Can Doula Support Help Address Disparities in Maternal Health Outcomes?

By Birth & Baby University · Last updated: October 2026 · 9 min read

Doula care is often described as a way to narrow racial and economic gaps in maternal health. The hope is understandable, because the gaps are large and well documented. But the claim deserves careful handling. Doulas are non-clinical supporters, the causes of disparities are largely structural, and the research on doula support in populations facing the greatest risk is still limited. This article sets out the size of the problem, what the research on doula support does and does not show, and how doulas can contribute without overpromising.

Key takeaways

Quick answer: there is encouraging but incomplete evidence that doula support is associated with better experiences and some better outcomes, including among people at higher risk of disparities. There is not enough evidence to say doula support closes outcome gaps by itself. Reducing disparities requires changes in care systems, coverage and policy as well.

• The National Center for Health Statistics reported a 2024 maternal mortality rate of 44.8 deaths per 100,000 live births for non-Hispanic Black women, compared with 14.2 for White, 12.1 for Hispanic and 18.1 for Asian women, and 17.9 overall.
• Maternal Mortality Review Committees in 36 states judged 84.2 percent of pregnancy-related deaths in 2017 to 2019 (839 of 996 with a determination) to be preventable.
• A 2026 meta-analysis of U.S. studies found that among studies made up entirely of people at risk of disparities, four of five reported at least some benefit from doula support, with moderate to high risk of bias in most included studies.
• A randomized trial in Stockholm of bilingual community doula support for migrant women found no difference in care experience ratings or emotional well-being, a reminder that results depend on context and delivery.

What the research says

The size of the gap. NCHS Health E-Stat 113 (March 2026) reports 649 maternal deaths in 2024 (17.9 per 100,000 live births, not significantly different from 18.6 in 2023). For non-Hispanic Black women the rate was 44.8 (212 deaths), significantly higher than for each other group shown. The year-to-year changes were not statistically significant, so one year’s decline should not be read as a trend. The CDC’s analysis of review committee data from 36 states for 2017 to 2019 (CDC) found that 84.2 percent of pregnancy-related deaths were preventable, defined as at least some chance of the death being averted by reasonable changes to patient, community, provider, facility or system factors. It also found that over half of deaths occurred seven days to a year after pregnancy ended, and that leading causes varied by group, with cardiac and coronary conditions leading among Black women and mental health conditions leading among Hispanic and White women.

Two points follow. The causes are medical and systemic, so the response must be as well. And many of the deaths occur after the period in which doulas are most often involved, which is why continuity into the postpartum period matters.

What doula research shows. A 2026 systematic review and meta-analysis in Obstetrics & Gynecology (Viswanathan and colleagues, 2026) included 12 randomized trials and 18 nonrandomized studies from the United States. It concluded that doula support is likely associated with lower rates of preterm birth and cesarean delivery, improved birth experiences and increased postpartum visit attendance (moderate certainty), and may be associated with several other improvements (low certainty). Among studies composed entirely of people at risk of disparities arising from race, carceral settings, low income or public insurance, four of five reported at least some benefit. Only one study had low risk of bias, and the review found insufficient information on the effects of different types and intensity of doula support.

A 2026 systematic review of studies focused on Black women (Gray and colleagues, 2026; 16 studies, 10 of doula support) found doula support fostered positive care experiences and was associated with improvements in preterm birth, cesarean delivery, low birthweight and breastfeeding initiation. The authors stated that population-specific literature remains severely limited.

An analysis of the 2018 Listening to Mothers in California survey (Mallick and colleagues, 2022; 1,977 women) found higher odds of respectful care with doula support (odds ratio 1.4), larger for non-Hispanic Black women (2.7, 95% CI 1.1 to 6.7) and for Medicaid recipients (1.8), but not for women with private insurance. This was a cross-sectional survey, so the association may reflect who chooses or can obtain a doula as well as what doulas do. A modeling study of Medicaid-funded births in the Upper Midwest (Kozhimannil and colleagues, 2016) found lower preterm birth and cesarean rates among those supported by a community doula organization, with the usual limits of observational data.

Why the experience matters. A qualitative study of Black clients of a free community doula program in San Francisco (Arteaga and colleagues, 2023) found that motivations for seeking a doula included a general lack of support and knowledge of mistreatment of Black women in hospitals, and that doulas offered information about the perinatal period and rights, advocacy in hospitals and connection to resources beyond pregnancy and birth. These are accounts of experience, not outcome measures, and they point to a mechanism: doulas may shape how care is experienced and navigated.

Where the evidence is mixed

• A null trial. The Stockholm randomized trial (Schytt and colleagues, 2022; 164 migrant women) found no difference in ratings of intrapartum care or in emotional well-being at 6 to 8 weeks, and only 73.2 percent of women assigned to doula support received it during labor.
• Inconsistent outcomes. A 2026 systematic review of clinical and pilot trials in JAMA Network Open (Groves and colleagues, 2026) found the most consistent benefits for anxiety, postpartum follow-up and breastfeeding initiation, with variable results for cesarean delivery and pain, and it noted underrepresentation of marginalized populations and poor reporting of how interventions were delivered.
• Low-quality trial evidence overall. The Cochrane review of continuous labor support (Bohren and colleagues, 2017) rated much of its evidence as low quality, and reported that it could draw no conclusions about low-income countries.
• Doulas are not a substitute for clinical change. The federal ASPE evidence review (December 2022) says doula coverage is one option for improving the maternity care experience and that improving access to doula services would not single-handedly address the need to improve access to clinical care.

What this means for doulas

• Speak accurately. “Research associates doula support with better experiences and some improved outcomes, and the evidence is still developing” is accurate. “Doulas end racial disparities” is not.
• Know that support is more than presence. Respectful care, information about rights, advocacy and connection to resources are the mechanisms most often described. Practice them deliberately and within scope.
• Take postpartum seriously. The review committee data show many deaths occur after birth. Helping clients attend postpartum visits and recognize urgent warning signs, such as those in the CDC’s Urgent Maternal Warning Signs, is a concrete contribution. Do not assess or diagnose.
• Address access. If clients cannot afford your services, learn about Medicaid enrollment in your state, sliding scales, community programs, and referral to community-based doulas who share clients’ language or background. The Stockholm trial suggests language alone is not sufficient, and delivery and fit matter.
• Do not outsource the problem to individual clients. Disparities involve bias, system design and access. Support clients in advocating for their care, and support efforts to improve the systems around them.
• Collect and share responsibly. If you take part in programs or research, protect client privacy and avoid collecting more than is needed.

Putting the evidence into practice

1. Write a two-sentence, accurate statement of what research shows about doula support, with limits, and use it consistently with clients, clinicians and funders.
2. Learn your region’s disparities from state maternal mortality review reports or health department data, and which community organizations work on them.
3. Build referral relationships with clinicians and community resources that serve the families you work with.
4. Prepare scripts for respectful ways to raise concerns with a care team on a client’s behalf, in line with your certifier’s advocacy standards.
5. Look at your own practice: whom you reach, whom you do not, and why.

Limits and uncertainty

Most of the evidence is from the United States, uses observational designs and is rated as having moderate or high risk of bias. Studies of doula care in specific populations are few, and the programs studied differ widely in training, intensity and setting. Mortality figures describe population groups and say nothing about the care any one client will receive. Reporting and categories of race and ethnicity have limits as well.

The bottom line

Doula support can be one useful part of a response to maternal health disparities, particularly for experiences of respect, information and connection to care, and the available evidence is encouraging but incomplete. Presenting it that way is both honest and more credible than a promise that doulas alone can close the gap.

Birth & Baby University’s For Doulas page describes its birth and postpartum doula training, recertification and mentorship for doulas. Confirm that any program meets your certifier’s, employer’s or state’s requirements before you enroll.

This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• National Center for Health Statistics. Maternal Mortality Rates in the United States, 2024, Health E-Stat 113 (March 2026). Read the source
• Centers for Disease Control and Prevention. Pregnancy-related deaths: data from Maternal Mortality Review Committees in 36 U.S. states, 2017 to 2019. Read the source
• Viswanathan M, et al. Doula support during pregnancy, childbirth, and postpartum: a systematic review and meta-analysis. Obstetrics & Gynecology (2026). Read the source
• Gray A, et al. Midwifery care and doula support for Black women in the United States: a systematic review of maternal, birth, and infant outcomes. Journal of Racial and Ethnic Health Disparities (2026). Read the source
• Mallick LM, et al. The role of doulas in respectful care for communities of color and Medicaid recipients. Birth (2022). Read the source
• Schytt E, et al. Community-based bilingual doula support during labour and birth: a randomised controlled trial in Stockholm, Sweden. PLOS ONE (2022). Read the source
• Groves P, et al. Doula care and health outcomes: a systematic review. JAMA Network Open (2026). Read the source
• Bohren MA, et al. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews (2017). Read the source
• Kozhimannil KB, et al. Modeling the cost-effectiveness of doula care. Birth (2016). Read the source
• Arteaga S, et al. “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. Women and Birth (2023). Read the source
• Knocke K, et al. Doula Care and Maternal Health: An Evidence Review. ASPE Issue Brief (December 2022). Read the source
• Centers for Disease Control and Prevention. Urgent Maternal Warning Signs (Hear Her). Read the source

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