Summary
South Florida has top-class medical facilities but poor maternal and newborn health outcomes persist in the region, with especially high inequities between Black and white women. In many ways, the region’s maternal health problems reflect US-wide failures to address health impacts of interpersonal racism and systemic racism, and the cost barriers created by the country’s predominantly for-profit health care system. This system often provides excellent quality health care for people with the resources to pay, while excluding or limiting the choices of many more, including while giving birth.
The governments of Florida and the United States should take urgent and systemic action to address the maternal health crisis, and its racially disparate human rights impacts. This includes greater access to lifelong health care for low-income people and maternal health, and to midwifery care, as well as specific steps to counter racism in the health care system.
This report focuses specifically on one intervention that Black activists in Florida have called for, and that has proven to make a difference in practice: increasing the availability and support for culturally congruent doula care in communities of color. It analyzes what is needed for the governments of Florida and the US to make this intervention, as one step authorities should take to fulfil their human rights obligations and address the maternal health crisis and its human rights injustices.
Doulas are non-medical health workers who aim to provide allyship and informational, emotional, and physical support to pregnant women and other pregnant persons. They provide individualized information about health care options and the rights of pregnant people, and resources for the pregnant person as they go through the major health events of pregnancy and birth in a medical system that they can experience as depersonalized, profit-driven, opaque, and racist. Doula care attempts to focus on the whole person (and partners or family), on non-medical and often transformative elements of pregnancy and childbirth and on respect and on ensuring as much informed choice as possible for the pregnant/birthing person. Academic studies, some of which are described in this report, show improvements in maternal and infant health outcomes associated with doula care, and that doula care can provide culturally congruent and respectful care including for low-income groups that are poorly represented in medicine in the US. Doulas can help pregnant people make informed decisions about their health care and have more protection against obstetric violence, which the US government has recognized as a significant problem in the US.
Some forms of doula assistance improve health outcomes directly, but in other ways doulas can indirectly increase access to quality health care by helping eliminate physical, discriminatory, economic, and informational barriers, by helping clients access local resources like low-cost health care, support groups and diaper banks, for example.
As a result, across the US, reproductive justice activists, their allies, maternal health workers and policy makers and government authorities have increasingly looked to doula care as an immediate step that can be taken to mitigate racial inequities and disconcerting increases in rates of preterm births, some serious maternal illnesses, and maternal deaths. As governments and health care systems engage in the challenging process of undoing structural racism and improving access to health care overall, increasing access to doula care offers a rapid way to begin to help people who are struggling with these systems now.
Yet doula access in Florida is limited, particularly for low-income pregnant people. For this report we sought to understand what obstacles stop Black doulas from being able to provide care to low-income pregnant women and other people in Florida, even though the state and federal governments have committed to addressing the Black maternal health crisis and have sometimes even said doula care is an important part of doing this. This report is the result of almost 50 interviews, conversations, and partnerships across two years with Miami area maternal health experts, including doulas and other providers and experts from the Black reproductive justice community. Academics and activists and doula care experts from across the US were also consulted. The report accepts the value of doula care, having already been the subject of much research, and seeks instead to provide some insight into some of the major maternal health challenges for minority groups in the Miami area especially and some of the challenges doulas face being able to serve them in an efficient and systematic way.
We found that in south Florida, the southern-most counties of the state that include the populous Miami Dade and surrounding areas, cost limits access to doula care for pregnant people, as does low knowledge about the benefits of doula care. Additionally, doulas who want to work with the low-income pregnant people who need their services the most, and who may be from their own communities are hampered in doing so, due to confusing health insurance reimbursement systems, complex registration processes, and inadequate rates.
When doulas receive poor pay, it limits the availability of doula care. Serving doulas must rely on grants, a second job, or do free work. By not providing just compensation, the government is burden shifting onto already stressed Black and brown care workers (mostly women) as well as undermining its articulated goal of equity in who gets to have a healthy pregnancy, a safe, informed, and even beautiful birth, and a healthy newborn baby.
Doula and other forms of community-based perinatal care has deep roots in Black and immigrant communities and resilience to slavery, colonialism, and white-centered systems. The work of providing support at a time of extreme vulnerability for other members of your community is “heart work” but currently it is also uncertain, under supported and underpaid.
Stress and burnout are common in doulas trying to serve Black and brown women in a system that works better for white women. As a result, not only does South Florida have a shortage of doulas of color able to provide culturally competent care to low-income pregnant people of color, but the sustainability of what care that is available is uncertain.
Improving compensation and respect for care work is a feminist priority in the US and globally, because so much of this work is done by women and girls, saves lives and deserves to be compensated justly, and because inadequate compensation poses a major obstacle to achievement of the right to the highest attainable standard of health.
Recent political, economic, and environmental instability in the region and the country should also encourage policy makers to invest in care workers, including doula care. South Florida is one of the US’ most vulnerable regions to extreme heat and other extreme weather events intensified by the climate crisis, and especially for low-income communities. A growing body of evidence shows links between extreme heat and disasters, for example, and poor maternal health outcomes such as preterm birth. This report provides some initial thoughts gathered in consultation with doulas and others why perinatal community health workers like doulas might be especially well-placed to protect pregnant people from some climate harms.
Although Florida was one of the first US states that compensated doulas for their services under Medicaid, the US public health insurance scheme for people with low incomes, the current system is not working well. However, this first step provides an excellent starting point. Florida should work closely with doulas to make all health insurance, including importantly Medicaid, works for the human rights, dignity and justice of pregnant people and these care workers who seek to serve them. Advocacy by reproductive justice advocates, doulas and allies have pressed other US states into action on the issue of just payment for doula care. States including California, Illinois, New Jersey and Ohio are all implementing new policies that ensure that Medicaid provides coverage for doula care. Efforts by other states have provided plenty of evidence that policy improvements should be informed by extensive consultation and partnership with doulas, and that Medicaid compensation for doulas should be sustainable. Based on other states’ policies and Florida’s comparative cost of living in its most populous areas a roundtable of maternal health workers and experts suggested to Human Rights Watch that legislators consider $2,000 per client as a starting point for the term of their pregnancy and postpartum visits.
This report recommends legislative action that ensures the independence of doulas is respected by hospitals and other healthcare institutions; that other supports like billing assistance and public education on doula work are provided; and that a diverse range of doula expertise is recognized by entities established to register doulas as Medicaid service providers.
Florida has recently taken important steps towards improving maternal health and human rights for pregnant people by banning the shackling of incarcerated people in labor and permanently extending Medicaid post-partum coverage for 12 months. However, Florida can and needs to do much more to improve access to free or low-cost healthcare, including midwifery care, to address racism and anti-immigrant prejudice in the health system. But in the short term, they should take the immediate step of enabling the care work that is already fortifying pregnant people, and the community of workers that do it, to flourish and grow, to meet needs and help address unjust inequities in who gets a healthy pregnancy and a healthy baby.
Methodology
This report aims to contribute to the large and growing movement across the US to ensure the contribution of doulas and other perinatal community health workers to improving the right to health is celebrated and respected by all, and properly compensated where appropriate by federal and state governments. Human Rights Watch is deeply grateful to Metro Mommy Agency and the Southern Birth Justice Network who, with their partners, have fought for years for quality, accessible, and respectful maternal and postpartum care in the South Florida region, nationally, and internationally. These organizations supported this research process with their expertise.
Human Rights Watch interviewed seventeen doulas and twenty other health care providers in South Florida, including midwives, and public health workers, and ten public health experts including health insurance experts for this report. Doula interviewees provided expert information on obstacles to maternal and newborn health equity in the region and talked about obstacles facing them and other doulas in making the work sustainable. External experts reviewed sections of report or the entire report, including two working doulas, two midwives who work with doulas and a legal expert. Other healthcare workers also provided information about challenges and, when asked, the ways doula care could be part of building a pro-human rights healthcare system.
This report relies on the information about maternal and newborn racial inequities that activists, academics, and practitioners have already extensively and qualitatively explored. The epidemiological and other public health evidence is consistent. A large body of academic and community expertise, some referenced in this report, provides evidence for the value of doula care, including for racial minorities. This report seeks only to provide a human rights case for Florida and the federal government to enact policy to ensure that low-income pregnant people can access doula care in a sustainable manner, that enables doulas to do lifesaving work in the communities they care about. This report does not claim that this is the only, or even the most important action the state should take to address maternal and newborn health problems, including stubborn racial inequities.
This report does not, for example, focus on the also-important need for midwifery to be a more accessible career for people from marginalized communities and better compensated including by Medicaid. (Midwives, unlike doulas, are medical/clinical workers.) Community-based and people-centered midwifery is currently not accessible for most low-income people in Florida. An extensive body of evidence supports the benefits of midwifery care and culturally congruent midwifery care.[1] Examining obstacles to midwifery care in Florida is a crucial endeavor but complex and beyond the scope of this report. Doulas and midwives often work together but are not alternatives to each other. Like many of our expert interviewees we support a future in which pregnant women can easily choose what their maternal health care looks like. Even a future with plentiful midwifery care should include affordable doula care.
We did not interview pregnant people for this report because the focus of the report is doula experiences of obstacles to being able to do their work.
All interviews were conducted between 2021 and 2023, and most were conducted remotely. All interviews were in English with full, informed consent. Interviews were semi-structured and usually around 30 – 45 minutes, time frames that reflected the other pressures on interviewees’ time. All interviewees were provided with an overview of the project and asked to provide information about what they understood to be major obstacles to maternal and newborn health and equity. Experts that were also doulas were also asked about the impact of their work and other obstacles.
Metro Mommy Agency provided close partnership throughout this project including connecting Human Rights Watch interviewers to doulas and other experts. In accordance with its policy, Metro Mommy Agency provided a $25 gift card for seven doulas who they connected with Human Rights Watch for an interview out of respect for their time and expertise. The Southern Birth Justice Network also provided key insights and guidance, including an early suggestion that rather than research well-known inequities in maternal health the report instead uplifted solutions already identified within these communities to address these problems and ask what is getting in the way of these solutions.
A workshop was held in June 2023 in Miami Dade county to discuss recommendations and key obstacles to doula care and this process greatly improved the report. Human Rights Watch also received feedback from maternal health professionals at a Health Baby Taskforce meeting, run by the state Department of Health in Miami Dade county. Human Rights Watch wrote to insurance companies providing Medicaid insurance care in September 2023 with questions about doula care, compensation, and related issues. Human Rights Watch did not receive any substantive responses to our questions, but two insurance companies did acknowledge receipt of the inquiry.
Recommendations
The Florida Legislature should:
Pass legislation designed in close consultation with birth workers, including doulas, and community experts, to improve access to doula care by ensuring all private health insurance plans adequately compensate for doula care and improving Medicaid compensation for doula care, so that doulas can earn a living wage.
Adopt legislation integrating the so-called Medicaid expansion, which, among other things, expands the public health plan’s coverage to single persons without dependents, into state law.
Pass legislation to extend Medicaid or other government insurance to all lawfully present, qualified (both terms as defined in US law) pregnant non-citizens, regardless of the length of time they have been in the United States.
Provide state-funded public health insurance or government assistance to unauthorized pregnant immigrants so they can access high quality medical care for at least the duration of pregnancy and for 12 months afterwards.
Take measurable and time-bound steps to ensure continuing healthcare coverage for all individuals who accessed Medicaid coverage during the Covid-19 pandemic but who may or will otherwise lose access now that the Covid-19 public health emergency has ended.
Pass legislation to ensure funding for multi-year collaborative government-funded programs with communities and community-based advocacy organizations to expand access to doula care and other services such as midwifery care and lactation support, develop and fund initiatives to raise awareness of Medicaid benefits including doula care. Important partners include with other service providers, such as those providing TANF (Temporary Assistance for Needy Families) and SNAP (Supplemental Nutrition Assistance Program), as well as hospitals.
Pass legislation that guarantees all state employees have insurance that covers doula care.
Pass legislation funding the Florida Department of Health to run public health education campaigns on the benefits of doula care.
Pass legislation to reduce greenhouse gas emissions in Florida and better protect human health in the state, including pregnancy health from the climate crisis.
Repeal bans and restrictions that interfere with pregnant people’s right to access abortion care.
Florida Agency for Health Care Administration, the Florida Department of Health, and the Department of Management Services should:
Work together to improve access to doula care, including through public health education efforts, grantmaking, and allocation of Medicaid contracts to insurance companies seeking to establish Medicaid healthcare plans in Florida.
Ensure all insurance companies, not only those providing Medicaid, include coverage for doula services and ensure doulas are sustainably compensated and can bill for additional time and services. Consider $2,000 per client as an appropriate starting point.
Provide financial support and a communication link with doula-led organizations to assist with billing and other administrative tasks to protect doulas from onerous bureaucracy.
Support community-based organizations to increase credentialing of doulas and mentorship and other career and support for doulas.
Provide funding to reimburse doulas who incur costs, including those related to transportation and childcare services, while working.
Ensure that any system to register doulas is simple to use and respects the many different routes doulas take to come to their work.
Widely communicate potential benefits of doula care and how to access this care to pregnant people and families.
Expand programs to cover transportation costs for clients, both Medicaid enrollees and those who are not Medicaid-eligible, to attend pre-natal and postpartum appointments; provide resources and funding to improve access to existing transportation programs and to ensure information on these programs is widely disseminated.
Support insurance companies in providing incentives for patients to attend regular prenatal and postpartum appointments, including appointments with doulas.
Reduce greenhouse gas emissions from the health sector in Florida.
Support improved access to information about climate harms to human health, including pregnant people and programming for most at-risk communities, including through doulas.
Hospital Systems and Other Medical Institutions Providing Maternal Health Care in Florida should:
Take concrete steps to eradicate systemic racism and, anti-immigrant bias. These efforts should include a thorough review of policies to identify and appropriately revise those that discriminate against or otherwise harm people from low income or marginalized communities, even if inadvertently.
Provide clients/patients with information about doula care and how to access free doula care.
Educate staff about doula care, including through training designed by/in consultation with doulas, and work with doulas as a valued member of the birth team, including independent doulas.
Drastically reduce greenhouse gas emissions and phase out fossil fuels. Ensure hospital systems are prepared for climate crisis related emergencies, including through connections with community doulas.
Philanthropists and Donors Interested in Addressing Maternal Health Inequities should:
Provide supplemental funding for doulas who take on uninsured, Medicaid, or low-income clients, including unauthorized pregnant immigrants, to ensure an adequate salary and to help spread recognition of the value of this service.
Work to build-out programming on climate activism in the reproductive justice space.
Fund community-based organizations (CBOs) and nonprofits providing doula services or supporting doula work, including those building solidarity and providing ongoing training and career support for doulas, especially if they work with low-income clients or with clients from marginalized communities, including unauthorized immigrants.
Create or sponsor business development programs to support small businesses and CBOs involved in improving maternal health, like doulas.
Provide grants to support education on the role of doulas in addressing the maternal health crisis and the intersecting issues that doulas address in their work.
Support efforts to capture necessary data to better understand the impact doulas are having on at-risk pregnant people and their families and communities.
US Congress should:
Introduce and pass the Mamas First Act or similar legislation to require state Medicaid programs to cover doula and midwife services, including prenatal, delivery, and postpartum services, in a variety of settings.
Pass the Midwives for Moms Act to address maternity care shortages and promote optimal maternity outcomes by expanding educational opportunities for midwives.
Pass the MOMMIES Act to establish a series of programs and requirements under Medicaid and the Children's Health Insurance Program (CHIP) relating to maternal health.
Pass the Protecting Moms and Babies Against Climate Change Act, part of the MOMNIBUS package of laws, to establish grants and direct other activities to address health risks associated with climate change, particularly for members of racial and ethnic minority groups, pregnant or postpartum individuals, and children younger than age three.
Pass the Commission to Study and Develop Reparation Proposals for African Americans Act to establish the Commission to Study and Develop Reparation Proposals for African Americans. The commission would examine slavery and discrimination in the colonies and the United States from 1619 to the present and recommend appropriate remedies.
Pass the HEAL for Immigrant Families Act to expand access to healthcare services for immigrants, including non-naturalized immigrants who are lawfully present, by removing legal and policy barriers to health insurance coverage.
Pass the Women’s Health Protection Act to protect a person's ability to determine whether to continue or end a pregnancy, and to protect a health care provider's ability to provide abortion services.
Background
The Maternal Health Crisis in the US, in Florida, and the Role of Racism
[To improve maternal health], the main thing is dismantling racism in an oppressive system. People always say, “The systems are broken,” and I correct them quickly: “No, the systems are not broken, they are doing exactly what they were created to do.”
— Dr. Sharetta Remikie, Chief Equity and Community Engagement Officer, Children’s Services Council of Broward and former Director, Maternal and Infant Health, March of Dimes Maternal and Infant Health, March of Dimes, September 13, 2021
When I think about the healthcare system, I think about how, for Black women, most of the time, if you go to the hospital, you go to the doctor and you say you have a pain, they don’t believe you. Black women are not believed by the healthcare system.
— Ruth Jeannoel, founder and director of Famn Saj, September 8, 2021
More is spent on maternal health in the US than in any other country, but it is the only industrialized nation to have worsening rates of maternal deaths.[2] Preterm birth rates are growing.[3] Deep inequities between white women and Black and Indigenous women, mark maternal and newborn data sets from rates of maternal mortality and serious illness to infant deaths.[4]
Advantages for white pregnant people cut across income levels, as noted by a report by 2021 US Civil Rights Commission report that evaluated the federal government’s role in addressing the US’ maternal health crisis.[5] The report, like others, called for more resources and workers for maternal health, but also that authorities acknowledge and address the role racism in care plays in creating inequities, because “one notable reason [for maternal health racial disparities] is due to differences in the quality of care that women of color receive as compared to [w]hite women.”[6] Research and community activism has pressed a growing number of US authorities to acknowledge that racism is a public health crisis and that direct health harms from interpersonal racism and unaddressed systemic racism in housing, work, education, and environmental and social determinants of health, have led to racial disparities.[7] Racism experienced across a lifetime is increasingly understood as a core reason why the maternal health crisis is deepening.[8]
The World Health Organization and others have increasingly called for better recognition for the human rights of pregnant people in the health system, including respectful care.[9] A United Nations Population Fund (UNFPA) report from 2023 about maternal health inequities facing African American women in the Americas, including the US, said governments should, and can, meet “maternal and sexual and reproductive health needs of Afrodescendent women and girls by addressing the root causes of structural racism, sexism and discrimination.”[10] In the US, studies and analysis by experts have consistently linked shockingly common disrespectful maternity care, and its harms, with racism.[11]
Maternal health outcomes in Florida, including its southern counties, are consistent with chilling US-wide trends. Overall numbers of maternal deaths and racial disparity rates in maternal mortality in the state, for example, has risen in the past three reporting years, as shown in the first graph below. Rates of preterm birth, a major cause of infant death, are far higher for Black pregnant people than for white people, as the second graph illustrates.
In response to the maternal health crisis, the Biden administration has promised to increase healthcare workers and infrastructure to reduce maternal deaths and address equity but also improve quality of care. Maternal healthcare should be “respectful and culturally competent.”[12]
The federal government, following advocacy spearheaded by BIPOC reproductive justice leaders and organizations and the findings of academic studies, has incorporated increasing access to culturally congruent doula care as part of fulfilling its promises to reduce maternal deaths and address equity.[13] (For a fuller description of international human rights law relevant to this report please see section: “Maternal Health-Related Rights and How Doulas Advance Them”).
Black reproductive justice advocates in the Miami area have called for improvements to the quality of maternal health care and measures to address racial inequities, from anti-racism trainings for healthcare providers, to increasing midwifery care and the number of Black medical providers.[14] They have also been successful in attracting attention from policy-makers in Miami Dade County, including the mayor’s office and a large hospital network, to the important difference doulas can make.[15]
Why Focus on Doula Care?
What is a Doula?
At my first birth … I called out at my actual job I do to pay my rent, took an Uber to the other side of town, got there at midnight, supported my client all through that day, slept one or two hours, working different positions, helping her with breathing, working with doctors making sure they were asking for her consent. I was up as much as she was up, timing contractions, talking back and forth with my mentor. My client gave birth at 6 p.m. The next day, I helped with her lactation nurse, again with the consent, helped her with what to do with the baby, checked [the mother] got consent with all the shots, worked with her on her post birth plan. … Then I went straight to work at my other job.
— Nadirah Sabir, doula and social worker, November 5, 2022[16]
Doulas are trained professionals who provide expert care and emotional, physical, and informational support to a significant health-related experience such as pregnancy, childbirth, miscarriage, induced abortion, or stillbirth. Doulas adopt a holistic, “whole person” approach to care that considers social determinants of health outcomes, such as the pregnant person’s financial situation, immigration status, mental health, and access to housing, nutrition, familial support, and childcare.[17] Doulas try to help address these factors through “wraparound support” by connecting the pregnant person to relevant resources and supports to deal with challenges.[18]
The doula model is non-judgmental, culturally sensitive, and centers autonomy, consent, and collaboration in determining care.[19] It allows the birthing person to express their genuine needs, which in turn helps improve their access to the resources needed to ensure their well-being.[20]
For people of color, the wraparound support provided by many doulas is particularly beneficial because it positions the doula as a strong advocate for low-income, non-white people who are often subjected to bias and discrimination in the medical system. [21] Community-based doulas, like the ones interviewed for this report, are more likely to know where clients can access respectful and useful services like diaper banks and about local obstacles to healthy pregnancies may be, like poor air quality or providers who do not consistently provide respectful care.
As advocates, doulas ensure their patients have information on their birth options and understand their rights.[22] They also help improve communication between pregnant people and their healthcare providers, better ensuring that the birthing person can ask questions or speak up about clinical decision making.[23] This has prevented unnecessary and unwanted clinical interventions, such as unnecessary cesarean births, and contributed to the fight against interpersonal and systemic racism in healthcare settings.[24]
What Do Studies Say About Doula Care and Health Outcomes?
Studies show a correlation between the use of doula care and improved maternal health outcomes and lower rates of medical intervention in childbirth.[25] While local and national BIPOC reproductive rights groups and advocates have led the charge for renewed interest in culturally competent doula care, the American College of Obstetrics and Gynecology has stated that “in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel such as a doula is associated with improved outcomes for women in labor.”[26]
According to global studies, including in the United States, increased access to doulas or midwives was associated with higher rates of vaginal delivery, breast- or body feeding, and improved parenting skills as well as lower rates of C-sections, premature births, low birth weight infants, newborn deaths, use of analgesics, and medical interventions.[27] A study in 2022 of three states, including Florida, found improvements to preterm birth rates, cesarean rates, hospital admissions during pregnancy and ER visits postpartum in Medicaid patients who had a doula compared to those who did not.[28]
Reducing overuse of unnecessary cesareans in South Florida is a public health priority.[29] Florida, and its southern counties in particular, have some of the highest rates in the US (see graphics “Florida has High C-section Rates Compared to the Rest of the US and “South Florida has Some of the Highest Rates of C-section Births in the US”), where rates are also high compared to other high-income countries. Cesarean births are a lifesaving intervention when needed but can be harmful when not medically required and, especially when performed without informed consent, can constitute obstetric violence.[30] There are many reasons for the overuse of the surgical procedure including financial and efficiency concerns for providers.[31] Studies on doula care has showed that the reduced likelihood of cesareans and the provision of wraparound support contributes to decreased maternal morbidity and mortality.[32]
South Florida Has Some of the Highest Rates of C-section Births in the State
C-section Deliveries as Percentages of Total Births by County, 2022
Source: Florida Department of Health, Bureau of Vital Statistics
Data: South Florida Has Some of the Highest Rates of C-section Births in the State
| County | Rate |
|---|---|
| Alachua | 31.2 |
| Baker | 30.4 |
| Bay | 32.9 |
| Bradford | 31.9 |
| Brevard | 34 |
| Broward | 40.2 |
| Calhoun | 37.8 |
| Charlotte | 36.3 |
| Citrus | 32.3 |
| Clay | 29.6 |
| Collier | 33.3 |
| Columbia | 28.5 |
| Miami-Dade | 45.1 |
| DeSoto | 32.5 |
| Dixie | 23.3 |
| Duval | 30.8 |
| Escambia | 34.4 |
| Flagler | 35.7 |
| Franklin | 28.1 |
| Gadsden | 36.3 |
| Gilchrist | 27.2 |
| Glades | 40.5 |
| Gulf | 29.4 |
| Hamilton | 32.6 |
| Hardee | 26.5 |
| Hendry | 36.7 |
| Hernando | 35.1 |
| Highlands | 38.3 |
| Hillsborough | 33.6 |
| Holmes | 35.6 |
| Indian River | 29.9 |
| Jackson | 32.6 |
| Jefferson | 30.4 |
| Lafayette | 31.6 |
| Lake | 35.6 |
| Lee | 36.2 |
| Leon | 36.1 |
| Levy | 27.1 |
| Liberty | 35.4 |
| Madison | 36.4 |
| Manatee | 33 |
| Marion | 32.2 |
| Martin | 30.6 |
| Monroe | 40.8 |
| Nassau | 31.5 |
| Okaloosa | 32.1 |
| Okeechobee | 31.1 |
| Orange | 34.4 |
| Osceola | 36.1 |
| Palm Beach | 36.9 |
| Pasco | 34.6 |
| Pinellas | 33 |
| Polk | 33.4 |
| Putnam | 31.3 |
| Saint Johns | 34.1 |
| Saint Lucie | 34.3 |
| Santa Rosa | 34.3 |
| Sarasota | 32 |
| Seminole | 32.4 |
| Sumter | 31.8 |
| Suwannee | 26.1 |
| Taylor | 33.6 |
| Union | 29 |
| Volusia | 33.7 |
| Wakulla | 33.7 |
| Walton | 31.1 |
| Washington | 33.2 |
Doulas and midwives positively affect not just physical health outcomes, but also mental health ones: people with access to doulas report better pregnancy, birth, and postpartum experiences, including because they had greater feelings of control over pregnancy-related decisions.[33] The continuous emotional support and companionship of a doula mitigates the stress and may improve self-esteem for the person giving birth.[34] Mental health conditions are a driving cause of maternal deaths in the US and as many as one in four women will experience depression during their pregnancy, and up to 56 percent of postpartum people living in poverty experience postpartum depression.[35]
Local, state, and federal governments in the US have agreed to better resource doula care explicitly as a tool to try to address racial inequities. In 2022, the US Department of Health and Human Services provided $4.5 million for building doula capacity.[36] Miami-Dade county’s “Roadmap for Child Success” explicitly calls for increased access to doula care for high-need communities.[37]
Doulas’ Role in Mitigating Racial Disparities
Access to doula care can be an important tool improving health outcomes for low-income, non-white pregnant people, who face higher risks for poor maternal and infant health, including because of racism and unequal and inadequate medical care.[38] Working with a doula can positively improve the likelihood of having healthier pregnancies and childbirths. For instance, a doula support program in a neighborhood with the highest rates of infant mortality, premature births, and low birthweight in New York City resulted in lower rates of premature birth and low birthweight for non-Hispanic Black women’s infants. These women also reported feeling empowered to make informed decisions related to childbirth.[39] That sense of control is especially important for people from marginalized communities who are giving birth, including people who are BIPOC, who have experienced rampant discrimination and trauma in the US healthcare system, including by medical professionals who have ignored their pain, denied their bodily autonomy, and subjected them to coercive medical practices.[40] Given the ongoing harms and centuries of medical exploitation and abuse against them, Black pregnant people suffer more stress and anxiety than pregnant people of other races and they have difficulty trusting the medical system.[41] Community-based doulas, who are often community members themselves, offer culturally appropriate support and care, help Black families understand disparities in their treatment and outcomes, and discuss cultural issues with healthcare providers.[42] In this manner, a doula can help foster trust between the birthing person and their medical team by ensuring they retain control over their pregnancy and childbirth.[43]
The role of doulas in equipping people with the information and knowledge they need to advocate for their desired childbirth outcomes has at least sometimes translated into more effective advocacy not only for themselves, but also for their community.[44] In this way doula care can become part of improving health outcomes and fighting systemic racism in the healthcare system.[45]
In recent decades it has been mostly white middle-class or high-income pregnant people who have used doula care, because they can afford it. Organizing by Black, Indigenous, and other doulas has greatly expanded access especially in some big cities in the US often through “community-based doula” non-governmental organizations or collectives. A report providing much insight into the work of community-based doulas and urging improved compensation for this work by three organizations, Ancient Song Doula Services, Village Birth International and Every Mother Counts provide a useful description of community-based doula:
[Community-based doulas] typically provide more home visits and a wider array of services and referrals for individuals who need more comprehensive support than would be provided by a traditional doula. The support provided is low or no cost and focuses on ensuring safe, dignified, and respectful care. Most community-based doulas are members of the community they serve, sharing the same background, culture, and/or language with their clients and have additional training that supplements the traditional doula education curriculum.[46]
Advocacy calling for Medicaid reimbursement by grassroots reproductive justice activists as well as larger institutions including non-profit organizations and even government research and implementation agencies has been successful in many states including California, Massachusetts, Michigan, Oregon, Oklahoma and Washington.[47] Recently, states that provide for Medicaid compensation have increased rates. California increased Medicaid reimbursement in January 2024 to up to $3,000 per client.[48] Washington state in March 2024, agreed to increase the repayment to $3,500 according to a reproductive organization working in the state.[49] A draft bill, the Mamas First Act, if passed by the US Congress, would ensure federal reimbursement for doula care for Medicaid patients.[50]
Experts on Obstacles to Maternal and Infant Health in South Florida and How Doulas Can Help
[Quality maternal health care] is not just about physical care, it’s also about spiritual wellness, mental wellness, and [applying] a nonjudgmental way of care. Especially for Black midwives and Black doulas, there’s already cultural competency, understanding. Birth workers who do this work also interrupt racism and white supremacy.
— Ruth Jeannoel, Famn Saj September 8, 2021[51]
Doulas, midwives, and people who are community-based in their birthing professions provide care that’s patient centered, holistic, responsive to the patient, and allows the patient to have autonomy and the support of their loved ones and other things that they need to have a healthy experience. [Birth should not be] an ordeal to survive or overcome, but rather part of a healthy, joyous, fulfilling life.
— Dr. Okezi Otovo, Professor, November 2, 2022[52]
In interviews experts in South Florida laid out many causes of inequities in maternal and newborn health outcomes (including low access to affordable doula care). This chapter of the report provides an overview of some of the problems and then further explores a few of these obstacles together with some examples of how skilled doula engagement may help mitigate harms.
Racism and Attitudinal Barriers
Racism and Discrimination
Expert interviewees from the Miami area often said that racism means Black women, and other women of color, receive worse or disparate care during their pregnancy or birth, and postpartum. Some of them provided examples. Esther McCant, a doula with her own company, for example said:
I work with all women—Black, white, rich, poor, everyone—and in the case of privilege, what I’ve seen is more of a prompting to offer the information and willingness to explain, [or a] willing[ness] to bend certain rules as it pertains to maybe eating during an induction, for example, or positioning [during birth].
The complex bureaucracy of health care in South Florida mixes with anti-Black or anti-immigrant prejudice in toxic ways. Robin Grunfelder from the Broward Healthy Start Coalition provided an example where at one clinic, front desk staff were turning away pregnant people who lacked insurance or had not completed a Medicaid application. This not only denied these women care in the short term, but also made them feel unwelcome and more nervous about trying to get prenatal care in the future. She said that race was likely a factor in staff’s assumptions about which women would ultimately be eligible for Medicaid.[53]
Lack of Respectful Care
Patients who feel that their concerns are trivialized, or even unheard, can be discouraged from seeking care. “If staff are dismissive or the pregnant person is made to feel like they have too many questions, but the doctor doesn’t want to answer, they think ‘I don’t want to go back there’,” said Belci Encinosa, a licensed clinical social worker.[54]
This lack of respect for pregnant people can be especially acute during hospital births. Doulas and other maternal health advocates told Human Rights Watch that pregnant people in South Florida too often feel pressured to agree to medical interventions, such as Pitocin (a synthetic hormone that causes contractions), even when other options for birthing are available.
In addition to individual experiences of racism and discrimination, interviewees described how BIPOC people who are pregnant or immigrants often receive care that is not respectful of them or their individual health concerns and needs. Patients sometimes say, "that their visit felt rushed or that they felt like a number, that the provider wasn't really listening to them,” according to Marissa Rosario from Planned Parenthood in South Florida. “That can be very discouraging for a patient and make them feel reluctant to want to continue their care.”[55] A health coach, Shantel Briget, said, "I have some women that go to their doctors now and they're just like, ‘I was in, and I was out.’ That was it. They don't even ask, ‘How are you?’”[56]
Interviewees also noted that Black and Latinx immigrants, but especially unauthorized immigrants worried about poor treatment, may delay getting prenatal care and choose not to ask questions or challenge providers. “I know a lot of times [pregnant women] are also very worried about the type of care that they’re going to receive from some of the providers based on their status,” Nikky Dawkins, a doula, said for example. “It’s a real fear.”[57]
Language Barriers
Immigrant patients face additional language hurdles if they are not fluent English or Spanish speakers. “The bureaucracy of the system makes it very hard to access care, especially for someone who does not speak English and doesn’t have [legal immigration] status and is trying to figure out ‘what do I really need to do to get into that office?’,” Robin Grunfelder said.[58] These language barriers can intensify fears of having concerns dismissed or silenced, causing pregnant people to feel they are “not allowed” to ask questions. Esther McCant provided examples of the long-lasting impacts of language barriers between provider and clients. “What ends up happening is they get used to not being understood and they also get used to not being able to speak up for themselves,” she said. She recounted an example where, because no interpreter was available, a Haitian-Creole-speaking client in Miami was not informed that she could pump and provide breastmilk to her baby in a Neonatal Intensive Care Unit.[59] “I see that English and mostly Spanish is covered, but there’s other languages like Creole which for South Florida is really important,” Nicky Dawkins said.[60]
Doulas’ Role in Addressing Discrimination and Dismissiveness
Doulas and experts interviewed for this report did not see doula care as a solution to the deep problems of discrimination and racism in the US healthcare system. Doulas, similarly, cannot make up for failures by clinics and others to provide adequate language interpretation, for example. However, doulas and others who work with doulas and reproductive justice activists did see doulas as one important source of support in a system that is not set up for people outside of white dominant culture and an important way to ameliorate some of the harms.
“We’re here to provide those services that are wholly centered on the birthing person’s needs,” said Elizabeth Simmons, for example, a doula who also runs The Doula Network, which registers doulas with insurance companies providing compensation for doula care and files reimbursement claims. “There’s a difference between the maternity care team and the birthing person’s care team and we are on the birthing person’s care team.”[61]
Other doula interviewees said that they felt their presence in the birthing room created an incentive for medical practitioners to treat the pregnant person with respect. “The stakes are a little higher because now you have someone who’s kind of a witness,” Esther McCant said.
Our doula interviewees also said that helping a pregnant person self-advocate was a defining part of the work. Shantai Latoya Young said that she feels a core part of her role is to ensure “moms really feel like they are active decision-makers.”[62] Others also noted that their presence can help clients have their needs and desires heard in intimidating clinical settings. “I’ve had this happen with clients where their OB-GYN [a doctor/surgeon specializing in obstetrics and gynecology] didn’t listen to them,” doula Nicky Dawkins said, adding that she often tells clients that doctors work for them, not the other way around.
Angelique Francois, Program Director of Healthy Mothers, Healthy Babies Coalition of Palm Beach County, created a doula access program because “we thought this can definitely strengthen that mom's confidence.” She said, this was important for the Black community. “I've heard from so many of our mothers [that they were] automatically being told that they have to have a c-section and moms didn’t know that they could ask questions,” she said.[63]
In addition to promoting self-advocacy, doulas interviewed for this report tried to make sure healthcare staff were getting informed consent from pregnant people ahead of any interventions.[64]
Doulas interviewed for this report said that supporting pregnant people experiencing racism or worries about poor treatment was a significant part of their role. “I had a client for whom [racism and the fear of poor treatment] was the main stressor in her entire pregnancy, [it was] the focus of all of our prenatal meetings, all of the conversation,” Esther McCant said.[65] Many also talked about how important it was for them to support other women of color in the face of the US maternal health crisis.
Cultural competence is increasingly recognized as an important aspect of healthcare, but shortages of doctors, nurses, and other healthcare providers from BIPOC communities is an ongoing problem. Having a doula from your community can help “bridge the gap” as one healthcare worker put it. Doula, Juliana Escalera, said “I feel like I attract more Black and brown clients. That's just how the world is, when I was pregnant that's what I was looking for. I was looking for Black and brown birth workers. … It's just a matter of comfort and feeling like those are the people that are going to protect me.”[66]
While expanding culturally congruent doula care that provides the client a knowledgeable witness and an advocate may assist with reducing racism and dismissiveness directed at pregnant and birthing people, dismantling these barriers requires a much larger transformative effort, interviewees agreed.
Physically and Economically Inaccessible Health Care
Physical and economic accessibility of healthcare are central aspects of the right to health (see “Maternal Health Related Rights and How Doulas Advance Them” below). South Florida, especially around Miami-Dade County, hosts some of the best quality healthcare facilities in the world, but it is often too far away or expensive for people in need. Interviewees often cited a lifelong lack of access to health care as a major obstacle to pregnancy and newborn health in South Florida. Such lack of access is an important reason why many people living in South Florida are starting a pregnancy in poor health.
Doulas can connect clients to wraparound support, helping them negotiate the complex systems required to access low-cost health care and other essential services from both state and non-state institutions in their local areas. Doulas may also know the best medical providers for their client in their area and can help clients shift their provider to access the best care and to best meet their wishes for pregnancy and childbirth.
Lack of Nearby Healthcare Facilities and Transport Challenges
Interviewees often identified transportation as a barrier to accessing health care for low-income people. Even when pregnant people technically have access to low-cost or free care, transportation costs and time needed (given the inadequate infrastructure in South Florida’s sprawling urban areas) to get to that care, childcare and work obligations (plus the difficulty in taking time off), and extreme heat are just some of the obstacles they might face.[67] “There is an access to care issue even in transportation,” Angelique Francois said. “A lot of moms were not keeping consistent prenatal care appointments because they didn't even have transportation to get to those appointments.”[68]
Lack of Affordable Care or Adequate Health Insurance
Cost of care, especially when factored in together with high cost of housing and food was cited as an obstacle and also a stressor in interviews. “Even going to the health department, that’s on a sliding fee scale, you know, and people just assume, well, it’s only $50. Well, $50 is groceries. $50 is a water bill for some families,” said Angelique Francois.[69]
Having Medicaid does not mean women can access the health care most suited to their needs. One example is being able to work with a midwife. Ruth Jeannoel of Famn Saj noted that, for people in the African diaspora, having a midwife “lowers maternal mortality and helps to have great and beautiful births and deliveries.”[70] Yet accessing a midwife can be a challenge. “[You] have to have like a certain type of insurance, go through all of these loopholes, just to be able to access that midwife,” she added. There are also significant financial obstacles. Tamara Tait, who runs Magnolia Birthing Center, one of the few Black-owned birthing centers in the US, explained that Medicaid reimbursement for midwife care is considerably less than for a doctor, even though a midwife usually spends much more time with a patient than a doctor does, and birthing centers like hers struggle to make ends meet because they are committed to taking on Medicaid patients. “A very common thing for [midwife] providers to say is that it costs them money to take Medicaid,” she said.[71]
Other women might be insured, but not have insurance accepted by the provider they want. “A woman might identify a doctor willing to meet her in how she wants to labor, for example, [that doctor] is willing to do a VBAC [vaginal birth after cesarean] but does not accept your insurance,” Doula Nikki Smith said. Unless the woman can find a doctor willing to perform a VBAC and who takes her insurance, she may be forced to have another cesarean against her wishes for childbirth.”[72]
Maternal mental health is affected by a lack of mental health care options. Even when mental health care may be heavily subsidized or free, several interviewees noted its scarcity because needs are greater than availability. Angelique Francois’ program provides counselling services, for example, but there’s a long wait list. The shortage of mental healthcare providers is a US -wide problem and a crucial one for pregnant people, given high rates of pre- and post-partum depression and maternal mortality linked to mental health conditions.
A federal law passed in 2009 means states can waive, for pregnant people and/or children, a requirement that lawfully residing residents wait five years before enrolling in Medicaid (or a sister government program for children known as CHIP).[73] Florida has waived the requirement for children, but not for pregnant people. “[My client] had not met the five-year criteria from Immigration, so [as far as accessing Medicaid] she is actually treated like an undocumented [unauthorized] person,” said a social worker, referring to this policy.[74]
Additional Barriers for Unauthorized Pregnant People
Unauthorized immigrants have less access to coverage, although pregnant people may be able to get some prenatal care based on “presumptive eligibility.” In Florida, a pregnant person who meets income requirements and has proof of pregnancy can get 45 days of prenatal care per pregnancy through temporary Medicaid coverage.[75] One interviewee described trying to provide as much care as possible for clients within those 45 days, including tests and scans that would be otherwise unaffordable for that client.
Some clinics have sliding scales and accept unauthorized pregnant immigrants, but these might be far away or still too costly. Their health situation is compounded by a lack of access to non-maternal and other forms of health care. Consequently, some pregnant people have unaddressed health problems by the time they receive health care for their pregnancy. A midwife of Haitian descent whose clinic works with many immigrant women said:
Unfortunately, a lot of my patients are at high-risk with a lot of other comorbidities, and when they come to us, this is the first time they see a healthcare provider in this country. Or they don’t even see a healthcare provider until they are at the hospital where they deliver. They arrive there with diabetes and/or high blood pressure, or are obese, or have other complications.[76]
Florida has been home in the past five years to a number of policies that have created obstacles to immigrants accessing government services.[77] “There’s a lot of fear [for] women that are undocumented [or unauthorized],” Robin Grunfelder said, noting that this is why “a lot of women do not seek prenatal care and only go to the hospital to deliver.”
Doulas and community-based doula organizations cannot solve these deep structural and bureaucratic problems for low income clients and/or unauthorized immigrants and Florida should follow other states (like Illinois where state funds pay for healthcare for unauthorized immigrants) in improving access to healthcare including to prenatal care for pregnant people. But doulas can help clients find quality and affordable services, provide supplemental information, and assure them of patient rights within an intimidating system including while negotiating Medicaid for the first time. Several experts interviewed for this report noted that pregnant people on Medicaid may be especially likely to feel they have to follow clinicians’ instructions without questioning.[78]
High Cost of Living and Related Stress
The high cost of living is yet another contributing factor to worse pregnancy outcomes for people from marginalized communities. The cost of living, which increased in 2022 and 2023 because of high rates of price inflation for staple goods and services, can cause people, including pregnant ones, to purchase less nutritious food. For pregnant people, this is harmful to maternal and newborn health. Several interviewees also mentioned the prohibitive cost of housing and low availability of public housing, especially in areas in or around the city of Miami. Economic hardship also prevents pregnant people from obtaining necessary health care. “[Low-income women] are not going to miss work, because then they would not have enough money to pay rent or to buy food,” Belci Encinosa said. “But that means they can miss medical appointments.”[79] “They have to worry about housing, worry about food, worry about daycare, childcare, all this has a large impact on people’s stress,” Ruth Jennol said.[80]
Many doula interviewed mentioned stress as a health obstacle for their clients, especially for BIPOC families and immigrant families. Immigration status is a huge issue and according to Dr. Connie Morrow, Director of the Jasmine Project, a community-based collaboration of organizations dedicated to the health of pregnant women and infants in the Miami-Dade area: “Many of the women who have a questionable immigration status feel that their life is spiraling out of control with no solutions.”[81]
Doulas’ Role in Addressing Physically and Economically Inaccessible Health Care and Associated Stresses
Doulas can do little to address the barriers to pregnancy health described in the section immediately above. However, doulas and commentators interviewed for this report did note that doula support could help ameliorate some of the difficulties in a personal, humane, and concrete way through their presence and knowledge.
Many of the doula interviewees said that they felt an important part of their role was to provide presence and acknowledge stress faced by overwhelmed clients. "I don't think providers pay attention to the stressors and they don’t provide tools for people to manage stressors,” Esther McCant said adding that she can also provide massage therapy, before, during or after the birth.[82] One doula explained the impact of stress during pregnancy and how doulas can help mitigate those feelings:
Stress leads to cortisol build up in your body. When you’re stressed, the baby is stressed, in comparison to someone in an environment where they didn’t have to worry as much, someone who has the finances, being able to have a relaxed and happy pregnancy. Doulas provide emotional support, non-judgmental listening, and advocacy for you, your needs, and wishes for childbirth.[83]
Interviewees said isolation and feeling “cut off” from their community, including because of poverty, was another obstacle to a physically and emotionally healthy pregnancy and postpartum period. This can be especially problematic regarding breastfeeding and for recently postpartum women who commonly struggle to breastfeed, as one doula explained. She said ongoing encouragement from a doula and connecting moms to further services can be crucial in supporting mothers as they establish breastfeeding with their baby.
As well as providing emotional support and solidarity, doulas from or familiar with the client’s community can also provide important connections to local support services.
Extreme Heat and Other Climate Crisis Challenges
Being a farming community, we have seen how our clients end up in the ER because hydration has been a challenge for them, and some of them end up in the hospital … and some of them going into early labor because of dehydration.
— Midwife working with immigrant farmworkers.[84]
Florida is struggling with devastating and costly consequences from the climate crisis, including extreme heat, hurricanes, and sea level rise and their impacts, which are expected to drastically worsen over the coming decades.[85] Heat is one area of growing concern, with significant increases in temperatures already recorded especially at night and scientists worrying that (without significant, quick cuts in global carbon emissions) dangerous temperatures will occur every day for 187 days of the year by 2050.[86] Low-income communities have and will experience the worst impacts because they are the most exposed, most at risk and least able to adapt. However, the health impacts of extreme heat have only recently been acknowledged in South Florida, including through the appointment of a chief heat officer for Miami-Dade County in 2021.
The distinct maternal, fetal, and newborn harms from extreme heat are increasingly well-understood. Extreme heat, like many climate-related harms, has distinct biological and socioeconomic impacts for pregnant people. Pregnancy creates additional stress on the body. Pregnant people’s lungs, hearts, and hormonal systems are all working harder or differently. They breathe more air (about 40 percent more than non-pregnant people), and their cardiac output increases by 150 percent.[87] These changes render them more vulnerable to an unhealthy environment including extreme heat. The developing fetus, which undergoes rapid changes in a delicately balanced process, is especially vulnerable, especially in the first trimester.[88]
Many studies suggest links between exposure to high temperatures during pregnancy and adverse birth outcomes such as preterm birth, low birth weight, and stillbirth. For example, a 2020 systemic review of US-based studies published in the Journal of the American Medical Association found an increased risk of preterm birth, low birth weight, and stillbirth resulting from maternal exposure to heat. According to at least four studies, exposure to unusually high temperatures during the first trimester is linked to increased rates of congenital anomalies such as heart defects.[89] Still more studies have emerged showing links between poor maternal health, including rates of gestational diabetes, maternal hospitalizations, and hypertension, and high temperatures.[90]
Studies in the US that disaggregate by race often find greater effects of higher-than-normal temperatures on adverse birth outcomes for Black mothers compared to white ones suggesting that increasing temperatures are exacerbating inequities. The reasons for this may be complex. In many US cities, due to structural, institutional, and systemic racism, Black neighborhoods and apartments are hotter than lusher, better planned, white ones. Due to interpersonal, structural, institutional, and systemic racism Black mothers have higher rates of health conditions that may make them especially sensitive to heat, such as high blood pressure and/or poor respiratory or cardiac health. These findings demonstrate why climate adaptation (preparing communities for climate impacts) approaches to maternal health should center reproductive justice by primarily accounting for and involving the most at-risk pregnant people and the people who serve them, such as doulas and midwives.
There are several reasons why doulas may be especially well-placed to also assume the role of climate workers. Community doulas are trusted in their communities as information providers and share lived experiences with their clients. Doulas spend more time with clients than traditional health workers, often have a pre-existing interest in their clients’ environment and holistic health, and tend to understand the relationships between environment, stress, and their clients’ wellbeing. A lack of time with patients has been recognized as a major obstacle to medical providers, including obstetricians, providing information and advice about environmental determinants of health for pregnant people.[91]
Esther McCant, who began providing information to trainee doulas about climate impacts on maternal health, said that she and other doulas are seeing extreme heat disrupt pregnant people’s ability to maintain their health through exercising and socializing. Doulas often provide individualized advice to pregnant people that does not require spending a lot of money.
Some doulas serve as a bridge between the communities they serve and a broader public health community, in addition, some choose to act as advocates for their communities. These capacities may make some doulas well-placed as climate advocates and experts on otherwise unnoticed harms of the climate crisis to communities. Advocacy and alarm-bell ringing about emerging problems is often part of the work community-based doulas do, one doula noted: "As doulas, we are advocates and activists first, and the work that we're doing comes from that passion of wanting to create change.”[92]
Key Obstacles to Doula Care in South Florida
I think, in general, there is a challenge with women and specifically Black women's professional expertise being taken seriously and being compensated fairly as experts in what they do. So, one of the challenges that I think is a limitation is the way that birth work operates in this country is an assumption that birth work is lesser valued than medical training … and doesn't need to be compensated at a professional rate that would allow the birthing professionals to practice their profession.
—Dr. Okezi Otovo, Associate Professor, Department of History and African and African Diaspora Studies Program at FIU: Principal Investigator and Project Lead, The Black Mothers Care Plan, November 2, 2022[93]
We don't have many community doulas and community doulas are not supported. Why is it that only 20 percent of doulas that go to doula training end up being a doula a year later?
—Brittany Fadiora, certified doula trainer and doula, Healthy Mother, Healthy Babies Palm Beach, August 17, 2022[94]
It can be tough to be a doula, the work is challenging, getting a business set up is hard and can be costly, and compensation can be uncertain and low. The inability to secure a living wage as a doula, especially while serving low-income clients, impacts the availability of doulas and the ability of women from marginalized communities to access doula services as does a lack of information about doula care and how to access this service. “Midwives need doulas, so do obstetricians. But they have trouble finding trained doulas who are actually practicing because there’re just not enough people doing this kind of work. And a lot of it is a result of it being very difficult to get in the profession and stay in the [doula] profession,” one Miami maternal and child health expert noted.[95]
This produces a form of discrimination based on social and economic status.[96]
This section of the report lays out some of the obstacles doulas we interviewed, and other experts in the Miami area, said they saw stopping doulas from being able to maximize the beneficial impact they can have on the pregnancy and birthing experience for pregnant people, particularly low income people.
Investment, Start Up Costs
Becoming a doula starts with training, and while doula training is inexpensive compared to clinical training, for low-income people it can still be a significant burden and a leap of faith, especially as it is so uncertain if they will be able to recoup costs and making a living doing this work. One interviewee described crying tears of joy when she heard she had received a scholarship for her training. During their career, doulas can take additional training to make more money to support their core work. For example, they may get certified to conduct placenta encapsulation or take training to build awareness about their work. These training costs may add up, rendering the situation particularly difficult for a doula building up her business. Some organizations provide doula training, and some programs also provide employment opportunities for trainees. However, many doulas get trained and then have to find a way to build their business independently.
Cost of Building and Running a Business
Interviewees agreed that doulas need to build a business, which can be stressful and time- and money-consuming without knowing whether it will be financially worthwhile. “A lot of doula work is not about the skillset of working with someone who is pregnant or in labor and delivery,” Nadirah Sabir, doula, and social worker, said. “Twenty-five percent of this is how to do this as a business.”[97] Doula Brittany Fadiora estimated: “It's probably an investment of $2,000 in your first year … training and networking fees and putting up a website, getting your name out there. It is not attainable to be a community doula and then have clients that can't pay you.”[98]
All the costs of getting started and running a business as an independent doula are prohibitive for some of the people who might make the best doulas for at-risk pregnant people in marginalized communities, who simply cannot afford them. “We have compassion, but all the extra stuff it takes to succeed is not available to us,” said Brittany Fadiora. “But the doulas that have the money, they don't necessarily have trust … some of the best doulas I have ever met aren’t even good readers.”[99]
Inadequate Income
All interviewees wanted to work with low-income women, whom they saw as most needing their services. One doula described working with low-income women as her “heart-work.”[100] “Of course I want to work with low-income people,” said another doula. “The lower income families and moms who go through postpartum depression and lack support are under a lot of stress.”[101]
Medicaid-funded health plans in South Florida cover doula care but doulas interviewed for this report said that they would not be able to live on Medicaid reimbursement alone because the compensation is too low. Insurance companies, including those chosen by Florida to provide Medicaid services, provide doula care as a form of “expanded benefits … provided at no extra cost to the state”.[102] However, in Florida, insurance companies have not been mandated to provide this form of care by a law and so how much they pay doulas and for how many sessions with pregnant people, whether their Medicaid members will know about this service and how well the system will work for doulas, is at their discretion.
Humana Health Horizons in Florida, according to their member handbook, offers, at no cost to the pregnant person, four doula prenatal visits, presence during birth and four postpartum visits.[103] Humana was the only plan Human Rights Watch was able to find that provided public information about compensation for doula care ($75 for prenatal and postnatal visits, and $200 for birth attendance, for a maximum total of $800).[104] Other plans do not provide compensation rates or ranges for doula care online and did not respond to Human Rights Watch requests for information about compensation for doulas.[105] According to doulas and administrators who have used the system, as well as health insurance experts in the state, doulas seeking to bill for working with Medicaid clients must register separately with each plan that their clients (or clients they may wish to work with in the future) are on, an arduous bureaucratic process that also differs between plans which sometimes have different requirements for doula accreditation. “You need [for some plans] to be certified with specific doula certification programs, so you might be an experienced doula but need to go get re-certified with that company and find the money to do that,” Kiwasi Apeh who runs Black Birth Workers Rock company that helps doulas and clients connect said. She also added that the process of registration can feel difficult and alien to many people outside of medical world, and “it’s easy to check the wrong thing.”[106] Doulas must also negotiate with each plan they wish to get Medicaid compensation from for how much they will receive in compensation and for what services. This means doulas are in competition with each other, and doulas are rewarded for their confidence in negotiating rather than their skills with clients. Insurance companies call the shots in other ways too. A plan may also decide to only compensate doulas for high-risk clients.[107] Plans may also decide to only compensate doulas that come through a specific agency or organization, which could cut others out. Because the Medicaid compensation for doula care is not provided for by law, the state of Florida could also choose new companies to provide Medicaid coverage who do not provide doula care.
Because of these difficulties doulas wanting to work with Medicaid patients may sign up with The Doula Network (TDN), a company which negotiates with each Medicaid plan for all its clients and helps its doulas with the billing process too, which is also arduous. In 2022 TDN negotiated as a “standard doula benefit” (three prenatal visits, labor support and two postpartum visits, a fairly limited amount of care) where doulas under its umbrella will receive between $830 and $1,122 for completing this package of care, with compensation from the two largest plans (where the larger numbers of Medicaid patients registered with them) Aetna and Sunshine at $830 and $850 respectively. Repayment by insurance companies only takes place after all the services are provided, a representative of TDN said, including the birth and postpartum support, so doulas have had to wait up to nine months, or longer, to get paid for their work.[108]
Tamara Taitt, a midwife who runs a birth center that has negotiated with insurance companies for Medicaid compensation said the plans compensated between $600 to $1,000, depending on the plan, for doula care per client. She added that in the case of two plans she never received payment after billing for doula services and ended up not continuing working with those plans as she did not have the staffing capacity to be able to do the necessary follow up work.[109]
Taitt also noted that insurance companies win Medicaid contracts for six years at a time and the current contracts will end in 2024, so individual doulas and collectives will have to soon go through a new process of finding out what plans offer compensation for doula care (if any decide to provide this service), registering their interest with the plans, renegotiating compensation rates, working out new systems for billing, etc.[110]
Currently an experienced doula may be able to charge up to $3,000 per client (for out-of-pocket clients). [111] Doulas with less experience tend to charge less than $2,000, or even nothing at all for their first clients, to build up experience and get their name out into their community. Most doulas interviewed for this report had a second job, which in most cases was their primary source of income.
Doula work can be both emotionally and physically onerous; it is not “9-to-5” work. To provide high-quality services, even experienced doulas need to limit how many clients they take on. According to interviewees for this report, doulas cannot take on more than about four pregnant people a month, and only as long as other clients are cycling out at the same rate every month. Doulas need to ensure their clients’ births are staggered, as being present during labor and delivery is a core component of most full spectrum doula work. To earn even a “low income” or 80 percent of Annual Median Income ($57,800) for a one-person household in Miami-Dade County (the most populous part of South Florida, but also an expensive place to live relative to much of the US), doulas would need to make $1,200 a client, but that would mean working constantly and always having four clients. Average (median) household income in Miami-Dade County is $74,700 a year.[112]
In a roundtable meeting attended by Human Rights Watch, doulas, midwives and academics working on Black maternal health in the South Florida area suggested that a reimbursement rate of around $2,000 per client over the term of their pregnancy would be a current ideal target for doula compensation for South Florida, which would need to be adjusted for inflation and cost of living in the future.[113] This proposed target fee is also comparable to the per-client rate in Washington DC of up to $1,950, of $3,000 in California and $3,500 in Washington State, but is more than other states compensate in legislation (Oregon, $1500, New Jersey $1165, Michigan, $1150, Minnesota, $770, Nevada $450).[114] Advocates at the National Health Law Program, a non-profit that advocates for Medicaid reimbursement for doulas, have noted that much time has been lost in states trying to improve maternal health outcomes but which set low compensation rates. In these scenarios, doulas do not register for Medicaid compensation or do low-income client work when rates are too low, unless they are part of doula organizations that provide services for free using philanthropic or other grants.[115]
One doula said she still felt exasperated about how much work she needed to do to get registered with a Medicaid plan. “Things are constantly changing, constantly requesting more docs, certification, once you’ve met the criteria there’s a lot of paperwork and it takes time to get reimbursed,” another doula said.[116]
Reimbursement for doula care seems even less fair when accounting for the realities of effective doula care. Doulas provide an individualized human service that is meant to be the exact opposite of, and offset the harms of, an industrialized for-profit health system that aims to see as many patients as possible in the shortest amount of time. “An average OB prenatal visit is maybe 7 to 8 minutes, or maximum 15 minutes, a midwife spends about 45 to 60 minutes on average, but doulas often spend a minimum of 3 hours to cover important childbirth education and address prenatal concerns,” Esther McCant said.
The intensity of a doula’s work is increased if the client needs additional support, as Nicky Dawkins, an experienced doula in Miami said:
The kind of support that somebody on Medicaid is going to need, it is probably going to be different. And in some cases, there might be other things going on, there might be economic security or housing and [physical] security problems. A doula who is trying to support that mother in having a healthy birth is also going to end up helping that family address those issues as well.[117]
Doulas have several other problems with Medicaid compensation that make working under the Medicaid model more financially insecure than working with private clients who pay out-of-pocket. The main payout is for birth attendance with prenatal compensation being as low as $36 per visit, an amount one doula called “totally not worth the paperwork to prove you did that.” If a client does not tell their doula they are giving birth or if a partner or provider dissuades them from calling the doula, the doula can miss that childbirth payment entirely despite providing important services and time before labor.
Doulas we interviewed felt disheartened by the low compensation. "For many of us in my doula circles, we're like ‘I don't know how much longer we can do this’, or ‘will we be able to take Medicaid next year at all’," one doula said with exasperation. [118] Another decided to change her client base altogether: “I have worked with Medicaid, but with the level of reimbursement the energy and the time, all the care that is given, it is not congruent, so I have switched to self-pay clients.”[119]
Edine Collot loves working as a doula and has a rich history of supporting women and girls during pregnancy and birth. “[But] if I wasn’t [also] a social worker, I wouldn’t be able to sustain myself,” she said.[120] “I want to be a happy doula and financially safe in my work,” she added.
Burnout
[Burnout] is very common in the doula community because you are caring for someone else, because you’re underpaid and overworked especially if you’re trying to serve the community ... A lot of doulas are ‘do the most’ types, they will go the extra fifty-seven miles for you.
— Shontaye Wimberly, doula, March 31, 2022.[121]
Doulas also referenced burnout as a major problem for sustainability. Burnout is linked with inadequate compensation, more so for doulas determined to provide Medicaid clients with care. "I have a doula friend of mine that does take Medicaid and she's a community doula and she is just burnt out. … I think if you are working with clients with that many needs, you need way more resources and you need to be paid a lot more money," doula Brittany Faidora said.[122] Doulas are additionally vulnerable because they are highly motivated to help. Some doulas choose doula work because of their own pregnancy and birth experiences, either because they were served well by another doula or because they want to prevent the hardships they experienced in childbearing. Consequently, several doulas said that they themselves and colleague doulas have a tough time maintaining boundaries because they are so mission driven.
Doulas with a second job and/or children face additional difficulties in managing their doula work because they need to be available for prolonged periods and at strange hours for births. “There was a lot of praying and asking the great mother and thankfully a lot of my deliveries would occur during the night,” doula Nikki Smith said, adding that finding childcare at other times was difficult, especially with short notice. Another doula does postpartum work because the hours are more controllable, but she still needs to work nights. “As much as I love this work [when I] tuck my babies in to care for another’s, there’s always some sadness, maternal guilt [when] driving away into the night to care for someone else,” she said.[123] Having to organize their lives around clients’ needs, especially around births, also has other impacts, for example on relationships with other family members or friends. Nikki Smith described the pressures on doulas: “You are expected to be highly flexible, meet the needs of others at expense of our own lives and lifestyle.”[124]
Birth is inherently intense and exhausting. One doula noted that even if a birth was going well, she needed to take short breaks from providing physical and emotional support. Exposure to stress or other adverse experiences for the birthing person and their family during birth can add to burnout, especially for doulas of color who live with interpersonal and systemic racism and marginalization every day. “Some of my doulas, they go back to their jobs at 7-Eleven [a national convenience store] after witnessing a horrible birth and not having those tools to process it for themselves,” a doula trainer said. “It can make them bitter and upset.”[125]
Regardless of the difficulty of the birth, doulas must balance the emotions that come with being intimately involved in the birth, a person’s life-changing moment, but not necessarily in their life for long after. As Brittany Fadiora said:
We are in a very intimate part of someone's life, a very raw part of someone's life. And then we are out. And then we are in and we're out. We are in and we're out.
Chrissy Justilien is a therapist who has worked with doulas but also studied doula care and mental health as part of her academic research. She said that she had seen doulas provide important maternal health benefits like more information, a greater sense of control and reduced anxiety for the birthing person. But she said burn out was a major concern for all doulas driven by a passion to serve. Poor compensation puts additional pressures on doulas impacting the quality of their work she added. “It is difficult to be there and present for a birth if you are barely surviving. This is something I found in my research,” she said.[126]
Lack of Respect
While doulas may experience job satisfaction by providing good service and from the gratitude of their clients, they often do not get the more formal appreciation or respect given to doctors and medical providers. Doulas are, as one doula noted, determined to “make the difference,” but “you're not the one that's ever noted for making the difference.”[127]
Centering another person—the birthing person and also their family—is work that requires humility and grace, but it makes the doula vulnerable to a lack of respect for the same reason. One doula said: “On the one hand, I am honored. I'm respected. I'm there. On the other hand, I'm a true servant, you know.”[128]
Clients, including those paying out of pocket, can overstep boundaries and request support that a doula may not consider part of their service. “When you deal with high end clients [who are] more likely used to having help, having a maid or a nanny, a lot of them ask you to live with them,” one doula said. “They want you to fall into that role of an overall support person.”[129] This kind of overstepping or misunderstanding can also happen when clients, including Medicaid clients, do not properly know what doulas do.
Thanks to activism by doulas and other advocates wanting to improve maternal health and reduce interpersonal and systemic racism as well as racial disparities, traditional medical providers are increasingly understanding and respecting doulas and the value of their work. The Covid-19 pandemic also shone light on “the importance of support and wraparound services after delivery in our healthcare system,” Nikki Smith said. “Respect is growing, but we still have a way to go.” Some hospitals and individual doctors still refuse to allow doulas in the birthing room, and some providers even dissuade women from using them.[130]
Often doulas are not valued or seen as a necessary part of the birthing person’s care team. “Providers don't necessarily want doulas in the room,” Dr. Dr. Rokeshia Renné Ashley said. “They don't want their expertise or their medical practice to be infringed on by someone else.”[131] For part of the Covid-19 pandemic, hospitals shut doulas out, undermining birthing people’s choice of companion, a doula said, “We were shut out … we were not seen as essential for birth.”
According to Esther McCant, medical providers should view doulas as members of the birthing person’s support team: “We are a member of the healthcare team, we just weren't hired by the hospital or the OB, but we are there to also provide a very valuable service.”[132] Sharetta Remikie, Director of Maternal and Infant Health at the March of Dimes, stressed “the importance of making sure that doulas are seen as part of the care team for moms and not in an outside entity” and “that they are recognized as a part of the healthcare team in totality.”[133]
While respect and understanding felt important to our interviewees, several doulas, midwives, and policymakers said they want more than that for doulas and their work. They also want respect for birthing as a natural, person-centered process to match the respect and deference given to medicalized interventions, for example. And although all doulas and other experts interviewed for this report want better understanding, communication, and teamwork from other maternal health providers, they also want their independence from the health system to be respected. “Women are dying in the system; I am not in that system [and] the solution is not to add more people to that system. It's for that system to come closer to where the solution is,” one interviewee said.
Lack of Information about Doulas and Their Work
A problem for low-income pregnant people who might benefit most from doula care is low knowledge about this service, including that their insurance company might provide them one even if they are on Medicaid. Only some clinics and hospitals will link low-income patients to doulas.[134]
But this is a circular problem as it also impacts doulas who need a steady stream of clients. "I think a lot of people just don't know that having a doula is even an option,” said Nicky Dawkins, a Miami area midwife and doula.[135] Dr. Otovo said, “There's a lot of confusion about what doulas do and whether or not doulas are an alternative to a hospital birth.”[136]
Florida insurance companies can choose to cover doula care (that is, to compensate doulas for providing care), but patients, including Medicaid enrollees, and their doctors may not know whether their insurance covers doula services or how they can get one. To close this information gap, Nicky Dawkins tells people to ask their insurance if doulas are covered and “dig” for the answer.[137]
Some interviewees said that knowledge about doula care and how to get it was a problem in the communities they serve. “If Medicaid is offering it, information about doula care should be in every OB GYN office, should be put out there, providers should let everyone know it’s affordable for everyone now,” doula Juliana Escalera said. “Most people are discouraged think[ing] that they need lots of money [to] afford it.”[138]
Maternal Health-Related Rights and How Doulas Advance Them
Doula care can help in improving maternal and infant health outcomes, mitigating racial disparities, and ensuring that pregnant people have full access to information to make safe and informed decisions about their health, pregnancy, birthing choices, and outcomes. As such, doulas can play a pivotal role in protecting and promoting the human rights of pregnant people, including their right to health, information, and equality and non-discrimination. Transforming access to doula care can only be one aspect of a holistic plan to improve maternal health and address unjust racial inequities, but the problem in Florida and the US more broadly is deep and the strong evidence of efficacy and support from communities for this service should make this a compelling step forward.
The reproductive justice movement in the US was initiated by a group of Black women who visioned a human rights movement that included the harms of interpersonal and systemic racism and poverty, especially on women of color, as well as restrictions on contraceptive choice and abortion access. This sexual and reproductive rights framework includes rights outlined below but also centers the right to have a child, to not have a child and to be able to raise a child in a safe and healthy environment. This framework is increasingly helpful for developing rights-protecting policies in the US and elsewhere, especially as the climate crisis and other environmental harms to reproductive health and rights continue to grow.
The Right to Health
Everyone has the right to the highest attainable standard of health.[139] It requires governments to enact policies and dedicate the maximum of their available resources towards the progressive realization of the right to health, including access to health services, goods, and facilities for all people, without discrimination, that are available, accessible, acceptable (including culturally appropriate), and of good quality.[140]
To eliminate discrimination against women, states should develop and execute a strategy to promote women’s right to health throughout their lifetime. This strategy should include measures to prevent and treat diseases and policies to “provide access to a full range of high quality and affordable health care, including sexual and reproductive services.”[141] The right to health’s components also include non-discrimination in services, which must be accessible to all, “especially the most vulnerable or marginalized.”[142] The World Health Organization and others have called for ‘greater action, dialogue, research and advocacy’ for mistreatment of people during birth, including from a human rights perspective.[143]
The UN Committee on Economic, Social and Cultural Rights has said that the availability, accessibility, acceptability and quality of health care are all key parts of ensuring the right to health. These are also relevant to doula care and the importance of making doula care affordable for all, and justly compensated.
Availability: includes “other health related buildings, trained medical and professional personnel receiving domestically competitive salaries.”
Physical accessibility: includes “health facilities, goods, and services must be health facilities, goods and services must be affordable for all. Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households; within safe physical reach for all sections of the population.”
Economic accessibility: “health facilities, goods and services must be affordable for all. Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.”
Information accessibility: “includes the right to seek, receive and impart information and ideas concerning health issues.”
Acceptability: “All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned;”
Quality: “As well as being culturally acceptable, health facilities, goods and services must also be scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation.”[144]
Doulas promote and protect the right to health by ensuring the health and safety of people giving birth and providing culturally appropriate care.
The Right to Information, Including Effective Maternal Health Information
Everyone has a right to access health-related information, which includes access to information that is necessary for safe and healthy pregnancy and childbirth.[145]
Doulas promote and protect the right to information by ensuring their patients have information about their birth options and understand their rights. The provision of access to critical information during a transformative, often dangerous, phase of a person’s life, is crucial for positive maternal outcomes, especially for Black women and other women of color.
The Right to Nondiscrimination
Core international human rights treaties expressly prohibit discrimination and require governments to take measures to eradicate discrimination, including based on race. Federal, state, and local governments in the US are obligated to address all forms of racial discrimination, including disparities in maternal health care.
Under the International Convention on the Elimination of Racial Discrimination (ICERD), states parties, which include the US, must undertake to eliminate racial discrimination and guarantee everyone, without distinction, the right to public health and medical care.[146] When warranted, states parties must take “special and concrete measures,” including in the realm of health, to ensure the development and protection of certain racial groups with the aim of guaranteeing their full and equal enjoyment of human rights.[147] The committee on Economic, Social and Cultural Rights have also said: "Individuals and groups of individuals must not be arbitrarily treated on account of belonging to a certain economic or social group or strata within society."[148]
Last year, the Committee on the Elimination of Racial Discrimination (CERD), the international expert body responsible for monitoring implementation of ICERD, expressed concern about racism’s impact on access to sexual and reproductive health services and “the limited availability of culturally sensitive and respectful maternal health care, including midwifery care for those with low incomes, those living in rural areas, people of African descent and indigenous communities,” in the US.[149] Consequently, it recommended the US include midwifery care in its programs aiming to decrease maternal mortality and morbidity affecting Black and Indigenous communities.[150]
According to the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, acceptable health requires an urgent focus on ensuring an end to the demonization and belittling of Indigenous and traditional health. Instead, it should promote an inclusive approach that is respectful and seeks to understand and support integration into primary health care, as well as recognition of their importance.[151]
Access to doula and midwifery services promotes and protects equality and non-discrimination by helping to address racism and racial disparities in maternal health care. Doulas and their role are particularly essential for Black and Indigenous communities in the US.
A Right to Respectful Maternity Care
Every childbearing person is entitled to respectful maternity care. Beyond preventing morbidity and mortality during birth, respectful maternity care “encompass[es] respect for women’s basic human rights, including recognition of and support for women’s autonomy, dignity, feelings, choices, and preferences, such as choice of companionship wherever possible.”[152]
Doulas protect and promote respectful maternity care by improving people’s experiences of pregnancy, birth, and postpartum, including by increasing their feelings of control over pregnancy-related decisions.
Care workers are crucial to human health and to the functioning of the health system, but this labor is very often unpaid, for example when family members care for each other, or underpaid. In the US care work is also racialized, with Black women taking an unfair burden of lifesaving work that is also often dramatically underpaid, hard, and emotionally draining. One study found that more than one in five working Black women are in the health sector: “Black women are overrepresented in health care at higher rates than any other group and are heavily concentrated in low-wage jobs in the long-term care sector and in hospitals.” The authors said Black women’s experience of care work in the US retains “links back to the division of care work in slavery and domestic service.” Like this report, the study concluded that paying care workers better and providing opportunity for advancement and addressing systemic racism would all improve working conditions and the quality of health care provided.[153] In February 2023, the UN High Commissioner for Human Rights called for global transformation of care and support systems with greater respect for how care work is both a burden mostly borne by women and girls and central to realization of human rights. “Both those providing and receiving care and support have rights. That means support and care systems must respect and advance the enjoyment of human rights for all.”[154]
Birth Justice and the Birth Bill of Rights
The birth justice movement in the US supports the right of everyone, regardless of their background, to holistic, culturally appropriate reproductive health care. Birth justice includes access to comprehensive pregnancy, labor, and birth options, including midwives and doulas.
Acknowledgments
The report was drafted by Skye Wheeler, senior researcher in the Women’s Rights Division, with support from Annerieke Smaak Daniel, researcher in the Women’s Rights Division, Suze Bergsten Park, officer in the Women’s Rights Division, and the senior editor in the Women’s Rights Division, at Human Rights Watch. Esther McCant of Metro Mommy Agency and Jamarah Amani of the Southern Birth Justice Network improved the report at multiple stages of the process. In June 2023, a roundtable of doulas, midwives and academics working on maternal health in Miami Dade workshopped the recommendations and key findings, and the authors are immensely grateful to all the participants. The following Human Rights Watch staff also reviewed this report: Alison Leal Parker, deputy director of the US Democracy Initiative, Katharina Rall, senior researcher, Margaret Wurth, senior researcher, Matt McConnell, researcher. Aisling Reidy, senior legal advisor, provided legal review. Maria McFarland Sánchez-Moreno, acting deputy Program director, provided program review.
Vanessa Charlot took all the photographs and retains copyright. Please contact media@HRW.org to learn more about the photographs.
Most importantly, we thank the doulas interviewed for this report for their insights, analysis, and for sharing their experiences.
