Counties Are Investing in Doulas to Advance Birth Equity

Counties Are Investing in Doulas to Advance Birth Equity

Maternal Mortality Rate, 2018-2021

Source: Centers for Disease Control and Prevention

Counties across the country are investing in community-based interventions, such as doula services, to combat the nation's rising maternal mortality rates and address the social determinants of health that impact perinatal outcomes. The United States has the highest maternal mortality rate among high-income countries, yet research tells us that many of these deaths are preventable. Research also shows that U.S. communities do not share the burden of death equally: Black and Indigenous people are three to four times more likely than non-Hispanic white people to die from pregnancy-related causes.

Doulas As a Provider of Holistic Support for Pregnant People

Doulas are trained non-medical professionals that provide physical, emotional, educational and advocacy support to expectant parents during pregnancy, labor/delivery and the postpartum period. Doulas provide three broad services to parents: information, navigation and advocacy. While doulas alone are not the solution to the maternal health crisis, they are a community-based intervention with the ability to meet the needs of people most affected by health inequities and address the social determinants of their patients’ pregnancy experience. Doulas interrupt the cycle of harm to pregnant people including discrimination, exclusion and loss of autonomy by recentering compassion and humanity into pregnancy-related care. Evidence shows that when pregnant people are connected with doulas, they have improved birth outcomes and safer, healthier and more satisfying birth experiences. Benefits include:

• Decreasing the prevalence of cesarean sections, low birthweight babies, preterm births, the use of epidural, postpartum depression and low APGAR scores

• Identifying early signs of mental health conditions among pregnant people

• Connecting pregnant people to community resources such as the Supplemental Nutrition Assistance Program or housing assistance

• Supporting caregivers by supplying meals and comfort to the infant between feedings, among other services, and

• Increasing the return on investment for healthcare systems and off-loading the burden on front-line providers.

What are Counties Doing to Support Doula Care?

Doula care is not widely available in this country. Currently, only six percent of birthing people receive doula care and only eight states cover doula care under Medicaid. Those with relatively limited resources often cannot afford a doula, making them inaccessible to those with the greatest need.

Counties can play a key role in managing complex systems affecting maternal health and several are dedicating resources to increase access to doula care for all pregnant people.

• Los Angeles County, Calif.: In response to California including doula care as a Medicaid benefit, the Los Angeles County Board of Supervisors unanimously approved a motion to expand doula services and grow the doula workforce in the county. The motion calls on the Department of Public Health—in collaboration with the Department of Health Services, the Anti-Racism, Diversity, and Inclusion Initiative and other stakeholders—to create a report on how to fund and implement doula-related services. This working group will report back to the board, who will then consider another motion to enact these proposals. The group’s report will explore strategies for:

  • Increasing access to doula services for families

  • Supporting doulas who want to become Medi-Cal providers

  • Training people who want to become doulas and existing birth workers

  • Expanding the county’s existing African American Infant and Maternal Mortality Initiative, and

  • Increasing the diversity of the doula workforce.

• Henrico County, Va.: In collaboration with the state Department of Health, Birth in Color and Urban Baby Beginnings, Henrico County is launching a community-based doula program for pregnant Black and African American people. The Henrico County Office of Emergency Management supplied funding for this project. The project’s goals include integrating doulas into the county’s provider team, ensuring a safe journey to parenthood and helping parents make the best decisions for their children.

•  Rock County, Wis.: The Rock County Public Health Department and the Sisters of St. Mary Health St. Mary’s Hospital-Janesville announced a partnership to combat the high rates of infant mortality in the community by promoting and providing doula care to families. A grant from Wisconsin Partnership Program allowed them to recruit and hire doulas. The partnership anticipates that these doulas will help bridge the gap between patients and healthcare organizations, which can be important for marginalized communities who may not trust the healthcare system.

To learn more about the impact doulas have on infants and families and specific policy levers to strengthen the doula workforce, read the new Community-Based Doulas Brief from the PN-3 Policy Impact Center.

Further reading:

• Maternal Mortality Rates in the United States | Centers for Disease Control and Prevention

• Doula Care Saves Lives, Improves Equity, And Empowers Mothers. State Medicaid Programs Should Pay For It | Health Affairs

• Doulas Can Improve Maternal Health Yet Are Out of Reach for Most | National Partnership for Women and Families

• Community-Based Doulas and Midwives | Center for American Progress

• America’s Maternal Mortality Crisis Is Worsening | The Century Foundation

• The U.S. Maternal Mortality Crisis Continues to Worsen: An International Comparison | The Commonwealth Fund

Local Strategies for Preventing Adverse Childhood Experiences

Children’s positive or negative experiences during the prenatal-to-three period have a lasting impact on future development, health and well-being. Studies have found that adverse childhood experiences (ACEs)— defined as abuse, neglect or household challenges like substance use or an incarcerated parent—can cause toxic stress, which may lead to increased risk for physical and mental health conditions, decreased life expectancy and poorer educational outcomes throughout the lifespan. Recent research has expanded beyond the ACEs defined in the original study to explore how community and systemic factors, such as poverty and racism, can also cause toxic stress that affects brain and body development.  

While ACEs can be traumatic, they are not inevitable. Especially in the first three years of a child’s life, safe, stable and nurturing relationships and environments can reduce the likelihood of ACEs and prevent toxic stress from occurring. As the frontline safety net for residents, counties administer and invest heavily in health and human services and are well-positioned take the lead on primary prevention strategies that increase protective factors and mitigate trauma. Counties connect families to economic and social supports, partner with stakeholders to increase the supply of high-quality child care and offer effective evidence-based home visiting programs to support new parents. County leaders can also leverage their platform to raise public awareness on ACEs and create a cross-sector, community-wide vision for preventing ACEs and creating safe, nurturing spaces where infants, toddlers and families thrive.

County strategies

Supporting healthy parent-child relationships

• Madison County, N.Y.: The county’s health department offers the Healthy Families home visiting program to support expectant families. Through the program, public health nurses visit parents at home during and after pregnancy to connect parents to community resources, provide education on parenting and child development and assess children for developmental delays. The county also throws a community baby shower where expectant mothers can ask questions about having a baby in a relaxed, informal setting and receive a gift bag with baby essentials.

 Connecting families to economic supports and resources

• Contra Costa County, Calif.: First Five Contra Costa has partnered with a local medical clinic to implement ACEs screening and connect families to resources. Providers screen both young children and new or expectant mothers for signs of toxic stress and refer families to the local Help Me Grow (HMG) affiliate. HMG staff answer questions about child development and connect families to needed resources and services. The ACEs screening is funded by ACEs Aware, a statewide initiative which awards grants at the local level to educate clinicians and communities about ACEs and toxic stress.

 Convening stakeholders across sectors to create a cohesive vision for ACEs and resiliency

• Clatsop County, Ore.: Resilient Clatsop County, a coalition of local organizations who serve children and families, is working to reduce ACEs and build resilience. The coalition convenes working groups who explore specific trauma-prevention strategies for the education, healthcare and child welfare sectors as well as the community. The coalition is tracking outcomes and impact with a robust data dashboard.

• Durham County, N.C.: In 2019, the Board of County Commissioners passed a resolution pledging to take a community action approach for becoming an ACEs-informed community and developing a community resilience plan. The county also hosts an active ACEs resilience taskforce whose mission is to build upon the strengths of Durham communities and systems and advance an equitable and culturally responsive approach to prevent and respond to toxic stress and trauma.

Learn More

• Centers for Disease Control and Prevention: Preventing Adverse Childhood Experiences toolkit

• PACEs Connection: Positive and Adverse Childhood Experiences Science 101

  • Guide to establish a local PACEs initiative

• Handouts for parents: Understanding ACEs and Parenting to Prevent and Heal ACEs (available in additional languages here)

• University of North Carolina: Racism is an Adverse Childhood Experience

• Explore state-level efforts

  • California: ACEs Aware

  • Ohio: Health Policy Institute of Ohio ACEs advisory group