Doula Care Becomes Essential Health Care

A pregnant mother with two kids told her doula Ebonie Bailey that she was not having a good experience with her health care provider. She didn’t know why she needed to do certain things, like take a glucose test, and what questions she should ask to receive better care. She didn’t feel like she could ask questions. When Bailey told the mother that she could switch providers, the mother was surprised.

“Within the Black community, we are often taught that providers are in this hierarchy, and we don’t get to challenge them,” said Bailey, who is one of the founders of the Iowa Black Doula Collective.  “We sometimes have to tell our clients, ‘Now, you need to ask your provider this.’ They’re like, ‘Wait, I can ask them for that?’ This is about breaking some of those generational ideas of support and showing what support actually looks like.”

Bailey was among the first Black certified doulas in Iowa. Her work is centered in ensuring Black birthing individuals are supported throughout their reproductive health journey. This kind of culturally congruent, community-based health care is becoming more widely recognized as an evidence-based approach for addressing disparities in Black maternal health outcomes.

In 2021, the Iowa Department of Public Health (IDPH) launched the Iowa Title V Community-Based Doula Project for African American Families. Today, approximately 15 doulas identifying as Black or African American are working with birthing individuals through four federally funded Title V Maternal Child Health (MCH) clinics throughout the state, and maternal health leaders are advocating for changes that would make doula care an integrated part of Iowa’s health care system.

“I think the Doula Project shows our commitment to health equity for our state and recognizing that there are populations—Black and African American women—who are dying at much higher rates than White women in the state,” said Marcus Johnson-Miller, Bureau Chief and Title V MCH Director in the Bureau of Family Health at IDPH. “We really need to target our interventions to where the need is, and I think this project is proving that we're committed to that philosophy within the Health and Human Services Agency.”

Mid-Iowa Health Foundation provided a two-year grant to the Doula Project. The investment recognizes the importance of promoting supportive systems that increase access to care and services, especially for historically excluded populations. The doula care model can have a multi-generational impact by not only improving the health and well-being of birthing individuals, but also their infants.

“As an organization focused on reducing disparities, working with community members, and supportive of systems change efforts, Mid-Iowa Health Foundation was the perfect partner to support a data-driven, evidence-based, and community-informed project like the Title V Doula Project,” said Dr. Nalo Johnson, CEO and President of the Foundation. “I am particularly proud of the ways in which the project was informed, developed, and implemented by Iowa’s Black maternal health leaders at IDPH, University of Iowa, and members of the Iowa Black Doula Collective.  While focused on reducing the state’s Black maternal health outcomes, the information gained through this project has the potential to expand access to doula services to every birthing person in the state.”

A targeted approach

African American and Black-identifying Iowans experience worse health outcomes throughout the birthing experience. Black Iowans are six times more likely to suffer maternal mortality than White birthing individuals, according to the 2020 Iowa Maternal Mortality Review Report. Black birthing individuals also have higher rates of complications during pregnancy and birth and are more likely to initiate prenatal care later and breastfeed at lower rates than White individuals. Black babies are more likely to be born at a lower birth weight and have a higher likelihood of being born prematurely than White babies. These disparities exist regardless of income or education levels.

Disparities in health outcomes for Black Iowans extend beyond just maternal health. A history of inequitable policies and practices, including “redlining”, has created underinvestment in Black and African American communities. In Polk County, for example, 13.3 percent of adults living in predominately Black tracts lack health insurance compared with 8.6 percent of adults in non-black tracks. The median household income for Black or African American households in Polk County is $33,816; in comparison, the median household income for all of Polk County is $63,530. These factors are among the social determinants of health that greatly influence health and well-being outcomes.

Interviews with patients at Iowa’s Title V clinics as a part of a 2020 needs assessment also elevated how bias and racism in the health care system impacts individuals. One African American individual in Black Hawk County shared:

“[It is hard to] find a doctor that look like you … Because they’re gonna understand you a little bit differently … Going to treat you a little bit differently … and that’s hard to do. …because of where we live, that’s dang near possible. But if you can find somebody that understands our diversity, our culture a little bit differently … I think you end up having better experiences and even if they don’t necessarily look like you, but if they understand your struggle.”

Reviewing data and experiences gathered through the needs assessment, along with a broader conversation around doula support as a disparities-reduction strategy, inspired Johnson, then serving as Division Director for Health Promotion and Chronic Disease Prevention at IDPH, to work with a team on implementing a model that would reduce disparities in the state’s maternal health outcomes and improve care for Black and African American birthing individuals.

Having doulas as a part of the health care team is an evidence-based approach that is gaining national attention. A doula is a non-medical professional trained to provide emotional, physical, and informational support for laboring, birthing, and postpartum families. Access to Black and African American doulas especially offers birthing individuals from historically excluded communities to receive care from someone who likely has similar lived experiences with racism and intergenerational trauma and can support in ways that honor identity and culture.

Patients who work with doulas report increased self-efficacy regarding their ability to impact their own pregnancy outcomes. Among many improved outcomes, doula support has been shown to decrease the likelihood of complications for birthing individuals and their babies and increase the likelihood of breastfeeding.

“As we see these disparities in health care, there is hesitation in the community to trust a health care provider, to walk into a hospital and think you're going to be well cared for,” said Ashley Ezzio who leads the Doula Project at IDPH. “If you have a doula by your side, they're really encouraging that [trust] and creating safe spaces.”

Defining the project

Although Ezzio works in a different Bureau at IDPH than the Title V program, she was brought into the project because of her previous training and work as a certified doula. From the start, she made connections with members of the Iowa Black Doula Collective and other professionals in the maternal health care community who could help guide and implement the project. Most of the project’s leaders are Black maternal health experts who are focused on system change to improve maternal health outcomes of Black Iowans.

“We didn’t come in and just plan a doula project,” said Johnson-Miller. “We’ve been able to build trust within each of our systems and work together.”

“The partnership is unique,” said Bailey, “because they’ve allowed us to have input.”

The project especially has worked alongside the Iowa Black Doula Collective’s efforts of promoting holistic and evidence-based doula care. The Collective first formed because of a connection among three Black doulas—Bailey, Jazzmine Brooks, and Selchia Cain-Hinton—who saw the value of doula care, as well as challenges working within the traditional health care system and in managing a business.

The Collective provides regular training for Black and African American individuals to become certified doulas, and has trained 34 doulas through summer 2022, covering the training fees and supplies. It also offers mentorship for new doulas as they support patients through three births to finish their certification process. In addition, the Collective supports new parents with coaching and groups, including one focused on breastfeeding.

The Doula Project through IDPH has pulled ideas from Iowa and other models across the U.S. and helped advance doula care in Iowa in these ways:  

First, Black certifying and certified doulas are paid for providing services through Title V clinics located in Des Moines, Davenport, Dubuque, and Waterloo. IDPH chose these four clinics because they serve a large percentage of African American and Black birthing individuals. Title V clinics serve a low-income population and are designed to provide holistic support to patients beyond just medical care, including home visiting services and access to social workers who can connect clients to community resources. A doula fits into the model of the health care team, offering birthing individuals a trusted partner, advocate, and educator.

Paying doulas a living wage to support Title V patients makes the project standout nationally, said Bailey. “I’m proud that to be right there in the Midwest, for Iowa to be mostly White, and we’re making groundbreaking moves,” she said.

With funding from the Mid-Iowa Health Foundation, IDPH also funded training for seven Black doulas through the Collective in Fall 2021 and has supported mentors to work with newly trained doulas. In addition to working with the Collective, IDPH contracted with Lastascia Coleman, MSN, ARNP, CNM, with the University of Iowa, to help recruit, mentor, and support doulas. As a certified nurse midwife, Coleman created materials to help doulas address specific items at each step in the birthing process and has worked with health care providers and administrators to understand the role of doulas as a part of the team.

“Doulas are able to meet people in the community,” said Coleman. “They can make plans and talk to people about different choices they are going to make during pregnancy and birth and have conversations with us as providers, so we feel informed about what things we might recommend and what might be necessary. I think people feel more confident when working with doulas.”

The project also is tracking data and experiences to inform stakeholders and encourage a statewide strategy that would expand culturally congruent, community-based doula services to all Title V clinics. Leaders especially are interested in seeking Medicaid reimbursement for doula services, which would ensure low-income individuals have access to this supportive strategy.

Building a sustainable system of doula care within a two-year pilot has been a critical focus. IDPH and its partners are spending time educating and advocating for opportunities on multiple levels of the system to build and support a diverse perinatal workforce and integrate the model.

“It shows IDPH’s commitment to addressing inequities in our health care system that are data driven,” said Coleman. “It’s not something we pulled out of a hat to do. It’s something we know works, so having their support and their infrastructure available to these first couple of cohorts of doulas trained for Title V sites is a big deal.”

What’s happened

The project launched in summer 2021 with an initial focus on building the processes and systems that allow doulas to work with the Title V clinics and on supporting doula training. The number of doulas working with the clinics has grown from an initial four to 13, and from January-July 2022, more than 40 clients received doula services through the four clinics, exceeding the target for the first year.

With the workforce and systems now in place, the Project aims to support at least 80 birthing individuals in the coming year. The hope is that patients work with a doula from the first trimester through postpartum.

While project leaders are just starting to gather data and expect an initial report in November 2022, they are already hearing about the impact of the project from personal experiences.

Bailey, who is now based in Atlanta, supports Title V patients through virtual doula services. She says this model can be beneficial for clients, because she can meet with them in their homes and engage the entire family in coaching sessions. In addition to helping patients advocate for what they need, she has seen success with engaging partners in how to support through labor and with siblings in understanding the role they can play as a caretaker.

Black Hawk County Public Health officials appreciate the role doulas, like Bailey, are playing in the maternal health care system. While it’s still too soon to have specific outcomes data for the individuals working with doulas through the Title V clinic run by Allen Women’s Health, Tonya Wilder, RN, MSN, MPH, who serves as Clinic Manager at the Public Health department, has heard how doulas are making a difference: “You have a lot of pregnant persons who do not have that support during pregnancy and birth. They don’t have someone to share with them what to expect, how to manage stress, or a lot of other issues a person would experience during pregnancy. The doula is there to give them that emotional stability.”

Becky Borgman, Maternal Health Child Director at EveryStep who oversees the process of getting doulas connected to the Title V clinic in Des Moines, says she’s also heard how having a doula helps individuals feel supported in making choices and speaking up about concerns. In particular, she shared the story of how one Black mother had a traumatic and unexpected C-section when she was pregnant with twins. With the mother's next birth, her doula was there when the doctor told the mother she would have to have a C-section again. This time, with the doula’s advocacy, the doctor talked the mother through the process so that it did not feel forced upon her. After the baby was born, the doula also encouraged the mother to get care when the she experienced swelling and pain, a sign of an infection.

Because doulas are trusted members of the community, many doulas refer patients to the Title V clinics. Borgman says the doula model is especially important for patients who identify as Black or African American because not only have they likely experienced racial trauma in the medical system that leads to distrust, they may also face social-economic barriers that can have a compounding effect on the pregnancy. With a connection to the clinic, patients can get access to resources to meet essential needs like food, housing, and mental health care.

Integrating doulas into the Title V clinic model, said Borgman, “is the most holistic approach to health care a pregnant individual can get.”

Black Hawk County Public Health Director Nafissa Cisse Egbuonye, PhD, MPH, says doula care is about authentically engaging diverse communities.

“I think that the health disparities within our communities of color show that we need to go beyond just community outreach and conduct community engagement to understand what the needs of the population are and how they want to be served, what’s working for them, not working for them,” she said. “This project shows that when you invest in these coaches, the overall benefit at the local level is that it’s effective. This is really how public health can continue to move forward in terms of providing preventative services and having those kinds of collaborations.”

Making a case

Building a sustainable system involves educating health care providers, Medicaid and other insurance leaders, and other state system leaders about the importance of doulas as part of the care team and how they are different than midwives, social workers, and other professionals. While the role of doulas is more understood and accepted in places like Des Moines, the model is less familiar in other parts of the state.

As doulas raise concerns through their advocacy for patients, IDPH and other maternal health professionals are also providing trainings on how bias and racism are embedded within the health care system and can impact patient care. Bailey especially spends time meeting with providers and staff with the goal of building stronger relationships to have these difficult conversations about how care could improve.

“We’re still breaking down barriers of bias in these health care systems,” said Ezzio with IDPH. “Someone must do that work in order to create space for doulas to come in and properly serve clients. We have to build understanding. We have to build health care teams.”

Making a case with Medicaid Managed Care Organizations (MCOs) is another critical piece of the project. Doula services tend to cost between $800-$1,500 per pregnancy, a cost that many low-income birthing individuals cannot afford. Some MCOs support doula training and offer the service as a value-add to their policies, but many Medicaid patients still must pay out of pocket.

Maternal health professionals often describe doulas’ work as “heart work” but this can lead to burnout without better support, including pay that allows doulas to earn enough to support their own families. Bailey argues that paying doulas is about expanding the number of Black entrepreneurs in the state as most doulas start their own businesses to provide their services.

Sustainable funding builds trust with communities, said Cisse Egbuonye. When pilot projects are funded for a year or two and then go away, communities won’t engage in accessing services.  

“If we are putting this out there, it’s a wonderful program, it benefits you in these ways, then all of a sudden, we take it away, now you are going to have a very negative impact in how the community not only views the public health department, but also the health system.”

IDPH hopes through its data collection to show the cost savings of doula care for Medicaid patients through reduced C-sections and complications for the birthing parent and baby, making MCOs want to cover the service for its members. Coleman wants to make sure the reimbursement would be at a rate that values each doula’s time, while recognizing that midwives and physicians already are reimbursed at lower rates through Medicaid.

IDPH also is making a case with state leaders to value the department’s time in building the system. The team sees value in being able to offer technical assistance, support for trainings, relationship-building with providers and hospitals, and advocacy with state leaders.

Having IDPH involved in the project “builds community trust,” says Bailey. “What’s cool is that our clients are able to see us interacting with Title V, they see us interacting with IDPH, and so it builds a different level of community trust.”

“We showed through this project that we support a diverse workforce, that doulas have a space here, that they are a valued profession, that they should be compensated fairly, and that their services and interventions are just as critical as other interventions that we use to put money behind,” Ezzio said. “We want them to be entrepreneurs. We want to see their leadership in this state.”

Building a maternal health system

Beyond making a case for doula care, Coleman is among those who are thinking about all the pieces needed in the maternal health system to improve outcomes for Black and African American individuals. Her vision of this system includes access to diverse health care professionals at many levels, including midwives and doctors. She also would like to see more birthing centers.

For the past two years, she’s been developing a certified nurse midwife training program at the University of Iowa and, pending accreditation, will welcome the first cohort this fall. She also is involved in the Iowa Maternal Quality Care Collective focused on improving standards of care, with an initial focus on reducing primary C-sections and postpartum hemorrhaging.

“It’s all of these things above that are making a statewide difference,” said Coleman.

Cisse Egbuonye sees the doula project as the type of work that is “overdue” in working collaboratively as a system that can engage diverse communities. Over her six years at the Public Health Department, she and her team have led efforts to increase collaboration among nonprofits, government agencies, and health care institutions to break down siloes and operate as a system that addresses the social determinants of health and increases access to health care.

“We need to continue to accelerate and expand our efforts,” she said, “especially if our population continues to have an influx of diverse communities coming in. We need to be prepared.” She especially is interested in the community health worker model and how doulas can be a part of that integration of care in communities. Wilder agrees that greater focus should be on training doulas who are within the Waterloo community and that training needs to be offered in other languages to certify doulas within Liberian, Congolese, and other communities.

As part of the system, Bailey sees a need for greater access to mental health services during the postpartum period. With a shortage of mental health providers, the Collective is looking for other ways to support new parents, such as partnering with a Black-led yoga studio.

In the second year of the Doula project, IDPH and its partners expect to double the number of pregnant individuals served and to write a white paper that makes the case for continued state and potential Medicaid support of doulas. They will also continue to host trainings for providers and offer a trauma-informed breastfeeding certification for doulas.

Already those involved are encouraged by the way a diverse doula workforce is expanding far beyond the three doulas who started the Collective three years ago, and patients and the broader community are recognizing the value and opportunity.

“What I love the most, and what makes it all worth it to me,” said Bailey, “is when we have clients who go through the birthing process, and one, they’re like, ‘This was amazing,’ and two, ‘How do I become a doula?’ It’s opening doors in so many ways.”

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