Recent data from the Centers for Disease Control and Prevention (CDC) show that the U.S. maternal mortality rate has continued to worsen, with Black women and birthing people still disproportionately experiencing the brunt of poor maternal health outcomes due to systemic racism and discrimination. Even the American College of Obstetricians and Gynecologists agrees that maternal health disparities cannot be reversed without addressing racial bias. In 2020, the maternal mortality rate for Black women increased 26 percent, from 44 deaths per 100,000 live births to over 55. For contrast, that is roughly three times the rate for white women. These inequities are unacceptable.

This Black Maternal Health Week (BMHW) offers an opportunity for advocates and policymakers to reflect on what has been working, and what is failing. The theme of this year’s BMHW, “Building for Liberation: Centering Black Mamas, Black Families, and Black Systems of Care,” makes it clear that we cannot have these conversations in silos, ignoring the experience and the expertise of those with lived, first-hand knowledge of the U.S. maternal health crisis.

Solving the Black maternal health crisis will require listening to that first-hand knowledge. For this purpose, I have conducted interviews with community doula, reproductive justice expert, and founder of Ancient Song Doula Services, Chanel Porchia-Albert, as well as one of Chanel’s clients, Assistant Professor of Theology and African Diaspora Studies Dr. Amey Victoria Adkins-Jones.

Centering Black Systems of Care

“Having a doula can help you to center your voice and be able to advocate for yourself and your bodily autonomy, which is grossly missing within the health care system, where individuals feel like they don’t have the power to be able to speak up and share their approval or disapproval of the care that they’re receiving and not be met with reprisal or refusal of care.”
— Chanel Porchia-Albert

Doulas are trained professionals who provide non-clinical emotional, physical, and informational support for people before, during, and after labor and birth. When they are involved in a birthing experience, research shows that doulas are associated with better health outcomes, including lower cesarean rates and fewer obstetric complications. Community-based doulas are often members of the communities in which they work, sharing the same background, culture, and/or language with their clients and offering culturally appropriate support to those at risk of poor outcomes.

Doula care has a rich cultural history for Black women and birthing people. Throughout the dehumanizing history of slavery in the United States, enslaved people preserved many traditional African birth practices, for which birth workers, such as midwives and doulas, were of vital importance. Even following Emancipation, Black birth workers continued to bridge the gap between their disenfranchised communities and the U.S. health care system, despite facing ostracism and attempts to discredit their knowledge and professionalism.

One of the many advantages of having a doula is the holistic model of care that they can provide. While a traditional medical model of care may be more focused on markers of health such as blood pressure, iron profile, or cholesterol level, a doula is focused on the whole person, including looking at social determinants of health such as their housing situation, the nutrition to which they have access, familial support, child care, or economic hardships. Chanel speaks to this element of her work:

It’s not just about that episode of care that’s happening to that individual. It’s never been about just that. When we show up even in our pregnant bodies, it’s not about just being pregnant, it’s about all of the things that have happened to us before we became pregnant. Because all of those things influence how we feel about ourselves and how we see ourselves. Those things don’t go away because you become pregnant—if anything, they become more visible.

Centering Black Mamas

“I knew how important Black maternal health was, intellectually and interpersonally, but I understand on a completely different level now, how serious these things are, having lived it. I cannot express my gratitude enough for folks like Chanel and the work that they do.”
— Dr. Amey Victoria Adkins-Jones

Doulas are an underutilized workforce, one with the potential to reduce racial disparities in maternal health outcomes. They act as advocates for the birthing person, and in doing so combat the institutional racism that often occurs in health care settings, prevent medically unnecessary and undesired clinical interventions and support their clients to share in the clinical decision making. Birthing people of color in the United States, specifically Black women and birthing people, are often distrustful of the medical system, and rightfully so, after centuries, historically and to this day, of medical professionals harming their communities. Doulas can be helpful liaisons in building some of that trust and ensuring that Black women and birthing people feel safe and their voices listened to during their pregnancy and births.

After experiencing a traumatic and racially discriminatory encounter at the hospital while seeking treatment for another, unrelated health challenge prior to conceiving, Amey Victoria knew that she wanted to have doula support throughout her pregnancy and birthing experience to help her better navigate the health care system:

When I got pregnant—which was a miracle, I was still recovering from all the things that had happened to my body over the past year—the first thing I did was look for a doula and midwives. I did not want my birth experience to be narrated through medical trauma. I did not want my voice to be drowned out. I did not want to experience stress and pressure to make decisions under duress. I wanted to have advocacy, I wanted my spouse to be supported in supporting me, and I wanted to have a birth experience that left space for autonomy, grace, beauty, and joy.

Doula Workforce Inequities

“I don’t think that I was only willing to work with a Black doula, but I really wanted that experience. I wanted someone who deeply understood what was at stake for me as a Black woman and the anxiety that I carry around giving birth, communicating with doctors, and being heard.”
— Dr. Amey Victoria Adkins-Jones

The doula workforce is primarily composed of white women. However, the population that stands to benefit most from the positive health outcomes associated with doula care are people of color. This discrepancy may seem trivial, but it has real health implications. Culturally congruent health care—meaning quality care that includes humility, openness, and acceptance of different cultures—has been shown to result in more effective outcomes. Amey Victoria spoke to the challenges she faced in finding a program that could fit her cultural needs when, wanting to know more about reproductive justice for Black women and birthing people, she decided to seek doula training to become a birth worker herself:

I found that so few doula trainings took reproductive justice seriously; so few of them were asking and thinking about questions of cultural identity. A lot of the programs were using cultural practices but were separating some of those practices of birth work from the stories of the people that they came from. For me, both intellectually and as a potential practitioner, that never quite settled well.

Building a birth workforce that is representative of the communities most at risk for poor outcomes must be a priority for any stakeholders or policymakers interested in maternal health.

Barriers to Care

Despite all of the prior stated benefits of doulas, research indicates that low-income women and women of color, who are disproportionately at risk for poor birth outcomes compared to their higher income and white counterparts, are the groups most likely to report wanting, but not having, access to doula care.

Knowledge and affordability are often the two major barriers that Black women and birthing people face in accessing doula care. Mothers whose primary payer for childbirth was Medicaid (Black women are disproportionately represented among Medicaid recipients) are far more likely to have never heard of doulas when compared to mothers whose primary payer for childbirth was private insurance. Due to structural racism and economic barriers, Black women and birthing people are the least likely to be able to afford doula care out-of-pocket.

Even those who are not Medicaid beneficiaries still often struggle to get doula care covered by their insurer, as was Amey Victoria’s experience:

Only at this point in my life would it not have been potentially cost-prohibitive. If I had been pregnant two or three years prior, I would have had to make a different payment schedule. It was something I was willing to financially sacrifice for, because it was something that was important to me, but I never felt like that was a sacrifice I should have had to make. And we still did end up paying quite a bit out-of-pocket both for doula care and midwifery services that insurance would not cover.

Most private doulas charge $700–$1,500 per birth, a cost that is unattainable for many new parents to afford out-of-pocket when insurance cannot or will not cover it. While community-based doulas, like Chanel, may charge clients on a sliding scale based on their household income and what they can afford, this often prevents doulas from being able to earn a living wage for the critically important work they do. The cost of doula care may be expensive for many individuals, but it is nothing compared to the costs of medical complications such as cesarean sections or preterm births in traditional hospital settings. In fact, investing in doula care can lead to significant cost savings for health care systems.

Looking Ahead

“Good policy ends up going sour when the implementation and accountability is not placed within the context of the policy. How are we holding these state-wide institutions accountable for the ways in which they continue to implement policies that are harmful to communities?”
— Chanel Porchia-Albert

The maternal health crisis in the United States is steadily worsening. Black women and birthing people deserve access to affordable, compassionate, and culturally congruent doula care before, during, and after childbirth, should they desire it. Doulas also deserve the ability to access affordable training to enter the perinatal workforce, and thriving wages for the important work they do.

In order to achieve these goals, lawmakers should undertake the following:

  • States should enact Medicaid reimbursement legislation for doula care, at rates that support a living wage. Some states already have comprehensive legislation for doula Medicaid reimbursement, and the states that do not can model their new policies after those of their predecessors. It should be emphasized that the reimbursement must be at a living wage in support of the birth worker.
  • Congress should reintroduce and pass the Mamas First Act. This bill would require states’ Medicaid programs to cover doula and midwifery services, including prenatal, delivery, and postpartum services.
  • Congress should pass the Perinatal Workforce Act. A critical piece of legislation, this bill is part of the Black Maternal Health Momnibus package, which would establish grants to diversify the perinatal workforce, including doulas.

This Black Maternal Health Week, by centering Black voices and experiences, more light can be shed on the real life impact and urgency to advance better access to Black-led systems of care, including community-based doula care. Beyond enacting these policy measures, in order for more Black moms to have access to the care and support they need and deserve, we also need proper implementation, accountability, and follow-through. Lawmakers must act swiftly to ensure that maternal morbidities and mortality are prevented at all costs, and ensuring access to compassionate, patient-centered doula care is a key part of any such effort. Black women and birthing people cannot wait any longer for this crisis to be resolved.