Advertisement

“They’re gonna be there to advocate for me so I’m not by myself”: A qualitative analysis of Black women’s motivations for seeking and experiences with community doula care

Open AccessPublished:September 08, 2022DOI:https://doi.org/10.1016/j.wombi.2022.08.007

      Abstract

      Problem

      In the United States, Black women are disproportionately impacted by inequities in maternal health.

      Background

      Community doula support may improve birth outcomes and experiences, including lower rates of preterm birth and low birthweight and increases in positive birthing experiences. Few studies have explored client experiences with doula care, specifically community doula care.

      Aim

      To explore Black doula clients’ motivations for seeking and experiences with community doula care.

      Methods

      Data are from a mixed methods process evaluation of an organization providing free community doula services in San Francisco, California. We conducted two rounds of qualitative interviews with doula clients who identified as Black or Pacific Islander between August 2019 and March 2020. Interviews explored clients’ knowledge of, experiences with, and motivations for seeking doula care and their perceptions of the services they received. We utilized a Rapid Assessment Process to synthesize findings and thematic analysis.

      Findings

      Clients’ motivations for seeking doula care included general lack of support and knowledge of mistreatment experienced by Black women in hospital settings. Doulas provided support in the form of information about the perinatal period and clients’ rights, advocacy in hospital settings, and connection to resources beyond pregnancy and birth. Some clients described doulas as helping them stay focused and make decisions during difficult labor experiences and described positive birth experiences despite experiencing complications.

      Conclusion

      Community doulas play an instrumental role in the birth experiences of Black women and birthing people. Efforts should be made to expand access to this needed support via policy and hospital practices.

      Keywords

      Statement of Significance
      Problem
      In the United States, Black women are disproportionately impacted by inequities in maternal health.
      What is already known
      A growing body of literature supports doula care as an intervention to improve birth outcomes and patient experiences with pregnancy-related healthcare. Community doulas are uniquely positioned to support pregnant Black women and birthing people as they provide services tailored to the specific needs of the communities they serve at little or no cost, and are often racially, linguistically, and/or culturally concordant with their clients.
      What this paper adds
      This study contributes important findings about Black women’s motivations for and experiences of having community doula care and adds to the limited literature on doula care in general. Our analysis confirms a need for community doula care among Black women and found that this care positively impacted clients' pregnancy and birth experiences.

      Introduction

      The maternal mortality rate in the United States is one of the highest among high-income countries [

      N. Martin, R. Montagne, U.S. has the Worst Rate of Maternal Deaths in the Developed World. NPR. 2017; published online May 12. 〈https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world〉. (Accessed Oct 20, 2021).

      ,
      • Tikkanen R.
      • Gunja M.Z.
      • Fitzgerald M.
      • Zephyrin L.
      Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.
      ], with Black women most impacted. Black women are three to four times more likely to die from pregnancy related causes and more likely to experience outcomes like preterm birth and low birth weight compared to white women [
      • Creanga A.A.
      • Syverson C.
      • Seed K.
      • Callaghan W.M.
      Pregnancy-related mortality in the United States, 2011-2013.
      ,
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • et al.
      Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 States, 2013-2017.
      ,
      • Martin J.A.
      • Hamilton B.E.
      • Osterman M.J.K.
      • Driscoll A.K.
      Births: final data for 2019.
      ]. Mistreatment of Black women in medical settings is widespread and an important factor in these inequities. A national study found women of color (that is, Black, Hispanic, Asian, and Indigenous women) reported higher rates of mistreatment in maternity care [
      • Vedam S.
      • Stoll K.
      • Taiwo T.K.
      • et al.
      The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.
      ], while other research suggests that Black women in California had lower levels of decision-making autonomy, support, and good communication with staff during labor compared to other racial/ethnic groups [

      C. Sakala, E.R. Declercq, J.M. Turon, M.P. Corry, Listening to Mothers in California: A Population-Based Survey of Women’s Childbearing Experiences, Full Survey Report. Washington, D.C.: National Partnership for Women & Families, 2018.

      ]. In the face of the maternal health crisis, Black community-based organizations and birthing people have worked to narrow racial disparities through continued advocacy and policy work. This notably includes successful efforts to expand access to full-spectrum doula care in California and support for federal legislation, like the Black Maternal Health Momnibus Act, a package of 12 bills to comprehensively address the maternal health crisis, which includes support for community-based organizations to grow and diversify the perinatal workforce [

      Black Maternal Health Momnibus. Black Maternal Health Caucus. 2020; published online March 7. 〈https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus〉. (Accessed April 4, 2021).

      ].
      A growing body of literature supports doula care as an intervention to improve birth outcomes and patient experiences with pregnancy-related healthcare. Doulas are trained, non-clinical professionals who provide physical, emotional, and educational support to people during pregnancy, birth, and postpartum [

      A. Bey, A. Brill, C. Porchia-Albert, M. Gradilla, N. Strauss, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019.

      ]. Previous studies have found that women with doula-supported births have lower rates of cesarean delivery, preterm birth, and low birthweight and higher rates of breastfeeding initiation [
      • Gruber K.J.
      • Cupito S.H.
      • Dobson C.F.
      Impact of Doulas on healthy birth outcomes.
      ,
      • Kozhimannil K.B.
      • Attanasio L.B.
      • Hardeman R.R.
      • O’Brien M.
      Doula care supports near-universal breastfeeding initiation among diverse, low-income women.
      ,
      • Kozhimannil K.B.
      • Hardeman R.R.
      • Alarid-Escudero F.
      • Vogelsang C.
      • Blauer-Peterson C.
      • Howell E.A.
      Modeling the cost effectiveness of doula care associated with reductions in preterm birth and cesarean delivery.
      ,
      • Paterno M.T.
      • Van Zandt S.E.
      • Murphy J.
      • Jordan E.T.
      Evaluation of a student-nurse doula program: an analysis of doula interventions and their impact on labor analgesia and cesarean birth.
      ,
      • Thomas M.-P.
      • Ammann G.
      • Brazier E.
      • Noyes P.
      • Maybank A.
      Doula services within a healthy start program: increasing access for an underserved population.
      ]. A 2017 Cochrane review affirmed the benefits of continuous labor support, including lower likelihood of reporting negative feelings about their childbirth experience [
      • Bohren M.
      • Hofmeyr G.
      • Sakala C.
      • Fukuzawa R.
      • Cuthbert A.
      Continuous support for women during childbirth.
      ].
      The scant existing literature on client experiences with doula care suggests clients are satisfied with the care they receive and that doulas play an important role in their birthing experiences. Clients describe doulas providing important emotional and physical support, as well as helping them feel empowered in their choices during birth [
      • Deitrick L.
      • Draves P.
      Attitudes towards Doula support during pregnancy by clients, Doulas, and labor-and-delivery nurses: a case study from Tampa, Florida.
      ,

      H. Holland, Relational spaces in maternal healthcare: a qualitative study of young mothers’ experiences with community-based doula care, 2009.

      ,
      • Hunter C.
      Intimate space within institutionalized birth: women’s experiences birthing with doulas.
      ,
      • Koumouitzes-Douvia J.
      • Carr C.A.
      Women’s perceptions of their Doula support.
      ,
      • Lanning R.K.
      • Oermann M.H.
      • Waldrop J.
      • Brown L.G.
      • Thompson J.A.
      Doulas in the operating room: an innovative approach to supporting skin-to-skin care during cesarean birth.
      ,
      • McLeish J.
      • Redshaw M.
      'Being the best person that they can be and the best mum’: a qualitative study of community volunteer doula support for disadvantaged mothers before and after birth in England.
      ,
      • Simon R.M.
      • Johnson K.M.
      • Liddell J.
      Amount, source, and quality of support as predictors of women’s birth evaluations.
      ]. Clients and doulas have described close and trusting relationships, which allow doulas to better understand and meet their clients’ needs [

      H. Holland, Relational spaces in maternal healthcare: a qualitative study of young mothers’ experiences with community-based doula care, 2009.

      ,
      • Hunter C.
      Intimate space within institutionalized birth: women’s experiences birthing with doulas.
      ,
      • McLeish J.
      • Redshaw M.
      'Being the best person that they can be and the best mum’: a qualitative study of community volunteer doula support for disadvantaged mothers before and after birth in England.
      ]. Only one study with a majority white sample has examined clients’ decisions to hire private doulas, finding that clients wanted to ensure they had expert-level care and support not found in the medical system [
      • Henley M.M.
      “The goddess of the room”: birth as a feminist issue among doulas and mothers.
      ]. Private doulas, who are often white, upper-middle class women, typically use a fee-for-service model where clients pay out-of-pocket, making them less accessible for women of color or with low incomes [
      • Lantz P.M.
      • Low L.K.
      • Varkey S.
      • Watson R.L.
      Doulas as childbirth paraprofessionals: results from a national survey.
      ,

      M. Main, Beyond the Beast: Culturally Competent Doulas as a Breastfeeding Intervention. Northwest Bulletin. 2017; published online June. 〈https://depts.washington.edu/nwbfch/archives/beyond-breast-culturally-competent-doulas-breastfeeding-intervention〉. (Accessed Sept 1, 2021).

      ].
      To our knowledge, limited research focuses on client experiences with community doula care. Community doulas provide services tailored to the specific needs of the communities they serve at little or no cost, and are often racially, linguistically, and/or culturally concordant with their clients [

      A. Bey, A. Brill, C. Porchia-Albert, M. Gradilla, N. Strauss, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019.

      ]. The present study explores motivations for and experiences with doula care among Black clients of a San Francisco-based community doula organization. This analysis aims to fill several gaps in the literature related to client experiences with doula care, particularly community doula care. First, it describes Black women’s experiences with and perceptions of community doula care. A 2018 report found Black women in California had the highest rate of doula use (15%) and interest in utilizing doula support in the future (66%) compared to other women in the study [

      C. Sakala, E.R. Declercq, J.M. Turon, M.P. Corry, Listening to Mothers in California: A Population-Based Survey of Women’s Childbearing Experiences, Full Survey Report. Washington, D.C.: National Partnership for Women & Families, 2018.

      ]. These findings suggest a need for doula support among Black women. Second, this analysis contributes to the scant literature on community doula care for birthing people of color more generally.

      Participants, ethics, and methods

      We utilized qualitative data from a mixed-methods process evaluation of SisterWeb San Francisco Community Doula Network, a community doula organization providing no-cost doula services to Black, Pacific Islander, and Latinx pregnant women and people in San Francisco, California. SisterWeb launched in 2019; in 2021, the organization supported 86 births. Clients are referred to SisterWeb via medical providers, social workers, or others at community-based services, or self-referral through their website. SisterWeb’s model of care includes three prenatal visits, in-person birth support, and four postpartum visits, with increased support provided to clients experiencing heightened stressors, including community or intimate partner violence, poverty, and homelessness. In the program, clients receive support from cohorts of two to three community doulas during pregnancy, birth, and postpartum. In March 2020, doulas transitioned to providing virtual support via phone, text, or videoconference due to the onset of the COVID-19 pandemic. In July 2020, doulas largely returned to providing in-person birth and labor support, but generally provided virtual support for prenatal and postpartum visits. Further details about SisterWeb’s programs are available elsewhere [
      • Gomez Anu Manchikanti
      • Arteaga Stephanie
      • Marshall Cassondra
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Jackson Andrea
      SisterWebSan Francisco Community Doula Network: Process Evaluation Report.
      ,
      • Marshall Cassondra
      • Arteaga Stephanie
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Jackson Andrea
      • Gomez Anu Manchikanti
      Barriers and Facilitators to the Implementation of a Community Doula Program for Black and Pacific Islander Pregnant People in San Francisco: Findings from a Partnered Process Evaluation.
      ,
      • Gomez Anu Manchikanti
      • Arteaga Stephanie
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Mehra Renee
      • Logan Rachel G
      • Jackson Andrea
      • Marshall Cassondra
      “My 9 to 5 Job Is Birth Work”: A Case Study of Two Compensation Approaches for Community Doula Care.
      ,
      • SisterWeb San Francisco Community Doula Network
      ].
      The process evaluation was guided by the principles of the Equitable Evaluation Framework, centering equity, attunement to historical, structural, and cultural context, and collaboration. Thus, researchers at local academic institutions and leaders from the doula organization collaborated on the evaluation design, data collection and interpretation, and dissemination of findings. Detailed information on the process evaluation has been published elsewhere [
      • Gomez Anu Manchikanti
      • Arteaga Stephanie
      • Marshall Cassondra
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Jackson Andrea
      SisterWebSan Francisco Community Doula Network: Process Evaluation Report.
      ]. Methods and results are reported according to the Consolidated Criteria for Reporting Qualitative Research [
      • Tong A.
      • Sainsbury P.
      • Craig J.
      Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.
      ].
      As part of the evaluation, we invited clients from the programs serving Black and Pacific Islander clients to participate in a two-part qualitative study to understand their experiences with the program. As evaluation funding was restricted to these two programs, this analysis does not include data from the Latinx-serving program. Further, due to the later start and limited capacity of the program serving Pacific Islander clients, we mainly recruited from the program serving Black clients. We recruited clients between August 2019 and March 2020. To be eligible for the study, SisterWeb clients had to identify as Black or Pacific Islander, be between the ages of 18 and 45, have an estimated due date (EDD) before May 2020, and have not yet completed their third prenatal doula visit at the time of the initial interview. During the client intake process, the SisterWeb doula coordinator provided clients with information about the study. Fifty-six clients were approached by the doula coordinator and all consented to having their contact information shared with the research team. Of these, 40 clients were contacted by the research team; 16 clients were not contacted because they had an EDD after April 2020 or were deemed ineligible for another reason. Two contacted clients were no longer interested at the time of contact, 10 were ineligible, 12 did not respond to three contact attempts, and two enrolled but did not interview. A total of 14 clients participated in the study, a sample size considered sufficient for reaching saturation, particularly for samples including participants with similar characteristics [
      • Hennink M.
      • Kaiser B.N.
      Sample sizes for saturation in qualitative research: a systematic review of empirical tests.
      ].
      Participants completed two individual in-depth interviews, one in the prenatal period before the 35th week of pregnancy, and a second after eight weeks postpartum. Prenatal interviews occurred between September 2019 and March 2020 and explored clients’ knowledge of doula services, their experiences in the doula program, and their motivations for seeking doula care. Postpartum interviews occurred between January and May 2020 and explored clients’ birth and postpartum doula care experiences and their overall feelings about the services they received through the doula program. Three members of the study team, including CM, conducted all interviews and were concordant with participants in race and gender. Prior to engaging in data collection, two interviewers participated in a qualitative interviewing training led by CM and AMG, conducted practice interviews, and received feedback from SA and JA. Participants did not know interviewers prior to data collection.
      Prior to interviews, staff obtained informed consent from participants. We conducted interviews in-person or via phone or videoconference. All interviews were digitally recorded and professionally transcribed. Prenatal interviews lasted an average of 45 min, while postpartum interviews lasted an average of 23 min. Most participants were interviewed by the same interviewer for both interviews. We did not employ participant checking in this study. The Committee for the Protection of Human Subjects at the University of California, Berkeley approved the study protocol.
      Our analytic process included two parts. Initially, we utilized a Rapid Assessment Process (RAP) to analyze all qualitative data collected for the process evaluation [

      A.B. Hamilton, Qualitative methods in rapid turn-around health services research. 2013; published online Dec 11. 〈https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/780-notes.pdf〉. (Accessed June 23, 2021).

      ]. RAP employs rigorous and strategic analytic methods to expedite data reduction and synthesis and produce actionable preliminary findings, making it ideal for time-sensitive projects, including evaluation research. First, we developed a summary template for prenatal and postpartum interviews with neutral domains matched to interview questions. Interviewers used this template to create field notes in the form of an interview summary after completing each interview, and later updated these summaries after transcript cleaning. Once finalized, we transferred all interview summaries to an individual-level data matrix and synthesized key data across participants and domains. Lastly, we created group-level memos to further synthesize findings.
      Next, two authors, SA and EH analyzed the client interview data using a modified reflexive thematic analysis approach [
      • Braun V.
      • Clarke V.
      Thematic Analysis: A Practical Guide.
      ]. We each read all transcripts and RAP transcript summaries in their entirety, taking note of our initial thoughts and observations in an ongoing memo. We then developed a parsimonious codebook based on our interview guide, review of the data, and the RAP findings, focusing on clients’ knowledge of doula services, motivations for seeking doula care, birthing experiences, and experiences receiving support from their doulas. Codes were mostly deductive, with a few inductive codes derived from the data. We then coded two transcripts together, discussed code placement, and refined and finalized the codebook. We continued coding transcripts independently using a lumping approach, wherein large excerpts of text are coded to identify overarching themes, using Dedoose, an online mixed methods analysis program [

      SocioCultural Research Consultants, Dedoose, web application for managing, analyzing, and presenting qualitative and mixed method research data, 2022. 〈https://www.dedoose.com/〉.

      ]. After coding all transcripts, SA and EH met multiple times to review coded data and develop themes in consultation with CM and AMG. We began by identifying a preliminary list of themes and developing a thematic map. We then reviewed the preliminary themes in conjunction with coded data and finalized the findings, utilizing the thematic map to visually group similar themes together until all authors reached consensus on a final list of themes.

      Findings

      Fourteen clients completed prenatal interviews (Table 1). Of these participants, nine completed postpartum interviews. Most participants (n = 13) were clients of the program serving Black clients and all participants (n = 14) identified as Black, with one participant also identifying as Pacific Islander and receiving services from the Pacific Islander-serving program. The average participant age was 30 years (SD=7). All participants lived in San Francisco; 10 had lived in San Francisco their entire lives. Ten participants were insured by Medicaid. Eight participants were parents, while six were expecting their first child. Five participants gave birth after the start of the COVID-19 pandemic; two of these participants received virtual birth support from their doulas via text or phone. Overall, three participants did not have doula support at their births; one participant moved from San Francsco prior to childbirth, a second did not contact her doulas until after her baby was born, and the third, who gave birth after the start of the COVID-19 pandemic, was unable to communicate virtually during her labor.
      Table 1Participant demographic characteristics and doula care received (N = 14).
      Demographic Characteristicn%
      Mean age, years (SD)30 (7)
      Race/ethnicitya
      Black14100
      Pacific Islander17.1
      Insurance type
      Private428.6
      Medi-Cal1071.4
      Time living in San Francisco
      San Francisco native1071.4
      More than 10 years214.3
      Less than 10 years214.3
      Parent Status
      Parenting642.9
      Expecting first child857.1
      Clients requiring extra support321.4
      Doula support during birthb1178.6
      Gave birth before prior to COVID-19 (3/20/20)964.3
      Pregnancy or birth complicationsc1071.4
      Notes: (a) Participants could report identifying with multiple racial and ethnic groups, thus the sum of all categories exceeds 15. (b) Doula support during birth includes in-person support, or virtual support via video, phone, or text. (c) Pregnancy and birth complications included high-risk pregnancies, preeclampsia, gestational diabetes, and babies’ stay in the NICU.
      Most participants had never heard of a doula before learning about SisterWeb; however, a few learned about doulas through their own research or from a friend or family member. Even among those that had heard of doulas, knowledge of the services they provide was limited. Most participants were referred to SisterWeb by their healthcare provider or a local program offering perinatal services for Black pregnant women.

      Need for support during pregnancy

      Nearly all participants described a need for support during pregnancy and birth as the main motivating factor for seeking doula care. This need for support stemmed from various factors, including a general lack of support from family, friends, and partners. One participant described her rationale for working with a doula:“A lot of help that I need with my baby, I'm not getting it from my mom. So I'm doing a lot of stuff on my own… She's not helping me with a baby shower. She doesn't help me with, like, Pampers or anything or help me fix my living situation. So, it's like stuff that I want help with, I'm not getting it from her.”
      Another participant mentioned:“[My] first and second birth, although they were easy, it would've been nice to have somebody there, you know, just to say supportive words or asking me if I needed things. I was just doing a lot of stuff as far as to alleviate the contraction pains by myself while [my partner] was just like, in the doorway 'Are you okay?' and I'm like ‘Really? That's all I get? Like, I don't get my back rubbed?’”
      Other participants described needing extra support due to persistent maternal health inequities plaguing Black women in the U.S. Specifically, they were drawn to community doulas for the culturally congruent care they provide, with the expectation that community doulas would be attuned to their needs. When asked about her decision to have a doula, one participant said:“Knowing that, like, the high rates of death [among Black women], or just how we're not taken that seriously when we're in doctors’ offices… I think that was probably the biggest part of [my decision-making].”
      Another participant described why she needed extra support as a Black immigrant woman:“When you are a foreigner with [an] accent, maybe the color speaks before you. Like, I'm well educated, and I can do my research, and I can be self-sufficient, but sometimes you feel like people, you know, there are stereotypes, and people might… undermine you in a way, or reach to conclusions. And sometimes when you come with someone who has experience in that area it helps.”
      There was an overwhelming sentiment among participants that Black women are often “not listened to” or dismissed in medical settings, and an expectation that this would happen to them while receiving pregnancy-related care. In response, some participants tried to compose a care team of Black providers who would better understand their needs.“I want, if possible, a team of Black women… so [the community doula program] hooked me up with the Centering Pregnancy for Black Women. It's something at [hospital], where the midwife is a Black woman, the doctor's a Black woman, on top of your doulas being Black, they have a Black pediatrician. Like, it's just dope. And so, just preference. I wanted the first face that my child saw coming into this new place to be a person of color.”
      Importantly, two participants described previous negative experiences with hospital staff as motivating factors for seeking doula support, including hospital staff being “very rude” and uncommunicative.“[The hospital staff] were just being very rude towards me and stuff like that after I had the baby. As far as monitoring the baby part, because…I had got discharged first, and they never discharged my baby… So it was hard, you know, because I'm a new mother. I didn't really know what to expect. You know, and then I was young and stuff.”“My last visit with the hospital, the staff took my daughter for like two hours, and they asked to do something specific, and it was never done. So for nobody to have gone with her, it's like, ‘What happened? What did you guys do?’”
      Overall, participants who lacked support during their pregnancy felt a doula would provide the care necessary to have a safe and positive pregnancy and birth by advocating for them in hospital spaces and ensuring that their concerns would be heard.

      Doula care as distinct from clinical care

      Once engaged with their doulas, participants reported receiving doula care that was “comfortable” and “reassuring,” which contrasted with their experiences of medical care. As one participant said about her doula care, “It wasn't clinical, it wasn't stale. Just very open.” Another participant noted, “It was just like sitting and talking with a friend who just has all this information about what goes on during pregnancy.” Indeed, many participants described relationships with their doulas akin to family or friends. One participant mentioned how meeting with her doulas was “just like having family over.” For many participants, this level of comfort stemmed from a shared culture and community with their doulas, a hallmark of community doula care that is not often experienced in the medical system.“The doulas are aware of… systematic racism within healthcare and a lot of people aren't privy to that. And so, it was just an insurance of like, ‘Hey, we got you. We'll walk you through everything, and we'll just make sure that you feel comfortable with everything.’”“We spent half that time laughing and joking… [one of my doulas is] my friend's daughter, and [the other doula], we had had several meetings with each other, so it felt very heartwarming and family-like.”
      The comfortable environment doulas fostered allowed participants to be open and honest, expressing their needs and concerns without fears of being dismissed.“It's just comfortable. Like it makes you just want to talk. But at the same time, like professional, and not feeling like, ‘Oh, I don't know if I should say that.’ You know, just open.”
      Participants met with their doulas at least three times during pregnancy, but noted their doulas were available whenever they needed, which cultivated feelings of trust. When it came time for birth, many participants had built strong relationships with their doulas that made them feel understood and supported.
      Participants discussed specific ways their doulas provided holistic care during pregnancy, birth, and postpartum that differed from traditional medical care. During pregnancy, participants mainly described their doulas providing educational support, including information about their rights in the hospital during labor and birth and assistance with developing a birth plan.“[My doulas] gave me another packet of information of things I should be eating. Um, things like preterm labor signs that I should be looking out for… and then things like optional versus protocol in a hospital setting. Like when I'm in labor. Just things that I didn't even think about or know about.”
      Doulas also shared information about strategies to manage pain, which was especially important for a minority of participants who desired to birth without pain medication. Participants recounted how their doulas acted as their advocates during birth, making sure their preferences and rights were honored in the hospital; this was particularly important for one participant, who shared how her doula requested a new doctor when the one she had was being “rough” with her:“[My doula] told them to get me another nurse or doctor that knew what they were doing with checking me down there. She advocated for me to get another doctor. [Then I] got a lady doctor, which she was perfect… 'Cause every time [the previous doctor] stuck his hand in me, he made me bleed.”
      Furthermore, participants described their doulas providing physical support during labor and birth not typically provided by medical staff. One participant noted, “[They] rubbed my feet, walked around the hospital and stuff with me. So, they were definitely very helpful and supportive.” Another participant described, “When [the medical staff] asked me to hold my legs up, and I was on an epidural, [I was] like, ‘I can barely do it.’ [My doulas] were there and they helped.” Lastly, participants spoke about how their doulas supported them postpartum by providing breastfeeding support and resources, helping with cleaning or cooking in their homes, and holding the baby while participants showered. Notably, some participants detailed how their doulas interacted with and provided support for their partners.“[My partner] was actually also very stressed out, nervous. So also, to physically help him, even if it's simple things, like to give us something, or to bring the heated pad or whatever it is in addition to the massage and positive affirmation was very helpful, even on the times that he needed to rest or take a nap or something.”
      Importantly, participants described support their doulas provided that went beyond pregnancy and birth, including social support and referrals for services. This included doulas checking in with them between visits, asking how they were doing, and letting them talk about the stressors in their lives. Additionally, doulas connected participants to needed services, like referrals for housing and legal aid.“For somebody to pay attention to me, it felt really good… when I first met [my doula], I was going through some stuff with my job and stuff, and the first meeting, I think it was like two to two and a half hours. Cause I was just rambling off at the mouth, and she wasn't rushing me either. I didn't feel rushed.”“I had some issues postpartum and just feeling overwhelmed and emotional with having two new babies and not really getting any sleep, and then dealing with some personal issues with their father. [My doula’s] been a great support system offering resources of other agencies that can assist me with dealing with the postpartum.”
      In providing these extended services, doulas helped participants access necessary social and structural support that addressed their health needs not served by their clinical care.

      Doulas as benefitting birth experiences

      Participants expressed satisfaction with the doula care they received and generally described this care as benefiting their birth experiences. As one participant said, “[My doulas] made me feel really comfortable doing something that I've never done before.” Importantly, a crucial factor contributing to participants’ positive experiences was the relationship and trust they developed with their doulas over the prenatal period.“[My doula] was on one side and [my] husband was on the other side, and, you know, when you have those relationships prior and you know, they've been well established, it just feels like an extra support. And yeah, it was very comfortable and it was great having her there.”
      Another participant described having her doula present at her birth as feeling “natural” and like “they were family already.” Two participants recalled how their doulas supported them through difficult birth experiences by helping them stay focused and present. One participant, who had to deliver by cesarean section while under general anesthesia, described how her doulas helped her labor for as long as possible:“I think I could have easily gave up a few hours after the [fifth] centimeter if we were by ourselves. But the fact that I tried that much, every time I feel like, ‘Oh, my god, I didn't even see my baby when he came out,’ for me, it helps to think that I did everything in my capacity. But I think it was really helpful that they were there to push through that.”
      Another participant, who experienced complications after giving birth and needed to consent to additional procedures, described how her doula kept her calm and supported her decision-making:“She was holding my hand. And then there would be times when [she] would be, like, ‘Okay, it's me and you talking,’ like, ‘What do you think?’ You know? Just [like a] huddle. Because, you know, I don't even know what I'm signing.”
      Other participants discussed how their doulas helped them recognize their own power during birth by providing useful information that informed their decision-making, ultimately leading them to have the births they envisioned.“[Preparing with my doulas] made me feel good, definitely offered some reassurance that this is my experience and I wanted to make it as comfortable as possible. Them listening to what I had to say, and also being a support system for me, really helped make the decision in regard to the pain management.”
      Having doulas they trusted, related to, and felt comfortable with enabled participants to experience birth on their own terms, even when their birth plans changed. Further, the level of understanding doulas exhibited with participants contributed to their sense of confidence that their preferences and rights would be honored as much as possible.
      Five participants received modified doula services because of the COVID-19 pandemic—none of these participants were able to meet with their doulas in-person for postpartum visits, and two did not have their doulas present at their births and instead received virtual support during this time. While lack of in-person care was disappointing, participants still expressed positive feelings toward having participated in the community doula program and felt they had access to support they may not have had otherwise.“[My doula] just texted me last week, just checking up on me to see how everything was and if I needed additional support… So, I think it's been a very pleasant experience going through the program, even with the circumstance with COVID and the shelter in place. And I would definitely recommend this to anybody who qualifies in using the doulas.”
      For these participants, the knowledge, resources, and social support doulas shared positively impacted their overall experience with the doula care they received, even when in-person services were not available.

      Discussion

      While research suggests that doula support is associated with lower risk of adverse birth outcomes, including preterm birth [
      • Gruber K.J.
      • Cupito S.H.
      • Dobson C.F.
      Impact of Doulas on healthy birth outcomes.
      ,
      • Kozhimannil K.B.
      • Hardeman R.R.
      • Alarid-Escudero F.
      • Vogelsang C.
      • Blauer-Peterson C.
      • Howell E.A.
      Modeling the cost effectiveness of doula care associated with reductions in preterm birth and cesarean delivery.
      ,
      • Thomas M.-P.
      • Ammann G.
      • Brazier E.
      • Noyes P.
      • Maybank A.
      Doula services within a healthy start program: increasing access for an underserved population.
      ,
      • Kozhimannil K.B.
      • Johnson P.J.
      • Attanasio L.B.
      • Gjerdingen D.K.
      • McGovern P.M.
      Use of non-medical methods of labor induction and pain management among U.S. women.
      ], less is known about how doulas impact women’s experiences during pregnancy and birth. Our analysis found that community doula care benefitted participants’ experiences by creating comfortable spaces in which participants felt understood, supported, and emotionally prepared during their pregnancies and births. This is notable, given that Black women often report receiving poor treatment and a general lack of support from medical providers in healthcare settings, including loss of decision-making power and being shouted at and ignored [
      • Vedam S.
      • Stoll K.
      • Taiwo T.K.
      • et al.
      The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.
      ,

      C. Sakala, E.R. Declercq, J.M. Turon, M.P. Corry, Listening to Mothers in California: A Population-Based Survey of Women’s Childbearing Experiences, Full Survey Report. Washington, D.C.: National Partnership for Women & Families, 2018.

      ]. Importantly, the relationships and trust participants built with their community doulas upon a foundation of shared cultural and community knowledge enabled these comfortable spaces; these reports of positive relationships and trust are in line with the current literature on doula care [
      • McLeish J.
      • Redshaw M.
      'Being the best person that they can be and the best mum’: a qualitative study of community volunteer doula support for disadvantaged mothers before and after birth in England.
      ,
      • Wint K.
      • Elias T.I.
      • Mendez G.
      • Mendez D.D.
      • Gary-Webb T.L.
      Experiences of community doulas working with low-income, African American mothers.
      ]. While we did not directly examine participants’ partners’ experiences with community doula care, we found evidence that doulas may also benefit the non-birthing partner’s experiences. Future research should examine how doulas interact with and support their clients’ partners and families.
      Among our sample, motivations for seeking doula care largely stemmed from a general lack of support in participants’ lives. Importantly, participants described needing emotional, person-centered support due to their knowledge of maternal and infant health disparities affecting Black women and their babies. This knowledge added to participants’ level of anxiety and stress, factors shown to be associated with preterm birth and other adverse birth outcomes [
      • Dole N.
      • Savitz D.A.
      • Hertz-Picciotto I.
      • Siega-Riz A.M.
      • McMahon M.J.
      • Buekens P.
      Maternal stress and preterm birth.
      ,
      • Lilliecreutz C.
      • Larén J.
      • Sydsjö G.
      • Josefsson A.
      Effect of maternal stress during pregnancy on the risk for preterm birth.
      ]. In our study, community doulas decreased participants' feelings of stress by providing them with important education and advocating for them in the hospital setting, allowing participants to relax and focus on the birthing process. Indeed, no participants in our study described their overall birth experiences as negative, despite some participants experiencing birth complications and birthing in restrictive environments due to the COVID-19 pandemic; importantly, the lack of negative birth experiences in our sample may be due to the doula care participants received. Notably, a systematic review of the literature suggests that people receiving continuous labor support, like that provided by doulas, are less likely to report negative birth experiences [
      • Bohren M.
      • Hofmeyr G.
      • Sakala C.
      • Fukuzawa R.
      • Cuthbert A.
      Continuous support for women during childbirth.
      ]. While we did not explicitly set out to examine mistreatment of Black women in hospital settings, the experience of mistreatment by one participant, and the response from their doula, warrant further exploration of how doulas may actively combat mistreatment in hospitals through their work.
      Our analysis suggests increasing access to racially and culturally concordant community doula care may improve birthing experiences for Black, Indigenous, and other people of color, particularly Black women. One potential avenue for increasing access is through Medicaid coverage of doula care. Several states currently offer, have recently passed legislation, or budgeted for coverage of full-spectrum doula care services [

      A. Chen, Doula Medicaid Project. National Health Law Program. 〈https://healthlaw.org/doulamedicaidproject/〉. (Accessed Nov 2, 2021).

      ,

      A. Chen, A. Robles-Fradet, H. Arega, Building a Successful Program for Medi-Cal Coverage for Doula Care: Findings from a Survey of Doulas in California. National Health Law Program, 2020 〈https://healthlaw.org/resource/doulareport/〉.

      ]. While these policies will increase access to vital doula services for women and birthing people of color, additional work is needed to ensure equitable access to and support for the doula workforce [

      A. Bey, A. Brill, C. Porchia-Albert, M. Gradilla, N. Strauss, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019.

      ,

      Every Mother Counts. NY Medicaid Reimbursement of Doula Care: Honoring a Community-Based Approach. Every Mother Counts (EMC) | Improving Maternal Health, 2019; published online March 27. 〈https://everymothercounts.org/on-the-front-lines/ny-medicaid-reimbursement-of-doula-care-honoring-a-community-based-approach/〉 (accessed Nov 2, 2021).

      ]. Increasing structural support for people of color who wish to become community doulas is crucial to increasing access to doula services, including financial support for attending doula trainings and sustainable employment models for community doulas to fully devote themselves to birth work. Various organizations are examining how to provide sustainable employment for community doulas and can offer lessons learned for other organizations seeking to do this work [

      A. Bey, A. Brill, C. Porchia-Albert, M. Gradilla, N. Strauss, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019.

      ,
      • Gomez Anu Manchikanti
      • Arteaga Stephanie
      • Marshall Cassondra
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Jackson Andrea
      SisterWebSan Francisco Community Doula Network: Process Evaluation Report.
      ]. However, these programs need funding to cover not only paying doulas, but the administrative costs involved with running an organization [
      • Gomez Anu Manchikanti
      • Arteaga Stephanie
      • Marshall Cassondra
      • Arcara Jennet
      • Cuentos Alli
      • Armstead Marna
      • Jackson Andrea
      SisterWebSan Francisco Community Doula Network: Process Evaluation Report.
      ]. Funders should invest in community doula programs to improve maternal care for those most impacted by health disparities. While increasing funding to pay for community doula care is an important step in increasing access to these critical services, it is imperative to also consider hospital policies and practices, given that 98.4% of U.S. births occur in the hospital setting [
      • MacDorman M.
      • Declercq E.
      Trends and state variations in out-of-hospital births in the United States, 2004-2017.
      ]. Specifically, implementation of implicit bias trainings for healthcare providers, targeted quality measures in hospitals, and educating hospital staff on the benefits of doula care may incentivize healthcare providers to provide respectful, patient-centered care and welcome community doulas into the hospital space [
      • Wint K.
      • Elias T.I.
      • Mendez G.
      • Mendez D.D.
      • Gary-Webb T.L.
      Experiences of community doulas working with low-income, African American mothers.
      ,

      A. Higgins, D.G. Safran, N. Fiore, E. Murphy, M.B. McClellan, Pathway To Patient-Centered Measurement For Accountability | Health Affairs Blog, 2019; published online Sept 12. 〈https://www.healthaffairs.org/do/10.1377/hblog20190910.733376/full/〉 (accessed Nov 2, 2021).

      ,
      • Cooper L.A.
      • Roter D.L.
      • Carson K.A.
      • et al.
      The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.
      ,
      • Neel K.
      • Goldman R.
      • Marte D.
      • Bello G.
      • Nothnagle M.B.
      Hospital-based maternity care practitioners’ perceptions of doulas.
      ].
      Our study is one of few to qualitatively examine Black women’s experiences receiving community doula care. Strengths of the study include our study design developed in partnership with community doulas. Furthermore, longitudinal data collection in both the prenatal and postpartum periods allowed us to examine participants’ experiences with their doulas for the entire duration of their care, providing richer data on the benefits provided by, and the role of, community doulas. Limitations of the study include the specific geographical context, which may have contributed to increased structural instability and need for support among our sample, sampling from a single community doula program, and lack of information about relationship status. Further, we have no information on SisterWeb clients who chose not to participate in the study and who may have had different pregnancy and birth experiences.

      Conclusion

      This study contributes important findings about Black women’s motivations for and experiences with community doula care. Our analysis confirms a need for community doula care among Black women and found that community doula care positively impacted clients' pregnancy and birth experiences. These findings should be used to advocate for equitable access to community doula care via policy and hospital practices, as community doula care is a promising intervention to improve the pregnancy and birth experiences of Black women and birthing people, as well as other birthing people of color.

      Ethical Statement

      This study was conducted according to the guidelines of the Declaration of Helsinki and approved by The Committee for the Protection of Human Subjects at the University of California, Berkeley (protocol 2019–02–11792, date of approval 13 May 2019).

      Funding

      This research was supported by the UCSF California Preterm Birth Initiative (PTBi-CA), funded by Marc and Lynne Benioff. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official view of PTBi-CA.

      Author Contributions

      SA contributed to the conception or design of the work, data analysis and interpretation, and drafting and critical revision of the manuscript. EH contributed to data analysis and interpretation and drafting and critical revision of the manuscript. JA contributed to the conception or design of the work, data analysis and interpretation, and critical revision of the manuscript. AC contributed to the conception or design of the work, data analysis and interpretation, and drafting and critical revision of the manuscript. MA contributed to the conception or design of the work, data analysis and interpretation, and critical revision of the manuscript. AJ contributed to the conception or design of the work, data analysis and interpretation, and critical revision of the manuscript. AMG contributed to the conception or design of the work, data analysis and interpretation, and critical revision of the manuscript. CM contributed to the conception or design of the work, data collection, data analysis and interpretation, and critical revision of the manuscript.

      Conflict of Interest

      The authors do not have conflicts of interest to report.

      Acknowledgements

      The authors acknowledge Monica De La Cruz, Cristina Gomez-Vidal, Candice Moses, Camille Stanton, and Dougie Zubizarreta for their contributions to data collection and analysis.

      References

      1. N. Martin, R. Montagne, U.S. has the Worst Rate of Maternal Deaths in the Developed World. NPR. 2017; published online May 12. 〈https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world〉. (Accessed Oct 20, 2021).

        • Tikkanen R.
        • Gunja M.Z.
        • Fitzgerald M.
        • Zephyrin L.
        Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.
        The Commonwealth Fund, 2020 (accessed Feb 1, 2021)
        • Creanga A.A.
        • Syverson C.
        • Seed K.
        • Callaghan W.M.
        Pregnancy-related mortality in the United States, 2011-2013.
        Obstet. Gynecol. 2017; 130: 366-373
        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • et al.
        Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 States, 2013-2017.
        MMWR Morb. Mortal. Wkly. Rep. 2019; 68: 423-429
        • Martin J.A.
        • Hamilton B.E.
        • Osterman M.J.K.
        • Driscoll A.K.
        Births: final data for 2019.
        Natl. Vital Stat. Rep. 2021; 70: 1-51
        • Vedam S.
        • Stoll K.
        • Taiwo T.K.
        • et al.
        The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.
        Reprod. Health. 2019; 16: 77
      2. C. Sakala, E.R. Declercq, J.M. Turon, M.P. Corry, Listening to Mothers in California: A Population-Based Survey of Women’s Childbearing Experiences, Full Survey Report. Washington, D.C.: National Partnership for Women & Families, 2018.

      3. Black Maternal Health Momnibus. Black Maternal Health Caucus. 2020; published online March 7. 〈https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus〉. (Accessed April 4, 2021).

      4. A. Bey, A. Brill, C. Porchia-Albert, M. Gradilla, N. Strauss, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019.

        • Gruber K.J.
        • Cupito S.H.
        • Dobson C.F.
        Impact of Doulas on healthy birth outcomes.
        J. Perinat. Educ. 2013; 22: 49-58
        • Kozhimannil K.B.
        • Attanasio L.B.
        • Hardeman R.R.
        • O’Brien M.
        Doula care supports near-universal breastfeeding initiation among diverse, low-income women.
        J. Midwifery Women’s Health. 2013; 58: 378-382
        • Kozhimannil K.B.
        • Hardeman R.R.
        • Alarid-Escudero F.
        • Vogelsang C.
        • Blauer-Peterson C.
        • Howell E.A.
        Modeling the cost effectiveness of doula care associated with reductions in preterm birth and cesarean delivery.
        Birth. 2016; 43: 20-27
        • Paterno M.T.
        • Van Zandt S.E.
        • Murphy J.
        • Jordan E.T.
        Evaluation of a student-nurse doula program: an analysis of doula interventions and their impact on labor analgesia and cesarean birth.
        J. Midwifery Women’s Health. 2012; 57: 28-34
        • Thomas M.-P.
        • Ammann G.
        • Brazier E.
        • Noyes P.
        • Maybank A.
        Doula services within a healthy start program: increasing access for an underserved population.
        Matern Child Health J. 2017; 21: 59-64
        • Bohren M.
        • Hofmeyr G.
        • Sakala C.
        • Fukuzawa R.
        • Cuthbert A.
        Continuous support for women during childbirth.
        Cochrane Database Syst. Rev. 2017; https://doi.org/10.1002/14651858.CD003766.pub6
        • Deitrick L.
        • Draves P.
        Attitudes towards Doula support during pregnancy by clients, Doulas, and labor-and-delivery nurses: a case study from Tampa, Florida.
        Hum. Organ. 2008; 67: 397-406
      5. H. Holland, Relational spaces in maternal healthcare: a qualitative study of young mothers’ experiences with community-based doula care, 2009.

        • Hunter C.
        Intimate space within institutionalized birth: women’s experiences birthing with doulas.
        Anthr. Med. 2012; 19: 315-326
        • Koumouitzes-Douvia J.
        • Carr C.A.
        Women’s perceptions of their Doula support.
        J. Perinat. Educ. 2006; 15: 34-40
        • Lanning R.K.
        • Oermann M.H.
        • Waldrop J.
        • Brown L.G.
        • Thompson J.A.
        Doulas in the operating room: an innovative approach to supporting skin-to-skin care during cesarean birth.
        J. Midwifery Women’s Health. 2019; 64: 112-117
        • McLeish J.
        • Redshaw M.
        'Being the best person that they can be and the best mum’: a qualitative study of community volunteer doula support for disadvantaged mothers before and after birth in England.
        BMC Pregnancy Childbirth. 2019; 19: 21
        • Simon R.M.
        • Johnson K.M.
        • Liddell J.
        Amount, source, and quality of support as predictors of women’s birth evaluations.
        Birth. 2016; 43: 226-232
        • Henley M.M.
        “The goddess of the room”: birth as a feminist issue among doulas and mothers.
        Women’s Stud. Int. Forum. 2020; 82102393
        • Lantz P.M.
        • Low L.K.
        • Varkey S.
        • Watson R.L.
        Doulas as childbirth paraprofessionals: results from a national survey.
        Women’s Health Issues. 2005; 15: 109-116
      6. M. Main, Beyond the Beast: Culturally Competent Doulas as a Breastfeeding Intervention. Northwest Bulletin. 2017; published online June. 〈https://depts.washington.edu/nwbfch/archives/beyond-breast-culturally-competent-doulas-breastfeeding-intervention〉. (Accessed Sept 1, 2021).

        • Gomez Anu Manchikanti
        • Arteaga Stephanie
        • Marshall Cassondra
        • Arcara Jennet
        • Cuentos Alli
        • Armstead Marna
        • Jackson Andrea
        SisterWebSan Francisco Community Doula Network: Process Evaluation Report.
        SexualHealth and Reproductive Equity Program. University of California, Berkeley2020
        • Marshall Cassondra
        • Arteaga Stephanie
        • Arcara Jennet
        • Cuentos Alli
        • Armstead Marna
        • Jackson Andrea
        • Gomez Anu Manchikanti
        Barriers and Facilitators to the Implementation of a Community Doula Program for Black and Pacific Islander Pregnant People in San Francisco: Findings from a Partnered Process Evaluation.
        Maternal and Child Health Journal. 2022; 26: 872-881
        • Gomez Anu Manchikanti
        • Arteaga Stephanie
        • Arcara Jennet
        • Cuentos Alli
        • Armstead Marna
        • Mehra Renee
        • Logan Rachel G
        • Jackson Andrea
        • Marshall Cassondra
        “My 9 to 5 Job Is Birth Work”: A Case Study of Two Compensation Approaches for Community Doula Care.
        International Journal of Environmental Research and Public Health. 2021; 18: 10817
        • SisterWeb San Francisco Community Doula Network
        Programs.
        • Tong A.
        • Sainsbury P.
        • Craig J.
        Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.
        Int. J. Qual. Health Care. 2007; 19: 349-357
        • Hennink M.
        • Kaiser B.N.
        Sample sizes for saturation in qualitative research: a systematic review of empirical tests.
        Soc. Sci. Med. 2022; 292114523
      7. A.B. Hamilton, Qualitative methods in rapid turn-around health services research. 2013; published online Dec 11. 〈https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/780-notes.pdf〉. (Accessed June 23, 2021).

        • Braun V.
        • Clarke V.
        Thematic Analysis: A Practical Guide.
        SAGE Publications, 2021
      8. SocioCultural Research Consultants, Dedoose, web application for managing, analyzing, and presenting qualitative and mixed method research data, 2022. 〈https://www.dedoose.com/〉.

        • Kozhimannil K.B.
        • Johnson P.J.
        • Attanasio L.B.
        • Gjerdingen D.K.
        • McGovern P.M.
        Use of non-medical methods of labor induction and pain management among U.S. women.
        Birth. 2013; : 40https://doi.org/10.1111/birt.12064
        • Wint K.
        • Elias T.I.
        • Mendez G.
        • Mendez D.D.
        • Gary-Webb T.L.
        Experiences of community doulas working with low-income, African American mothers.
        Health Equity. 2019; 3: 109-116
        • Dole N.
        • Savitz D.A.
        • Hertz-Picciotto I.
        • Siega-Riz A.M.
        • McMahon M.J.
        • Buekens P.
        Maternal stress and preterm birth.
        Am. J. Epidemiol. 2003; 157: 14-24
        • Lilliecreutz C.
        • Larén J.
        • Sydsjö G.
        • Josefsson A.
        Effect of maternal stress during pregnancy on the risk for preterm birth.
        BMC Pregnancy Childbirth. 2016; 16: 5
      9. A. Chen, Doula Medicaid Project. National Health Law Program. 〈https://healthlaw.org/doulamedicaidproject/〉. (Accessed Nov 2, 2021).

      10. A. Chen, A. Robles-Fradet, H. Arega, Building a Successful Program for Medi-Cal Coverage for Doula Care: Findings from a Survey of Doulas in California. National Health Law Program, 2020 〈https://healthlaw.org/resource/doulareport/〉.

      11. Every Mother Counts. NY Medicaid Reimbursement of Doula Care: Honoring a Community-Based Approach. Every Mother Counts (EMC) | Improving Maternal Health, 2019; published online March 27. 〈https://everymothercounts.org/on-the-front-lines/ny-medicaid-reimbursement-of-doula-care-honoring-a-community-based-approach/〉 (accessed Nov 2, 2021).

        • MacDorman M.
        • Declercq E.
        Trends and state variations in out-of-hospital births in the United States, 2004-2017.
        Birth. 2019; 46: 279-288
      12. A. Higgins, D.G. Safran, N. Fiore, E. Murphy, M.B. McClellan, Pathway To Patient-Centered Measurement For Accountability | Health Affairs Blog, 2019; published online Sept 12. 〈https://www.healthaffairs.org/do/10.1377/hblog20190910.733376/full/〉 (accessed Nov 2, 2021).

        • Cooper L.A.
        • Roter D.L.
        • Carson K.A.
        • et al.
        The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.
        Am. J. Public Health. 2012; 102: 979-987
        • Neel K.
        • Goldman R.
        • Marte D.
        • Bello G.
        • Nothnagle M.B.
        Hospital-based maternity care practitioners’ perceptions of doulas.
        Birth. 2019; 46: 355-361