Introduction

A perinatal program to train Black doulas can improve access to social, emotional, and educational support from professionally trained, culturally concordant care. North Carolina’s maternal mortality in 2013–2017 was 56.8 (per 100,000) for Black women compared to 19.8 for White women.¹ Three nurse-midwives created a program to build a pipeline of Black doulas to attend the births of Black families in the Triangle region of North Carolina. The program’s goal is to decrease maternal mortality and morbidity in the Black community, improve birth outcomes, increase patient satisfaction, increase the maternity workforce, and potentially provide income for the doulas.

Documented Need

The United States has the highest maternal mortality and morbidity rates among high-wealth countries.² Black women and their babies in the United States die at three to four times the rate of non-Hispanic White women.² In the 2018 North Carolina Health Equity Report, the North Carolina Department of Health and Human Services (NCDHHS) reported that Black women receive late or no prenatal care at a rate of 39.1% compared to 23.9% for White women.³ In Durham County in 2019, Black babies died at > 4 times the rate of White babies. The infant mortality disparity ratio for Alamance County was 2.25, Granville County 1.98, Guilford County 2.87, Orange County 3.26, and Wake County 4.13.³ Black women and infants suffer disproportionately high rates of mortality and morbidity in North Carolina, including the counties in and around the Triangle. Controlling for education and socioeconomic status does not change this shocking health disparity.

In 2017, The American College of Obstetrics and Gynecology confirmed that perinatal outcomes, including decreased medical interventions and cesarean deliveries, improve when doulas are part of the maternity care team.⁴ However, there are barriers to use of doulas by Black families, including lack of awareness, few Black doulas, and the cost of doula services. The fee for a birth doula is approximately $1200. Currently, only one insurance company in North Carolina offers coverage for doula care, and twice as many Blacks (24%) as Whites (12%) in North Carolina live in poverty.⁵ It is well established that income is strongly associated with morbidity and mortality. Black families unable to afford doula services may not have access to this potentially life-saving service.

Given persistent racial and ethnic disparities in birth outcomes, workforce diversity is particularly urgent in supportive care during pregnancy and childbirth; however, training Black women to become doulas is also fraught with challenges. A DONA International certification is considered the “gold standard” in doula training and is likely to be one of the main certifications that third-party payers will require if doula services become an allowable and billable expense.⁶ Lack of recruitment, high fees, and limited availability of culturally appropriate training make it difficult for Black women to receive DONA certification.

A Unique Approach

Given the barriers to training Black women to care for Black families, we developed an innovative doula training program. DONA International, the world’s first, largest, and leading doula-certifying organization, was founded in 1992 and has certified more than 12,000 international doulas in more than 50 countries.⁷ DONA doula training in its original form is too short to explore the unique needs of Black birthing persons. Other doula training programs across North Carolina have varying requirements and curriculum elements offered by for-profit and nonprofit entities. Most of them appear to charge fees to their learners, and only a few focus on Black doulas or offer mentored childbirth for families needing doula services.

To implement this project, our team recruits Black women from Durham, Granville, Orange, Chatham, and Wake counties; utilizes an enhanced, replicable doula training curriculum for women from an underrepresented minority group; matches each doula with three women/families during training, for a total of 360 women/families supported free of charge; and supports newly trained doulas in developing a sustainable doula business that will allow them to offer their services to low-, middle-, or high-income areas.

First, we enhanced the traditional DONA labor support doula training to consider cultural needs, family dynamics, generational influence, the racial divide in maternal morbidity, institutional racism, and the lack of trust in the health care system from the Black perspective. Next, we added several topics to the fundamental doula curriculum weaving in the mind, body, and spirit connections essential for this work. Finally, we implemented an evidence-based model to address racial inequality in access to holistic, quality care for mothers and infants and inequities in access to doula certification among Black women in North Carolina. The training represents an example of culturally appropriate and concordant doula training.

The Power of Collaboration

This project is highly collaborative, both in the development and implementation of the training program and in the recruitment of learners, expectant families, birth locations, and policy advancement. The project is codirected by three Black certified nurse midwives from three medical centers: Venus Standard, MSN, CNM, LCCE, FACNM CD(DONA), assistant professor at UNC School of Medicine, Department of Family Medicine in Chapel Hill; Jacquelyn McMillian-Bohler, PhD, CNM, assistant professor at Duke School of Nursing in Durham; and Stephanie Devane-Johnson, PhD, CNM, FACNM, associate professor at Vanderbilt University in Nashville, Tennessee. These three women have 60 years of combined experience in women’s health and clinical education. All three are Black women, and each team member has a history of successfully engaging community partners and implementing community projects. The additional trainers in the program represent a variety of disciplines, including mental health, social work, advocacy, lactation, and wellness. Finally, the doulas are recruited from churches, universities, and community partners in the program counties. These future doulas are the gatekeepers to the Black community, who will increase trust, build relationships, and increase open communication between patients and providers for shared decision-making.

After training the doulas, it is critical that Black families have access to the doulas. Our current and future funding sources will allow the program to serve families that are being cared for by the medical providers serving pregnant women in an expanded service area, including UNC Health, Duke Health, local health departments, and more, as willing providers are identified. As part of the pilot launch, the C. Felix Harvey Foundation, which recognizes exemplary scholarship that reflects a commitment to innovation and impacts communities, awarded us $75,000. Funding was also provided by UNC Family Medicine and the Winer Family Foundation. In 2022, we received a $525,000 award from The Duke Endowment. This additional award allows us to expand the pilot project that is currently limited to patients of one area and one health system to multiple health systems in several North Carolina counties. We hope to sustain access to doula care to Black families by partnering with payers such as insurance companies and Medicaid. As suspected, these organizations have indicated they will likely require doulas to have a certification from an evidence-based organization, such as DONA International, to be reimbursed for services.

As insurance companies and payers begin to reimburse doula services, more women will be able to take advantage of this payment and benefit, adding income to their families and increasing the economic and workforce infrastructure in North Carolina. As evidence of this, NCDHHS recently requested proposals from agencies to implement a pilot Community Health Worker-Doula Program as part of its Medicaid transformation efforts. Also, a Medicaid managed care prepaid health plan has already discussed this with our team, and several are planning on covering doula services for their more vulnerable populations. United Health Care has just announced they will cover doula services. This project will be replicated within other marginalized and underserved counties with a high maternal mortality rate among Black women.

Another important goal of this project is to impact policy on several levels. Several organizations have specifically indicated their support and advocacy for this work. The March of Dimes will advocate for insurance companies to cover doula care.⁷ We have received letters of support for this work from the North Carolina Obstetrical & Gynecological Society, the NCDHHS Women’s Health Branch, the North Carolina Medical Society, and Dr. Erin Fraher at the Cecil G. Sheps Center for Health Services Research.

Conclusion

Black women continue to die in childbirth and in the postpartum period at unacceptable rates. At one time, the disparity between mortality rates for Black and White women was attributed to race and ethnicity. However, we now know that it is not genetics, it is racism and bias that overwhelmingly lead to this alarming statistic. All families receiving care from a doula have fewer medical interventions, infants with higher birth weights and fewer birth complications, and are more likely to breastfeed, leading to decreased maternal and infant mortality and morbidity rates.² In addition, racially concordant care increases the patients’ rating of trust, satisfaction, and adherence to care management.⁶ This program trains Black doulas to care for Black families in pregnancy, labor, and postpartum, thus providing a comprehensive approach to addressing perinatal morbidity and mortality in the Black community. After completion of the program and ultimately certification, the doulas have a valuable service they can offer to women of their community at no charge or at a reduced rate, and a billable service when third-party payers begin to reimburse. The data related to birth outcomes and patient satisfaction will help drive policy changes related to insurance coverage for doula care.

This doula project would be a significant step toward addressing birth equity as North Carolina embarks on Medicaid and health systems transformations. In addition, this project also models how an interdisciplinary group of professional Black women can join forces to specifically recruit, support, and provide funding to Black women for doula training to decrease the state’s maternal mortality and morbidity rates. This project’s overall strength is the team’s experience and the diversity of stakeholders and supporters paired with a holistic approach to addressing the mental and emotional well-being of the Black mother and the Black doula.

Disclosure of interests

All authors declare they have no conflicts of interest.