The Ancestral Practice of Doula Care Could Be the Future of Maternal Health for Black Moms
In the latest Friday Post, which is available for free, I talk about doulas and the role they play in keeping Black birthing people alive.
Word counts are a necessary evil in media. No editor or writer I know is particularly fond of them, but we understand that word counts keep a piece from going off the rails, thus making the content more engaging and informational for readers. That said, I performed somewhat of a gut job on my last piece published at New America, which was a story about how doulas can make a world of difference for Black moms. Don’t let the language I’m using cause you to assume that I hated the end result. I love the way it turned out, and I think 1,000 words more efficiently tells the story I wanted to tell.
But the original piece was nearly 4,000 words. It offered a more nuanced, in-the-weeds look at doula care that connected the current political climate to the very real lives of doulas, the people working with them, and the educators working to get them into the workforce. I decided to share it here, in full, after updating the data to the most recent available. You should also know that I interviewed these women before Trump was elected, and, where appropriate, I have added relevant information from more recent conversations with them. Most of them, however, hadn’t changed their thoughts on anything since, as we know, Black folks and our politics transcend presidential administrations—so much so that when we speak freely to one another about a topic as long standing as caring for Black birthing people whomever is in office barely comes up, if at all.
The constant vomiting and nausea began early during Tonya Abari’s first pregnancy in 2014.
It was far beyond the typical morning sickness, which happens once or twice daily, most commonly during the first trimester. Abari was throwing up multiple times—sometimes, she took as many as 20 trips to the nearest receptacle. “There was not one day that I didn't have five or more episodes of vomiting throughout the entire [10 months of] pregnancy,” Abari, now 42, said. “I was very weak and lost a lot of nutrients, and the only thing that made me feel better was eating bread. I ate a lot of bread.”
While the bread soothed her stomach, it also caused her to gain weight, which led the midwives and obstetrician she was working with in Nashville, Tennessee, to question if the vomiting and nausea were due to her size, even though her illness predated the jump on the scale. She wasn’t offered nutrition counseling or blood tests to determine what was wrong. Toward the end of her pregnancy, her blood pressure began to fluctuate, eventually ticking upward to hypertensive levels. She doesn’t remember how high, but she knows it was well above her pre-pregnancy average of 115/65. She believes she had preeclampsia, a disorder characterized by high blood pressure and the leading cause of death in the pre- and postpartum periods for Black women, but she was never officially diagnosed. (She later found out from her doctor that her vomiting was hyperemesis gravidarum, a severe form of pregnancy-related nausea and vomiting that can lead to dehydration, weight loss, and nutritional deficiencies.)
Another complication arose once it was time to deliver her daughter. Abari went to the hospital because her amniotic sac was damaged. It wasn’t wholly ruptured, or, as is more commonly said, her water hadn’t broken. The sac was torn and slowly leaking—a complication that can potentially lead to infection if not treated. She was admitted and told she’d need an emergency C-section due to her weight. “I refused because my weight is not a determinant of whether I need a C-section or not,” she recalls. “Let me walk around. Let me see if we can move the needle. I was zero centimeters dilated. Let me do what we've been talking about according to my birth plan.”
After 56 hours of labor, Abari got the C-section. Her heart rate dropped after, another potential sign of preeclampsia, and so did her newborn daughter’s. Abari’s first pregnancy and birthing experience were a nightmare.
“I felt like I was not heard. I felt like there was a lot of bias during the entire process,” said Abari. “The first birth was so traumatic that I felt that I didn't want to have any more children after that.”
Six years later, Abari and her husband decided to have another child. While planning the baby’s birth, they were adamant about having a birth team that could actually see and hear them, people who could navigate the complex relationship Black birthing people have with clinicians who often disregard and ignore Black patients. She also wanted to reclaim her autonomy and power within the birthing experience.
Abari met Tanzye Hill, a doula and owner of Birth Manifesta, an organization that offers full-spectrum doula support to birthing people and focuses on reducing rates of Black maternal and infant mortality, in Nashville, and they became friends. When Abari found out she was pregnant, Hill was the first person she went to, and she helped Abari by looking for a Black care team that would respect her wishes, and adding a doula was key.
What differentiates doulas professionally from obstetricians, nurses, or midwives is that they don’t have clinical duties or give medical advice. Instead, doulas fill in gaps that overworked clinicians often can’t or won’t in the birthing person's care. This includes emotional and physical well-being support to their patients during pregnancy, labor, birth, and postpartum. They supplement knowledge gaps between clinicians who don’t explain complicated medical knowledge well to patients and the birthing parent.
Across all causes of maternal mortality, Black birthing persons experienced 49.5 deaths per 100,000 live births in 2022—nearly three times the rate for their white (19) and Hispanic (16.9) counterparts, respectively, and almost four times as often as birthing persons of Asian descent (13.2). Sixty-five percent of pregnancy-related deaths happen in the 365 days after delivery, according to a report from the Centers for Disease Control (CDC). Death by suicide is the leading cause. Between 29 and 44 percent of Black women exhibit symptoms of postpartum depression, but many are not diagnosed or directed to mental health care. The CDC estimates that 80 percent of these deaths were preventable.
Doulas also catch other complications in the early stages and encourage the birthing person to receive life-saving care. They teach parents the skills needed to care for a newborn, like changing diapers and soothing, and they assist with housework and other chores to take the burden off new parents. Despite evidence showing that doula care could significantly reduce the U.S. maternal mortality rate, doula care is underutilized. A study in the American Journal of Managed Care found that Black women are more likely to desire doula care than their white counterparts.
‘The Buck Doesn’t Stop with Giving Birth’
Community-based doulas are especially adept at providing culturally competent care, which is what Abari was seeking, to those most susceptible to adverse birthing outcomes. Think of a doula as a birthing parent’s caregiver, helping parents, their children, and their communities thrive by reshaping the birthing experience and empowering parents to take control.
“In our history, communities have always had what we call now doulas,” said Myriam Webb, a longtime doula. “They didn't have a formal title. They were community members who would come by and drop off food, or help you with the baby, or they would attend the birth and help you with the labor.”
While many people think of doulas as additions to the birthing process, they play a crucial role during postpartum, providing vital emotional, physical, and informational support to new parents. Doulas can offer new moms a safe space to navigate their postpartum emotional ups and downs and alleviate the feelings of overwhelm and isolation new parents often feel. They’re also trained to recognize when postpartum depression has taken root and can refer families to critical mental health services.
After attending her first couple of births, Takeallah Rivera, a longtime doula based in Memphis, realized that the postpartum period needed more attention.
“I saw that the birth aspect as it pertains to being a doula was very saturated,” she said. “And I noticed the very critical postpartum period was being neglected, which is where Black women tend to suffer even more. [But] the buck doesn't stop with giving birth.”
“Usually, with a postpartum client, I'm there maybe a night or two to help mom prepare meals, making tea, tending to the other children she may have,” said Rivera, who also works as a postpartum counselor with the National Maternal Mental Health hotline. “I also focus heavily on the mental health aspect, so getting moms connected to resources for postpartum mental health supports, therapists, psychologists, online support groups, anything that would foster their wellbeing during the postpartum period.”
Covering Doula Care Under Medicaid and Private Insurance Could Expand Access
In December 2023, De Ajanae Gunn contacted Black Infant Health, a health equity program that provides resources to pre- and postpartum Black birthing persons toward the end of her pregnancy. She wanted to know what resources were available to her as she approached her due date. They pointed her to United and Guided, a Sacramento, California-based organization offering various services, including doula care. “My baby, during birth, his heart rate kept dropping, so I had to have an emergency C-section,” said Gunn, a 36-year-old child care provider. “It was very tough because I wanted to have a very holistic birth. I wanted to have a water birth, but it just didn't work out.”
Although her doula wasn’t there in person for the birth—she was sick and attended via Zoom—she helped Gunn navigate the postpartum period mood swings, offered breastfeeding support, and was an active listening ear.
Accessing the doulas who helped Gunn through a challenging birth and postpartum period would not have been possible were it not for Medi-Cal, California’s Medicaid program, which offers doula services to any pregnant person who wants one up to one year after pregnancy. As of June 2025, 24 states and the District of Columbia actively cover doula services for people on Medicaid, according to data from the National Health Law Program’s Doula Medicaid Project. Eight additional states are implementing doula coverage under Medicaid, and 15 others have programs adjacent to Medicaid coverage for doulas, such as pilot programs or exploratory efforts. But research shows that Medicaid expansion, even when it doesn’t include doula care, is crucial to reducing Black maternal mortality.
“Having a support person is very important, especially while you're going through pregnancy,” said Gunn. “With everything going on in healthcare and how systems are already not for us, it is important that we do have that support.”
Nearly 40 percent of births are covered by Medicaid, with this figure rising to 65 percent for Black birthing people. Disruptions in postpartum health coverage, particularly among Medicaid enrollees, are a persistent issue in preventing access to necessary care during this critical time, which is why expansion is associated with lower rates of maternal mortality. The American Rescue Plan Act of 2021 introduced a provision that allows states to extend Medicaid postpartum coverage from 60 days to 12 months through a state plan amendment. As of January 2025, 49 states and the District of Columbia have implemented 12-month Medicaid postpartum coverage, and Wisconsin has implemented limited coverage for up to 90 days.
Private insurance plays a role, too. The risk of maternal mortality for Black birthing persons is not bound by socioeconomic lines—wealthy Black mothers and their infants are still more likely to have an adverse outcome during the perinatal period. The coverage of doula services by private insurance varies across the country, depending on state regulations and individual insurance plans. Rhode Island became the first state to mandate that private health insurance plans cover doula services in 2021. Elsewhere, it’s less direct. California is encouraging private insurers to cover doula care. Lawmakers in Indiana introduced a bill in 2021 requiring state employee health plans to cover doula care, but it failed. Massachusetts and New York lawmakers are considering bills that would mandate all health plans to cover doulas. A bill in Virginia failed.
Research suggests doctors may be more likely to recommend doulas to their patients if Medicaid and private insurance cover their services. A doula in Rhode Island told the Women’s Bureau of the U.S. Department of Labor that since Medicaid and private insurance started covering their services, they’ve seen increased requests, especially from high-risk clients, because doctors are encouraging these patients to work with a doula.
However, following the 2024 election, the ability of millions to keep this critical coverage could depend on politics.
In May, House Republicans pushed through a budget reconciliation bill that would cut Medicaid by more than $800 billion over the next decade. Black women across the country would be left more vulnerable if Medicaid funding is slashed. Fewer providers amid an ongoing shortage, hospital closures, and the erosion of essential programs—like home visiting services—would exacerbate already staggering disparities in maternal and infant health.
Insurance isn’t a perfect solution. Medicaid doesn’t have the best reputation for paying providers. Plus, the payment rates are low and may not include the entire scope of a doula’s services. There’s also a significant administrative burden associated with insurance reimbursement—hours of paperwork, thoroughly logging hours, and filing precise claims to avoid an expensive medical audit. But having no option for people to afford doula care isn’t ideal or sustainable, either.
In Memphis, where Rivera practices, the demand for doulas is high, but so is poverty. Nearly 25 percent of Black residents in the city live below the poverty line. “I was pregnant with my son in Memphis, and there were virtually no doulas available to me,” Rivera recalls. “The doulas that were available to me were charging anywhere from $1,000 to $1,500 for support, and I recently left a pretty abusive relationship, so I was low-income. I could not afford that.”
Now, Rivera charges a sliding scale for her services, especially within the Memphis City limits. And, usually, she won’t charge Memphis residents at all. “Within the city limits is the highest rate of poverty and infant mortality, and I often do those for free,” she said.
“I have been thinking a lot recently about the future of doulas, especially Black doulas, because it's emotionally taxing, it's physically taxing—especially if you are in a red state like I am, and you're a proponent for reproductive justice as a whole,” Rivera continued. “We have a hell of a fight ahead of us for reproductive rights.”
(Editor’s note: Rivera told me in March 2025 that she has since stopped practicing as a doula in an effort to focus on taking care of herself.)
Despite GOP Desires to Slash Family-Supportive Policy, the Effort to Diversify the Perinatal Workforce Remains
That fight includes efforts to provide financial access for doula services and ensure the demographic makeup of doulas reflects the diversity of their patients. Few remedies to address the U.S. Black maternal health crisis are as directly impactful as getting more Black people into the perinatal workforce, research shows. Black patients live longer when they are cared for by Black care providers due to the reduction of implicit biases and a boost in trust, communication, and the chance that patients will adhere to medical advice when the person providing it looks like them. Currently, only 5.7 percent of physicians, 6.3 percent of nurses, eight percent of nurse practitioners, and 10 percent of doulas are Black—all of which are disproportionately low compared to the 13.7 percent of the U.S. population identifying as Black.
When Antonia Mead began overseeing Johnson C. Smith University’s (JCSU) doula and lactation program in 2017, its capacity to diversify North Carolina’s perinatal workforce was limited. Black maternal mortality was being discussed more in the news and online, and more people were discussing the benefits of doula support to birthing people. Interest in the program peaked as national conversations picked up more steam following the death of Shalon Irving, an epidemiologist at the Centers for Disease Control, from postpartum complications, becoming the focus of an in-depth ProPublica report. The story quickly went viral, shedding unprecedented national light on a crisis that has plagued Black birthing people for generations. But Mead was in a bind. She was the only full-time staff member for the program, tasked with scheduling courses, promoting them, and finding a doula to teach the students.
Mead’s reality shifted in January 2023 when the school became one of 75 projects in Mecklenburg County, North Carolina, to receive funding from the American Rescue Plan. JCSU, a historically Black college and university, was granted $943,000 to flesh out its Lactation and Doula Program. She used the funds to hire staff, invest in marketing, and increase the frequency with which the university offers the training.
“I was like a one-woman band with too many instruments—as the department chair, as the point person who would try to coordinate with our facilitator. It was all on me,” she said. “Those two things have been a blessing before God with everything I'm juggling.”
Even before receiving the funding, the course was open to anyone who wanted to take it—whether a student or a community member—with the primary target being North Carolinians. However, the school could only offer the course once or twice a year, depending on the schedule of the contracted trainers, one of whom lives in Raleigh. (Charlotte, where the university is located, is a roughly two-and-a-half hour drive one way with the usual traffic. Hitting rush hour in both cities can easily tack another hour or more onto the trip.) Marketing was also very “low budget,” Mead said, with the school depending heavily on social media.
Now, the program can appear at events and train students three times a year or once a semester, including the summer term. Funding from the American Rescue Plan has also allowed the university to fully cover the training cost and financially assist students with a portion of their total certification costs.
According to Mead, 75 students have graduated from the program, the most thus far.
That’s just step one. Becoming a certified doula is a multipronged and expensive process—and many states have some type of certification or training requirements. (They vary state-by-state and, in some states, they’re as simple as registering for a vague “certification course.”) Several organizations offer this distinction, but DONA International is the most popular. The nuts and bolts of DONA’s process begin with participating in a birth doula workshop. If a student is lucky enough to join a program like the one offered at Johnson C. Smith, the workshop will fulfill the childbirth and lactation support education requirements. If not, the student has to find additional classes. Next, the student completes two research papers and reads four books before completing a self-assessment, compiling a referral list of doulas in their community, and attending three births. The last step is submitting all materials in an application packet and uploading them to DONA International’s site, for a fee. Students have three years after participating in the training to complete all requisites.
While DONA International estimates this process costs prospective certified doulas anywhere between $600 and $1,000, Mead said $1,000 is closer to the low end. “If someone tried to do this program without our assistance, it could range anywhere from $1,200 to $3,000 for them to get their [full] training,” said Mead. “We removed that barrier, and we're able to help them move the needle closer to that certification.” JCSU’s facilitators also offer one-year mentorships to interested students working to get their certification—the university partners with local organizations to help students attend live childbirths.
JCSU, being an HBCU, is crucial to this effort and to increasing and diversifying the perinatal workforce. In June 2023, the Supreme Court effectively eliminated race-conscious affirmative action in higher education, which is expected to lead to declines in the number of Black students attending college.
The effect of that expected decline on the health and well-being of Black communities is currently unknown, but history offers up a grim possibility. In 1910, Abraham Flexner released a report that led to the closure of 75 percent of U.S. medical schools. Commissioned by the Carnegie Foundation to evaluate and standardize medical education, Flexner's investigation included six Black medical schools, four of which were shut down by 1923. Although the goal was to enhance the quality of medical care—and due to a lack of access to quality secondary school education, Black students arrived at medical schools unprepared—the consequences were particularly harsh for Black communities. Researchers estimate that, had those schools not closed, 30,000 to 35,000 Black doctors would have received a medical degree in the past century. With limited acceptance of Black students into predominantly white institutions, the number of healthcare providers willing to serve Black populations significantly decreased.
Of the Black doctors currently practicing, 80 percent were educated at Meharry Medical College or Howard Medical School, the only two Black medical schools left.
“Advocacy is the thread throughout this; that's key. That's the beauty of why we're doing it. History and advocacy are connected to the history of HBCUs,” said Mead. “HBCUs existed to educate us when nobody else would. Even if we didn't attend an HBCU, we were likely educated by someone who did. So, the legacy of HBCUs and that connection of advocacy and empowerment ties into what we're doing now.”
Doula Care Saves Black Lives
Tonya Abari’s second pregnancy was much different than the first.
Abari planned to have a vaginal birth at home—a decision that turned off many potential care providers due to her age and past complications. Abari and her husband decided that their six-year-old daughter would be as active in the birthing process as a small child could be. Their care team jumped on board, including the six-year-old in appointments, giving her homework—like keeping her mom’s food journal and writing down her blood pressure readings—sharing affirmations, and bringing her coloring books. It was a stark shift from her first pregnancy already. Her former OB didn’t even allow children in the office, which Abari found nonsensical.
“We needed a care team that was understanding of us needing to have her in the room—and I mean in the room literally while I'm giving birth,” she said. “A prerequisite for us in choosing was that you have to understand that we do things as a family.”
For centuries, Black birthing traditions have included a communal element. Abari’s doula arrived on the morning of labor and delivery with an apprentice, a birth photographer to document the process, and a therapist to provide mental health support, considering the trauma experienced during her first birth experience. Her care team held her hands during contractions, sang, made a playlist of her favorite songs, and recited affirmations with her. I am strong. I am magnificent. I am capable. They decorated her bedroom with photos of her family and art. More coloring books showed up for her six-year-old daughter, and they cooked for her family.
Labor and delivery went smoothly. In November 2021, Abari and her family welcomed a healthy baby girl.
Two weeks after giving birth, Abari had excruciating leg pain. But, suffering from postpartum depression, she kept that to herself. Late one night, she shared a photo of her swollen legs with her doula and midwife. They told her to get to the hospital. There, a kind-hearted Black woman OB told Abari that she had a blood clot and was having a light stroke. She was rushed into surgery to remove the clot. Her Black OB prayed with her alongside a few nurses.
Of Abari’s care team, her doula was the one who made it to the hospital. While there, she noticed Abari had been left to “sit in her own dirt.” She went to the managerial team and the doctors, demanding they clean Abari up. She was also able to help Abari pump so that she could continue feeding her daughter, who refused formula.
At this point, when sharing her story, Abari breaks down.
“I don't know how I pumped milk, but I pumped milk in the hospital, and my doula was there picking up the milk and delivering the milk. My baby would not drink anything other than my milk,” Abari said once she had collected herself. “She made runs. She was there. She did so much, so much, so much. And, honestly, it was lifesaving.”
“The most important time was postpartum because I didn't know things could fall apart that fast,” Abari continues. “I didn't know that I needed that extra help and that extra care after I had the baby—and what helped to save my life was their care.”