Abstract
Introduction:
Doula support is increasingly recognized as a promising strategy to address racial inequities in maternal health. The New York City Health Department launched the Citywide Doula Initiative (CDI) in March 2022 to expand access to free, community-based doula support in disinvested neighborhoods.
Methods:
To evaluate the program’s first year of implementation, we conducted semi-structured interviews with 44 clients, doulas, doula-organization staff, and Health Department staff between November 2022 and April 2023. We coded interview notes using template analysis (a thematic analysis approach) and grouped barriers and facilitators according to the Practical Robust Implementation and Sustainability Model.
Results:
Facilitators included high perceived value of the CDI, a shared commitment to community, open communication, and policymaker support for doula work. Barriers included insufficient time for planning, cumbersome bureaucratic processes, and cultural and capacity differences between the Health Department and community partners. Additional factors, such as—variation in hospital treatment of doulas, doula-organization capacity, doula skills and experiences, and client needs and circumstances—had mixed effects on program implementation.
Discussion:
Findings indicate that community-based doula models, which have been shown to improve birth outcomes in disinvested communities, can be successfully scaled in an urban setting. Programs seeking to expand access to doula support should prioritize time for planning, allocate sufficient resources for administrative support, and work to establish efficient and responsive payment and contracting processes. Having mission-driven staff at all levels of the program and prioritizing relationships with community-based organizations and doulas are vital for success.
Introduction
Interest in expanding access to doula support has recently grown in the United States. In 2022, the Biden administration called for increasing the perinatal workforce, including doulas, within a comprehensive strategy to reduce maternal mortality and address racial inequities in maternal health. 1 As of December 2025, 33 states had implemented or begun to implement Medicaid coverage for doula care. 2
Doulas are trained professionals who provide emotional, physical, and informational support before, during, and after childbirth. Doula support is associated with reductions in Cesarean birth,3–7 postpartum depression,5,6 preterm birth, and low birthweight,3,7–9 and higher rates of breastfeeding initiation and exclusivity,8,10–12 postpartum visit attendance,7,8 and satisfaction with the birth experience. 6
Despite its benefits, doula care is primarily available through a private-pay model, limiting access for families with the greatest need. To address this gap, community-based doula organizations, often led by Black, Indigenous, and other birth workers of color, have long provided low- or no-cost support to birthing people in their communities. 13 Additionally, they provide doulas with training, mentorship, administrative support, and peer networks, which can address turnover and other common challenges to expanding access to doula care.13–16 However, most of the programs are small and rely on a patchwork of private grants, limiting their work and sustainability.17,18 Innovative models for scaling up community-based doula programs are required to ensure that doula services are accessible to all who need them.
This study describes the implementation of a large-scale, government-funded community doula program in New York City (NYC). Via a mixed-methods process evaluation, we sought to understand the program’s perceived value among different stakeholders, assess fidelity to the program model, and identify barriers and facilitators to implementing a program of this scale. In this article, we focus on the evaluation’s qualitative findings to describe contextual factors that affected implementation.
Methodology
Program Description
The NYC Health Department (“Health Department”) launched the Citywide Doula Initiative (CDI) in March 2022. The CDI is an expansion of the agency’s By My Side Birth Support Program, which has served Brooklyn since 2010. 19 Through partnerships among the Health Department and seven other community-based doula organizations, the CDI aims to address maternal health inequities by: (1) providing no-cost doula care to 1,000-plus residents of disinvested NYC communities annually; (2) building a diverse and sustainable doula workforce through training, apprenticeship, and professional development; and (3) promoting systems change through hospital-doula-friendliness initiatives (Figs. 1 and 2).
The three components of the Citywide Doula Initiative’s program model. Arrows indicate the mutually reinforcing relationships between program components. Abbreviations: NYC, New York City.
The Citywide Doula Initiative’s logic model. The vertical arrows represent outputs or effects at one level of the program that directly influence another level of the program (e.g., training new doulas affects the ability to provide direct services to birthing people).
The CDI is implemented via contracts with doula organizations (Fig. 3), which, in turn, contract with doulas. Each organization employs one or more coordinators who oversee the program at their site and support their doulas. CDI doulas provide clients with three prenatal home visits, labor and birth support, and four postpartum visits (Fig. 4). During visits, doulas gather information using data-collection forms to identify client needs and facilitate referrals to resources. Table 1 describes the program’s scale and implementation in year 1.
The citywide doula initiative’s organizational structure. The health department contracts with each doula organization, which, in turn, contract with individual doulas to serve clients. The dotted line signifies an informal partnership across doula organizations, which come together regularly to discuss implementation. Abbreviations: NYC, New York City.
Doula visit schedule. Doulas are provided with a list of topics to discuss at each visit, along with structured data collection forms. All prenatal and postpartum visits are typically conducted in person and last approximately 2 hours. Labor and birth visits vary, with most lasting between 6 and 17 hours. For clients who have additional needs or join the program early in pregnancy, doulas can be authorized to provide up to two additional visits.
Key Indicators from the Citywide Doula Initiative’s First Year of Implementation (April 1, 2022–March 31, 2023)
Indicator includes only clients who gave birth during the reporting period.
Indicator includes only clients whose cases were marked closed during the reporting period.
Percentages do not add up to 100 because individuals were able to select multiple categories.
Study Design
CDI research staff undertook a mixed-methods, convergent parallel evaluation to assess the program’s first year of implementation (April 1, 2022–March 31, 2023), with a focus on its direct-services and capacity-building components. The program’s evaluation incorporated a review of monitoring data, surveys of doulas and clients, and interviews with key stakeholders. This article focuses on qualitative findings from stakeholder interviews, alongside monitoring data presented in Table 1, to identify contextual factors affecting implementation.
Two staff members conducted semi-structured interviews from November 2022 to April 2023 with 44 clients, doulas, doula-organization staff, and Health Department staff. Interview guides were developed for each group (Table 2). Doulas and clients were randomly sampled by organization and borough, respectively. Other participants were purposively sampled based on their role. All interviews were conducted virtually in English and lasted 45–60 minutes. Participants provided verbal consent to interviews. To encourage candor and protect confidentiality, participants were informed that conversations would not be recorded; interviewers took detailed notes. Respondents, apart from Health Department staff, received $50 for participating. The study was approved by the NYC Health Department’s Institutional Review Board.
Overview of Stakeholders Who Participated in an Interview (n = 44)
Note that staff from By My Side Birth Support Program are Health Department staff and were included in the Health Department category instead of the doula-organization-staff category.
Includes staff from the Fund for Public Health in New York City, which administers contracts and payments for the Citywide Doula Initiative.
Research staff analyzed interviews according to the Practical, Robust Implementation and Sustainability Model (PRISM), an implementation-science framework that emphasizes multi-level contextual factors that affect implementation. PRISM’s four contextual domains—(1) perspectives on the intervention (client and implementer perceptions of the program); (2) partner characteristics (qualities of clients and implementers); (3) implementation and sustainability infrastructure (organizational resources, capacity, procedures); and (4) external factors (policies, external systems, community resources)—make it well-suited for assessing and addressing structural drivers of inequities that can limit program success.20,21
Interview notes were analyzed using template analysis, a thematic analysis approach that uses an iterative hierarchical coding template and is highly flexible based on the research question and program needs. 22 Research staff read two interviews in each stakeholder category and independently generated a coding template, using a combination of a priori codes based on interview guides and codes identified from interview notes. They then discussed the codes and developed a complete coding template, grouping codes into hierarchies and themes. Themes were sorted into each of the PRISM domains and categorized as a facilitator, barrier, or influencing (one with mixed effects) factor.
Research staff independently applied the template to an additional set of interviews using Atlas.ti (Version 8.4) and met to compare and refine the template. They then divided the remaining interviews, analyzing each stakeholder group sequentially and meeting weekly to review coded passages. Both researchers are CDI employees and brought deep understanding of the program to the analysis, along with maternal health subject-matter expertise. The researchers engaged in reflexivity, meeting to discuss their assumptions and ways that prior knowledge could influence interpretation of interviews. Co-authors were consulted to sort themes into PRISM domains, interpret passages, and discuss relationships between themes.
Results
Several facilitators, barriers, and influencing factors were identified in the CDI’s first year (Table 3). Results are organized by PRISM domain.
Barriers, Facilitators, and Influencing Factors That Affected the Citywide Doula Initiative’s First Year of Implementation, Organized by PRISM Domain
PRISM (Practical, Robust Implementation and Sustainability Model).
Influencing factors are not barriers or facilitators in their own right, but can vary by individual or institution and therefore have mixed effects on implementation.
Perspectives on the Intervention
Facilitator: High perceived value
All stakeholder groups noted the value of the CDI, especially its financial accessibility and focus on reaching birthing people who could most benefit from doula care. Most clients were satisfied with the services they received and reported feeling supported by doulas in informational, physical, and emotional domains. I developed a relationship [with my doula] really quickly. I think everyone should reach out if they need a doula. I felt so much support. —Client
Respondents in each group also reported that the CDI’s breadth and scale had a high potential for impact, enabling the program to reach many birthing people and generate evidence on the impact of doula care. They saw the CDI’s multi-pronged approach, including doula training and hospital doula-friendliness, as unique. Having the funding, programming, and staff to support something this large is unique. Being able to collect data on doula-attended births and their outcomes is going to be incredibly helpful. —Health Department staff
Barrier: Tension between program structure and client-centered practices
Doulas and doula-organization staff expressed difficulty balancing the CDI’s data-collection requirements—including screening for depression, intimate-partner violence, and other needs—with a personalized care approach. While doulas understood the value of collecting data, many felt it was excessive and invasive for clients and that screenings and referrals extended beyond a doula’s scope. Such discomfort may have prevented universal screening during the program’s first year (Table 1). The data collection makes us spend a lot of time not really serving the client. It feels like taking from them more than serving. —Doula
Notably, no clients expressed concerns with data collection. Clients stated that they felt comfortable confiding in their doula and were able to build strong, personal connections with them. [My doula] allowed me to open up to her a lot more. She could tell when I wasn’t fine, even when I couldn’t actually say it myself. She was a godsend. —Client
Both clients and doulas indicated that the program could better meet client needs through increased flexibility in the postpartum-visit schedule. Several clients stated that they did not need postpartum support, while others found the length, number, or spacing of the visits inadequate.
Multilevel Partner Characteristics
Facilitator: Shared commitment to advancing community models of care
When establishing the CDI, the Health Department contracted with community-based organizations. Several doula-organization staff noted the importance of trusting in community partners and discussed how they used their organization’s experience providing doula services and network of resources within the CDI. [The city] decided to work with seven vendors who have existing programs and relationships with communities…. It’s really big to put trust in community programs [and] not disrupt a fully functioning ecosystem. —Doula-organization staff
Most doulas and doula-organization staff also reported that passion for community-based work drove their engagement with the CDI. This passion led doulas and staff to remain committed to the program amid early challenges. Before CDI, doulas were only accessible for people who had means, but now they’re accessible for people who are marginalized… . I believe in the work, so I continued even though I knew what I was getting into with the city contract [and its slow payment timeline]. —Doula-organization staff
Influencer: Variation across doula organizations, doulas, and clients
Respondents noted variation across doula organizations in the level of support provided to doulas, internal administrative and payment processes, and implementation of the apprenticeship program. Some doulas expressed dissatisfaction when they had different experiences than their peers at other organizations.
Many doula-organization staff also observed differences in doulas’ uptake of the program model and service quality based on their experience level and skillset, especially related to administrative and case-management responsibilities. A few clients also signaled inconsistency in implementation, reporting that their doula did not provide all four postpartum visits.
Additionally, doulas and doula-organization staff identified challenges supporting the CDI’s diverse clientele, including providing the full scope of services to individuals joining late in pregnancy (per Table 1, clients joined at a median 34 weeks gestation), engaging sufficient doulas to serve non-English-speaking clients, and maintaining contact with unhoused clients. One client transitioning to a shelter noted discomfort with home visits due to her living conditions: [My doula] did offer to come, but my living situation wasn’t conducive. I live in a really small apartment where two people couldn’t stand. I didn’t want her to be uncomfortable. —Client
Implementation and Sustainability Infrastructure
Facilitator: Open communication between CDI staff, doula organizations, and doulas
In its first year, the CDI implemented weekly emails to doula-organization staff, biweekly vendor check-ins, and monthly learning meetings with doula coordinators. Doula-organization staff appreciated these efforts to establish strong communication and were highly satisfied with the CDI administrative team’s responsiveness and support. CDI team members are amazingly available. New problems arise all the time, and we’re constantly moving and adjusting. Great receptiveness in my communication with the team. —Doula-organization staff
At the doula-organization level, many doulas praised open communication and support from their coordinators, which helped them manage difficult client cases and navigate implementation challenges. [My doula organization] keeps us up to date with what’s going on. Everything’s explained; we know there’s someone there we can reach out to if we need support. —Doula
Barrier: Insufficient planning time
The CDI launched in less than six months, which was considered an impressive feat. This timeframe posed challenges for implementation, since policies, data systems, and expectations for partners were developing in real time. Doulas and doula-organization staff expressed frustration and confusion with the lack of clear guidance. Process and organization [could have been better]… . The program was rushed when it started, and we were not well prepared to handle everything. —Doula-organization staff
Barrier: Cumbersome contracting and payment processes
Early in the program, city contracting and payment processes created strain for doula organizations. Health Department staff described these processes as slow-moving and cumbersome, requiring detailed documentation. Everything needs to be checked, all backup documentation needs to be submitted, there are multiple queues, and several people are checking. —Health Department staff
Initial contracts—and consequently, payments—to doula organizations were delayed by several months. Most organizations did not have financial reserves to pay doulas upfront, resulting in delayed payment to doulas. Implementers expressed frustration with payment delays, which was exacerbated by a perceived lack of transparency around city processes.
Payment delays affected doulas’ participation and morale, undermining the program’s goal of building a sustainable doula workforce. I wanted to throw in the towel a couple of months ago when waiting for pay. It’s tough, because a lot of us serve communities and also live in [those communities]. Clients have problems paying bills, and so do we. —Doula
Several doula-organization staff noted that advance payments issued in the second contract year helped them pay doulas upfront.
Barrier: Mismatch between health department and community partner expectations and resources
Stakeholders described challenges aligning Health Department expectations with partners’ capacity. Doula-organization staff said they had underestimated the administrative burden of the CDI and needed additional resources to adequately staff the program. We talk about CDI every day internally—the administrative responsibility, data entry, and invoicing process… It’s more of an administrative lift than expected. —Doula-organization staff
Some doula organizations temporarily provided in-kind staff support to manage the workload, but they too indicated a need for more CDI-funded staff to ensure staff were not pulled away from other programs.
External Factors
Facilitator: Political buy-in for doula support
A few interviewees mentioned growing interest in doula support among elected officials. The fact that the CDI is city-funded was viewed as a signal of strong support for doula work and a commitment to addressing maternal health inequities. Over the past couple of years, doula work has gotten elevated and is a crown jewel—we’re trying to leverage it. —Health Department staff
Influencer: Variation in hospital treatment of doulas.
Clients, doulas, and doula-organization staff described widespread variation in hospital treatment of doulas, which affected doulas’ ability to serve their clients. While some doulas described their experience as respectful and collaborative, others faced obstruction and animosity from hospital staff. Several participants reported that hospitals barred doulas from entering altogether or staying with their clients throughout labor and childbirth. The doula could not get into the room for the C-section…someone [on the medical team] said she could not go in. It would have been helpful for her to be there. —Client
Discussion
This study is the first to assess implementation of a large-scale, government-operated community doula program. Many of the facilitators identified, such as community partnerships, maintaining communication with implementers, and strong political will, align closely with literature on scaling up public-health interventions.23,24 The CDI also experienced common barriers to expansion, including vendor capacity constraints, insufficient time to establish implementation infrastructure, and variable implementation across doulas and organizations. 23
Several themes arose from the CDI’s position as a community-based program within a government agency. NYC’s establishment of the CDI signaled political will for expanding access to doula support and lent credibility to the new program. Bureaucratic processes, however, led to implementation challenges, consistent with findings from other studies on health department–community partnerships.25–27 Challenges were exacerbated by rushed implementation, resulting in payment and contracting delays, which eroded doulas’ trust and confidence in the program. Our study adds to research suggesting that a shared commitment to community, strong mission, and open communication with partners can provide a robust foundation for overcoming hurdles.24,26,28–30
Our findings may not be generalizable to other doula models or geographical contexts due to the CDI’s situation within a health department in an urban area, with multiple doula organizations and hospitals in proximity. Our use of the PRISM framework mitigates these limitations by sharing multilevel contextual factors that affected implementation, supporting translation to other settings. 21 Our study is also limited in that interviews were not recorded; detailed notes and the large number of interviews conducted helped ensure that we captured all themes. While interviews covered all PRISM domains, to reduce participant burden, we did not comprehensively address the external factors domain. Our findings reflect external factors that were most prominent but may not include more subtle influences on implementation.
Health Equity Implications
Health equity is “the assurance of the condition of optimal health for all people…whereby systems and structures are required to value everyone equally, rectify historic inequities, and distribute resources according to need.” 31 Community-based doula models have previously been shown to promote health equity and improve birth outcomes in disinvested communities by mitigating the effects of systemic racism and discrimination and providing culturally sensitive support, connection, and resources.7,9,32 Our study indicates that this approach can be scaled in an urban setting, offering a promising model for addressing maternal health inequities at the population level.
Our findings highlight the importance of partnerships to bolster rather than disrupt existing doula-support networks. Working with organizations that are rooted in these communities and have strong local resource networks is essential to reaching individuals from disinvested communities with high-quality, tailored support. Even with that foundation, doulas may need additional training to serve clients with higher needs, including those in shelter systems.
The CDI’s first year offers lessons for centering equity in government-community partnerships. Our findings emphasize a need to anticipate challenges related to government efficiency and establish clear expectations for stakeholders. We recommend a collaborative planning period of at least 6 months with implementing organizations and other key stakeholders to review contracting and payment practices to address potential pain points; conduct partner capacity assessments and tailor budgets accordingly; and develop program policies. Contracts should account for the substantial administrative effort required for coordination and include advance-payment options to reduce the financial burden on partners. For doulas, we found that setting clear expectations during onboarding and providing training regarding data-collection requirements (e.g., screening and referrals) can reduce variation in implementation and dissatisfaction with these requirements.
Additionally, our study illustrates the importance of establishing feedback mechanisms and communication channels to promote equitable implementation. The CDI’s learning collaborative, vendor check-ins, and community advisory board incorporated implementers and community members as true partners in planning, implementation, and evaluation. In response to feedback, the team also implemented quarterly town halls with doulas, which could be replicated by other programs to strengthen accountability.
Our findings demonstrate the importance of applying health-equity principles to all aspects of implementation, including supporting those who provide services. Our study underscores the administrative effort required to coordinate a community doula program; policymakers and payors, including Medicaid, should account for this cost when designing coverage for doula services.28,33–35 Our findings also indicate a need to collaborate with health care systems to improve doula integration in hospitals. The CDI’s implementation experience shows that advancing multisectoral partnerships among government agencies, community-based organizations, doulas, and hospitals offers a pathway to respectful care and support for birthing people.
Authors’ Contributions
M.B.: Conceptualization, methodology, formal analysis, writing—original draft, writing—review and editing. S.G.: Conceptualization, investigation, formal analysis, writing—original draft, writing—review and editing. I.D.: Conceptualization, investigation, methodology, writing—review and editing. G.A.: Conceptualization, writing—review and editing. M.J.: Conceptualization, writing—review and editing. N.J.M.: Conceptualization, writing—review and editing. M.-P.T.: Conceptualization, supervision, writing—review and editing.
Footnotes
Acknowledgments
Special thanks to Anabel Rivera, Chanel Porchia-Albert, Gracie-Ann Roberts, and Fajah Ferrer for providing input during the preparation of this article. We gratefully acknowledge the time and contributions of the CDI clients, doulas, doula-organization staff members, and Health Department staff members who participated in interviews. We thank the eight doula organizations—Ancient Song, By My Side Birth Support Program, Caribbean Women’s Health Association, Community Health Center of Richmond, Hope and Healing Family Center, Mama Glow Foundation, The Mothership, and Northern Manhattan Perinatal Partnership—which comprise the CDI and have made this work possible. Last, we acknowledge Zahirah McNatt for her leadership and support for this work.
Author Disclosure Statement
The authors have no conflicts of interest.
Funding Information
No funding was received for this research study.