Community-based doulas
Doulas provide physical and emotional support and education throughout pregnancy, birth, and postpartum to birthing people; they may work independently or as part of collectives, as private pay doulas, community doulas, or for hospitals1. Community-based doulas provide culturally appropriate doula care and other supports to birthing people who are at higher risk of poor outcomes and underserved by the medical community1, 2. Community-based doulas are trained non-medical professionals who reflect the communities they serve, sharing similar backgrounds such as culture, race and ethnicity, language2, 3, or gender identity4 and usually have additional training beyond a traditional doula curriculum, reflecting their community’s needs2. Like private pay doulas, community-based doulas provide birthing support and prenatal and postpartum home visits, though community-based doulas usually provide more home visits, as well as additional services and referrals appropriate to the communities they serve, such as childbirth and breastfeeding education, health navigation, and advocating for clients with and serving as a liaison to providers2, 5. Hospital-based doulas may only be available during labor and delivery6. Community-based doulas are usually low or no cost2, 3, as program funding may come through grants or partnerships, and such doulas often work as part of a large program or collective3, 7. They are not usually covered by insurance7, though a growing number of states provide doula coverage through Medicaid8. Community-based doulas are also sometimes called perinatal or maternity community health workers7. Doulas providing similar care include reproductive justice doulas9 and Indigenous doulas10.
In this entry “doula” is used to describe evidence from any type of doula care (i.e., hospital, private, and/or community-based). “Community-based doula” is used to summarize evidence related to community-based doula care specifically.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved birth outcomes
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced low birthweight births
Reduced preterm births
Increased breastfeeding
Reduced cesareans
Improved parenting
What does the research say about effectiveness?
Community-based doulas are a suggested strategy to improve birth outcomes, particularly among birthing people from racial and ethnic minoritized groups7. Available evidence suggests community-based doulas may reduce low birthweight births11, 12 and preterm birth12, 13. Additional evidence is needed to confirm effects.
Community-based doulas may also increase breastfeeding initiation14, 15. Community-based doulas impact on cesarean sections is unclear, with some studies suggesting they may reduce cesareans in some circumstances13, 16, while others find no impact12. A study in an urban safety net hospital suggests that combining community-based doulas with medical legal partnership services had non-significant but positive impacts on cesarean deliveries and exclusive breastfeeding for Black participants17. Community-based doulas as part of a home visiting program appear to improve health-related14 and parenting behaviors18, 19, including those related to learning20 and safety14.
In general, continuous labor support provided by doulas appears to reduce cesarean sections21. Doula support appears to decrease conditions associated with maternal morbidity22 and can increase breastfeeding initiation23. A study among Medicaid patients suggests doula support decreased cesarean sections and postpartum depression and anxiety (PPD/PPA)24.
Barriers: Barriers to expanding the use of doulas include lack of awareness among patients and providers about doulas and their services, high out-of-pocket costs due to lack of coverage of services by health insurers, and the limited numbers of doulas available1. Barriers to expanding the community doula workforce and recruiting more culturally congruent doulas from historically underserved populations is often related to cost: the cost of training and certification for individual doulas3, 25; finding and maintaining adequate funding3, particularly for smaller training organizations who are more likely to recruit from these populations3; and ineffective payment models26 that don’t pay a living wage3. The standard doula fee-per-client compensation model does not provide adequate compensation27 and leaves many community doulas financially unstable4. Providing services for free or low cost without adequate compensation hurts the long-term sustainability of the workforce28. Community-based doulas also face the same barriers as their clients, encountering structural and interpersonal discrimination while providing care4, 29. One study suggests doulas usually work in the profession only three to five years, often due to burnout30. Support and professional networks, such as those found in community-based organizations2 are needed4.
Recommendations: Community-based doulas often spend significant amounts of time providing support outside of direct patient care31; experts suggest additional compensation should be provided to reflect all aspects of care provided3, 31, and organizations employing community doulas should provide higher wages and benefits30. Experts also suggest community-based doula services be covered by Medicaid2, 3 and that Medicaid should reduce the complexity of enrollment and reimbursement paperwork where doula services are covered1, 30.
Recommendations for Medicaid coverage for all doulas includes diversifying the workforce by recruiting from low-income and rural communities, racial and ethnic minoritized communities, and others facing cultural barriers using fee waivers and scholarships for training2, 7, 32; providing a living wage and fair compensation for services2, 7, 32; covering full spectrum doula care that includes multiple pre- and post-natal visits and support for pregnancy loss32; and ensuring training requirements are inclusive to the spectrum of doula models (including flexibility around certification)32. Additionally, doulas and community organizations should be involved in Medicaid policy development and implementation2, 32, including scope of practice, training, reimbursement33, and funding32.
When creating a community-based doula program, experts suggest creating strategic partnerships with birthing sites26; using both research evidence and anecdotes to increase buy-in from hospitals and providers during implementation34; considering what resources will be necessary to support both creating an organization and implementing a program26, including beyond implementation34; and working to encourage an organizational culture committed to health equity34.
There are many different organizations that provide doula training and certification. Many emphasize that trainings should include information on structural racism in maternal health33. Community-based doula models can support doulas by providing opportunities for career development, mentorship, and administrative support that may be unavailable to private pay doula models35.
Cost: Limited research in Minnesota and Oregon suggests community-based doula programs can be cost effective and result in cost savings for Medicaid7. A cost-benefit analysis suggests that providing doulas to Texas Medicaid recipients is cost-beneficial, particularly for Black women36, and a model built using hospital-based birth data from the Upper Midwest and North Central U.S. also suggests community-based doula care can be cost-effective or even cost-saving13.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.
Community-based doulas have the potential to decrease disparities in clinical outcomes and improve care experiences for birthing people who have been underserved and marginalized by the health care system, including people from racial and ethnic minoritized groups1, 2, 7, those with low incomes2 and those from LGBTQ+ communities7. However, doula care alone cannot overcome the health inequities in the health care system; there is a need to acknowledge structural racism’s negative impact on maternal health33.
Available evidence suggests that community-based doulas and doulas providing care to at risk populations may reduce low birthweight or preterm birth, including among birthing people who are Black, Hispanic, or who have low incomes11, 12, 13, 45. This type of care may also reduce birth complications45; increase breastfeeding initiation14, 15, 45; reduce cesarean sections; and decrease postpartum depression and anxiety in some cases13, 16, 24. Doulas may also increase respectful labor and delivery care for women who are Black, Asian/Pacific Islander, or who receive Medicaid28
Medicaid is the most common form of health insurance for people in underserved communities22. It covers over 40% of births in the U.S., and over 60% of births among populations that are Black and American Indian/Alaska Native1, 7. Experts suggest providing and increasing Medicaid coverage for doulas could reduce morbidity and mortality among birthing people22 and the Centers for Medicare & Medicaid Services (CMS) names continuous doula support during labor as a tool to improve maternal care management1. However, some community-based doulas are concerned that Medicaid coverage might change their scope of practice by embedding doula practice within racist and classist structures in the existing medical system, and that reimbursement challenges might discourage individuals from practicing in a community setting33.
Women who are Black or American Indian and Alaska Native (AI/AN), and those living in rural areas have higher rates of severe maternal morbidity and mortality than women who are white or live in urban areas1. Many pregnant people in rural areas, particularly in the Midwest or the South, live in counties with no obstetricians or maternity care centers, severely restricting their access to care46. The maternal mortality rate in the U.S. is higher than in any other developed country47, and there are stark disparities in maternal outcomes and maternal mortality between Black and white populations47, 48, as well as racial bias and discrimination in maternity care for Black women47. Preterm birth is approximately 50% higher among Black births than white births, low birthweight is almost double for Black infants, and infant mortality is more than twice as high49. Pregnancy-related mortality is three times higher for Black women, and two times higher for American Indian and Alaska Native women compared to their white counterparts; maternal death rates and racial disparities increased during the COVID-19 pandemic50.
While the push for community-based doulas has been strongest for communities with lower incomes, and that are primarily Black or Hispanic, additional groups could benefit, including Indigenous populations, immigrants and refugees, the uninsured7, birthing people affected by substance use disorder51, women who are incarcerated52, and transgender and non-binary patients4.
There is additional need for greater gender inclusivity and community doulas for LGBTQ+ birthing people9. LGBTQ+ birthing people face additional barriers and discrimination interfering with adequate care, including provider bias and physicians misunderstanding transgender and queer reproductive health care needs7. Queer and transgender parents are also at higher risk for developing post-partum anxiety and mood disorders9. LGBTQ+ birthing people sometimes avoid care due to bias and mistreatment. Community-based doulas for LGBTQ+ birthing people (sometimes called reproductive justice doulas) practice radical inclusion and nonjudgemental care, and may help by disrupting traditional gender norms and assumptions in reproductive care9.
What is the relevant historical background?
In 1900, approximately half of children in the U.S. were born with the attendance of midwives32, with lay midwives providing care to women who lived in poverty53. Efforts to medicalize pregnancy and labor9 and misinformation around the safety of midwifery32 marginalized community midwives, particularly in communities that were Black or Native American9. By 1930 less than 5% of births were midwife attended32. This coincided with efforts to rate and standardize medical programs54, 55, with the 1910 Flexner Report on medical training contributing to decisions to virtually end women’s admission to medical schools and severely restrict Black students’ admittance55, 56.
During the 1960s and 1970s, midwifery remerged out of the feminist movement’s pushback against the medicalization of birth9, 32, and in the context of other social justice movements, including the growing popularity of community health workers which recognized that community members are best positioned to understand their community, evaluate its needs, and identify solutions57. The modern concept of the doula as a labor support emerged in 1969 from the natural birth movement, but the role did not become “professionalized” until the founding of DONA, the first doula training and certifying organization, in 199232.
In the U.S., doula care is not usually covered by health insurance; this exclusion and the need to pay out of pocket for services means doula care use has been largely limited to those with the ability to pay (i.e. women with middle- to high-incomes, who are disproportionately white)1, leaving those from low-income communities without access to doula care2. Additionally, doulas have most often been women who are white and have higher incomes1, and not reflective of the populations who need them most2. The push against patriarchal medicine which founded modern midwifery and doula work also brought with it gender essentialism in its training and language, which has made it un-inclusive of birthing people who are queer and their families9
Equity Considerations
- What disparities in birth and maternal outcomes exist in your community?
- What resources are available for prenatal, birth support, and postpartum care in your community? Are certain groups less able to access the care and services available?
- What are the barriers to high quality, linguistically and culturally appropriate care?
Implementation Examples
Community-based doulas programs exist across the country. Some are part of public health departments, such as the Community Doula Support Program in Philadelphia37, NYC Health’s Healthy Start Brooklyn38, and the Citywide Doula Initiative39. Others are private nonprofit organizations, like the SisterWeb San Francisco Community Doula Network40 or the Diversifying Doulas Initiative of PatientsRWaiting in Lancaster, Harrisburg, and York Pennsylvania41. The Minnesota Doula Prison Project provides doula support to incarcerated women42.
As of June 2024, 15 states and Washington, D.C. actively reimburse for doula care through Medicaid, and others are in process of implementation; several also require private insurance coverage of doula care8. Coverage and reimbursement vary by state. Nevada’s 2023 legislation, led by community doulas, reimburses $1500 to cover three prenatal care visits, labor attendance, and three postnatal care visits in urban counties, with an incentive payment bringing reimbursement to $1650 for rural counties8. The 2021 California “Momnibus” also includes coverage of doula services in pregnancies that do not end with a live birth, including coverage of miscarriage, stillbirth, and abortion1.
States can also support doulas beyond Medicaid funding. The New Jersey Department of Public Health partnered with HealthConnect One to create the NJ Doula Learning Collaborative, which provides doulas with billing support, education, training and development opportunities43. New York publishes a Medicaid fee-for-service Doula Directory (NYS DOH-Doula Directory).
Baby Dove’s Black Birth equity fund provides private philanthropy funding to increase access to community-based doulas44.
Implementation Resources
‡ Resources with a focus on equity.
NHLP-Doula Medicaid - The National Health Law Program (NHLP). Doula Medicaid project.
HealthConnect One‡ - HealthConnect One. Leading the nation in community birth worker training research and advocacy.
HealthConnect One-Zainab 2023 - Zainab S, Mullins M. Getting doulas paid: Advancing community-based doula models in Medicaid reimbursement conversations. Policy brief. HealthConnect One. 2023.
Lesser 2020 - Lesser A, Nogales R, Weiss A. Bringing community-based doula care to New Jersey. Health Affairs Forefront. 2020.
Footnotes
* Journal subscription may be required for access.
1 ASPE-Knocke 2022 - Knocke K, Chappel A, Sugar S, De Lew N, Sommers BD. Doula care and maternal health: An evidence review. Issue Brief no. HP-2022-24. Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services; 2022.
2 Bey 2019 - Bey A, Brill A, Porchia-Albert C, Gradilla M, Strauss N. Advancing birth justice: Community-based doula models as a standard of care for ending racial disparities. 2019.
3 Safon 2023 - Safon CB, McCloskey L, Gordon SH, Cole MB, Clark J. Medicaid reimbursement for doula care: Policy considerations from a scoping review. Medical Care Research and Review. 2024;81(4):311-326.
4 Kett 2022 - Kett PM, van Eijk MS, Guenther GA, Skillman SM. 'This work that we're doing is bigger than ourselves': A qualitative study with community-based birth doulas in the United States. Perspectives on Sexual and Reproductive Health. 2022;54(3):99-108.
5 PN3-Doulas - Prenatal-to-3 Policy Impact Center (PN3 Policy). Policy Roadmap: Community-based doulas.
6 Steele 2015 - Steel A, Frawley J, Adams J, Diezel H. Trained or professional doulas in the support and care of pregnant and birthing women: A critical integrative review. Health and Social Care in the Community. 2015;23(3):225-241.
7 PN3-Community-based doulas report - Prenatal-to-3 Policy Impact Center (PN3). Policy clearinghouse: Community-based doulas.
8 NHLP-Doula Medicaid - The National Health Law Program (NHLP). Doula Medicaid project.
9 Shui-yin 2022 - Shui-yin Y, Fixmer-Oraiz N. Against gender essentialism: Reproductive justice doulas and gender inclusivity in pregnancy and birth discourse. Women’s Studies in Communication. 2022;46(1):1-22.
10 Ireland 2019 - Ireland S, Montgomery-Andersen R, Geraghty S. Indigenous doulas: A literature review exploring their role and practice in western maternity care. Midwifery. 2019;75:52-58.
11 Thomas 2023 - Thomas MP, Ammann G, Onyebeke C, et al. Birth equity on the front lines: Impact of a community-based doula program in Brooklyn, NY. Birth: Issues In Perinatal Care. 2023;50(1):138-150.
12 Thomas 2017 - Thomas MP, Ammann G, Brazier E, Noyes P, Maybank A. Doula services within a healthy start program: Increasing access for an underserved population. Maternal and Child Health Journal. 2017;21(suppl 1):59-64.
13 Kozhimannil 2016a - Kozhimannil KB, Hardeman RR, Alarid-Escudero F, et al. Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery. Birth: Issues in Perinatal Care. 2016;43(1):20-27.
14 Hans 2018 - Hans SL, Edwards RC, Zhang Y. Randomized controlled trial of doula-home-visiting services: Impact on maternal and infant health. Maternal and Child Health Journal. 2018;22(suppl 1):105-113.
15 Kozhimannil 2013 - Kozhimannil KB, Attanasio LB, Hardeman RR, O'Brien M. Doula care supports near-universal breastfeeding initiation among diverse, low-income women. Journal of Midwifery & Women’s Health. 2013;58(4):378-82.
16 Kozhimannil 2013a - Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. American Journal of Public Health. 2013;103(4):e113-21.
17 Mottl-Santiago 2023 - Mottl-Santiago J, Dukhovny D, Cabral H, et al. Effectiveness of an enhanced community doula intervention in a safety net setting: A randomized controlled trial. Health Equity. 2023;7(1):466-476.
18 Edwards 2024 - Edwards RC, Hans SL. Young mother risk-taking moderates doula home visiting impacts on parenting and toddler social-emotional development. Development and Psychopathology. 2024;36(1):236-254.
19 Hans 2013 - Hans SL, Thullen M, Henson LG, et al. Promoting positive mother–infant relationships: A randomized trial of community doula support for young mothers. Infant Mental Health Journal. 2013;34(5):446-457.
20 Edwards 2020 - Edwards RC, Vieyra Y, Hans SL. Maternal support for infant learning: Findings from a randomized controlled trial of doula home visiting services for young mothers. Early Childhood Research Quarterly. 2020;51:26-38.
21 Cochrane-Bohren 2017 - Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. 2017;7:CD003766.
22 Crawford 2023 - Crawford AD, Carder EC, Lopez E, McGlothen-Bell K. Doula support and pregnancy-related complications and death among childbearing women in the United States: A scoping review. Journal of Midwifery & Women’s Health. 2024;69(1):118-126.
23 Acquaye 2021 - Acquaye SN, Spatz DL. An integrative review: The role of the doula in breastfeeding initiation and duration. The Journal of Perinatal Education. 2021;30(1):29-47.
24 Falconi 2022 - Falconi AM, Bromfield SG, Tang T, et al. 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;50:101531.
25 Van Eijk 2022a - Van Eijk MS, Guenther GA, Jopson AD, Skillman SM, Frogner BK. Health workforce challenges impact the development of robust doula services for underserved and marginalized populations in the United States. The Journal of Perinatal Education. 2022;31(3):133-141.
26 Marshall 2022a - Marshall C, Arteaga S, Arcara J. et al. Barriers and facilitators to the implementation of a community doula program for Black and Pacific Islander pregnant people in San Francisco: Findings from a partnered process evaluation. Maternal and Child Health Journal. 2022;26:872-881.
27 Gomez 2021 - Gomez AM, Arteaga S, Arcara J, et al. “My 9 to 5 job is birth work”: A case study of two compensation approaches for community doula care. International Journal of Environmental Research and Public Health. 2021;18(20):10817.
28 Mallick 2022 - Mallick LM, Thoma ME, Shenassa ED. The role of doulas in respectful care for communities of color and Medicaid recipients. Birth: Issues in Perinatal Care. 2022;49(4):823-832.
29 Thomas 2023a - Thomas K, Quist S, Peprah S, et al The experiences of Black community-based doulas as they mitigate systems of racism: A qualitative study. Journal of Midwifery & Women’s Health. 2023;68(4):466-472.
30 Brewington 2022 - Brewington T, Nogales R, Weiss A. Sustainably growing the community doula workforce in New Jersey. Health Affairs Forefront. 2022.
31 Arcara 2023 - Arcara J, Cuentos A, Abdallah O, et al. What, when, and how long? Doula time use in a community doula program in San Francisco, California. Women’s Health. 2023;19.
32 NHLP-Chen 2020 - Chen A, Robles-Fradet A, Arega H. Building a successful program for Medi-Cal coverage for doula care: Findings from a survey of doulas in California. The National Health Law Program (NHLP); 2020.
33 Van Eijk 2022 - Van Eijk MS, Guenther GA, Kett PM, et al. Addressing systemic racism in birth doula services to reduce health inequities in the United States. Health Equity. 2022;6(1):98-105.
34 Gebel 2024 - Gebel C, Larson E, Olden HA, et al. A qualitative study of hospitals and payers implementing community doula support. Journal of Midwifery & Women’s Health. 2024
35 HealthConnect One-Zainab 2023 - Zainab S, Mullins M. Getting doulas paid: Advancing community-based doula models in Medicaid reimbursement conversations. Policy brief. HealthConnect One. 2023.
36 Nehme 2023 - Nehme EK, Wilson KJ, McGowan R, et al. Providing doula support to publicly insured women in central Texas: A financial cost-benefit analysis. Birth: Issues In Perinatal Care. 2024;51(1):63-70.
37 Philadelphia DPH-Doula - Philadelphia Department of Public Health (DPH). The Community Doula Support Program.
38 NYC Health-Healthy Start Brooklyn - The City of New York, Department of Health and Mental Hygiene (NYC Health). Healthy Start Brooklyn: Pregnancy and prenatal support and classes.
39 NYC Health-Doula initiative - The City of New York, Department of Health and Mental Hygiene (NYC Health). The Citywide Doula Initiative.
40 SisterWeb - SisterWeb San Francisco Community Doula Network.
41 PRW-DDI - PatientsRWaiting (PRW). Diversifying Doulas Initiative (DDI).
42 MnPDP - The Minnesota Prison Doula Project (MnPDP). Minneapolis, Minnesota.
43 NJDLC - New Jersey Doula Learning Collaborative (NJDLC).
44 Dove-Black Birth Equity Fund - Baby Dove. Black Birth Equity Fund: Action for Black maternal health.
45 Gruber 2013 - Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on healthy birth outcomes. The Journal of Perinatal Education. 2013;22(1):49-58.
46 March of Dimes-Brigance 2022 - Brigance C, Lucas R, Jones E, et al. Nowhere to go: Maternity care deserts across the U.S. (Report No. 3). March of Dimes; 2022.
47 Tucker 2021 - Tucker CM, Felder TM, Dail RB, Lyndon A, Allen K-C. Group prenatal care and maternal outcomes: A scoping review. MCN: The American Journal of Maternal/Child Nursing. 2021;46(6):314-322.
48 CWF-Hostetter 2019 - Hostetter M, Klein S. Improving health for women by better supporting them through pregnancy and beyond. New York: The Commonwealth Fund (CWF); 2019.
49 Mehra 2017 - Mehra R, Boyd LM, Ickovics JR. Racial segregation and adverse birth outcomes: A systematic review and meta-analysis. Social Science & Medicine. 2017;191:237-250.
50 KFF-Hill 2022 - Hill L, Artiga S, Ranji U. Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. 2022.
51 Haerizadeh-Yazdi 2023 - Haerizadeh-Yazdi N, Huynh MP, Narva A. et al. Philadelphia department of health doula support program: Early successes and challenges of a program serving birthing people affected by substance use disorder. Maternal and Child Health Journal. 2023;27(suppl 1):52-57.
52 Shlafer 2021 - Shlafer R, Davis L, Hindt L, Pendleton V. The benefits of doula support for women who are pregnant in prison and their newborns. In: Poehlmann-Tynan, J., Dallaire, D. (eds) Children with Incarcerated Mothers. Springer Briefs in Psychology. Springer, Cham; 2021.
53 Dawley 2000 - Dawley K. The campaign to eliminate the midwife. The American Journal of Nursing. 2000;100(10):50-56.
54 Moehling 2020 - Moehling CM, Niemesh GT, Thomasson MA, Treber J. Medical education reforms and the origins of the rural physician shortage. Cliometrica. 2020;14:181-225.
55 Barkin 2010 - Barkin SL, Fuentes-Afflick E, Brosco JP, Tuchman AM. Unintended consequences of the Flexner Report: Women in pediatrics. Pediatrics. 2010;126(6):1055-1057.
56 Laws 2021 - Laws T. How should we respond to racist legacies in health professions education originating in the Flexner Report? AMA Journal of Ethics. 2021;23(3):E271-275.
57 NACHW-Mason 2021 - Mason TH, Rush CH, Sugarman MK. Statewide training approaches for community health workers. Boston: National Association of Community Health Workers (NACHW); 2021.
Related What Works for Health Strategies
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