The Black Maternal-Care Gap Continues to Widen Post-Roe. Doulas Are Fighting to Close It.
This article is part of POPSUGAR's project Roe, 50 Years Later, a collection of stories marking what would have been the 50th anniversary of Roe v. Wade. This moment comes more than six months after the Supreme Court struck down the constitutional right to an abortion in Dobbs v. Jackson Women's Health Organization, and these stories seek to mark the past, present, and future of abortion access in America.
When Roe v. Wade was overturned in June 2022, it sent a ripple of fear throughout the country — particularly for women of color. Why? The headlines spoke for themselves: "The end of Roe will be a death sentence for many Black women," one Los Angeles Times op-ed read.
But according to a recent analysis, the Black maternal-care gap was widening long before that fateful day in June, with the pandemic increasing maternal mortality rates disproportionately among Hispanic and Black women — and further exacerbating existing racial disparities in the US healthcare system.
"Patients, ultimately, want to be seen, they want to be heard."
The US has the highest maternal mortality rate of all industrialized nations, with about 24 deaths per 100,000 live births. Black expectant mothers face significant disparities in care leading up to, during, and after childbirth, creating a world where Black women are more than two times more likely to die from pregnancy-related causes compared with white women. Importantly, 60 percent of pregnancy-related deaths are preventable.
And while the systemic racism behind these statistics needs to be addressed through greater awareness and policy change, there is a single person in the delivery room who can be the difference between life and death for the pregnant person: a doula.
Doulas are trained, nonmedical companions for significant health-related experiences who provide emotional support before, during, and after childbirth. Whether that's guiding breathing and positioning during labor, navigating hospital policies, encouraging respectful communication between families and hospital staff, or encouraging physical and emotional recovery postpartum, they can be an essential part of this process.
With the support of a doula, expectant moms are two times less likely to experience birth complications and four times less likely to have a low-birth-weight baby, studies have shown. POPSUGAR spoke with experts to better understand why having a doula in the room has such a major impact, particularly in a post-Roe reality. Here's what we learned.
The Making of a Doula
After Chanel Porchia-Albert, founder of Ancient Song Doula Services and cocreator of JustBirth Space, experienced a "sterile" environment with an ob-gyn, she found a Black doula to support her first birth.
"It was everything that I could possibly have thought or dreamed about," Porchia-Albert says. "She really centered herself and my partner. I had a wonderful home birth in Brooklyn. And it just changed my life."
"I wanted to create a space where people can feel like they're being held."
Seven weeks after giving birth to her son, Porchia-Albert trained to become a doula herself, inspired by the experience. "I was with these elderly midwives and healers and different folks, and it was the first time that I had been in a community," she says of the training. "Being a new parent, I felt loved. Someone would say, 'Oh, give me the baby.' And you're like, 'Huh?' But they take this child. And then they're nurturing you but also nurturing your child. And that's the whole role of a doula."
That experience with her firstborn shaped the framework for how she centers families now, she says: "I wanted to create a space where people can feel like they're being held, not just on this interpersonal level, but on a larger scale."
And once she started her business, she began to see the ways in which Black, Brown, and Indigenous people are treated differently while giving birth. "I saw how they were illegally drug tested. I saw family separation. I started to witness how folks who were undocumented didn't have any rights at all," she describes. "I was also working with incarcerated pregnant women and seeing how they had lost their complete human rights to birth their child in meaningful ways and respectful ways."
As a doula, her work originally centered around interpersonal relationships, but she soon realized she had a voice as an advocate — and the power to shape legislative policy and human rights around birth. In 2022, she traveled to Geneva, Switzerland, as part of a United Nations committee to give a presentation on racial discrimination in maternal health for Black and Indigenous birthing people in the United States.
Her work also led to being featured in Hulu's "Aftershock," a documentary released last year that follows the preventable deaths of two mothers due to childbirth complications. "We have a systemic issue," Porchia-Albert says in the film. "Patients, ultimately, want to be seen, they want to be heard, and they want to know that somebody genuinely cares about their well-being."
This work taught her that it's not enough to be a traditional doula in today's climate, Porcia-Albert says. There is an added layer of knowledge needed in the delivery room, and there is always an intersectionality of human rights, reproductive rights, and the birthing experience.
Digging Deeper Into the Large-Scale Problem
Despite the deeply personal nature of the maternal mortality crisis, the issue goes far beyond any individual. Our country's healthcare infrastructure has long lacked adequate prenatal and maternal healthcare services in general — especially in places like the Midwest and the rural South.
"We have to think about the impacts of racism and implicit bias. Not race, but racism," Porchia-Albert says of these barriers to care. "And how it has impacted the ways in which people are seen or heard."
Though the crisis has been going on for the country's entire history, in 2018, the federal government started to track maternal mortality more systematically. Congress passed the Preventing Maternal Deaths Act of 2018, which authorized the Centers for Disease Control and Prevention to increase support for state and tribal maternal mortality review committees. This led to other bills addressing maternal health, including extending Medicaid postpartum coverage, funding for training on health equity and implicit bias, providing more maternity care in rural areas, and conducting research on the potential benefits of Medicaid coverage for doula care.
Neel Shah, MD, MPP, FACOG, a professor of obstetrics and gynecology at Harvard School of Medicine who is also featured in "Aftershock," began doing more research into the maternal mortality crisis around this time, too. One glaring example was the "explosion" in C-section rates, he says: "We intervene with major surgery 500 percent more than we used to in the 1970s. And maternal mortality rates just fly upwards." And when it comes to Black women, those risks are higher, he adds. "C-sections do save lives. I'm trained to do them. I believe in them. But major surgery is major surgery."
Surgical complications like organ injury, hemorrhage, and infection are about three times more likely to happen with a C-section than a vaginal delivery. And Black women have a higher rate of C-sections. Why? A big reason is the common use of a clinical algorithm to calculate the likelihood of having a successful vaginal birth. "And if they're Black, their odds drop," Dr. Shah says. "And it has nothing to do with who they are or their biology. The calculator ends up gatekeeping treatment, care, and support. So if you're Black, you're less likely to get good support to have the vaginal delivery that you want."
In December 2021, the calculator was updated to remove race and ethnicity as a risk factor, but it remains an example of how structural inequality can be baked into medical decision-making. Similarly to how Black Americans are systematically under-treated for pain, these racial disparities influence the level of care a person receives.
How Doulas Make a Difference
The essential work of doulas lies in hearing and advocating for their patients — an essential piece of effective healthcare that's often absent.
"When it comes to Black maternal health, we're balancing a space where power and privilege can dominate in a room, and we are leveling the playing field," Porchia-Albert says. "We're also giving someone the space to be able to feel like they had that extra bit of information and education to make an informed decision about their care."
"We're bringing that human experience back into the room."
Studies have shown that having a doctor of color dramatically decreases Black infant mortality, and doulas can further fill in gaps when it comes to disparate healthcare. "When we are in the room, we act as this mirror [for the medical staff], a reflection of someone having to remember their own humanity at the end of the day," Porchia-Albert adds.
"Often within their level of education, [medical doctors] go in with the framework of, 'I have to go through this checklist,'" she continues. "Then we forget that the person that's sitting before us is a human being. And that's what we're centering as doulas. We're bringing that human experience back into the room." How a doula centers someone can be the difference between someone having a good birth outcome or someone having a traumatic birthing experience — or worse.
Besides the major influence on the physical well-being of the parent and child during birth, it's also about providing a safe space postpartum.
"If a mom is not in a state where her mental health issues are affirmed, where her emotional well-being is being centered, where she's being nourished nutritionally, where she's having moments to be able to rest and to be still, how can you pour from a half-full cup?" Porchia-Albert explains. "So having someone to be able to affirm that makes you a better parent. And I think that oftentimes, that's what we forget. And having a doula really helps to remind us of that."
Essential Care in Post-Roe America
In her work as a doula and yoga instructor who specializes in prenatal and perinatal health, Danielle Jernigan recognizes that, in her words, "Mothers need to be mothered, too." And with the overruling of Roe v. Wade, Jernigan is hyperaware of how restricted abortion access will contribute to higher maternal mortality rates — regardless of whether a person wants to be a parent or not.
"The fact is, when you take away someone's autonomy, you take away the right to be human," Jernigan says. "Every human is designed to have choice, dignity, and rights. And as a Black woman, I know what will happen with maternal death rates, especially in communities of color."
"Birth is a community event."
Six months post-Roe, 24 US states have banned abortion or are likely to do so in the near future, which means the choice is becoming less and less of an option.
Twenty years ago, Jernigan herself received an abortion — an experience that impacts "how I do my work now," she tells POPSUGAR. "There are still times when I cry and I don't know why I'm crying. When people say, 'Why are you crying so much? It's what you wanted!' I think they forget it's often a decision we make for self-preservation."
These days, she wonders how life might've looked different if she had access to better support, perhaps even an abortion doula, who is specifically trained to offer emotional support before, during, and after the procedure.
This type of care is all the more crucial now. Jernigan says she knows of postpartum doulas who have been training to prepare for spikes in PTSD for those who are forced to carry a pregnancy to term in states with abortion bans. Patients might also experience the trauma of microaggressions that can come with medical care, she says, and the fear of the police coming to their door when they call 911 during labor.
Experts say that folks who are denied access to abortion care face other long-term health implications, too. "And so what you'll see is a greater maternal mortality rate, right? Because if you are already in a space where you are disenfranchised, now you're even further disenfranchised because now you just have no access to services," Porchia-Albert says. "So unfortunately, what we may see is higher maternal mortality rates because of it."
But she also has hope: "There's a lot of community-based organizations and others that are actively working to center folks and to find equitable ways for people to get the services that they need. And to do that in a way that centers not just the patient but also the provider."
Although doula services are rarely covered in private insurance policies and very few states require Medicaid to cover doula services, efforts are being made to increase access. Last year, Baby Dove partnered with leading advocacy groups like Black Mamas Matter Alliance (BMMA) to create the Black Birth Equity Fund, which provides Black individuals who will be giving birth with one-time grants of up to $1,300 to help cover the cost of doula services.
And with a growing awareness of how doula support can reduce racial inequities, some major cities like New York are implementing citywide doula initiatives that provide free or low-cost services. New York's initiative partners with national birth justice organizations like Porchia-Albert's Ancient Song, which provides doula training, community education, and advocacy for policy change in addition to traditional doula services.
At its most fundamental, the role of a doula is to provide emotional support for those undergoing the birthing process. But their services can save lives.
"Birth is a community event. It was never something that's just happening to an individual. It impacts us all," Porchia-Albert says. "You want to know that you're seen, you're heard, and you're loved. And that's all anybody ever wants."