper-class white women.

Doulas already struggle to stay afloat financially and constantly toe a tense line between wanting to charge what they’re worth, and not wanting to further exclude low-income clients. Possible solutions must include welcoming doulas as part of the health care team, rather than continue making them face a hostile hierarchy.

“There’s also a lack of understanding of the working conditions of community-based doulas and what is further needed to support their work and develop equitable policy,” Guenther said. “This is particularly important considering the COVID-19 pandemic where research has found that many birth doulas experienced barriers providing their services through being deemed nonessential personnel and not being allowed in delivery rooms during the pandemic.”

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States, a study conducted in part by Guenther and Kett, aimed to:

  • Examine organizational-level approaches to meet these needs and address challenges and identify what system-level changes are needed to redress health inequities.
  • Explore the work experiences, stressors, and strategies to mitigate these stressors of doulas who work primarily in underserved communities.

The study included current maternal health literature and policy review as well as 34 key informant interviews with community-based organizations (CBOs) and individual doulas. The results of the study provided hands-on perspectives on what system-level changes are needed to reduce health inequities in underserved communities through expanded access to doula services.

Community-Based Organizations and Doulas Lead the Charge

By analyzing responses from both national-level “mainstream” organizations and smaller, local CBOs, researchers found that CBOs were generally better positioned to address negative health outcomes through an equity lens. In both training and recruiting, CBOs focused on the specific needs relevant to the communities they serve.

“Both types of organizations discussed the importance of including content that specifically addressed the way that structural racism impacts pregnancy outcomes,” Kett said. “The difference is that CBOs tended to already have this incorporated and had been doing this for a long time, whereas for mainstream organizations, this was newer for them.”

Because of the rich history of expertise CBOs carry in addressing structural racism, they are a necessary partner in solutions. According to Kett, there is a need to shift the balance of power across organizations by empowering CBOs in the training and employment of doulas, as well as increasing the representation of CBOs and doulas in policy and decision-making processes.

For example, CBOs in the study highlighted that while policy change like Medicaid reimbursement has many potential benefits, there is also a trade-off: it can create a scope of practice that doesn’t align with the needs of doulas and pushes them further into the existing hospital hierarchy that does not treat them as equal members of clients’ care teams.

“We really highlight this here because right now there is a big focus on doulas as the answer to perinatal inequities,” Kett said. “Doulas are a big part of the answer, but as these CBOs said, if we aren’t also addressing racism in our structures, then we aren’t going to make any headway in outcomes.”

In addition to being isolated themselves, many of the individual doulas interviewed reported witnessing their clients being ignored or pressured into certain interventions and being concerned about how their clients were spoken to. One widespread report was the focus on patient compliance over informed consent. Fear-based messaging about the prevalence of high maternal mortality and morbidity rates, especially among people of color, seemed to be frequently used to scare patients into being compliant.

To help shift this power dynamic, doulas interviewed spoke about the trust, support, and education that doulas provide for patients. By being a stable presence throughout their clients’ pregnancy and birth experiences, they build and foster a deep connection that welcomes more transparency.

Through gaining the trust of their client, and continuously listening to and advocating for them, doulas are generally granted a better understanding of their health and social history, personality, social care needs, culture, and birth preferences. Clients, in return, feel more supported to be able to speak up, both to their doulas and to more traditional care providers.

“They empower clients to advocate for themselves to learn to listen to their own intuition and their bodies to be able to identify what they want and clearly communicate that,” Kett said. “This is important particularly among birthing people of color who often experience pain unseen and are ignored in perinatal spaces.”

Dismantling Structural Racism in Perinatal Health

While the study findings affirm current research about the positive roles doulas and their services play in addressing perinatal inequities, it’s important to remember that doulas should not bear the burden of responsibility for fixing broken systems. Rather, system-level changes are needed to make doulas an essential part of perinatal health care and treat them as such.

One of the greatest barriers to expanding doula services has been finding a sustainable method of paying doulas a thriving and livable wage. Currently, over half of all states are taking some action regarding expanding access to doula services, with many utilizing Medicaid. However, because Medicaid reimbursement rates are often low and can come with a trade-off, like a limited spectrum of applicable services, states are encouraged to explore new ways to approach the issue.

According to Chen, who works with the Doula Medicaid Project, Rhode Island was the first in the country to pass a bill requiring doula care under both Medicaid and private insurance. The benefit took effect on July 1, 2022, and doulas began successfully receiving reimbursement within the first month.

“I’ve spoken with doulas in Rhode Island and they’ve said unequivocally the reason why they pushed for doula coverage of both Medicaid and private insurance is that they know that Black pregnant and birthing people have very high rates of maternal mortality and morbidity and that is the case regardless of socioeconomic status, regardless of income, regardless of education,” she said. “Their goal is, if we want to really reduce the rates of maternal mortality and morbidity among Black pregnant and birthing people in Rhode Island, this cannot be something that is only rolling out in the Medicaid context.”

To truly shift the power differential between pregnant and birthing people (especially people of color) and their providers, dismantle the hospital hierarchy, and improve perinatal health inequities, doulas must be seen as an essential part of the perinatal health care team. More so, structural racism must be acknowledged and combatted at every level, from the individual support provided by a doula to the policies put in place by the care facility.

Doing so will require new approaches to dismantling systemic racism within existing structures and creating unique models of care that address inequities in a new way. This work must be led by the doulas and CBOs who have historically worked to combat inequity and can relate to the lived experiences of their clients and the communities they serve.

“As firm as my faith is in the power of doulas to positively impact the lives of their clients, we know that in the end, we can’t put it all on their backs,” Chen said. “Doulas can certainly help mitigate the impacts of racism on their clients of color by advocating for them in the face of systemic racism, but in the end that systemic racism is still going to be there harming other people. The solution to the underlying racism that plagues America’s maternal health care system can’t simply be throwing doulas at the problem. As we do this work, we have to remember this and continue to work in other ways to seek out and eradicate racism in all its forms.”

The MaIH Project: Improving Maternal and Infant Health Outcomes in Missouri

The Maternal and Infant Health (MaIH) Project, offered by Altruism Media, Inc. (AMI), is a new program serving pregnant and birthing people in Missouri and Kansas. The MaIH Project takes a new approach to providing equitable maternal and infant health care, particularly for Black, Brown, and rural clients, by deploying a doula and community health worker (CHW) to pregnant and birthing patients in the community. This unique care team helps identify clients’ health and social care needs, refers and connects them to care free of charge, and routinely follows up to ensure their needs are met through at least one year postpartum.

This innovative model takes the burden off patients who are already overwhelmed with a major life transition and allows them to focus on prioritizing their physical, mental, and emotional well-being. During the initial intake process, clients complete an assessment to identify any care needs, including social determinants of health such as food insecurity or lack of transportation.

The doula and CHW team then connect the client to local resources to maintain routine prenatal care, including support for mental health needs, substance use disorder, and any social care concerns. Throughout pregnancy and postpartum, the doula and CHW act as case managers, following up with clients to ensure services are going smoothly as well as answering questions, providing additional information, and offering support, including assistance with chores and childcare.

To help address maternal health inequities on a system-level scale, The MaIH Project is working toward building a maternal health literacy collective that educates and empowers pregnant and birthing people to advocate for themselves, with or without the support of a doula, and feel comfortable leading their health care. Through the maternal health literacy collective, The MaIH Project aims to shift the power differential in perinatal health spaces from providers to patients, resulting in improved trust, communication, and birth outcomes.

AMI is interested in partnering with other CBOs in the Kansas City metropolitan area and rural Missouri with the goal of expanding access to doula services and whole-person support that aims to specifically reduce health inequities among pregnant and birthing people of color. Contact us to learn more about partnership opportunities.

To get connected to perinatal care through The MaIH Project, text or call 844.860.0111 or visit