For over three decades, the maternal mortality rate in the United States has steadily increased, with Black women and birthing people facing a disproportionate percentage of poor health outcomes. To address the crisis levels of maternal mortality, lawmakers and advocates are increasingly recognizing doula care as a promising, cost-effective tool to improve maternal health outcomes and reduce racial disparities.
Doulas are non-clinical, trained health care workers who support pregnant people before, during, and after pregnancy. Compared with clinical providers and hospital staff, doulas spend six to eleven times as much time supporting their pregnant clients. The beneficial impact of such continuous support is widely recognized. The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine reported that the continuous presence of a doula during pregnancy is one of the most effective tools to improve labor and delivery outcomes.
Doula care improves health outcomes and leads to more satisfying birthing experiences
Studies on the effectiveness of doula care conclusively demonstrate that women who are supported by a doula during labor and childbirth are less likely to require a cesarean birth or use pain medication, and more likely to give birth spontaneously, have a shorter labor, and feel satisfied with their birthing experience. By reducing the need for medical interventions such as cesarean births, doulas help mitigate the potentially severe complications associated with risky interventions. For example, complications such as death, cardiac arrest, blood clots, and infections are three times more common following a cesarean birth. Babies born via cesarean birth are also more likely to experience health problems including asthma, Crohn’s disease, and allergies.
The documented health benefits of a doula increase further when care is initiated in the prenatal period, as this is the point when behavioral changes can most impact birth outcomes. During the prenatal period, doulas provide their clients with comprehensive support that helps pregnant people make more informed health care choices throughout pregnancy. For example, doulas help their clients implement healthy behaviors, effectively communicate with their health care providers, develop birthing plans, and mentally and physically prepare for the experience of childbirth and breastfeeding. Research shows that people who work with a doula throughout the prenatal period and childbirth are less likely to have a preterm delivery or a low birthweight baby, less likely to experience postpartum depression, and more likely to initiate and continue breastfeeding for a longer period.
Community-based doulas are well suited to reduce racial disparities
Black women in the United States are three times more likely to die from complications related to pregnancy and childbirth than white women. Notably, the deep racial disparities in maternal health outcomes persist across income and education levels, indicating that racism in the health care setting is a driving force of disparities. A growing body of research indicates that stress related to daily exposure to racism detrimentally impacts birth outcomes. Moreover, communities of color have consistently reported mistreatment and dismissive behaviors from perinatal health care providers.
Community-based doulas are particularly well suited to improve racial disparities in health outcomes by ensuring that pregnant people who face the greatest risk of discrimination and mistreatment in the medical system receive the additional support they require. As members of the communities they serve, community-based doulas are able to intimately understand the needs of their clients and effectively build trusting relationships. Research demonstrates that a strong doula/client relationship grounded in trust and shared experience increases a pregnant person’s engagement in care, agency in decision-making, and overall improved health outcomes.
Doula care reduces overall perinatal spending
Rigorous studies show that doula care results in substantial cost savings by reducing the need for medical interventions including cesareans, instrument assisted births, and pain medication. Considering that cesarean births cost 50 percent more than vaginal delivery, and about one-third of all births in the U.S. occur via cesarean, the potential cost savings is dramatic.
In addition to cesarean births, Neonatal Intensive Care Unit (NICU) admissions are a driving factor of high health care costs. The Institute of Medicine estimates that the annual health care cost in the United States associated with preterm delivery is $26.2 billion, or $51,600 per infant. One study found that when looking at the beneficial impact of doulas on cesarean and preterm birth rates among Medicaid beneficiaries regionally, doula care was associated with a savings of $58.4 million and 3,288 fewer preterm births annually.
In another study assessing the cost effectiveness of doula care among a theoretical cohort of 1.8 million women, Oregon researchers determined that doula care saved $91 million dollars and led to 219,530 fewer cesarean births, 51 fewer maternal deaths, 382 fewer uterine ruptures, and 100 fewer hysterectomies.
Doulas also have the potential to reduce spending as research shows that doula care increases the initiation and duration of breastfeeding. Breastfeeding reduces a parent’s risk of breast and ovarian cancer, type 2 diabetes, and high blood pressure. Breastfed babies have lower rates of asthma, type 1 diabetes, and sudden infant death syndrome. The CDC estimates that the health concerns associated with low rates of breastfeeding add over $3 billion dollars to U.S. health care costs annually.
As doula care is a proven, cost-effective means of reducing racial disparities in maternal health and improving overall health outcomes, policy advocates, legislators, and other stakeholders should undertake efforts to increase Medicaid and private insurance coverage of doula services. All pregnant and postpartum people deserve access to full spectrum doula care.
To realize the full breadth of benefits associated with doula care, state Medicaid agencies and private insurers must thoughtfully design doula coverage programs that are built to succeed. To accomplish this, coverage should span the full spectrum of doula care—ranging from prenatal care to post-partum and abortion care services. Additionally, reimbursement rates must be equitable and sustainable to encourage doula participation and overall program success. Reimbursement rates must account for the emotionally and physically demanding and time-intensive nature of doula work that typically restricts the number of clients a doula can care for each month.
Finally, it is imperative to note that while doulas offer a wealth of benefits, including a promising path to reducing racial disparities, we cannot rely on doula care alone to address the negative effects of racism within the health care institution. It is important to recognize that doulas of color are not immune to the racism their clients experience. Accordingly, in addition to advocating for expanded access to doula services, we must acknowledge the emotional cost of this work and continue to advocate for policies that dismantle systemic racism within the medical system.
 While this blog occasionally uses the words “woman” or women,” it is not intended to be exclusionary. We recognize that different categories of people, including cisgender women and transgender men, are able to become pregnant. Accordingly, we have tried to limit the use of the word “woman” or “women” to conform to cited research and data, or quoted statements and material.
* Mara Greenwald was an intern at NHeLP in summer 2022.
For more information about the National Health Law Program’s work on Medicaid coverage for doula care in California and nationally, please see our Doula Medicaid Project page.