Community-based organizations (CBOs) are uniquely positioned to excel in providing maternal health care. Not only do they tailor their services and outreach to meet the needs of the communities in which they are located, but their providers and staff are part of those communities themselves. Women and birthing people need comprehensive, continuous, and culturally cognizant care throughout their pregnancy experiences, including through the prenatal period, birth, and postpartum; the disparate rates of maternal mortality alone indicate these needs are largely not being met for Black and Indigenous populations in particular.
Many of the holistic, patient-centered models of care used by CBOs have demonstrated the ability to meet these needs and improve outcomes for birthing people, particularly those that are Black and Indigenous. Compared to large health systems and hospitals, though, they are operating on incredibly limited budgets. Maternal health CBOs must be better funded to continue their work, scale up programs, and improve outcomes in their communities. One of the most equitable, effective, and efficient ways for the federal government to address maternal health disparities is to ensure that CBOs have the resources they need to do their work to best advantage.
To illuminate the ways in which CBOs’ fine-tuned, demographic-specific services are administered, the potential impact of federal funding, and barriers to receiving those funds, TCF has conducted interviews with maternal health care CBOs. These in-depth, semi-structured interviews allowed CBOs to describe how their organizations improve maternal health equity and what they need from the federal government to continue and expand upon this work. Interviewees included staff and leaders from the six maternal health CBOs participating in an ongoing project with TCF. Interview findings revealed a number of barriers to applying for federal funding, including tangible obstacles such as the length of applications and turnaround time, as well as perceptions of the inaccessibility of federal funding that discouraged CBOs from applying. Interviewees offered a number of ideas for how the funding process could be made less burdensome and more worthwhile for CBOs, including more streamlined processes, unrestricted funding, and increased transparency.
Many of the holistic, patient-centered models of care used by CBOs have demonstrated the ability to meet these needs and improve outcomes for birthing people, particularly those that are Black and Indigenous. Compared to large health systems and hospitals, though, they are operating on incredibly limited budgets.
Although CBOs are eligible applicants for many federal grant opportunities, these grants are often inaccessible given the burden of the application processes. See the recommendations offered in the following section to learn how federal agencies and other funders can set CBOs up for success in grant opportunities so that these organizations can do their best work for their communities, scale up their programs, and expand their reach.
This report offers four recommendations on how to ensure that CBOs have accessible, sufficient, and equitable funding options. Although the focus of our study has been on the funding process for federal grants, these recommendations can and should be implemented by other funders, including state and municipal governments and private foundations.
1. Streamline and simplify application processes, and provide adequate turnaround time from grant announcement to application close.
Time and time again, our CBO partners named the structure and length of the applications themselves as a major barrier to even beginning the process of pursuing federal funding. While it is heartening to see opportunities that name CBOs as eligible recipients, this is only a meaningful distinction if applications are manageable for grassroots organizations, especially those operating on limited budgets with few staff. Applications should be made shorter (both the notices of funding opportunities themselves and the required applicant materials), use straightforward language, and provide more time between grant forecasting or announcement and the closing date for applications.
2. Offer technical assistance tailored to the needs of community-based organizations, including by providing one-on-one sessions.
Federal agencies currently offer technical assistance (TA) to applicants in the form of webinars and written materials, as well as making individual contacts available for outreach. However, needs in this vein continue to go unmet, and CBOs expressed a desire for more training that is tailored to the specific needs of community-based organizations. This assistance should include troubleshooting and guidance for navigating online application platforms, which posed issues for several CBOs in our interviews. In addition to assistance with the application process, CBOs described a need for ongoing support throughout the grant management process; this would include assistance to ensure awareness of and compliance with federal regulations and requirements. CBO leaders also expressed interest in continued communication after unsuccessful grant applications about how to improve in future funding cycles.
3. Increase government transparency, accountability, and quality of engagement with community-based organizations, and properly compensate CBOs for advisory contributions.
An overarching theme from these interviews was the need for (earned) trust, transparency, and accountability on the part of the federal government. By being clear and straightforward about the frameworks being used to determine who receives awards, who is reviewing these applications, and what reviewers are looking for, the federal government can provide transparency to CBOs about the review process and what CBOs can do to become more competitive and successful applicants going forward when they aren’t able to secure resources during a given application period.
The CBOs have communicated that due to the long and harmful history that the federal government has had within communities of color, intentionally building up trust and improving communication is essential. Trust must be earned in order to establish effective working relationships, and transparency is one major way that can happen. While the CBOs are excited that more focus and attention is being placed on community-based solutions at the federal level, this must also be an opportunity for government agencies to not just listen to CBOs, but keep lines of communication open and make meaningful changes in accordance with applicant feedback.
Hand-in-hand with this is the need for CBOs to be adequately compensated for any work they do in an advisory capacity with federal agencies: many CBOs are ready and able to support the federal government in their efforts to engage with communities, but this work must be valued and compensated. Given the resources and staff time necessary to complete applications, agencies could also consider exploring options to compensate CBOs for the time it takes to apply to federal grants. Doing so may alleviate some of the burden on CBOs and allay concerns of applications not being worth the effort.
4. Create opportunities for CBOs to access unrestricted funding, thereby better supporting them in building capacity and resources for their specific needs.
Unlike larger organizations such as health departments or academic institutions, many smaller nonprofits such as CBOs need support for their general operations in order to scale up their programming. Having unrestricted funding enables CBOs to be flexible in their spending and allocate the necessary resources to cover costs such as payroll expenses, utilities, and building maintenance to keep their operations running smoothly. Without having funding built into grants to support these indirect costs, CBOs often cannot justify applying for federal opportunities if it means they will end up needing to actually spend more money out of pocket just to keep up with the rigorous reporting requirements.
The Biden–Harris administration’s commitment to maternal health equity, including making available new funding streams, is a crucial and welcome response to the nation’s maternal health crisis. As this report’s findings have made clear, though, the work to make funding equitable must continue with its implementation. Just naming community-based organizations as eligible groups is not enough; agencies must intentionally center CBOs by creating application processes that are accessible, committing to transparency, and working to repair relationships between community-based groups led by Black, Indigenous, and other people of color.
The United States faces a maternal health crisis that is only worsening.1 Despite its outsized expenditures on health care costs, the country is an outlier among industrialized nations with its poor pregnancy-related outcomes: the U.S. maternal mortality rate is nearly three times that of France and Canada, and almost eight times that of Germany and the Netherlands. Our national statistics, though, bely the even more alarming racial disparities that drive this crisis. Black women and birthing people are over three times as likely as their white counterparts to die from pregnancy-related causes.
Despite its outsized expenditures on health care costs, the country is an outlier among industrialized nations with its poor pregnancy-related outcomes: the U.S. maternal mortality rate is nearly three times that of France and Canada, and almost eight times that of Germany and the Netherlands.
The causes of this crisis are complex and interconnected. The inequities we see today are a direct result of systemic racism, stemming from the control of Black women’s reproductive autonomy since slavery and continuing through the present day, including discrimination in health care settings, socioeconomic disparities, and unequal access to preventative care.2
Achieving maternal health equity will take a comprehensive and multifaceted set of solutions—and solutions of that caliber require robust funding. Given the scope of the maternal health crisis in the United States, and the deeply entrenched nature of maternal health inequities, the federal government must play a key role in this work if it is to succeed, especially when considering that federal grants typically offer larger awards than private grantmaking entities. Thankfully, the federal government is currently committed to the kind of investment needed. Maternal health has been a priority of the Biden–Harris administration, which it has declared with the first-ever Black Maternal Health Week and last year’s Maternal Health Blueprint, which outlines a whole-of-government response to the crisis.3 And although some crucial investments have already been made to support maternal health initiatives, more needs to be done to direct this funding to organizations doing the work in the communities most impacted.
Fortunately, there are a number of models carried out by community-based organizations (CBOs) that have been shown to improve outcomes.4 Through their community-centered and culturally responsive approaches, and their ability to offer services beyond what may be available through the traditional health care setting, CBOs are meeting the needs of their patients and advancing equity. When compared to larger organizations such as hospitals or health departments, CBOs have a better opportunity to build trusted relationships with and provide culturally congruent care for patients, because of their location within the communities they are serving. On top of that, they often provide employment opportunities and pathways to further education and job advancement for community members. For example, Mamatoto Village in Washington, D.C. delivers a perinatal health worker training (PHWT) program to strengthen and diversify the local perinatal health workforce by training women and birthing people to become community-based health and human service providers.5
CBOs have a better opportunity to build trusted relationships with and provide culturally congruent care for patients, because of their location within the communities they are serving.
A major barrier for these CBOs, however, is the lack of resources and sustainable funding, which hinders their ability to serve their communities, let alone scale up to provide care to larger populations. With increasing investments announced at the federal level, it is vital that funding is allocated to CBOs working in birth equity. But as most CBOs are operating with limited capacity, in large part due to historical and current day disinvestment, these groups are at a disadvantage in navigating complex and burdensome federal grant applications.6
In 2021, The Century Foundation (TCF) launched a project to assist Black-led community-based maternal health organizations in receiving federal funding. This effort includes practical support, information sharing and relationship-building among CBOs, and facilitation of an ongoing dialogue between CBOs and staff from the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS) that administers federal health care grants. HRSA provides equitable health care to the highest-need communities in the United States, offering grant opportunities to fund projects ranging from workforce development, to direct care provision, to research and data collection, and more. Some HRSA grants have specifically named CBOs as eligible applicants, making these opportunities especially desirable to the CBOs that TCF has worked with.
As part of this initiative, TCF conducted in-depth, semi-structured interviews with CBO leaders and staff to learn more about their experiences with federal funding applications, opportunities and challenges to receiving federal grants, and related topics. CBOs participating in this project and interviewed for this publication include the following: Ancient Song Doula Services, CHOICES, Commonsense Childbirth, Generate Health, Mamatoto Village, and Restoring Our Own Through Transformation (ROOTT). This report synthesizes interview findings and proposes recommendations for federal agencies and Congress to ensure that CBOs are set up for success in applying for, receiving, and implementing federal funding. These recommendations might also be relevant to state government funders and private philanthropic institutions as well.
Community-Based Organizations and Maternal Health Equity
Community-based organizations, particularly those led by and serving people of color, are inherently well-positioned to meet the needs of their clients. These groups are closest to the issues facing their communities and have already built trusted relationships, and are thus closest to the solutions they need. Health equity cannot be achieved without centering the voices and perspectives of the communities themselves. However, systematic disenfranchisement, particularly of Black and Indigenous community-based organizations, has hindered their work and deepened health inequities.7 In addition to being under-funded, communities of color have also actively been harmed, both historically and in the present day, by bad policymaking and a health care system entrenched in structural racism.8 This marginalization and under-funding of CBOs has, rightfully, resulted in a lack of trust in federal, state, and municipal agencies. Due to being deeply ingrained within the communities they serve, CBOs already hold the knowledge and the solutions necessary to improve health outcomes. To rectify these harms and ensure CBOs’ ability to address health equity in their own communities, these relationships must be intentionally repaired.
For community-based groups tackling maternal health equity, these issues are magnified. Maternal health CBOs often provide services that are excluded from traditional health programs and insurance plans, but which have historically been centered in Black birthing models throughout history.
Community-based doulas in particular provide nonclinical support throughout the pregnancy, childbirth, and postpartum period and improve outcomes for birthing people and their infants.9 Despite having a long history in the Black community, the doula workforce is predominantly white and doula care is often inaccessible to the patients who need it most: doula care reduces racial inequities and offers key support and advocacy to Black women and birthing people.
Similar to the exclusion of doula care, midwives represent key birthing care workers who have origins in African practice but were discriminated against in the U.S. health care system—with attacks based largely in racist rhetoric.10 Midwives, who in the United States are now primarily certified nurse-midwives or certified midwives, offer holistic care that improves outcomes and patient satisfaction.
Midwives represent key birthing care workers who have origins in African practice but were discriminated against in the U.S. health care system—with attacks based largely in racist rhetoric.
CBOs often utilize doula and midwifery care, along with other holistic models such as freestanding birth centers, lactation support, and group prenatal care, that are crucial to reducing racial inequities in maternal health.11 Yet these groups are often doing this critically important work without sufficient resources, due in part to a lack of federal investment. In addition to expanding the types of providers eligible for reimbursement through Medicaid and other insurers (and ensuring that those reimbursement levels allow for a living wage), federal grants offer a potential pathway to funding—if those grants can be made accessible to CBOs.12
This section includes the most salient themes from interviews with participating maternal health community-based organizations. CBO leaders and staff from across the country provided insight on their current funding statuses, their perceptions of federal funding streams, and barriers to applying for federal grants. They also identified what facilitating factors would help them apply for funding, what this funding would mean for their organizations, and why an intentional effort to rebuild trust between the federal government and communities must be prioritized. Select quotes are included to illustrate these themes in the words of interviewees.
The Status Quo: How Participating CBOs Operate and How They Are Currently Funded
The six community-based organizations participating in this project receive funding from varied sources, though none are current recipients of federal funding. These CBOs receive funding from a number of private family foundations and community foundations, in addition to individual gifts and fundraising efforts. Some groups are recipients of funding streams from local or municipal governments, either directly or as subgrantees. For CBOs that provide medical care, reimbursements are received from Medicaid and other insurers—although several CBOs highlighted the insufficient level of reimbursement rates, particularly from Medicaid.
Despite intensive fundraising efforts and diverse streams of funding, these CBOs are operating within limited budgets, constantly having to pursue additional opportunities to maintain—and ideally expand—their work. Interviews with CBO staff highlighted the tenacity of these organizations to provide care with limited resources, their impact far outpacing their budgets. Throughout our interviews, CBO leaders spoke about their dedication to serving pregnant and birthing people in their communities—even if it requires providing services without adequate reimbursement or offering sliding payment scales.
CBO’s Perceptions of Federal Funding and Barriers to Applying
“Is the juice worth the squeeze?”
Given barriers to sustainable and sufficient funding streams, many CBOs had considered applying for federal funding before being approached by TCF for participation in this project. However, the idea of applying for funding was daunting—with applications that one CBO leader described as “cumbersome”—the process was perceived as insurmountable and potentially not worth the effort. As Jordan McRae of Washington, DC-based Mamatoto Village put it, CBOs are having to calculate whether “the juice is worth the squeeze.” Jordan continued, “…it’s great to have, but also—is it worth it for all the barriers that are typically around it?”
Throughout our interviews, CBO leaders raised the idea of a catch-22: the infrastructure needed to successfully apply for and manage federal grants requires more funding to begin with. On top of that, there is a sense that these opportunities are not attainable for under-resourced CBOs, which makes these organizations less likely to put in the effort to pursue the funding.
“…for our organization, federal funding in the past has felt pretty elusive. It felt [like] something that required us to get to a certain level before we could actually apply for that funding and be a competitor to even receive that funding. And then also, internally, have the capacity to manage all of the components and aspects that come with federal dollars.”—Aza Nedhari, Mamatoto Village
“[Our perception was] that the process of applying and then stewarding, if we were to receive it, would demand more administrative infrastructure than we might have.”—Kendra Copanas, Generate Health
“A lot of that stuff is just time consuming and when you are running an organization like we’re running and you’ve got to prioritize some things, [do] you spend a lot of time on something that’s a million to one shot anyway, because how the politicals and their usual suspects still get the monies over you anyway, or do you focus on the work? We chose to focus on the work.”—Dorian Wingard, ROOTT
Burdensome and Convoluted Applications
A major barrier to applying is the application itself. Notice of funding opportunities (NOFOs) often have instructions alone that stretch over fifty pages, and the application can ask for upwards of sixty or eighty pages of answers and documents, depending on the funding opportunity. CBO leaders expressed not only the burden of completing applications, but also the short turnaround time allotted to do so.
“…the time it takes to either form partnerships, solidify programming, or even write the proposal, personally for me, I like a good four to eight weeks to at least get comfortable and read through the proposal and put things together. And not everybody has that time if they’re submitting grants or working on other fundraising, you know, concerns at the time.”—Jordan McRae, Mamatoto Village
“I think another perception is, we look when things would come up across our desk and we didn’t have time to mount the collaborative response to an application. And as a coalition…we do everything in partnership with community and organizations, and so we really need more lead time….to be ready to move on something because the application window is too small to do good collaborative planning, and get a grant submitted on time.”—Kendra Copanas, Generate Health
CBO leaders frequently raised the inaccessibility of these applications, frustrated by what they see as an unnecessarily complex and bureaucratic process.
“I think the process for federal funding is a very convoluted one. First off, you have to understand what the heck they’re talking about. Half the time you’re like, oh, okay, I gotta page through all of this. Like, what are you saying?…so you need someone just in and of itself just to be able to decode that. If you’ve never dealt with federal funding before…it’s just overwhelming.”—Chanel Porchia-Albert, Ancient Song Doula Services
“In my own, uninitiated way, when I would apply or try to apply before I could even get halfway through the, you know, the request for proposal, I’d be in breakdown mode. So I’ve never completed a federal fund grant application on my own. Getting myself registered into [grants.gov], SAM [System for Award Management]—that traumatized me.”—Jennie Joseph, Commonsense Childbirth
“…with federal funding, where it’s like, all right, you gotta have a dictionary to read the [request for applications] or the [notice of funding opportunity]. And then even with that, there are so many different rules and regulations around it that it’s difficult.”—Jordan McRae, Mamatoto Village
Grant Management Requires Additional Labor Capacity That Many CBOs Cannot Afford
In addition to the barriers of the application process itself, the administrative burden of managing grants can serve as a deterrent to under-resourced organizations. Frequent reporting requirements and complex compliance issues can be daunting for small organizations with small staff sizes.
“I think the biggest thing is the labor it takes to get your reports in, your financials, all that, with the small amount of money that you’re given.”—Rose Anderson-Rice, Generate Health
For CHOICES, which provided abortion care in Tennessee before abortion was banned in the state, there were heightened concerns around receiving federal funds. The use of federal funding in the provision abortion care in the U.S. is already prohibited (except in very limited circumstances) because of discriminatory budget riders such as the Hyde Amendment.13 The clinic, in its Tennessee location, is no longer providing abortion care. But in the aftermath of the Dobbs decision and the increasing criminalization of pregnant people and health care providers—particularly impacting people of color—there may still be a chilling effect that could discourage maternal health providers from receiving federal funds.
“We’ve always kind of shied away from any federal funding because of [our history as an abortion provider]. We are in Tennessee. [In] the state, we are a target. We recognize that even now that we don’t provide those services here in Tennessee because they’re illegal, we are still a target, I guess because we have—we are supportive and continue to be supportive of patients who need that type of care.”—Nikia Grayson, CHOICES
Doubts That the Review Process Can Appreciate CBOs’ Contributions
In addition to the work required for applications, community-based organizations—and Black-led groups in particular—expressed concern about the review process itself. Many CBOs doubted whether the unique work carried out by community-based groups would be understood and valued by grant reviewers.
“And while there are great opportunities to go after, you then get into the question of just, like, alright, who’s reviewing these proposals? Do they understand our work? Will they have the cultural background to get why we exist and why we’re doing this work? And for many times it’s just like, ‘I don’t know who’s on the other end of those proposals or who’s reading it or how they’re gonna score our work.’ And so there [are] a lot of challenges that come along with these great opportunities.”—Jordan McRae, Mamatoto Village
“[In 2014] we were in the Healthy Start Program [and] really came to find that the reviewers didn’t understand community-based organizations. And that more and more those that were getting funded were hospitals and academic centers and large multi-conglomerate social service organizations…reviewer comments were really not responsive and respectful of community-based work.”—Kendra Copanas, Generate Health
Overly Prescriptive Funding Structures
Many interviewees also expressed the restricted nature of federal funding that could limit the work they are able to do with those resources. Generate Health, who had previously received federal funding, spoke about this issue:
“[Federal grants] felt prescriptive and restrictive a bit in the funding. You’re usually funded for something pretty narrowly defined by the federal government.”—Kendra Copanas, Generate Health
“[Not having federal funding is] nimble, like it allowed you to, [say] ‘oh, okay, this really could be how we show up in community more authentically and not with such prescribed narrow functions and accountability.”—Rose Anderson-Rice, Generate Health
These limitations can also affect the population that groups are able to serve, and these designations can seem arbitrary to the CBOs already deeply enmeshed in their communities.
“…what I have noticed in working with county and city and state agencies is that when receiving federal funding, they are limited in how they’re able to provide services to those who are oftentimes most disenfranchised…for instance, like, zip code restrictions and limitations on like how the funding can work.”—Chanel Porchia-Albert, Ancient Song Doula Services
What Has Helped—or Would Help—CBOs Apply for Funding
Working with Partner Organizations Can Help with Technical Support and Capacity
Partner organizations—specifically larger, well-funded organizations with greater staff capacity—are also serving as intermediaries to help CBOs navigate the grant application process and fill in some of the gaps they are experiencing. For example, Generate Health has a long standing relationship with the Missouri Foundation for Health, which provides technical assistance like grant writing, as well as funding support. This project with TCF is another example of a partner organization stepping in to fill a gap.
Trust, accountability, and support were three major themes that arose in every interview when it came to CBOs addressing partnership with other organizations. These qualities and characteristics, when shared with partner organizations, made it feasible for CBOs to consider applying to certain federal funding opportunities.
“When TCF [approached us], this project came up, it made sense to us because it was a supportive dynamic. It allowed us to think differently about it. There were supports that insulated the process.”—Dorian Wingard, ROOTT
“You guys are like a support group right now. Thank goodness you’re running interference. But the fact that you have to, I think, sums up everything you need to say. Cause if you weren’t doing this, guess what would be going on? Nothing.”—Jennie Joseph, Commonsense Childbirth
The idea of CBOs operating as subgrantees, receiving funds through an intermediary who is the primary grant recipient, has also been suggested over the course of this project. Some CBOs have had negative experiences as subgrantees due to a lack of accountability when it comes to the distribution of funds.
“You’ll find that the awards that are for CBOs by themselves are still at a much lesser amount than they would be if they are [directly given to] or tied to a major university or entity. And then even in that, some of it isn’t clear about how the funds would be allocated.
“…we were approached to be a part of [a] funding opportunity for a multi-site [project], but nobody could answer [how funding would be allocated]. And it wasn’t clear in the definition as to how the money was going to be allocated. It was basically, ‘we want you to work with CBOs, but we’re going to fund you directly and then you have to give the money over to them.’ And we said, absolutely not. We’re not doing that.”—Jessica Roach, ROOTT
Despite some CBOs citing poor past experiences being subgrantees, many are still open to that type of partner relationship with a larger organization in the future, as long as specific conditions of trust and accountability are able to be met and maintained throughout the relationship. Due to the low staffing capacity many CBOs have described, acting as subgrantees could provide an opportunity to receive federal funding without the same level of administrative burden. When asked about their interest in receiving funding as a subgrantee, the CBOs shared the conditions that would have to be met for these relationships to be beneficial.
“Yeah, we would [be interested in being a subgrantee]. And we’ve done that before and, and it’s, and it’s worked out well…I think also those partnerships and collaborations are important and it also allows us to partner with organizations that we would not normally partner with, but also that would not normally get the type of funding”—Nikia Grayson, CHOICES
“Oh yeah, definitely [interested]. I think trust and having that oversight and accountability is something that we talked a lot about when it comes to grantees. And hopefully that’s something that we can, you know, continue reiterating to HRSA as well if they are going to be offering these grants to larger organizations that are going to have subgrantees.”—Jennie Joseph, Commonsense Childbirth
Additional Technical Assistance Is Needed
CBOs indicated they would like more support from federal agencies in the form of technical assistance. They emphasized the importance of having technical assistance not just before the application process begins, but during the review process and after the grant is rewarded, as well. Additionally, some CBOs mentioned that having assistance following an unsuccessful grant proposal is crucial so that CBOs can understand where they may have gone wrong and how to strengthen their applications for future grant cycles.
CBOs encountered issues in the past with both substantive questions about the application process as well as navigating the online platforms and systems used to manage the application process. Dorian Wingard from ROOTT spoke about receiving varying answers to questions from various agency staff throughout the process, and described a need for consistency and ongoing support.
“[We need] realtime technical assistance…And the systems that they have folks use—the platforms that you have to apply through—they’re not stable, they’re inconsistent sometimes, and you may lose this and that. The technical assistance is helpful at each level, from the pre-application level, to the questions, to the actual completion of it, to the post timeline of all that is yet to come.”—Dorian Wingard, ROOTT
“I think for CBOs’ capacity, some folks don’t have the capacity for grant management. And so, you get the grant, now how are you going to manage it? So being able to offer technical assistance in that realm, or a springboard of some sort, can help. [Offering] someone to come to you every three months or quarterly to go through things, see how you’re doing, offer technical assistance at any time, at no additional cost, to support you through this process…
…I think technical assistance and just maybe understanding the processes for how they designate grants, and how to properly submit an application, or if someone submits an application and the application doesn’t get approved, being able to walk somebody through that process of what that looked like and why.”—Chanel Porchia-Albert, Ancient Song Doula Services
Streamlined Processes and More Lead Time Will Increase Accessibility
Given the barrier of cumbersome applications and short turnaround time, a streamlined process was named as a potential facilitator to help CBOs apply for funding. Having a more streamlined application process and more ample lead time for these CBOs, who are already operating under limited capacity, to assemble the materials and documents necessary for them to have a successful application, would improve the likelihood of them applying for federal funding. CBOs also offered examples of potential solutions that could save their staff time and energy.
“I would just say [what would be helpful is] a clearer process. You know, something that they specifically say, okay… Here’s what you need to do, here’s a checklist: do this, this, and this. Offer a video series or something, a technical assistance series that allows you to be able to navigate it if you have questions. And just streamline the process… I think if that happens, then the actual implementation of the funding would be a lot smoother and easier.”—Chanel Porchia-Albert, Ancient Song Doula Services
“What I think would really help may not be feasible. But, by simplifying the application, even having a quick letter of interest, an LOI [letter of interest], that’s a process where you don’t invest a huge amount of time and a full application only to find out that you’re not really competitive. An LOI process doesn’t drain the resources as much from your organization to see if you’re selected to move forward.”—Kendra Copanas, Generate Health
Greater Transparency Will Instill Trust in the Review Process
Having more insight into the application review process to better understand who receives awards and why, and receiving feedback at the end of application cycles were all things the CBOs emphasized wanting more of in order to feel more confident about applying for funding. Mamatoto Village called for more information about who is reviewing these applications, whether or not they understand the CBO applicants, and for clarity on what frameworks agencies are using to determine who receives awards.
“I know that on their website they have a list of the different institutions and different organizations that they funded, but as you take a look down that list, you see large hospital systems, you see large academic institutions. So, as a person that has experience writing these grants, I know that those larger institutions are the primary awardees and they are sub-awarding to CBOs that are probably actually doing the work and doing a bulk of the work. When you have that sort of practice at play, it really puts the CBOs close to these structural causes that we’re trying to battle against.”—Jordan McRae, Mamatoto Village
While the Biden-Harris administration has made bold commitments to supporting CBOs, specifically those led by people of color, tracking progress towards these commitments is also needed in order for communities to feel as though they are not being made empty promises.
“If there is an intention to support more Black or BIPOC led organizations at the CBO level, then I think it’s very helpful for there to be a framework that folks can actually see and actually assess the progress towards those goals. Because if there’s no framework, there’s just unorganized intention, and that really doesn’t take us anywhere. It just kind of keeps us spinning our wheels and hoping for something to change.”—Jordan McRae, Mamatoto Village
Federal Funding’s Potential: What Access to This Funding Would Change for CBOs’ Work, and What Kind of Opportunities CBOs Want to See
Federal Grants’ Structures Are More Sustainable Resources
The multi-year nature of many of the federal funding opportunities would enable CBOs to have consistency and continuity, in contrast with the shorter term grants often provided by private funders. Additionally, the dollar amount of funding available through federal grants is typically greater than the funding these organizations are already receiving.
“It’s a more sustainable source of funding for organizations, generally because it’s not a ‘one and done’. You have more multi-year funding and you have a larger pot of funding that you’re able to work with. Even though those dollars are very much restricted for whatever it is that you applied for, it’s the amount of funding that is going to give you what you need to build, whether it is to build capacity, to bring something to scale, capacity to build an evidence base for something, or to have the people power to be able to move something forward.”—Aza Nedhari, Mamatoto Village
Scaling Up and Capacity-Building Will Come within Reach
Without sustainable funding, CBOs find it challenging to scale up the important work they do and critical services they provide to their communities. The CBOs involved in this project are all demonstrating models of care with impressive outcomes and metrics that ideally, they want to make accessible to as many people as possible. Direct service organizations, such as CHOICES, mentioned actually losing money when relying on Medicaid reimbursement rates; by prioritizing the communities they serve, they often are doing work that is unfunded.
“Our state Medicaid is TennCare. Presently, the majority of our patients, actually 70 percent of our patients, are on TennCare. That’s purposeful. We do center them recognizing that they need access to high quality, non-judgmental care, and they also need access to midwifery care—which is very scarce in our community—and need access to other birth options. Additional funding would definitely allow us to hire more midwives and expand our programs.”—Nikia Grayson, CHOICES
Ancient Song also referenced scaling up the workforce capacity of her organization as something that could come from receiving federal funding.
“We have such a high demand. I mean, we get about a hundred plus referrals every month. We can’t meet the needs of the people who are requesting the services because we just don’t have enough people to cover, unfortunately. So, being able to build up capacity would be amazing. And then we can hit all those target deliverable numbers that [the federal government is] looking for.”—Chanel Porchia-Albert, Ancient Song Doula Services
With federal funding, ROOTT could build the capacity of their successful program models as well as develop their staff.
“We would be able to expand into being not only an aid for our own organization, but be able to [provide] better technical assistance to other organizations…. If we were to get those levels of federal funding resources, we would be able to utilize the skills, ability, and the brain trust that is in this organization at a maximum level, and be able to continue to develop the programs…staff could be even better supported and we could have more staff to be able to have a further reach.”—Jessica Roach, ROOTT
The Support Necessary for Meaningful Data Collection and Research
Data collection and research capacity is another area where the CBOs are looking to expand if they obtain federal funding. Strong data collection enables CBOs to capture the impact of their work in communities and equips them with metrics that in turn, can make them stronger candidates for future, bigger funding opportunities.
“We just implemented a new data system, it’s taken a while to get it off the ground, but we have a researcher. I would like to build that out and really be able to scale it up, as well as data collection to really show the impact of what the community is doing through education, through resources, and through getting interpersonal interactions with folks.”—Chanel Porchia-Albert, Ancient Song Doula Services
A Need to Build Trust and Repair Relationships
The historic and ongoing harms that have been inflicted on communities of color by the federal government, as discussed earlier in this report, also impact the way community-based organizations approach potential federal funding opportunities. Throughout our interviews, CBO leaders expressed feeling hesitant to devote resources to entering into funding agreements with federal agencies.
“…trust is a two two-way street, and given the long history that the federal government has had within communities of color, building up trust is something that has to be oftentimes earned in order to establish good working relationships. And so, although you may be throwing money somewhere, it’s not just about the money, it’s also about where’s the intentionality around communication, transparency, equity and justice…understanding that this is also an opportunity for repair and reconciliation by also taking the time to listen to community-based organizations—but not just listen, but take into the fold of the work that you do and where you can make changes.
“…Because again, you’re working from a place of not even an empty cup when it comes to trust within communities of color. And so how can you fill up that cup? Well, you wanna make sure that you fill it up. You know, integrity and intention and reciprocity and a level of openness that traditionally hasn’t been within that space.
“…okay, how can we work this out? Like, you know, get HRSA to understand how good intentions can go sideways—where you don’t necessarily have the voice of the people who are most impacted in the room, you know, and that voice happens to be these community-based organizations who are doing the work every day.”—Chanel Porchia-Albert, Ancient Song Doula Services
Jennie Joseph of Commonsense Childbirth spoke of her struggle to receive Medicaid reimbursement from the state of Florida, and how that experience affected her desire to pursue federal funding.
“It’s taken me the full twenty-five years [of operating] to get to the point that we can send a claim and get paid, and that has been a lone wolf, independent fight, the fight on your own, you know—all but marching on Tallahassee, ready to lay in the street, to be run over so that we can have a point made and all of the heavy, horrendous, deep bureaucratic nonsense that we’ve had to deal with just to get paid. To me, I’ve maybe wrongly connected the federal grant processes to be similar. My experience when I go to events, you know, conferences or I’m joining on these webinars or whatever, and the way it comes across is, yeah, you’re right behind…there’s never been a sense in any interaction with them that there is anything other than that mad bureaucracy behind it.”—Jennie Joseph, Commonsense Childbirth
Repairing these relationships, CBO leaders argued, requires acknowledging the racism embedded in the structures of federal agencies and their bureaucracies.
“We have to quit acting like these processes are not examples of systemic and structural racism. They are, it’s embedded in there. They’re built for the usual suspects in the larger organizations with the higher capacities…which are typically PWIs [predominantly white institutions] that claim that they’re doing work with certain communities…let’s understand that they have to be deconstructed in a way and then reconstructed in a better way that’s more inclusive and reflective of the contemporary landscape that we’re on right now…They have to switch up.”—Dorian Wingard, ROOTT
Community-based organizations like those interviewed by TCF are already doing the life changing and lifesaving work to reduce health inequities; as active and engaged members of their communities, they know what their clients need and how to best serve them. These organizations are too often under-resourced, though, and face barriers to applying for and receiving federal funding. This funding could play a critical role in allowing CBOs to not only continue their work, but also to scale up their programs and expand their reach. The insight provided by the CBO leaders interviewed for this report can and should be translated into action items to make federal maternal health funding accessible to the communities that need it most.
The authors greatly appreciate the time and insight of the CBO leaders and staff who were interviewed for this report: Chanel Porchia-Albert from Ancient Song Doula Services; Nikia Grayson from CHOICES; Jennie Joseph from Commonsense Childbirth; Kendra Copanas and Rose Anderson-Rice from Generate Health, Aza Nedhari and Jordan McRae from Mamatoto Village; and Jessica Roach and Dorian Wingard from Restoring Our Own Through Transformation (ROOTT). The authors of this report would also like to thank Dr. Jamila Taylor, former senior fellow and director of health care reform at The Century Foundation, for her work to set the vision and establish this project, and the staff at the Health Resources and Services Administration who have participated in listening sessions and offered technical assistance to CBOs throughout this project as they work to make their funding processes more equitable.
- Jamila Taylor, Anna Bernstein, Thomas Waldrop, and Vina Smith-Ramakrishnan, “The Worsening U.S. Maternal Health Crisis in Three Graphs,” The Century Foundation, March 2, 2022, https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/
- Jamila Taylor, “Racism, Inequality, and Health Care for African Americans,” The Century Foundation, December 19, 2019, https://tcf.org/content/report/racism-inequality-health-care-african-americans/
- “A Proclamation of Black Maternal Health Week, 2021,” The White House, April 13, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/04/13/a-proclamation-on-black-maternal-health-week-2021/; “White House Blueprint for Addressing the Maternal Health Crisis,” The White House, June 2022, https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf
- “Community-Based Models That Are Improving Equity and Black Maternal Health Outcomes: A Focused Analysis,” Families USA, July 2021, https://familiesusa.org/wp-content/uploads/2021/07/2021-232_Analysis_MCH-CBO-Landscape-Summary_E.pdf
- Mamatoto Village, “Maternal Health Care for Black Women, by Black Women,” The Century Foundation, September 22, 2022, https://tcf.org/content/commentary/maternal-health-care-for-black-women-by-black-women/
- Urban Institute, “Opportunity for All: Federal strategies to support strong and inclusive neighborhoods,” September 9, 2020, https://www.urban.org/opportunity-for-all
- Eva H. Allen, Jennifer M. Haley, Joshua Aarons, and DaQuan Lawrence, “Leveraging Community Expertise to Advance Health Equity: Principles and Strategies for Effective Community Engagement,” The Urban Institute, July, 2021, https://www.urban.org/sites/default/files/publication/104492/leveraging-community-expertise-to-advance-health-equity_1.pdf
- Ruqaiijah Yearby, Brietta Clark, and Jose F. Figueroa, “Structural Racism In Historical and Modern US Health Care Policy,” Health Affairs, February 2022, https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01466; Martha Hostetter and Sarah Klein, “Understanding and Ameliorating Medical Mistrust Among Black Americans,” The Commonwealth Fund, January 14, 2021, https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans
- Vina Smith-Ramakrishnan, “Solving the Black Maternal Health Crisis Will Require Advancing Access to Community-Based Doula Care,” The Century Foundation, April 2022. https://tcf.org/content/commentary/solving-the-black-maternal-health-crisis-will-require-advancing-access-to-community-based-doula-care/
- Anna Bernstein, “This Black Maternal Health Week, Let’s Expand Access to Midwifery Care,” The Century Foundation, April 2022. https://tcf.org/content/commentary/this-black-maternal-health-week-lets-expand-access-to-midwifery-care/
- Laurie Zephyrin et al. “Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity,” Commonwealth Fund, Mar. 2021. https://doi.org/10.26099/6s6k-5330
- Vina Smith-Ramakrishnan, “Working to Expand Doula Coverage This Black Maternal Health Week,” The Century Foundation, April 2023. https://tcf.org/content/commentary/working-to-expand-doula-coverage-this-black-maternal-health-week/
- Jamila Taylor, “Let’s Get Rid Of Abortion Coverage Restrictions Once and for All,” The Century Foundation, September 26, 2019, https://tcf.org/content/commentary/lets-get-rid-abortion-coverage-restrictions/