Maternity care in rural areas is in crisis. Can more doulas help?

When Bristeria Clark went into labor with her son in 2015, her contractions were steady at first. Then, they stalled. Her cervix stopped dilating.

After a few hours, doctors at Phoebe Putney Memorial Hospital in Albany, Ga., prepped Clark for an emergency cesarean section.

It wasn't the vaginal birth that Clark had hoped for during her pregnancy.

"I was freaking out. That was my first child. Like, of course you don't plan that," she said. "I just remember the gas pulling up to my face, and I ended up going to sleep."

She remembered feeling a rush of relief when she woke to see that her baby boy was healthy.

Clark, a 33-year-old nursing student who also works full time in county government, had another C-section when her second child was born in 2020. This time, the cesarean was planned.

Clark said she's grateful the physicians and nurses who delivered both of her babies were kind and caring during her labor and delivery. But looking back, she said she wishes she had had a doula for one-on-one support through pregnancy, childbirth and the postpartum period. Now she wants to give other women the option that she didn't have.

Clark is a member of Morehouse School of Medicine's first class of rural doulas, called perinatal patient navigators.

The program recently graduated a dozen participants, all Black women from southwest Georgia. They have completed more than five months of training and are scheduled to begin working with pregnant and postpartum patients this year.

"We're developing a workforce that's going to be providing the support that Black women and birthing people need," said Natalie Hernandez-Green, an associate professor of obstetrics and gynecology at Morehouse School of Medicine, while speaking at the doula commencement ceremony in Albany.

Albany is the second site for Morehouse School of Medicine's perinatal patient navigator program. The first site has been up and running in Atlanta since training began in the fall of 2022.

Georgia has one of the highest rates of maternal mortality in the U.S., according to an analysis by KFF, a health policy and research organization.

And Black Georgians are more than twice as likely as white Georgians to die of causes related to pregnancy.

"It doesn't matter whether you're rich or poor. Black women are dying at [an] alarming rate from pregnancy-related complications," said Hernandez-Green, who is also executive director of the Center for Maternal Health Equity at Morehouse School of Medicine. "And we're about to change that one person at a time."

Improved birth outcomes with doulas

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies also link doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals. They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the health care system and to provide emotional and physical support before, during and after childbirth.

Morehouse School of Medicine's program is among a growing number of similar efforts being introduced across the country as more communities look to doulas to help address maternal mortality and poor maternal health outcomes, particularly for Black women and other women of color.

Now that she has graduated, Clark said she's looking forward to helping other women in her community as a doula.

"To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect," Clark said. "The ultimate goal is to make them feel comfortable and let them know 'I'm here to support you.'" Her training has inspired her to become an advocate for maternal health issues in southwest Georgia.

Grants fund Morehouse School of Medicine's doula program, which costs $350,000 a year to operate. Tuition is free, and the graduates are given a $2,000 training stipend. The program also places five graduates with health care providers in southwest Georgia and pays for their salaries for one year.

"It's not sustainable if you're chasing the next grant to fund it," said Rachel Hardeman, a professor of health and racial equity at the University of Minnesota School of Public Health.

Doula coverage can save Medicaid millions of dollars

Thirteen states cover doulas through Medicaid, according to Georgetown University's Center for Children and Families.

Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in health care costs. "We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries," she said.

That's because doulas can help reduce the number of expensive medical interventions during and after birth, and improve delivery outcomes, including reduced cesarean sections.

Doulas can even reduce the likelihood of preterm birth.

"An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive," Hardeman said.

There is growing demand for doula services in Georgia, said Fowzio Jama, the director of research for Healthy Mothers, Healthy Babies Coalition of Georgia.

Her group recently completed a pilot study that offered doula services to about 170 Georgians covered under Medicaid. "We had a waitlist of over 200 clients, and we wanted to give them the support that they needed, but we just couldn't with the given resources that we had," Jama said.

Doula services can cost hundreds or thousands of dollars out of pocket, making it too expensive for many low-income people and in rural communities and communities of color, many of which suffer from shortages in maternity care, according to the March of Dimes.

The Healthy Mothers, Healthy Babies study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive effect on patients.

"There was a reduced use of Pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birth weight," Jama said.

Maternity deserts need more than doulas

Still, Jama and others acknowledge that doulas alone can't fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Hardeman said.

"I think it's important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool," she said. "They are a piece of the puzzle that is helping to impact a really, really complex issue."

In the meantime, graduate Joan Anderson, 55, said she's excited to get to work supporting patients, especially those from rural areas around Albany.

"I feel like I'm equipped to go out and be that voice, be that person that our community needs so bad," said Anderson, a graduate of Morehouse School of Medicine's doula program. "I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned."

She would love to open a birthing center someday to provide maternity care, Anderson said. “We do not have one here in southwest Georgia at all."

In addition to providing support during and after childbirth, Anderson and her fellow graduates are trained to assess their patients' needs and connect them to services such as food assistance, mental health care, transportation to prenatal appointments and breastfeeding assistance.

Their work is likely to have ripple effects across a largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs SOWEGA Rising, a nonprofit organization in southwest Georgia.

"So many of the graduates are part of church networks. They are part of community organizations. Some of them are our government workers. They're very connected," Byrd said.

"And I think that connectedness is what's going to help them be successful moving forward."

This reporting came out of a fellowship with the Association of Health Care Journalists, supported by the Commonwealth Fund. It was produced in partnership with NPR, WABE and KFF Health News.