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This article was written by Loral Patchen, CNM, MSN, Karey M. Sutton, PhD, and Shelby Wyand, MSc, BA.
Our research, accepted for presentation at the APHA, ACOG District IV meeting, Academy Health, and IAPHS, explores the critical role of doulas in improving maternal health outcomes.
In the U.S., Black birthing people are three to four times more likely than their white counterparts to die from pregnancy-related complications, and 80% of these deaths are preventable. Research shows these startling statistics are driven by factors such as systemic racism, implicit bias, and unequal access to care.
Getting personal and community support during the perinatal period (the time before, during, and after giving birth) can help mitigate these barriers and enhance maternal health outcomes.
In two studies, each accepted for presentation at professional conferences and the MedStar Health-Georgetown University Research and Education Symposium, our teams examined the barriers and explored how increased access to doulas improves outcomes for mothers.
Doulas, midwives, and community health workers all support patients and families in different and meaningful ways. These caregivers support birthing individuals by providing access to resources, knowledge, care, and advocacy, thereby making pregnancy safer and improving outcomes.
Studying the impact of doula care.
Support from a trained professional doula during the perinatal period has been shown to improve birth outcomes, reducing the number of medical interventions such as C-sections and fewer preterm births, and leading to greater patient satisfaction.
Our research examined how and where doulas are integrating into hospital teams, as well as how one state is leading the way in expanding access.
A nationwide environmental scan and content analysis of hospital-based doula programs.
Traditionally, patients engage an independent doula outside the hospital, but they’re increasingly becoming part of hospital teams.
To understand how doulas are part of hospitals in the U.S., our team reviewed doula-related website content for more than 3,400 hospitals throughout the country that provide birthing care. Then we analyzed the data to identify themes and understand how doula programs differ.
More than 75% of all hospital websites didn’t mention doulas at all. Among the hospitals we studied, just 7.3% had a hospital-based doula program. There was a significant difference based on region. The South showed the fewest doula programs (1.7%), while the Northeast (20.8%) had the most.
Our research found that there are several different types of doula programs in use in the U.S., including:
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Affiliated Doula Network: Hospitals refer patients to a vetted list of independent doulas (36.1%)
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Hospital-employed: Doulas are hired as hospital staff and integrated into care teams (25%)
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Hospital-CBO Partnership: The hospital partners with a community-based organization to provide doulas (20.2%)
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Volunteer-based: The hospital offers free doula support from trained volunteers (7.5%)
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Research-driven: Doulas are part of a formal study to assess outcomes (4.4%)
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Unknown: Programs with unclear or incomplete details (6.3%)
Among hospitals with internal doula programs, many websites lacked clear or easily accessible information about these programs and the enrollment process.
This study relied on publicly available data and does not include outcomes data for the programs. While further research is needed, the data indicate that hospital-based doula programs remain uncommon. Those that exist often lack clear public information, which limits patients’ access.
By partnering with community-based organizations (CBOs), hospitals have an opportunity to integrate doula care and expand access, particularly among Black mothers who face the most risks.
Related reading: New Mother-Baby Intensive Outpatient Program Supports Mental Health in Pregnancy and Beyond.
Evaluation of the Maryland Medicaid Doula Program.
Medicaid coverage is linked to 47% fewer C-sections and 29% fewer preterm births, improving outcomes for Medicaid enrollees, especially Black birthing individuals. When public insurance covers these services, more people with low incomes can get care.
To help expand access to doula services and improve maternal health outcomes, some states are expanding Medicaid coverage to include doula services. These programs differ from state to state, but they’re helping.
Maryland has been a national leader in this effort, lobbying to help streamline reimbursements for doulas. Our research set out to learn more about the Maryland Medicaid Doula Program (MMDP), including:
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How MMDP impacts costs and use of doula services
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The experiences of birthing individuals, doulas, and policy and practice leaders
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MMDP’s impact on racial disparities in maternal health and infant outcomes
Our research, in partnership with community doulas, involved gathering Medicaid claims data and conducting interviews and focus groups with key informants. This mixed-methods approach enables us to gain a deeper understanding of the lived experiences of individuals involved in the program.
The MMDP began in February of 2022. It covers up to eight visits with a doula, before, during, and after delivery at no cost to people with Medicaid.
Our research shows the program is reaching mothers at risk. Black birthing individuals were 71% of program participants, with an average age of 31. They tended to live in urban neighborhoods and have higher social vulnerability compared to the rest of the state.
MMDP is also improving pay for doulas, boosting community collaboration, and spurring grants to help train new doulas and provide administrative support.
Our research also identified barriers throughout the system. These included challenges with regulations, lower federal Medicaid reimbursement rates compared to private payers, the absence of national licensing, and a shortage of available doulas.
As payer models continue to evolve, our recommendations can help better integrate doula services and solve payment backlogs to make even more progress. These include:
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Administrative support: Partnering with CBOs to streamline enrollment and billing
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Compensation & reimbursement: Increase first-visit rates or use flat fees and address delays
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Continuous feedback: Gather ongoing input from doulas and managed care organizations
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Expand knowledge: Raise awareness of doula services and create program materials for distribution
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Flexibility: Increase the services Medicaid covers so high-risk patients can get support
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Honoring doulas: Hospitals should partner with community-based doulas to ensure their traditional role remains intact
Related reading: Partnering with the Community: Best Practices for Equitable Clinical Research.
Different roles, similar goals: Improving maternal health.
Community health workers (CHWs), doulas, and midwives are all committed to helping birthing individuals and their families have healthy pregnancies, deliveries, and postpartum experiences. These caregivers play different roles supporting birthing people and families.
Related reading: Study Published in NEJM Catalyst Finds Patients Cared for by MedStar Health’s Safe Babies Safe Moms Program Have Better Outcomes
| Role and Scope | Support Timeline | Where They Work | Benefits for Patients | |
| Community Health Workers | A CHW is a trusted member of the community who works as a liaison between health services and the community to help patients navigate the healthcare system. They don’t provide medical care. | CHWs primarily support birthing people and their families before and after childbirth. | CHWs are usually found in community-based organizations, clinics, and social service agencies. | CHWs can help patients overcome challenges such as transportation, housing, and food insecurity. They advocate for patients’ needs and connect people to available resources. |
| Doulas | A doula is a trained professional who provides ongoing physical, emotional, and educational support for a birthing person and their family. A doula does not provide medical care or deliver babies. | Doulas provide support during preparation for birth. They are present throughout labor and delivery and assist with care of the newborn and maternal postpartum recovery. | They can work in various settings, including hospitals, birth centers, and private homes. Often, doulas work independently. Sometimes they are part of a private medical practice or are employed by a hospital or CBO. | Doulas support patients to have a better birth experience. They provide continuous support that may not be available from medical staff, including advocating for the needs and wishes of the birthing individual and their family. |
| Midwives | A Certified Nurse Midwife is a licensed professional with specialized training in nursing and women’s health and childbirth. They provide primary health care to women of all ages, including throughout the perinatal period, as well as gynecological exams, family planning, and menopausal management. | Midwives offer care throughout pregnancy, from prenatal care to managing labor and delivery, and providing postpartum care for both birthing individual and newborn. Midwives also provide preconception and comprehensive well-woman care. | They work in many clinical settings, including hospitals, birth centers, and private practices. The Midwives of MedStar provide services at MedStar Health and its outpatient sites. We work independently, with access to the team of MedStar Health physicians if needed. | Midwives offer a patient-centered, holistic approach to maternity care. Offering a full range of clinical services to support pregnancy, working with a midwife often leads to fewer medical interventions, such as C-sections. |
Related reading: What is a Midwife? The Truth About 5 Common Midwifery Myths.
Building on success to support more babies and moms.
Maternal health remains a crisis across the nation. At MedStar Health, our D.C. Safe Babies Safe Moms Program is building on its success to grow across our care facilities. We’re committed to supporting this expansion with research that helps us understand how to improve outcomes for all mothers and babies, especially those at greatest risk.
The key to maintaining success is engaging effectively and meaningfully with community-based organizations. These hubs are central to understanding the issues our patients face. Working together, we can craft goals and solutions that make a real difference, like doula pilot programs to learn how best to adapt these critical roles to the healthcare setting. Additional research on these topics will help us understand our progress and identify the most efficient path to success.
