More Doulas Are Needed in California’s Health Workforce

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For centuries, devoted community members have supported expectant parents during pregnancy, birth, and postpartum. In the late 1970’s, the term “doula,” a Greek word meaning “a woman who serves,” was used to describe an emerging profession following this tradition. These nonclinical health professionals provide physical and emotional support to families before, during, and after childbirth, which is part of a well-established tradition in Black and Indigenous communities. Yet only recently has “community-based” doula care, as opposed to individual doula business entities, been recognized for its potential to help address the Black maternal health crisis in California and nationwide.

On January 1, 2023, the California Department of Health Care Services (DHCS) implemented the Medi-Cal doula benefit, opening the door for doula-attended births and related services for Medi-Cal enrollees. Mothers and birthing people can receive up to 11 visits from a doula during the prenatal and postpartum periods. Because Medi-Cal covers 40% of California births, this policy change represents a significant opportunity to advance birth equity. California needs to build a strong doula workforce to support this benefit, but officials do not maintain an official count of the number of doulas working in the state. Nearly 250 Medi-Cal enrolled doulas were listed in the DHCS Doula Directory (PDF) as of last month. CHCF has commissioned research from the National Health Law Program to understand the size, demographics, and landscape of California’s doula workforce.

Sayida Peprah-Wilson, PsyD, is a full-spectrum doula who has supported mothers and birthing people in many aspects of the reproductive experience, including preconception, miscarriage, abortion, postpartum, and more. She also is a licensed clinical psychologist, an implicit bias trainer, and founder and executive director of Diversity Uplifts, a nonprofit consulting and training organization. The agency focuses on increasing the cultural competency and humility of providers, hospital staff, and others to foster the well-being of women, birthing people, children, and families. She also serves on the CHCF Birth Equity Advisory Group and the DHCS Medi-Cal Doula Implementation Stakeholder Workgroup (PDF). I recently interviewed Peprah-Wilson about her work and the future of doula care. Our conversation has been lightly edited for length and clarity.

Q: What led you to become a full-spectrum doula and an advocate for birth equity?

A: My journey into this work began at a young age. I grew up in New Jersey and New York in the 1980s, and in my family, there was a lot of conversation about human rights and self-determination in the Black community. My grandparent’s lives during the Civil Rights Movement, the end of the apartheid, and police brutality were frequently discussed at the kitchen table. I understood that the community had to fight for our rights, so advocacy was always a part of my consciousness.

Even though my maternal grandmother died when I was 10, as a teenager I heard stories about how she was an early supporter of Planned Parenthood. Years later, I learned about reproductive justice and the early testing of birth control pills on the Black community, and I felt connected to the fact that she had been an advocate.

When I was a teenager, a lot of my friends struggled to access reproductive care when they became sexually active. I was the friend who made sure everybody got to Planned Parenthood. I knew when they were doing special condom giveaways and presenting talks about the female condom when it came out. If I heard that somebody might have had an STD, I encouraged them to go to Planned Parenthood.

When I was 17, I was a birth doula for one of my best friends, and this was before I knew the term or that it was a profession. I had a couple of friends who had pregnancies that they didn’t want to sustain. I found out where the abortion clinics were and took them to their abortions, and I sat with them at home afterwards. I went on to become a support person for family members and friends when they had babies. It has always felt natural to me to be an advocate and to provide support in people’s reproductive life.

I had a lot of exposure to the concept of midwives as I was growing up. I knew that many women in our Muslim community gave birth at home and with midwives, and that they supported each other as women in their birthing as well. My expectation was that when I became an adult, I’d also have access to holistic and culturally centered maternity care. But I didn’t experience that when I was pregnant. That was frustrating, surprising, and a little bit debilitating, because I didn’t see how I was going to achieve the birth I wanted within the systems that existed.

Q: There is strong evidence that continuous doula support can improve maternal and infant outcomes. How can traditional community models of doula care inform institutional maternity care models in the state?

A: We’d need to interweave the community model with the institutional model. If we expand the definition of maternity care teams to include community doulas — not just supporting our own clients adjacent to the health care system, but working in partnership with ob/gyns, nurses, midwives, and maternal-fetal medicine specialists to support families — we have the opportunity to mitigate some of the stereotypes and implicit biases in the health care system.

We still have a very segregated system, and the best international maternity care models are where all the providers’ services are integrated, doulas included. Other countries that do that have lower maternal mortality rates, infant mortality rates, and maternal mental health challenges. Often, birthing people meet the person who is going to deliver their baby only a few times before they go into labor. Medical providers are also overbooked with their existing patient load. Doulas help fill the gap. Doulas are able to provide additional emotional and physical support for birthing families while encouraging them to keep their medical appointments and communicate with their providers.

Q: The Listening to Mothers in California survey found that mothers and birthing people who are Black were more likely than those of other races and ethnicities to express interest in having doula support for a future birth. While we don’t know the demographics of the doula workforce in California, it’s safe to deduce that we need more Black doulas. What are some of the challenges that impede diversification of the doula workforce in California?

A: It really depends on where you are. Diversification is difficult in places where older doula cohorts might have been mostly White doulas serving only affluent and White families. In other places, doulas of color came on the scene first, some as independent doulas, but many through the community-doula pilots and program.

The financial burden of becoming a doula is a challenge. You generally need training that costs money, and not everybody can afford it. Having scholarships and distinct funding for doula education, with a specific focus on certain regions and populations of need, could help. There also needs to be continued support to the community-doula programs in existence, so that the programs and the doula themselves, are supported in expanding their services through the Medi-Cal doula benefit.

Q: We currently lack enough doulas in California to provide care for all mothers and birthing people using Medi-Cal. How can we build a strong workforce in the state to address this?

A: Even if more doulas were to register with Medi-Cal, there still would not be enough doulas to meet the needs of Medi-Cal enrollees. Many of the working doulas who have established businesses don’t want to be part of a bureaucracy even though they might make more money in some cases. The process of registering with Medi-Cal and billing for their services can be extremely discouraging.

People want to know how many doulas are out there, but I don’t think that’s the right question. We need to know how many people are interested in becoming doulas and what it would take to support them. And we need to know if there are doulas already out there who are supported enough to complete the Medi-Cal provider enrollment process.

We need a new workforce in addition to the existing workforce because a lot of those people have jobs and other contracts that enable them to make a living. In contrast, the community-based doulas are more likely to be interested in the Medi-Cal benefit and represent a new cohort and typically are younger. We have some seasoned ones, but new doulas need to shadow experienced doulas, they need to attend at least three births, and they need mentorship. These are things that Diversity Uplifts and other community-based birthworker organizations provide. Support is needed for doula hubs [which help doulas gain access to hospitals and qualification for Medi-Cal reimbursement] and the local communities that are training doulas to enroll for the Medi-Cal doula benefit.

Doula work is like nothing else. You are there with families during their most vulnerable moments. People must have a calling to this work — it’s a ministry. So it’s important that people who are committed to this work are supported by Medi-Cal, so we can fill the care gaps.

Q: How does birth equity show up in doula practice?

A: Birth equity in practice is the creation of environments where people can give birth in a joyous, uplifting space. Reproductive Health Impact [formerly known as the National Birth Equity Collaborative] defines birth equity as “the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort.” The key part of that definition is that all people be free of birth trauma and free of unnecessary interventions that could lead to unnecessary complications and ultimately unnecessary losses.

An optimal birth includes community support. Sometimes in the Black community pregnancy is met with a negative response because of generational experiences where pregnancy was associated with a lack of financial resources or fear of having another mouth to feed. We must reframe this.

Birth equity means providing needed education, using empowering community-centered models, and asking what is needed: Do people need childbirth education? Do they need conversations in therapy to mitigate trauma from a past experience? It means ensuring that people have access to information and support that will enable an optimal birth.

Birth equity means thinking about social inequities and the best way to address them, so that each pregnant woman or birthing person and infant have the best outcome. And even if the outcome is to end a pregnancy, there are so many things that can be done to make sure that experience doesn’t have negative consequences for the future. For many people, the end of a single pregnancy isn’t the end of their reproductive experiences or their pregnancies in general. How they’re cared for, even in an abortion experience, could impact their reproductive future, both physically and psychologically.

Q: What policy or practice changes would improve maternal and infant health outcomes for Black families?

A: We need better access to perinatal mental health care. It’s imperative to have free and accessible individual and group mental health support, screening, and interventions for people who are pregnant. This includes community-based and culturally-centered models to mitigate stress. We know that managing stress can help mitigate preterm birth, which means fewer babies would be born too soon and too small with significantly higher rates of infant mortality. Everything’s a domino effect.

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