Today's Doulas Support Birthing Parents, But Aren't the Solution to a Broken System

Looking at doulas from a global health perspective.

In 2022, 817 women* died of maternal causes in the United States. Admittedly, that’s a decrease from the 1,205 maternal deaths in 2021. But despite a gradual decrease in annual maternal deaths nationally, a few things remain unchanged. First, the majority of these deaths (80 percent) are preventable. Second, Black and Indigenous women face the highest risks of maternal death. And third, the United States continues to have the highest rates of maternal death of any high-income nation globally. 

 The “baby-first” obstetric model, which prioritizes the needs of the fetus over the health and wellbeing of the pregnant person and often illustrates what scholars call “fetal personhood” plays an essential role in this trend. A growing number of birthing people turn to doulas, nonmedical support professionals who aid patients' in developing their voice and sense of agency, to recenter their autonomy and humanity under the baby first model.

Mortality: The tip of the iceberg

Today’s conversation on maternal health offers a necessary, but incomplete US-centric conversation about birth and death. Maternal morbidity, which the World Health Organization defines as “any health condition attributed to and complicating pregnancy and childbirth that has a negative impact on the woman’s well-being and functioning,” is rarely mentioned, though roughly 20 to 30 birthing people experience morbidity for each maternal death. 

Ericka Dorsey, a doula, maternal and infant health consultant, and Co-Founder of Flourishing Families, Inc., notes that in California, then-senators Kamala Harris and Holly Mitchell were instrumental in pairing maternal and infant health outcomes. Nationally, she saw birth advocate and Irth founder Kimberly Seals Allers expanding the conversation. The requested redefinition that infant mortality-only conversations be shifted for a holistic approach that supported breastfeeding strategy and reminded mothers and birthing people that their needs and health mattered, too. 

While the United States is unique in its experience as a high-income nation with such high maternal deaths, women of color experience morbidity and trauma globally. Reframing maternal death as an essential though non-exclusive marker of a nation's health and outcomes offers a more comprehensive image of the diverse factors birth advocates and birth workers, like doulas, seek to challenge. 

Dorsey says she and others asked, "What were the things we did long ago that carried us?"

“In this holistic approach, what are some of the components that have historically helped Black women? How can we reintroduce those? And that's where we start talking about doulas. That's where we start talking about midwifery. What were the things we did long, long ago that carried us?”

The Role of Doulas in Support

“Our role in perinatal care is to be the physical, emotional, and mental support systems and advocates for our clients,” says Anna Balagtas, founding member of the National Collaboration for Doula Access. “We are focused on making sure the birthing person and family are completely cared for during our time together and that their needs are met—spoken or unspoken.”

She views a doula as a built-in advocate throughout care, including in instances where medical staff coerce patients into unwanted treatments or interventions. Doulas support pregnant women and birthing people in nearly every setting, from hospitals, birth centers, and home births through c-sections and vaginal births.  Research highlights doulas and birth companions to improve positive outcomes during pregnancy, birth, and postpartum. Doula-assisted births involve fewer cesarean sections, less anxiety and depression for pregnant people, less pain-relief medication during labor, shorter time in labor, and fewer negative childbirth experiences. 

Brianna Simmons, a lifecycle facilitator with Unearthing Tradition, says doulas play a crucial role in the childbirth experiences of Black birthing people; with representation, affirmation, and information, Black birthing people are better equipped to access healthy outcomes with a doula by their side. This includes ensuring our families are well-resourced, informed about their options, and prepared to navigate many situations.

Doulas improve outcomes but can’t solve maternal risks alone.

She notes that doulas shift power dynamics in birth settings but can’t erase them. “Doulas, especially community birth workers, who look like the clients and families that they work with, are under the same oppressive systems; unless we are directly challenging the root causes of the maternal health care crisis in this country, doulas will continue to play a key role, but cannot be expected to remedy the problem all alone.”

Despite the benefits, concerns, and misunderstandings persist.

“There is an information gap that makes it appear as if doulas are a luxury add-on to your pregnancy journey, while some of the most vulnerable populations have no idea what a doula is or how they can support them through their reproductive journey,” says Simmons.

She worries about the pattern of extracting cultural customs and leaving those connected to the traditions behind. “As birth workers become more mainstream, it is vital to ensure that the needs of Black and Indigenous birthing people remain at the forefront of birth equity conversations and actions,” she says. “It is our ancestral traditions of community care throughout pregnancy, labor, birth, and postpartum that have shaped the practices we've professionalized.”

For many doulas, this work is bigger than birth. It’s about restoring a sense of agency through traditions. She notes Black, Indigenous, and other communities have faced unspeakable injustices from the healthcare system while also experiencing the highest health disparities. She says community-based solutions aren’t just life-saving—they offer empowerment and agency to those historically harmed.

Challenges and Opportunities for Doulas

Balagtas, who practices as a doula in Canada, says she supports insurance coverage as a way to increase the affordability of care but is mindful that it may raise new concerns.

“Here, doulas are an unregulated profession. However, as we see a rise in insurance coverage for doulas, we also see a rise in markers of regulation towards our work,” she says, noting that doulas must be certified for families to receive insurance coverage. With few certifying bodies and even fewer that address systemic injustice. “Many of these doula trainings are not aligned with the values of many doulas who practice with radical, political, and anarchist care.”

Balagtas isn’t the only doula with concerns. The Department of Labor’s Women’s Bureau conducted two listening sessions with doulas and doula servicing organizations that found the struggle to have work-life balance and equitable pay even as they enjoy the work.  The sessions found that community-based trainings are more effective than standardized courses for Black, queer, and other doulas who serve historically disenfranchised populations. Insurance reimbursement provides benefits, but mental health support, childcare access, and other issues persist.

“Because of systemic barriers and the racial wealth gap, BIPOC doulas often feel the need to provide pro-bono care to BIPOC families who would not be able to afford their services in the first place,” she says. “This just perpetuates the cycle of BIPOC doulas feeling burnt out from this work and is left feeling unsustained and underpaid.” 

Balagtas is concerned that standardized certification will impact those who want to practice more radically to meet the needs of the systematically marginalized?”

Mindful of these concerns, Dorsey encourages the doulas she supports to get certified anyway to avoid the eradication of Black midwives that occurred in the aftermath of the  Sheppard Towner Act. “We'll change this landscape; right now, get all the things they're telling you to get.” Instead, she focuses on securing funding, like grants, to reduce out-of-pocket costs for current and hopeful doulas. This work has been successful in California.

Investing in the BIPOC doula community is essential to improve the experience for doulas and patients. 

Dorsey notes the importance of creating opportunities for current and hopeful doulas with funding to further create pathways of community support and sustainability. "I want this person who has a desire to help the community, for their family, to be sustained on the work that they're doing, to help the community," she says. "That completes the circle because they're giving back to the community, but the community is giving to them and their children and the sustainability of their lives."

“While doulas offer crucial care and support to their families, they can't remedy the maternal health care crisis in this country without a deeper analysis and effort toward remedying the root causes of maternal and infant mortality and morbidity,” Simmons says, noting the need for a cultural shift that earnestly prioritizes all life and all families.

“We need to embrace the necessity of sharing resources and working together to protect the planet. We need a cultural shift that works to remedy the degradation of entire communities while also creating pathways for the reclamation of Black traditions and Indigenous practices,” she says. “We need pathways for doulas to become midwives and pursue other clinical pathways. We need to address the profit-seeking practices of our healthcare system that misleads and takes advantage of vulnerable people.”