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Women's Health Education Program (WHEP) Blog The Role of Doulas in Addressing Black Women’s Maternal Mortality

Pregnant woman with doula touching baby bump.

This article includes discussion of maternal mortality that may be challenging for some readers.

May 10, 2023
By Daneka Stryker, Drexel University College of Medicine

The maternal mortality ratio (MMR) in the United States has approximately doubled in the past two decades while the global MMR has decreased nearly 40%1. This is a troubling statistic as the U.S. has the highest rate of maternal mortality in the developing world. Specifically, the pregnancy-related mortality ratios (PRMR) for Black and American Indian/Alaska Native (AI/AN) women are 41.7 and 28.3: more than 3 and 2 times higher, respectively, than the ratio of 13.4 for white women2. Approximately 60% of these deaths are preventable and are due to causes such as cardiovascular conditions, infections, hemorrhage and hypertensive disorders3. Therefore, it is imperative for health care providers to find a solution to this ongoing and avertible public health crisis.

Factors contributing to these pregnancy-related deaths include lack of knowledge of warning signs and when to seek care, missed or delayed diagnoses, lack of continuity of care, and case coordination or management issues extending up to 12 months postpartum3. Experts on maternal and child health recommend combatting these risks by expanding team-based management of hypertension-related maternal morbidity to include doulas, obstetricians and midwives to improve care coordination4. Multiple studies that expand these teams via the introduction of doulas have demonstrated promising results. Mothers receiving prenatal doula assistance demonstrate better birth outcomes, such as the lower likelihood of birth complications or having a low-birthweight baby, and higher likelihood of initiating breastfeeding5. Women who received doula care via Medicaid in three U.S. states had lower odds of postpartum depression and anxiety6.

Doulas provide ancillary care services that include offering continuous emotional support to mothers through childbirth and enhancing their agency, knowledge and ability to communicate with their wider health care team: presenting an opportunity to mitigate preventive causes of maternal morbidity7. Doulas can uniquely provide trauma-informed care to mothers, as trauma-related health conditions, including PTSD, sexual assault, substance use and postpartum depression, are increasingly common occurrences amongst childbearing people and may be associated with nearly 1 out of 5 maternal deaths8.

Community-based doulas, integrated within communities they serve, can provide culturally and linguistically congruent care that supports communication between mothers and their health care team. This is a factor identified by Black women’s health organizations as an essential aspect of the birthing experience9. One such multiracial, culturally specific, community-based doula model demonstrated improved birthweight outcomes and decreased primary Cesarean rates in mothers who utilized the Yiya Vi Kagingdi Doula Project, as compared to Indigenous, Latinx and other mothers in New Mexico who did not utilize doula services10. Doulas can provide culturally competent care to Indigenous mothers by supporting Indigenous cultural practices that promote individual and intergenerational healing11. Latinx mothers benefit from the immediate support of trained, Spanish-speaking interpreter/doulas who can offer timely, effective care while enhancing patient and staff satisfaction12.

Professional organizations, including the American College of Obstetricians and Gynecologists, support evidence-based findings that “continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor”13. The doula licensing organization DONA International offers certification programs for both birth and postpartum doulas that involve educational courses, workshops, live birthing experiences, and annual maintenance recertification14 The support that doulas provide is different from that of midwives, who are trained to provide medical care, promote healthy births and facilitate access to medical care for mother and child15. Thus, doulas offer the unique potential to supplement health care teams in the provision of care for mothers at risk.

States including New York, Nebraska, Minnesota, Oregon and Indiana have implemented strategies to provide doula service reimbursement through Medicaid, with varying monetary reimbursements and degrees of coverage16, 17. Both Minnesota and Oregon funded doula reimbursements through Medicaid and outlined requirements for doula qualification, which include undergoing licensing and training through a choice of government-approved organizations16. The resulting cost-saving potential of doula care, reimbursed through Medicaid at an average of approximately $1,000, results from reduced rates of Cesarean sections and preterm births18. This demonstrates an overall potential cost savings of $58.4 million, representing an important opportunity for investment in the lives of mothers in the U.S. and in our health care system.

Doula care remains underutilized due to barriers regarding information about services provided, access to services, cost, and diversity of the doula workforce, as assessed by national surveys19. Variable coverage for number of doula visits, as well as low reimbursement rates, may hinder the financial viability and effectiveness of doula care integration efforts20. Therefore, a solution to decreasing barriers to access is improving cost through increased reimbursement through health insurance.

Only twelve states and Washington, D.C., have introduced legislation regarding doula certification and doula service coverage through Medicaid21. National support to increase access to doula services from pregnancy through one-year postpartum is outlined in the Black Maternal Health Momnibus Act of 2021, which was reintroduced at the 117th Congress and was referred by the House to the Subcommittee on Crime, Terrorism, and Homeland Security22. In April 2022, the U.S. Department of Health and Human Services allocated $4.5 million for hiring, training and compensating doulas to combat the maternal mortality crisis23. This funding will increase the number of nationwide Healthy Start doula programs and will hopefully continue to grow with its demonstrated effectiveness.

The COVID-19 pandemic highlighted significant shortages in health care personnel that could potentially be supplemented by doulas24. Both health outcomes and cost-effectiveness data have shown that the use of doulas presents a promising strategy for reducing maternal mortality disparities in the U.S. The statewide trials of doula insurance coverage through Medicaid are a step toward increasing access to doulas for the populations most at risk. The American Medical Association has existing policy that supports the inclusion, regulation and complementary role of midwives as allied health professionals, but none that outlines the role of doulas, revealing an area for advocacy at the national level25. This represents an avenue for medical student and physician advocacy, both state- and nationwide, to increase access to doula care for all pregnant and postpartum people.

Drexel's Employee Assistance Program is available to help employees in need of support through confidential, 24/7 counseling at 888.628.4824. This is offered at no cost to benefits-eligible faculty and professional staff, their family members, and Drexel graduate students. More information is available on the Human Resources website. Students can reach out for support via Student Wellbeing.


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  2. Prevention CfDCa. Pregnancy Mortality Surveillance System. 2020.
  3. Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. 2019:423–429
  4. Phillips-Bell G, Holicky A, Macdonald M, Hernandez L, Watson A, Dawit R. Collaboration Between Maternal and Child Health and Chronic Disease Epidemiologists to Identify Strategies to Reduce Hypertension-Related Severe Maternal Morbidity. Prev Chronic Dis. Dec 12 2019;16:E162. doi:10.5888/pcd16.190045
  5. Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on healthy birth outcomes. J Perinat Educ. Winter 2013;22(1):49-58. doi:10.1891/1058-1243.22.1.49
  6. Falconi AM, Bromfield SG, Tang T, Malloy D, Blanco D, Disciglio RS, Chi RW. Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. EClinicalMedicine. 2022 Jul 1;50:101531. doi: 10.1016/j.eclinm.2022.101531. PMID: 35812994; PMCID: PMC9257331
  7. Kozhimannil KB, Vogelsang CA, Hardeman RR, Prasad S. Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. J Am Board Fam Med. May-Jun 2016;29(3):308-17. doi:10.3122/jabfm.2016.03.150300
  8. Mosley EA, Lanning RK. Evidence and guidelines for trauma-informed doula care. Midwifery. Apr 2020;83:102643. doi:10.1016/j.midw.2020.102643
  9. Mottl-Santiago J, Herr K, Rodrigues D, Walker C, Feinberg E. The Birth Sisters Program: A Model of Hospital-Based Doula Support to Promote Health Equity. J Health Care Poor Underserved. 2020;31(1):43-55. doi:10.1353/hpu.2020.0007
  10. United TW. Expanding Access to Doula Care Birth Equity and Economic Justice in New Mexico. 2020:58.
  11. Ireland S, Montgomery-Andersen R, Geraghty S. Indigenous Doulas: A literature review exploring their role and practice in western maternity care. Midwifery. Aug 2019;75:52-58. doi:10.1016/j.midw.2019.04.005
  12. Maher S, Crawford-Carr A, Neidigh K. The Role of the Interpreter/Doula in the Maternity Setting. Nursing for Women's Health. 2012/12/01/ 2012;16(6):472-481. doi:
  13. Bryant AS, Borders AE. Approaches to Limit Intervention During Labor and Birth. 2019. ACOG Committee Opinion
  14. International D. Birth Doula Certification A Doula's Guide 2016
  15. America MAoN. What is a Midwife?
  16. Platt T, Kaye N. Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid. 2020
  17. Mehra R, Cunningham SD, Lewis JB, Thomas JL, Ickovics JR. Recommendations for the Pilot Expansion of Medicaid Coverage for Doulas in New York State. American Journal of Public Health. 2019/02/01 2019;109(2):217-219. doi:10.2105/AJPH.2018.304797
  18. Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth. Mar 2016;43(1):20-7. doi:10.1111/birt.12218
  19. Thomas MP, Ammann G, Brazier E, Noyes P, Maybank A. Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Matern Child Health J. Dec 2017;21(Suppl 1):59-64. doi:10.1007/s10995-017-2402-0
  20. Mehra R, Cunningham SD, Lewis JB, Thomas JL, Ickovics JR. Recommendations for the Pilot Expansion of Medicaid Coverage for Doulas in New York State. Am J Public Health. Feb 2019;109(2):217-219. doi:10.2105/ajph.2018.304797
  21. Gebel C, Hodin S. Expanding Access to Doula Care: State of the Union. 2020.,%3A%20Indiana%2C%20Oregon%20and%20Minnesota
  22. Black Maternal Health Momnibus Act of 2021, H.R.959 (Rep. Underwood L 2021). 02/08/2121
  23. Health Resources and Services Administration Announces Availability of New Funding to Support Community-Based Doulas. (2022, April 1). National Health Law Program. Retrieved February 25, 2023, from
  24. Rivera M. Transitions in Black and Latinx Community-Based Doula Work in the US During COVID-19. Original Research. Frontiers in Sociology. 2021-March-11 2021;6(16)doi:10.3389/fsoc.2021.611350
  25. AMA. Midwifery Scope of Practice and Licensure D-35.989. American Medical Association; 2018

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