Black women in the United States are nearly three times more likely to die during childbirth than white women  and in 2021 had the highest mortality rate in the United States at 69.9 deaths per 100,000 births, according to the Center for Disease Control and Prevention Maternal.  In addition, more than one in five Black women have been refused pain medication or had their pain ignored during their pregnancies.

As a result, more Black women are turning to doulas to manage their maternal care. For Black women navigating systemic racism and medical neglect, doulas offer emotional and physical support while ensuring that mothers’ voices are heard. 

 When Black women work with a doula, their risk of preterm birth drops by 22%, according to a study from the University of Minnesota School of Public Health. They’re also four times less likely to have an underweight baby, two times more less likely to experience birth complications and 70.3% more likely to initiate successful breastfeeding than the general medicaid population, according to theNational Library of Medicine, 2023. 

 “We’re dealing with your emotions, and all of the changes going on with you throughout this journey,” said Leslie Okorie, a doula, herbalist, and owner of Birthing: By The Ellemental in Brooklyn, New York.

Okorie, a Black doula, is rare. According to the American College of Nurse-Midwives, nearly 90% of midwives and 84% of doulas in the U.S. are white, while only 10% are Black. This lack of diversity indicates the need to expand representation in maternal care roles.

The Roots and Impact 

Black doulas and midwives offer culturally competent and individualized care for their patients of color. They counteract the effects of systemic racism in healthcare, according to the U.S. Department of Labor Blog, 2024.

The word “doula,” meaning one who mothers the mother, provides all around support throughout early pregnancy, birthing and postpartum stages. Unlike a midwife, a doula is not a medical professional, but instead emotionally eases the laboring process. 

 The history of Black birth workers in the United States stretches back to when enslaved women served as midwives and used their traditional customs and practices. Post-emancipation, Black midwives, also referred to as “Granny Midwives” in the South, fostered comforting environments to ensure Black families had the care and support they needed during labor and delivery. These Black birth workers provided the sensitive and compassionate care needed by other enslaved pregnant women, but also to the enslavers. Today Black doulas provide safe spaces for Black women who may experience implicit racism and bias in medical settings.

“We don’t speak for our birthing people,” said Julie Roberson, a certified doula and owner of Your Doula In Love, based in the Hampton Roads area. “Instead, we help them find their voice, ask the right questions, and make their concerns heard. When bias creeps into the room, we turn the conversation around to empower the birthing person to advocate for themselves.” 

Although midwives were present in half of all births across the country in the early 1900s, the evolution of healthcare combined with racial and sexual prejudice has led to drastic declines in midwife-attended births, and more of an increase in maternal mortality rates, particularly for Black mothers, according to the U.S. Department of Labor.

Doulas in Action

Birthing plans with a doula incorporate strategies such as stretching, position adjustments, and massages to give mothers more sense of comfort and control during labor, according to American Pregnancy Association, 2023. Personal narratives and testimonies from licensed Black doulas, highlight the power of doula care and how some of these doulas’ advocacy for their patients is inspired by their own experiences with medical racism in medical settings.

Roberson, a certified doula, found out when she was just 15 years old that she had an ectopic pregnancy. Her mother fiercely advocated for her, repeatedly telling doctors her bleeding was far more than a long period. Finally, they paid attention, she said.

“I literally was bleeding out, coming home from school on a school bus. And I had to have my entire left ovary and fallopian tube and the pregnancy removed,” Roberson said. “Had they listened to my initial emergency room visit, I could have been administered the medications that they gave me weeks later, earlier in the pregnancy, and I could still have a full reproductive system right now.”

Roberson also advocates for her patients. One Black mother, in her third trimester, had unusual swelling and persistent headaches. “Despite the clear symptoms of preeclampsia, medical staff dismissed her complaints,” Roberson said.

For Kenda Sutton El, Executive Director of Birth in Color, advocating for clients often means confronting systemic discrimination head-on. She recalls one of her patients being mocked by medical staff for making her co-pay in cash. When her patient complained and wasn’t believed, Kenda booked an appointment at the same place, asked to pay in cash and was also mocked, by the same person who mocked her patient she said. 

“I was actually recording at that moment,” Sutton said, And I took the recording to them. And I said, “Now that you made me prove it to you, you can either fire her or I will go public with it.” 

Okorie said becoming a doula felt like pouring all her passions into the right cause. 

“We have so much history in the medical industry of abuse and degradation and horrifying situations, that being able to create a space where a woman, a black woman, a dark -skinned black woman can feel safe, is the most important experience to ever create,” she said.

A doula’s impact extends beyond just the patient. They often encourage a mother’s partner to remain involved during labor, which can foster emotional support and alleviate stress. This involvement provides reassurance and boosts the mother’s confidence during labor. Research shows that partner presence can reduce instances of pregnancy loss and low birth weight, according to the National Library of Medicine, 2018.

Certified doula and Hampton University Alumna, Amy Green said she eases patients’ partners into this new journey of parenthood, 

 “I find a really strong connection teaching spouses how to help their birthing partner get the baby to latch on to breastfeed.   I educate, I have dolls, I bring prenatal to visits to show how you know how latching works and the day of birth typically doulas kind of come in and step in and help the baby latch. But I actually, cue in the spouse at that point. I remind them,’You can do this.’ And the biggest compliment that I get following a birth is thank you for showing us how to feed our child,” she said.

Picture this: dim lighting, string light ambience, soft music, and smells of lavender. Roberson ensures the senses are soothed in the birth room to reduce negative emotions during labor. 

 “Birth can be extremely overstimulating at times. So, we like to dull everything as much as we can,” she said. “In the hospital room, we all have those bright white lights. We just turn everything off. And we replace those lights with string lights, with flameless candles, and a star projector. So we make it feel like a kind of spa -like, really low stimulation, a low dull environment.” 

Altering the environment puts patients at ease and allows women to experience the joy of birth. 

“They’re in a more secure, more safe space where they can really talk to you one on one like a person and not feel like they’re fighting or having this tug of war against you,” Roberson said. “Our clients have enough information so that they feel empowered so that they can advocate for themselves. So it all goes hand in hand. That’s a big reason why I have to see my birthing people prenatally several times in order to adequately support them in that birth space.” 

By providing culturally individualized care, Black doulas and midwives help mitigate the impacts of racism that are embedded within the healthcare system, including addressing the causes of pregnancy-related deaths, such as cardiovascular conditions, hemorrhage, and preeclampsia, according to the U.S. Department of Labor Blog, 2024. 

Types of Doula Care 

Doulas serve in various capacities such as birth, postpartum, full-spectrum, community-based, and end of life doulas. Birth or pregnancy doulas are the doulas who handle women from conception to birth, providing essential continuous support.

“The birth doula is basically your labor coach. They’re like, you got this, go ahead, get this baby out,” said Okorie. 

Roberson also shared, “We’re always on call, because birth is very unpredictable. We stay with our patients matter how long the labor, sometimes providing continuous support for 12, 13, 14 hours.” 

“And any good doula will ensure their clients needs are met above all else, even if that means confronting medical staff. “I’ve definitely had my fair share of arguments and threats and things of that nature from hospital staff who have not been comfortable with letting my client do what she would want to do,” said Okorie.

Its vital to know that midwives and doulas are not the same. Midwives are healthcare providers with medical training who deliver babies, provide prenatal care, and teach new mothers how to care for their infants. doulas are non-medical professionals who focus on emotional support, pain management, and advocacy for mothers during labor and delivery.

Postpartum doulas are also an essential bridge of support needed to help ease the transition into parenthood, including helping with postpartum depression, assisting with breastfeeding, bathing, or swaddling the baby. Much like a birth doula, they are hands on. 

Death doulas specialize in helping those who experience loss in any capacity, a miscarriage, abortion, or the loss of a family member while pregnant. 

Full spectrum and community based doulas cover all of these aspects. They extend their support throughout reproduction, from fertility, pregnancy, abortion, loss, and postpartum. Community-based doulas are well suited to combat and improve racial disparities in healthcare outcomes by ensuring that pregnant patients of color, who are more likely to face discrimination and mistreatment in the medical system are advocated for and receive any support they may need, according to the National Health Law Program.

 “If they don’t have a doula or someone that they felt connected to through their pregnancy, they don’t feel safe enough or secure enough to tell somebody that something’s going on,”  Roberson said.

Services and Accessibility 

Doula care is a growing yet unevenly distributed field, with more doulas available in urban areas than in rural regions. This creates challenges in accessibility, especially for marginalized communities. Despite these obstacles, doulas carve out unique practices that reflect their values and the needs of their clients.

The lack of national licensing provides flexibility,  Okorie said. “That gives us the freedom to kind of create our own practiceI know that my trajectory is specifically within herbalism and traditional midwife and doula studies. So I know that’s where I’m going to lean towards,” she said.

While doulas have the freedom to thrive in their practice without undergoing a solidified national license, this also highlights the complexities of doula care regarding accessibility.

Unlike midwives, who are nationally certified through the American Midwifery Certification Board (AMCB), doulas operate without mandatory accreditation. That makes it harder for mothers to navigate hiring a doula compared to a midwife. However, efforts to expand access to doula care are growing. Initiatives like California’s expansion of doula programs and federal support for policies such as the Black Maternal Health Omnibus Act aim to bridge gaps in care and address these disparities head on, according to the U.S. Department of Health and Human Service, 2022. 

Financial barriers remain a significant hurdle as well. Private doulas often charge out-of-pocket fees, which can be inaccessible to low-income families. Yet, Black women in California report higher rates of doula use (15%) and a strong interest in future doula support (66%), reflecting the value they see in this care despite challenges, according to the National Library of Medicine, 2019.

While medicaid coverage for doulas is available in states like New Jersey and Virginia, these states require doulas to complete state-approved training and certification processes to qualify for reimbursement, according to the National Health Law Program, 2022. 

Organizations like Birth In Color provide services for those who may not qualify for Medicaid, Sutton El said.  “If you’re low-income or you don’t qualify for Medicaid, Birth in Color has different programs and different things that we try to make sure that everyone can afford a doula and get the support these patients need,” she said.

Amy Green also understands these barriers firsthand and through her organization, Birth and Renew, works to make doula care accessible for all, regardless of financial constraints, using a donation-based model.

“Doula work is expensive,” she said. “Not only do you donate to the services that you’re receiving, but you also can donate to the service of others,”  This creates a ripple effect of support within the community, she explained.

Green hopes that as more states recognize the value of doula care, this essential support will become available to all expectant mothers.