Measuring Equity in Doula Programs: What Outcomes Should Organizations Track?

By Birth & Baby University · Last updated: October 2026 · 7 min read

An organization that starts a doula program, or funds one, eventually has to answer a plain question: how will we know whether it is working, and working for whom? The answer is harder than counting births. Outcomes like cesarean rates depend on many people besides the doula, the best-known experience measures were not designed for every community, and a program can look successful on average while leaving some families behind. This article walks through what the research suggests organizations might track, how to read the numbers fairly, and where the evidence for any single measure is still weak.

Key takeaways

Quick answer: track who is reached, what support is delivered, how families experience it, a small set of outcomes that the research links with doula support, and how doulas themselves fare, and break each down by race, ethnicity, language and insurance. Use clinical outcomes carefully, because they are influenced by many factors and most studies of them carry a high risk of bias.

• Two recent reviews associate doula support most consistently with birth experience, postpartum visit attendance, anxiety and breastfeeding initiation, while evidence on cesarean delivery and some other outcomes is more variable.
• Few experience measures are well validated. A systematic review of 25 maternity patient-reported experience measures, in 45 language versions, found only one version earned the top recommendation for real-world use.
• Few measures were developed for or validated with racially, ethnically, culturally and linguistically diverse women, which matters for an equity program.
• Program data without a comparison group can describe delivery and participation, but cannot show that a program caused an outcome.

Start with who is reached

Equity questions begin before any outcome. Who was eligible, who was offered a doula, who enrolled, and who received support through labor and postpartum? An evaluation of a community-based doula program in Washington State (Riley and colleagues, 2025) reported program data on more than 1,800 families, most of whom identified as Asian, Black, Indigenous, Latina or multiracial, along with visit counts and hours. That kind of reach and dose information is a reasonable baseline measure. It does not show effect, and the evaluation had no comparison group.

Tracking the same reach measures by race and ethnicity, preferred language, insurance type, and geography lets an organization see whether a program is reaching the families it intended to. It also shows where people drop out, such as between referral and first visit.

Outcomes with the strongest research link

Viswanathan and colleagues (2026) reviewed U.S. studies and found moderate-certainty evidence that doula support is likely associated with lower rates of preterm birth and cesarean delivery, improved birth experiences and increased postpartum visit attendance. Associations with other outcomes, such as prenatal mood, breastfeeding initiation and respectful care, were of low certainty. Most included studies had moderate or high risk of bias, and the authors reported insufficient information on how the type or intensity of support matters.

Groves and colleagues (2026) reviewed clinical and pilot trials and found the most consistent findings for maternal anxiety, postpartum follow-up and breastfeeding initiation, with more variable results for cesarean delivery and pain management. They also noted limited reporting of how interventions were delivered and failure to account for crossover in control groups.

Together, these point to a short list of candidate measures that match what the studies examined: postpartum visit attendance, breastfeeding initiation, anxiety or mood screening results (where screening is part of the program), and the family’s own rating of the birth experience. Clinical outcomes like preterm birth and cesarean delivery can be tracked, but they are shaped by many factors outside a doula’s control, so they are poor measures of an individual doula’s performance. An observational Medicaid claims study across three states (Falconi and colleagues, 2022) found lower odds of cesarean delivery and of postpartum depression or anxiety among 298 matched pairs, but it was retrospective, and the authors disclosed that the research was completed as part of employment at a health insurer. Single-source retrospective findings like this are a reason for caution, not a benchmark.

Measuring experience, and the measurement problem

Birth experience is one of the outcomes with moderate-certainty evidence in the Viswanathan review, and it is central to equity. But the tools are imperfect. Bull and colleagues (2023) appraised 25 maternity patient-reported experience measures, grouped into 45 language versions. The quality of the evidence behind their development was generally poor, only 2 versions (4.4 percent) reported sufficient content validity, and only 1 (2.2 percent) received the level “A” recommendation required for real-world use.

For equity, the gap is wider. A 2026 scoping review (Weerasingha and colleagues, 2026) found 25 maternity-specific and four generic measures across 55 studies. Only three were developed specifically for racially, ethnically, culturally and linguistically diverse women, and six were psychometrically validated with them. Measures were mostly administered in English, with inconsistent cultural adaptation, and these women’s involvement in developing the tools was limited. Communication, respect, autonomy and safe, supportive care were commonly covered, while culturally specific dimensions were less often captured.

The Annals of Internal Medicine review of respectful maternity care (Cantor and colleagues, 2024) found 12 validated tools, no gold standard, and no single tool that stands out as best. In practice this means an organization should say which tool it used and why, test whether families understand the questions in their own language, and not treat a single score as a verdict.

What this means for programs and for doulas

• Choose a small set. Reach, dose of support, family experience, a few outcomes linked in the research, and doula retention and satisfaction are enough to start. The Washington evaluation’s findings about burnout and doula support suggest including the workforce.
• Break every measure down. Report by race and ethnicity, language, insurance and location, and look for differences before drawing conclusions about the average.
• Do not rank individual doulas by clinical outcomes. Cesarean rates and similar results depend on clinicians, hospital policy and clients’ health, and holding a doula accountable for them risks pressure to overstep scope.
• Involve families and doulas in choosing measures. The review of experience measures calls for participatory development with the communities being measured.
• Protect privacy. Collect only what you need, store it securely, and report small groups with care so that no family can be identified.

Putting it into practice

1. Write down the program’s purpose in one sentence, then list the three to five measures that would tell you whether that purpose is being met.
2. For each measure, say who collects it, when, and how the data are stored and shared.
3. Offer experience surveys in the languages your families use, and test them with a few families first.
4. Review the results by group twice a year, and write down what you will change if a group has worse participation or experience.
5. Pair numbers with listening: short conversations or focus groups with families and doulas often explain what the numbers cannot. Our article on pricing doula services sustainably is a reminder that sustainable pay is part of keeping a doula workforce in place.

Limits and uncertainty

This article draws on systematic reviews, a scoping review, a program evaluation and one observational study. No source identifies a validated, agreed core set of equity measures for doula programs, so the suggestions above are a reasoned shortlist built from what studies measured, not an established standard. Findings may differ across states, payers and populations, and measurement tools continue to change.

The bottom line

An equity-minded doula program tracks who it reaches, what it delivers, how families experience it and how its doulas fare, and looks at every number by group. Clinical outcomes have a place, but they are weak measures of any one doula and carry a high risk of bias in the studies that report them. The honest message to funders is that measurement tools are still developing, and the priority is to measure fairly, with families at the table.

Birth & Baby University’s For Doulas page outlines its online, self-paced birth and postpartum doula training, recertification and mentorship, which can support doulas and program leaders building their skills.

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

Sources and further reading

• Riley T, Buchanan ZV, Perera D, et al. Evaluating the implementation and outcomes of a community-based doula program in Washington State: a mixed-methods analysis. Perspectives on Sexual and Reproductive Health (2025). Read the source
• Viswanathan M, Middleton JC, Sathe NA, et al. Doula support during pregnancy, childbirth, and postpartum: a systematic review and meta-analysis. Obstetrics & Gynecology (2026). Read the source
• Groves P, Williams H, Salter CL, et al. Doula care and health outcomes: a systematic review. JAMA Network Open (2026). Read the source
• Falconi AM, Bromfield SG, Tang T, et al. Doula care across the maternity care continuum and impact on maternal health: evaluation of doula programs across three states using propensity score matching. eClinicalMedicine (2022). Read the source
• Bull C, Carrandi A, Slavin V, Teede H, Callander EJ. Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review. American Journal of Obstetrics & Gynecology MFM (2023). Read the source
• Weerasingha TK, Slavin V, Seib C, et al. Patient-reported experience measures (PREMs) in maternity care for racially, ethnically, culturally and linguistically diverse women: a scoping review. Midwifery (2026). Read the source
• Cantor AG, Jungbauer RM, Skelly AC, et al. Respectful maternity care: a systematic review. Annals of Internal Medicine (2024). Read the source

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