How Community-Based Doula Programs are Promoting Birth Equity

Doulas are working to reduce maternal mortality in the US

By Esha Chhabra

9 mins


Moms have it hard in America. It may be 2024, but the US continues to have the highest maternal mortality rate among developed (OECD) countries. It is, as US News and World Report describes it, “a stubborn issue” in America. And it’s only getting harder for women of color. 

According to a 2019 study, published in the Journal of American Medical Association, Native American women and Black women had the highest maternal mortality rates among all ethnic groups in America. Overall, the national maternal mortality rate has more than tripled since 1999 from 19 deaths per 100,000 live births to 69.3 per 100,000 in 2019. 

On top of that, one out of three births are now cesarean sections. This, Twylla Dillion, President & CEO of HealthConnect One (HC One), a nonprofit dedicated to community-based doula training, support, and advocacy, says, is in stark contrast to other developed nations. C-sections are not only an added cost to the healthcare system but are riskier for the mom, and means the child will not benefit from the immunity gained during a vaginal birth. 

“You know, it's avoidable in most instances in the US, because there's no way on earth that we should have 30% of people undergoing major surgery to have their babies. It just shouldn't happen that way, pregnancy, a natural part of life has been medicalized. Other countries have measures in place to reduce the likelihood.”

The difficult statistics don’t end there. Maternal mental health is now a leading cause of death for women. So it’s not just about providing more support to expecting mothers, but also post-birth, given they’re navigating new waters, and often alone.

Reaching More Underserved Communities

Candelen is an Arizona-based nonprofit that has been tackling early childhood development. They offer educational programming like the “Kith and Kin” program that provides family, friends and caregivers training for 12 weeks to grow their knowledge and growth on child development, health and safety, nutrition, language and literacy, and behavioral challenges. Since being founded in 1979, Candelen has served over 400,000 children in the state.

With the help of the Foundation grant, Candelen hopes to reach more underserved families in Maricopa County in Arizona, a region that Ashleigh Leonard, Team and Relationships Manager at the nonprofit, says, has pockets of “maternity care deserts.” March of Dimes has been studying these maternity care deserts closely, and defines them as “counties without a hospital or birth center offering obstetrics care and without any obstetrics providers.” More than one-third of counties across the US (36%) are considered maternity care deserts, which are home to 2.2 million women of childbearing age, and more than 146,000 babies are born in these counties.

Her colleague Ruth Ray explains that maternity care in Arizona is pretty divided. According to the March of Dimes, one in five infants in Arizona was born to a woman who received inadequate prenatal care. In addition, the infant mortality rate among babies born to Black moms is more than double the state rate. 

Yet, it’s been studied that doula support can ensure better care before and after birth. One study found that “doula-assisted mothers were four times less likely to have a low birth weight baby, two times less likely to experience a birth complication, involving themselves, or their baby, and significantly more likely to initiate breastfeeding.”

If doulas work, why don’t more families have them? It often comes down to cost and what insurance will cover. While traditional doula care has been mostly for wealthier households, community-based doulas do work with marginalized communities for free or low cost. To pay themselves, they rely on philanthropic funding, programs such as Medicaid, and private insurance. However, the pay is not always fair. “The reimbursements are pretty low. It’s certainly not enough given the amount of time these women spend every week with one expecting mom,” says Leonard.

“The reality is communities that truly, truly need this support just cannot afford it. They’re the ones that have the higher death rates, and should be the focus. But it’s not within their reach. That’s why we wanted to start a new program to make doula care accessible for all communities,” she explains.

As a result, Candelen is launching a prenatal program called NewRoots, which has three primary goals: to increase the attachment between parents and their newborns, help with prenatal, postpartum, and parenting information and support, and overall reduce the rates of maternal and infant mortality in these communities. In Arizona, where Candelen’s efforts are focused, Medicaid does not currently cover doula services; neither do most private health insurance plans.

While Leonard works at Candelen, she’s also a part-time doula. “With my social worker lens on, I could see there was a clear gap here, and in my heart, I really want to serve the people of our local community who are in need,” she says.

The NewRoots program will extend their care post-birth which Leonard says is critical. She herself experienced a period of postpartum anxiety that woke her up to the challenges moms face in the early years. “I’d just jumped head-first into being a mother and was experiencing fear on a level I didn’t know existed. When I became a mother again just one year later, I was merely managing. At this point, I’d been living with anxiety for so long that I just accepted this constant cloud of terror to be the ‘norm’ and surrendered to the fact that it was just how motherhood goes. I was constantly on the brink of a mental breakdown.” 

Measuring the Value of Doula Support

“Doulas are always there. They’re not leaving your side unless they’re confident that you’re well. And when they’re burned out, there is a backup doula,” says Dillion.

Because doulas invest so much time with their clients, it’s important to understand if they’re being fairly compensated. That’s why HC One, the second organization being supported by the Foundation and led by Dillion, is working on building a community-driven data set that catalogs how much time doulas spend with clients and what they get for it. 

“We need this kind of data because, firstly, doulas are being paid vastly different amounts based on where they live and work and what that state’s policy is on community-based doulas," Dillon says. "But also, they spend much more time with clients than clinicians do. And we want to make sure we’re getting the whole picture so we can show their value. It’s frankly a data set that has never existed before.”

Community-based doulas, she adds, are spending about 30 hours a week with their clients, based on initial data and they are reaching families outside of clinical settings where they can address social determinants of health. 

While HC One is spearheading this data collection, Dillion iterates that it’s a collaborative process. “We’re working on data-sharing agreements. So it’s respectful to everyone involved. We have 20 to 30 doula organizations that want to share their data and to do this requires financial investment and takes time. The more data we have, the more impactful the work is. So this is going to be a work in progress.” 

It’s worth noting that there is no national organization representing doulas in the US. This data set could help create the foundation for an overlooked profession. As the use of doulas is on the rise, Dillion is concerned about the inconsistencies in the industry. While some doulas are getting just weekend-long trainings, others are enrolling ten to 20 week-long courses. HC One, for instance, offers 20 sessions, spaced out over at least ten weeks. Thus, more work is needed to bring doulas together and create a central framework. “We’re confident that this collaboration through a data consortium will only grow and support doulas all around.”

Dillion herself has experienced the benefits of doula care, which is why she’s so driven to bring policy-level change to the industry, she says. As a mom of four, she’s had multiple doulas guide her through the varying pregnancies. She recognizes that doulas can be an important part of the system needed to reduce maternal mortality. 

“We should all experience joy in our birth experience. Yes, it’s challenging, but if you have someone who is advocating for you, and guiding you through all the surges, it’s much better. We know that we have a serious nursing shortage in US hospitals. Many times, they’re not in the room with you when you’re giving birth because they’re tending to other patients. So having doulas there who keep an eye on you when you’re the most vulnerable, is so comforting and helpful. Plus, they know you best because they’ve been on this journey with you.”

Bezos Family Foundation is proud to support Candelen’s work to expand its Kith and Kin & Prenatal services and HealthConnect One’s doula training, support and advocacy.