Abstract
Introduction:
Systemic racism continues to shape maternal health care in the United States, contributing to higher rates of adverse outcomes for Black women and other women of color. Doulas have emerged as important advocates, yet little is known about how doulas’ own racial identities influence their work in challenging inequities.
Methods:
This qualitative study used a phenomenological approach to explore doulas’ perspectives on racism in maternal health care. Ten doulas in Northeast Florida participated in in-depth interviews and focus groups between 2021 and 2022. Data were transcribed verbatim and analyzed thematically using established qualitative methods.
Results:
Four major themes were identified: (1) challenging differential racial treatment, (2) leveraging privilege, (3) anti-racist doula training, and (4) advocating for Black doula recruitment and engagement. White doulas described using their privilege to support clients of color, while Black doulas described navigating heightened scrutiny and exclusion. Across participants, there was consensus that current training inadequately prepares doulas to address racism and that greater racial diversity within the profession is essential.
Discussion:
Findings highlight how doulas both confront and adapt to systemic racism in maternal health care. Their accounts point to gaps in training and structural barriers to equitable practice, while also illustrating how advocacy can both protect clients and, at times, reproduce inequities through unequal access to power and privilege.
Health Equity Implications:
Addressing how race and privilege shape advocacy pathways, reforming training to include racial justice, expanding recruitment and support for Black doulas, and integrating doulas into perinatal care models are important strategies for advancing maternal health equity and advocating for Black racial justice in health.
Introduction
Maternal health outcomes in the United States continue to reflect deep and persistent racial inequities. In 2021, the national maternal mortality rate reached 32.9 deaths per 100,000 live births, with non-Hispanic Black women experiencing 69.9 deaths per 100,000 live births, or 2.6 times the rate for non-Hispanic White women (26.6). 1 These disparities persist across socioeconomic and educational levels and reflect the cumulative effects of structural racism, implicit bias, and unequal access to respectful and responsive care.2–4 The resulting disparities in treatment, patient experience, and health outcomes highlight the urgent need for interventions focused on equity that extend beyond traditional clinical reform.
Doulas are trained professionals who offer continuous, person-centered support across pregnancy, birth, and the postpartum period, helping to bridge communication and trust between birthing people and providers. 5 Contemporary studies demonstrate that doula support improves communication, enhances patient autonomy, and reduces cesarean and preterm birth risk, particularly among Medicaid-covered and racially minoritized populations.5,6 However, access to doula care remains limited and inequitable because of high out-of-pocket costs, inconsistent reimbursement, and training programs that rarely address systemic racism or prepare doulas to navigate inequities in maternity care. 2 The doula workforce also remains disproportionately White and middle-class, reflecting structural barriers to entry and sustainability for doulas of color and illustrating how racial identity and professional culture shape advocacy within perinatal care. 3
Most doulas tend to be middle class White women with limited training on understanding racial inequalities in health care.3,7,8 The historical conditions from this process are tied to the suppression of Black midwifery during the twentieth century, as the growing medical model framed childbirth as physician-controlled hospital care rather than community-based reproductive knowledge. This shift marginalized Black midwives while contributing to the later “re-birth” of midwifery among middle-class White midwives during the 1970s and 1980s.7,8 Research on the racial composition, recruitment, and training practices of the doula workforce suggests that many doulas receive limited preparation on structural racism and racial bias, while doula organizations continue facing challenges moving beyond frameworks centered on the birth experiences of White women to more directly address the realities faced by Black birthing persons.3,9 These conditions have led to a system that disproportionately results in middle class White women as doula providers who often have limited understandings of racial inequalities as they grapple with their own positionality in the context of supporting birthing persons of color.3,10
These barriers are further exacerbated by the general issue of access, as doula services are rarely covered by private insurance and have only recently been included in Medicaid programs in a growing number of states that frame doula care as preventive. 11 Recent scholarship and policy analysis note that Medicaid reimbursement policies for doula services remain uneven across states, with substantial variation in reimbursement structures, covered services, certification requirements, and implementation approaches.11,12 Even in the states where there is some coverage, there have been some limitations with the level of doula care support under Medicaid, often not covering full doula service and limiting supporting doula work with access to livable salaries. This results in barriers to access doula services for people of color as well as limitations on racial minorities entering the doula profession.
A growing body of research on community-based doula care documents how these models respond to persistent racial inequalities in birthing.5,13,14 This work emphasizes cultural competence and racially concordant care as central to broader projects of birth justice and anti-racist practice. Community-based doula care is a model rooted in shared community connection, where doulas often share cultural, racial, and linguistic backgrounds with their clients, enabling culturally congruent care and stronger trust. National and regional organizations have increasingly developed training, mentorship, and advocacy initiatives focused on expanding culturally responsive doula care and improving workforce accessibility for doulas of color, including efforts surrounding Medicaid reimbursement and Black maternal health advocacy led by organizations like the National Black Doulas Association (NBDA).15,16 Some of these same organizations, including the NBDA, support community-based doula care, such as New Jersey’s Doula Learning Collaborative, and Birth Sisters at Boston Medical Center. The input from Black doula organizations is crucial to expand these sorts of policy efforts to increase doula coverage. This sort of organizing provides institutional support for doulas of color seeking to address racial inequalities faced by birthing persons of color.
This qualitative study explores how doulas of diverse racial backgrounds experience and respond to racial inequalities in birthing. Drawing on interviews with 10 doulas in Northeast Florida and guided by a phenomenological framework 17 that centers lived experience, the study examines how racial identity and structural inequities shape advocacy in maternal health settings. In doing so, it seeks to advance our understanding of the doula care experience, how doulas advocate for their birthing clients, and their role in developing equitable and culturally grounded models of perinatal care.
Methods
Study Design and Participants
An exploratory qualitative design was used to examine how doulas perceive and respond to racism in maternal health care, guided by phenomenological principles that center lived experience. 18 Participants were recruited through community networks in Northeast Florida using snowball and convenience sampling. Eligible participants were adults (18 years or older) who were currently practicing as doulas or in training. Although the study focused on advocacy practices among doulas supporting women of color, any doula willing to reflect on racial dynamics in health care was invited to participate. Participants had experience supporting clients who both did and did not share their racial background, which informed reflections on differential treatment and advocacy across client experiences. Of the 14 individuals contacted, 10 agreed to participate. The sample included doulas identifying as five White, four Black, and one Latina, with varying levels of professional experience. All participants identified as women. Two of the doula participants were in doula training and had shadowed births. Four of the doulas were part of doula organizations where they were assigned clients, while six were independently self-employed, offering doula service to clients from their networks. Participants reflected a range of professional experience and practice contexts. Most practiced under the traditional doula model, typically operating on a fee-for-service basis not covered by insurance. In addition, some participants described offering sliding-scale or pro bono services (e.g., “karma births”). Some of the participants were community-based doulas that reflect the communities they serve and often support historically marginalized clients, often at low costs. Access to doula care in this region reflects national trends of limited reimbursement and structural barriers to sustainability. 19 The population served by participating doulas was based in Northeast Florida and included both White and Black birthing clients.
Data Collection
Data were collected between 2021 and 2022 through individual interviews conducted via secure, password-protected video conferencing. Each session lasted 60–90 min and followed a semi-structured guide focused on advocacy practices, experiences of racism in health care settings, and perceptions of doula training. All sessions were audio-recorded and transcribed verbatim and de-identified using pseudonyms to protect confidentiality. Table 1 presents the interview guide used to explore doulas’ experiences with race in health care settings.
Doula Interview Questionnaire
Data Analysis
Thematic analysis followed Braun and Clarke’s six-phase framework, including familiarization with the data, generation of initial codes, searching for and reviewing themes, and defining and naming the final themes.20,21 A phenomenological orientation guided the analysis by emphasizing how participants understand and made meaning of their lived experiences. This approach was appropriate because the study sought to explore how doulas perceived, interpreted, and navigated issues of race, advocacy, and power within health care settings. Members of the research team independently coded transcripts and then met to compare interpretations, resolve discrepancies, and reach consensus. Coding emphasized participants’ descriptions and reflections on experiences of race and advocacy. Throughout analysis, reflexive discussions were used to address potential bias and consider researcher positionality. All participants provided verbal informed consent, and the study was approved by the Institutional Review Board of the University of North Florida.
Findings
All participants described advocacy as central to their role; however, their accounts revealed meaningful differences in how White and Black doulas experience and respond to racism in maternal health care settings. Four interrelated themes emerged from the data: (1) challenging differential racial treatment, (2) leveraging privilege, (3) anti-racist doula training, and (4) advocating for Black doula recruitment and engagement (Table 2).
Doula Research Findings. Major Themes, Supplementing Sub-Themes, and Example Quotes from in-Depth Interviews
Challenging Differential Racial Treatment
Different races, different treatments
The doula participants shared that they observed unequal treatment of their clients in health care settings based on their client’s racial background. Having experience supporting both White and Black clients led to a heightened awareness that Black clients were more likely to experience delays in care, dismissive treatment, or more pressure to consent to medical interventions to induce labor. In contrast, White clients often received more attentive and respectful treatment from health providers. There tended to be less pressure and a different social climate. Selena (Black doula) explains her experience seeing the differences between her Black and White clients, noting “…a different attitude, a different atmosphere, and they come in the room. It’s not like open, bubbly compared to my white clients” (Table 2). Rather than explicit forms of racial antagonism or discrimination, doulas describe settings that tend to be more welcoming for White women giving birth as compared to Black women. These are subtle cues on treatment in the social environment that significantly impact the birthing experience. By supporting clients across racial groups, doulas described being able to identify patterns in how clients were treated within health care settings. When reflecting on these differential treatments, another doula explained that their Black clients have a much different experience compared to their White clients.
Different concerns of Black women
Doula participants share the different concerns coming from their Black clients as compared to their White clients. Kim (White doula) described that Black clients often expressed embedded fears about the outcomes of their birthing experience (Table 2). Some doulas explain that White clients start from a place of empowerment to expect a smooth process for their birth, while Black clients feel marginalized, expressing more of a concern of surviving the experience of the birthing process. There are particular needs that require advocacy to address the real-lived experiences of the maternal health care crisis that Black women are aware of. Doulas fit a particular role to advocate and address these issues.
Leveraging Privilege
The savior complex
White doulas at times share their positionality of working from a place of privilege to attempt to provide better resources and care for their Black clients. One White Doula explains the following. Debra (White doula) describes how she can pressure wealthier, White clients to pay a higher fee that will afford them to subsidize care for clients with lower-income backgrounds. She describes, “I will milk any privilege that I have to charge wealthy people the full fee to then pay for other people’s stuff. And I tell them that too” (Table 2). They would refer to this as the “sliding scale” or “karma births,” with the implication being that this will allow the White doula to be able to take on more work with marginalized women of color. They explain this process as a way to lean into their privilege and play into what they refer to as the savior complex to pressure White clients into supporting these efforts. This strategy attempts to address the lack of insurance coverage for doula services, which are more commonly accessed by wealthier White women. The greatest need is in Black communities that face these significant health disparities and have less access to doula services due to these financial barriers. Thus, these White doulas attempt to take on more birthing clients from marginalized communities with sliding scales.
White passing advocacy
This study also explores how a White-passing doula can lean into their privilege to advocate for marginalized women of color. Maya (White-passing doula) shares a “…sometimes I’m in spaces where I’m very much perceived as white-passing and that offers me a ton of privilege” observing that her status offers her opportunities to navigate spaces that facilitate advocacy for her clients. In this way, doulas become aware of how their racial identity leads to rapport with health care professionals in ways that support mitigating inequalities for their clients. While they do share facing power struggles and pushback, they do share an awareness that their racial position allows them certain avenues toward advocacy for Black clients in White health care settings.
Anti-Racist Doula Training
Doula training reform
Several participants advocated for reforms to doula training, emphasizing the need for stronger preparation around racial bias and inequities in maternal health care. Selena (Black doula) shared that with some mainstream certification programs “…their core beliefs is not friendly as far as being culturally competent…” (Table 2). She went on to describe feeling unwelcome in these spaces as a Black woman. Participants noted that many certification programs do not adequately address racial inequality in maternal health care. While doula training was described as effective in preparing doulas for general advocacy and supporting physiological birth, it tended to emphasize avoiding medical interventions and placed limited focus on racism within health care settings. As a result, participants reported that understanding and responding to racial inequities was often learned later through hands-on experiences supporting Black clients.
Anti-racism and advocacy training
Rhonda (Black doula) explained that gaps in training contribute to differing approaches to advocacy in the context of racial disparities. She described how some White doulas emphasize educating clients to advocate for themselves, whereas she emphasized the importance of doulas actively advocating alongside Black women within health care settings. She stated, “…I think we as Black women, we’re becoming more educated, and we’re wanting more and we know we can have more. I think we just want a difference for this generation.” In this framing, anti-racist training involves recognizing when encouraging self-advocacy is not enough and when doulas need to intervene more directly to support Black clients. Rhonda underscored that racism in maternal health care can be a life-or-death issue, making passive or indirect advocacy inadequate in some situations. Similarly, two White doulas described seeking additional education on racism and intersectionality outside of standard certification pathways, highlighting that anti-racist advocacy training is not yet a routine part of doula preparation but should be more fully integrated to better support Black clients.
Advocating for Black Doula Recruitment and Engagement
The need for Black doulas
Many of the doula participants stressed the importance of increasing the number of Black doulas to ensure culturally responsive care. One White doula, Debra (Table 2) explains that White doulas often work with wealthier White women in certain hospital networks and have rapport with health care professionals in those settings. She described concerns about placing White doulas into Black community settings where they have not built rapport with hospitals in these networks that serve this community. “If [white doulas] were just like, ‘Oh, I really want to work with young Black women’ and then you go to a hospital, you’ve never been to, you are going to be a horrific advocate.” This unique reflection of placing White doulas from wealthy White communities among hospital networks in working class, Black communities is framed as a problematic strategy. The reality of racial segregation leads to different experiences for White doulas that make them less equipped to navigate hospitals that cater to the Black community. All doulas expressed the need to increase the role of Black doulas to advocate for their communities by recruiting more and providing financial support to sustain their involvement.
Engaging with Black women into the doula profession
Rhonda explained how Black women are increasingly stepping into doula roles and how generational shifts are contributing to new forms of advocacy and representation within the profession. She observes, “I think we just want a difference for this generation, you know, so we are demanding things we are seeking better for ourselves.” As Black doulas gain experience, participants described mixed responses within predominantly White doula spaces. Some described supportive doula organizations and individual doulas, including White doulas, who were more inclusive and offered opportunities for collaboration or shared practice. Others described environments that were less welcoming or more territorial, where Black doulas faced resistance when entering established networks or client spaces. Navigating these dynamics was described as challenging, particularly within doula spaces that remain predominantly White, and was framed as a barrier to sustaining Black doula involvement in efforts to address racial inequities in maternal health care.
Discussion
This study contributes to a growing body of research documenting how systemic racism shapes maternal health care and how doulas intervene to support women of color.2–4 Consistent with prior work,3,22 participants described how Black clients experienced dismissive treatment, delays in care, and disproportionate pressure to accept medical interventions. These findings show how such patterns persist in routine clinical encounters, reinforcing structural inequities and undermining trust.
The research also extends current literature by examining how doulas’ racial identities influence their advocacy practices. White doulas described leveraging their privilege to increase provider responsiveness and redistribute resources, while Black doulas emphasized the need for heightened vigilance in predominantly White clinical spaces and noted that their presence did not carry the same institutional authority. These dynamics illustrate how advocacy unfolds within racialized health care systems and are shaped by how privilege is perceived and used. This perspective positions doulas not only as support providers, but as racialized actors embedded within broader health care systems.
Participants were also critical of existing doula training programs, noting that many fail to address systemic racism or the Black maternal health crisis. In response, some doulas developed alternative curricula rooted in intersectionality and reproductive justice. These grassroots efforts represent important forms of leadership in reshaping training to center racial equity and client advocacy, and they align with ongoing calls for transformation in maternal health education. 23
Finally, participants identified the lack of racial diversity within the doula profession as a pressing concern. Black doulas described the burden of being among the only providers of color in their region, while White doulas emphasized the need for mentorship and structural support to diversify the field. Expanding the number of Black doulas and embedding culturally responsive training are essential steps toward addressing structural barriers in perinatal care.
By centering the lived experiences of doulas, this study illustrates both the possibilities and limitations of advocacy in the face of systemic racism in perinatal care. The findings highlight persistent inequities, the ways in which doulas use or confront privilege, and the structural challenges that shape training and workforce diversity. Together, these insights contribute to broader efforts to reimagine perinatal care in ways that are culturally responsive, equity-driven, and grounded in reproductive justice.
Limitations and Future Directions
While this study offers insights into how doulas navigate racism in health care, it reflects the perspectives of a small group of doulas from Northeast Florida. Expanding on this sample of doulas, including the experiences of birthing people, health care providers, and doula trainers may develop a fuller understanding of how advocacy unfolds in health care settings.
While this analysis centers race as a key dimension of social position shaping doulas’ advocacy experiences, further research should explore how the intersection of social class and ethnicity influences the path of both the doula profession and the birthing clients that seek out doula services. Prior research highlights that White middle-class women comprise the majority of both doula providers and doula service users. Greater attention to how socioeconomic status shapes access, participation, and practice is needed to better understand how doula services are organized and delivered across broader contexts.
Future research should explore how these dynamics play out across regions, practice settings, and policy environments, particularly as doula integration and insurance coverage expand. Medicaid coverage for doula services into new states offers opportunities to explore the impact doulas have on the birthing experience and outcomes.
Health Equity Implications
This study highlights the central role doulas play in navigating and responding to racial inequities within maternal health care. The doula participants shared experiences with advocacy in support of their birthing clients and how this process is shaped by race, privilege, and structural context. The perspectives reveal that racism in maternity care is often experienced through subtle, routine interactions rather than overt acts and that doulas become advocates to support their clients in ways that address birthing and racial justice. They are uniquely positioned to observe differences in treatment faced by White and Black clients in ways that enable them to address issues of health equity.
Several implications follow from these findings. (1) Health equity-oriented advocacy cannot rely on race-neutral models of support and must explicitly address how race and privilege shape advocacy pathways when there is a lack of racial concordance in health care. (2) Training and certification programs should be revised to center equity by including content on systemic racism, cultural humility, and reproductive justice, better preparing doulas to navigate inequitable care systems. (3) Sustained investment is needed to expand and support the doula workforce by increasing racial and cultural diversity, providing financial support and mentorship, and ensuring adequate reimbursement for doula services to reduce barriers to entry and improve retention, particularly for doulas of color. (4) Although this study did not specifically evaluate community-based doula programs, the doula participants expressed recommendations that fit with the goals of community-based doula approaches and should be considered sites for future research to advocate for marginalized birthing populations. Recognizing doulas as integral to perinatal care is critical, as their insights and experiences offer practical strategies for making care more inclusive, responsive, and equity-focused.
Authors’ Contributions
J.L.S.: Conceptualization, methodology, formal analysis, investigation, writing, review & editing, project administration, and supervision. T.D.: Investigation, and writing, review and editing. M.S.: Conceptualization, formal analysis, writing, review and editing, and supervision.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This publication was supported by a University of North Florida Publishing Grant.