Fall 2026
Putting Community Back in Birth
By Shelby Crosier
Illustration by Gianluca Foli, Photography by Theo Gayle and Erik Meadows
On This Page
How doulas connect pregnant people to needed support during birth, postpartum, and beyond
Putting Community Back in Birth
Loved ones close by to offer support. A comfortable room with low lights and minimal noise. Labor and delivery providers who listen to their patients’ needs and desires. The freedom to get up, move around, and change positions. These are things that many birthing people may request in their birth plans or verbalize to their providers. But on birthing day, these wants are often either dismissed, ignored, or unavailable.
Doulas and other community birth workers may be the key to enhancing the overall birthing experience—as well as improving maternal mortality rates—for people across the United States.
Birthing in America
What does it look like to give birth in the U.S.? In areas of the country that have adequate access to maternity care, it typically means delivering a child in a hospital’s labor and delivery unit, overseen by an OB-GYN, nurses, and maybe a midwife. This contrasts with countries like the United Kingdom or the Netherlands, where it is much more common for a midwife to attend a birth than a physician.
“The majority of births nationally are happening in hospitals, and that is the result of a very long process of the medicalization of birth. Even low-risk pregnancies are now happening in hospitals, and that's not the case in other countries,” says Elizabeth Mosley, PhD, a researcher affiliated with Emory University’s Center for Reproductive Health Research in the Southeast (RISE). She co-led the center’s Georgia Doula Study with Healthy Mothers, Healthy Babies Coalition of Georgia (HMHBGA) and is herself a practicing doula in Metro Atlanta.
Despite the norm of hospital births, many women find themselves living in areas with no access to birthing facilities or obstetric care providers. These areas are called maternity deserts. They exist in over one-third of U.S. counties, which are home to 2.4 million women and 149,000 babies. Women living in maternity care deserts have to drive, on average, three times longer to reach labor and delivery services than women living in counties with adequate access to care.
U.S. maternal deaths per 100,000 live births, the highest of any high-income country
higher maternal mortality rate faced by Black women
U.S. counties are maternity care deserts, home to 2.4 million women
And maternity care deserts are only one factor keeping people from having optimal pregnancy outcomes.
“Pregnancy is one moment in time when it is so critical for folks to receive the care and support that they need, but they have also lived a whole lifetime before that pregnancy,” says Mosley. “So many factors influence someone’s experience during pregnancy: stress from chronic poverty, racism and sexism in our society, or not having access to those basic human needs that would set someone up to be as healthy as possible during their pregnancy. Some of those needs include housing, employment, health insurance, and nutritional food.”
All these factors, often collectively known as social determinants of health, impact pregnancy outcomes, leading to poorer health for both birth parents and their babies. Given that the U.S. maternal mortality rate is 17.9 deaths per 100,000 live births (the highest of any hig hincome
country), and Black women face a maternal mortality rate three times as high, it is clear that pregnant and postpartum people—especially those experiencing racism—need more support.
“There is a lot of room for improvement in terms of expanding pregnancy, birth, and postpartum care options,” says Whitney Rice, DrPH, director of RISE. “For instance, many states, including Georgia, do not yet provide Medicaid reimbursement for doula services or require coverage of doula care in private insurance plans.”
Who Are Doulas?
Doulas are a vital resource for pregnant people during pregnancy, birth, and postpartum. They provide emotional and physical support before and during labor and can help connect their clients to services that address needs not directly related to birth, like helping them navigate signing up for SNAP, finding diaper assistance programs, and even assisting with breastfeeding or chestfeeding.
During labor in a hospital setting, doulas also play an important role in advocating for their client’s needs.
“In the Georgia Doula Study, doulas described their services as a sort of bridge between what the medical system provides and what birthing people want for their birth,” says Rice.
That can include facilitating communication between birthing people and providers, and validating and elevating their clients’ concerns to make sure they feel heard. This is a crucial component of person-centered care, which centers patients’ individual needs and values during health care interactions.
“Person-centered care is inherently important, because we all have the right to be treated with respect,” says Elizabeth Rhodes, PhD, assistant professor of global health at Rollins. “Person centered care is also vital because it can improve health care utilization and maternal health outcomes.”
Some of those outcomes include fewer depressive and post-traumatic stress symptoms at one and six months postpartum and a lower risk of maternal and newborn health complications. People who use doulas see similar health benefits. Doula care has been linked to fewer cesarean sections and premature births, shorter labor, less anxiety, and more successful breastfeeding.
Cultural Connection in Birth
Rofikah Karimullah (left), a community liaison and doula with Embrace Refugee Birth; Elizabeth Mosley, PhD (center); and Kelli Jackson (right), perinatal workforce initiatives manager for HMHBGA
Outside of just physical and emotional support, doulas can provide culturally and linguistically appropriate care for their clients during birth, another component of person-centered care.
“Cultural humility and rigor in particular are integral to greater patient-centeredness in birth and postpartum care,” says Rice. “Culturally appropriate and affirming care can be meaningful in the connection and communication between birth workers and birthing people. It can also be meaningful in the advocacy that community support people often provide on behalf of pregnant and postpartum people within medical and other systems.”
When culturally and linguistically appropriate care is not available, birthing people are less likely to use health care services, including prenatal care. Doulas and other community birth workers can serve as a vital link to such care, either through their own practices or connection to other resources.
In Atlanta, Embrace Refugee Birth embodies this philosophy. The program connects immigrant and refugee mothers with childbirth education and birth support services to help them navigate the complicated landscape of receiving maternity care in a new language and culture. Mosley has volunteered as a doula with Embrace since moving back to Georgia in 2018.
“Recently at Embrace, we have been pushing to get refugees and immigrants trained as doulas so that they are the ones offering labor support and childbirth education to women from the areas where they are from,” she says. “They were already doing this work, and we are just giving them some of the more formal training and tools so that they can be leaders in their community around birth support.”
“Knowing that I can help them access care, feel heard, and navigate the health care system with confidence has been one of the most rewarding experiences of my work.”
Rofikah Karimullah
Community Liaison and Doula, Embrace Refugee Birth
One such doula is Rofikah Karimullah, a member of the Rohingya community living in Metro Atlanta. She is a community liaison for Embrace, as well as a trained labor doula, community health worker, and certified medical interpreter.
“Supporting women from my community as a community liaison and doula has been deeply meaningful because it has allowed me to bridge language and cultural barriers during some of the most important moments of their lives,” she says. “Knowing that I can help them access care, feel heard, and navigate the health care system with confidence has been one of the most rewarding experiences of my work.”
Supporting Our Birth Workforce
Despite the vital services that doulas provide for birthing people, both in Georgia and nationally, they often do not receive the support that they need to continue working in the field long term. For doulas, according to Mosley, burnout rates are high. Much of that has to do with money.
“People are living week to week in terms of their paychecks, and a lot of what we end up doing as doulas is free,” she says. “In Georgia, there's no Medicaid coverage yet for doula care, and private insurance is not covering our services either, so for the most part, it is paid out of pocket. And so many of us want to serve people who cannot pay out of pocket.”
Currently, only 27 state Medicaid programs cover doula services. Two states require private insurance providers to cover doula care, with four more in the process of implementing a requirement. Mosley helps to lead a study with the University of Pittsburgh and Academy Health on Medicaid doula policies in six states and has documented the challenges doulas face with policy implementation and the harms that occur when no Medicaid doula policy is in place.
In Georgia, advocacy groups have pushed to get Medicaid coverage for doula services. HMHBGA ran a Medicaid reimbursement pilot program in 2023 and found that women in the program had better birth outcomes, and insurers found the program valuable. But, at time of publication, the state does not have a permanent policy in place.
“We care so deeply about our clients and their families, and then we carry their trauma with us.”
Elizabeth Mosley, PhD
Center for Reproductive Health Research in the Southeast
Burnout can also stem from a lack of mental health support.
“Doulas can witness a lot of trauma with things that can go wrong during birth or emergency C-sections,” says Mosley. “We care so deeply about our clients and their families, and then we carry their trauma with us. We need a place to fall back on where we can get that support that we need, someone to care for us and hold space for us to process what we have witnessed.”
Community organizations, doulas, and researchers in Georgia are working together to come up with solutions that better support doulas. For example, Rhodes is currently collaborating on a project led by the Georgia Community Doula Coalition to co-design strategies that promote doulas’ well-being.
Working with the Medical System
Adequate support can help doulas remain in the profession, passing on their birthing knowledge and improving maternal health outcomes for years to come. But that is only possible if doulas are also able to adequately work within labor and delivery teams in hospitals, something that
can be challenging.
“Perinatal health care professionals don't always understand the role of a doula, and the scope is not always clear,” says Mosley. “So, they don't understand what doulas do, which makes it hard to understand the value added of having a doula on the team. Doulas often say they feel like they're not part of the team and that they're seen as outsiders.”
But there is work being done to improve this perception. One example is the Doula Integration and Awareness Project, led by HMHBGA. The project trains medical providers on the role of doulas, builds partnerships with health care providers and hospitals, and works to integrate doulas and person-centered practice in maternity care teams. The American College of Obstetricians and Gynecologists also put out a statement in August 2026 with recommendations for how clinicians can partner with doulas.
“The successful models are there, and the data is already there. We do not need to continue proving that collaboration can work.”
Kelli Jackson
Perinatal Workforce Initiatives Manager, HMHBGA
“We are not trying to reinvent the wheel when it comes to doula integration,” says Kelli Jackson, perinatal workforce initiatives manager for HMHBGA. “We have seen successful models in states such as New York, North Carolina, and Arkansas, and even right here in Georgia through the Wellstar Health System. The successful models are there, and the data is already there. We do not need to continue proving that collaboration can work. Our hope is that more clinicians and hospital systems across Georgia will be open to learning from what has already been done and move from asking whether doula integration can work to working with us on how we make it work for Georgia families.”
This type of integration, according to Rhodes, starts with providers, doulas, and birthing people working together.
“Sometimes we put a lot on community health workers and doulas,” says Rhodes. “As we focus on integrating doulas into care teams and expanding the doula workforce, it is also critical that we focus efforts on protecting and promoting the well-being of doulas.”
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