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Commentary: Systemic Racism in Maternal Health Care

Centering Doula Advocacy for Women of Color During COVID-19

Salinas, Juan PhD; Salinas, Manisha DrPH

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doi: 10.1097/FCH.0000000000000293
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Systemic racism in the US health care industry has shaped unequal birthing experiences for women of color in the United States.1 Black and Latinx women especially have historically faced racial oppression in maternal health care settings, where they are often overlooked by traditionally white male health care professionals.1,2 The consequence of these conditions results in Black women being 2 to 3 times more likely to die of pregnancy-related causes than white women.2 Furthermore, women of color face higher rates of induction, cesarean births, interventions, and prenatal issues than white women.3 These oppressive conditions should not be tolerated in US society, and they are not adequately addressed by the traditional medical model focused on meeting the individual needs of only those who can afford premium health care. The health care industry would benefit from having more diverse voices to challenge the conditions of systemic racism, to address the crisis of unequal maternal health care outcomes, and to improve the lives of communities of color and their children. The health care industry must be receptive to change and become in tune with the maternal health care needs of women of color. This involves acknowledging the extent of structural racism within health institutions, along with respecting the survival strategies that challenge racism by centering the experiences and perspectives of women of color through birth support doula advocacy.


A strategy to challenge the conditions of systemic racism in health care settings is to promote birth support doula advocacy toward women of color. Studies have demonstrated that doulas help mitigate the poor birthing outcomes tied to the long-established forms of systemic racism in maternal health care settings.3,4 Often coming from their own communities, doulas can bring a supportive and anti-racist health approach in the interests of women of color. For instance, research has found that mothers who use doulas have lowered rates of cesarean births, less birth complications, less likely to have low birth weight, decreased maternal distress, and appropriately mediated communication with providers among people of color and those who experience cultural or linguistic barriers.5,6

The health care industry must recognize the importance of doula work to address the extent of racism embedded in health institutions. Currently, a range of hospital policies limit the support doulas can give toward women in maternal health care settings, and research shows tension exists in the dynamics of the birthing process between the role fulfilled by doulas and the traditional health care system.7 Removing these barriers is a necessary step needed to embrace the support doulas provide for their birthing clients toward better maternal health outcomes. There are social, institutional, and informal biases against accepting doula work as medically necessary because it falls outside the frames of the medical model in which the US health care system is based. Although doulas are an important part of ensuring safe birthing, they are often not covered by health insurance and not allowed in full capacity to interact in certain hospital and clinical settings. They are treated as visitors and not respected for their commitment to the birthing process and meeting the physical, social, and emotional needs of the birthing person.7,8 If health care settings want to seriously address racism in these settings, partnerships with community-based doula networks are a necessary step to dismantle the embedded forms of racism in maternal health care.

There are major challenges to addressing these racial inequities through the work of doulas due to the highly stigmatized role they experience in medical settings. Health care professionals often see doulas as a low-status form of employment, outside of official accreditation and medical-centered knowledge, resulting in many doulas working as consultants or with small businesses and facing an ongoing struggle to be seen as legitimate in health care settings.4,5 However, incorporating doulas into maternal health care is overwhelmingly beneficial, as they often share common cultural, social, and economic characteristics and connections with their birthing clients. This gives them significant advantages in relating to, and developing rapport with, birth clients from their same cultural and racial background, particularly when this may be lacking from medical staff in various hospital settings. In addition, health insurance companies largely do not cover the costs of doula work, despite their commitment to women of color and the demonstrated evidence of doula participation improving birth outcomes. The health care industry must step up to acknowledge the real impact of doulas and to help pressure insurance partners in covering doulas in order to support women of color in having access to advocates that directly address racial inequalities in maternal health care settings.


The COVID-19 pandemic illuminates the social forces of systemic racism, where racial minorities are more likely to be concentrated in the essential workforce and have more exposure to the coronavirus. Doulas are often juggling multiple forms of employment to make ends meet and are further disrupted by the limitations of COVID-19 in maternal health care settings. Doulas are navigating an uncharted territory and face precarious conditions in their advocacy toward birthing clients who are now difficult to reach in person. There is a need to explore these new challenges to doula work, how to maintain current clients, how to best perform doula work during birthing preparation, labor, and postbirth support under unprecedented and turbulent circumstances. As doulas and their birthing clients adjust to the realities of the pandemic, they become the experts on how to realistically continue supporting their birthing clients to alleviate racial inequalities in maternal health care.

There is not yet a consensus on best practices for birthing support during COVID-19. Hospitals' rapidly changing restrictions for face-to-face contact during labor and postpartum care lean more toward barring more than 1 person present during birth, forcing individuals to face the difficult decision to choose between a loved one or a trained doula for labor and birth support. Without a trusted advocate, minority women are left extremely vulnerable in a crucial turning point in their lives, leaving them susceptible to further exposure to the existing systemic racism and discrimination faced in medical care.


The health care industry must come to terms with the extent of systemic racism in order to fully embrace the doula model toward improving maternal health care outcomes for women of color. There is room for both health care professional medical knowledge and anti-racist doula support birth justice through dynamic partnerships between the health care industry and the doula advocacy model. This can be achieved by collaboratively involving doulas within the health of communities of color, along with local hospitals and allies, to develop strategies to improve the effectiveness and quality of maternal health care. These are long-standing, historical racial inequities the health care industry must now address and overcome to support the most vulnerable during the turbulent situation of COVID-19. Doulas are key community maternal health care workers who make a significant impact on these prevailing racial inequalities in maternal health care.


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