When Ebonie Bailey first began working as a doula—a non-medical professional who provides physical, emotional, and logistical support during childbirth—in 2015, she did not yet know that she was the only Black doula in the entire state of Iowa at the time.
“I just took the training, and it was like, ‘I could do this work,’ ” says Bailey. “I gravitated towards the Liberian community. What I recognized really quickly is that just like in any other space, when you’re in a white room and you see another Black face, there’s an immediate connection.”
In the United States today, Black women are nearly three times more likely to die from pregnancy-related complications than their white counterparts—a staggering disparity that reflects the systemic neglect and abuse that Black people face in health care settings during pregnancy and childbirth. This phenomenon, known as obstetric racism, can take the form of harmful practices by medical professionals such as dismissing pregnant Black patients’ pain or ignoring their birth plans, and it contributes directly to the disproportionate maternal mortality rates among Black women. These disparities in care prompted Bailey to found the Iowa Black Doula Collective, a network of Black doulas and birth justice advocates who provide access to doula services, advocacy training, and community education in an effort to dismantle the systemic barriers faced by Black birthing people.
The Iowa Black Doula Collective’s work is part of a larger birth justice movement led by Black doulas and midwives (whose role differs from that of doulas, as they are certified to deliver babies and provide medical care) Across the country, a new generation of Black birth workers is charting the path toward a more equitable future of community-based obstetric care, with a focus on reclaiming ancestral practices, combating obstetric racism, and ensuring that Black people have access to culturally competent care during pregnancy and childbirth.
The historical roots of Black midwifery in the United States date back to the era of slavery, when Black women served as midwives for both Black and white communities. Unlike doulas, who provide emotional, physical, and informational support during pregnancy and labor, midwives are trained health professionals who can deliver babies and provide medical care. These midwives were not only birth attendants, but also community leaders and healers. But with the eventual professionalization of obstetrics and systematic exclusion of Black women from medical institutions, the role of midwifery was nearly eradicated by the mid-twentieth century.
According to Leia Belt, a medical sociologist who studies fertility equity, obstetric racism is an overarching issue in the medical field. “Even when we account for transportation, socioeconomic status, education, and neighborhood, we still see racism being one of the biggest factors impacting Black women’s outcomes,” says Belt. “From prior to conception all the way through postpartum, Black bodies are often devalued in the medical system.”
In recent years, community-based care models led by Black midwives and doulas have been at the forefront of challenging this reality. Birth centers such as Kindred Space LA in Los Angeles, Roots Community Birth Center in Minneapolis, and Birth Detroit in Detroit aim to offer an alternative to traditional hospital settings—where Black people have often felt unseen, unheard, or unsafe—by providing safe, culturally affirming, and holistic care.
At the heart of this model is trust—and, as Bailey notes, doulas can play a critical role in bridging the gap between medical professionals and Black birthing people. “As a doula, I see my client as more than just a patient in a room,” she says. “To me, she’s my sister, my neighbor. I will go to bat for her in a way that most people wouldn’t for a stranger. That’s what makes Black doulas different.”
This care is not only deeply personal—it’s also backed by data. According to research from the National Library of Medicine, doula-supported births are associated with a reduced use of medical interventions such as unnecessary cesarean sections or labor inductions, as well as higher rates of breastfeeding and lower incidences of postpartum depression. Yet access to these services remains limited, especially for Black families in rural or low-income communities.
Belt emphasizes that addressing these disparities requires more than just statistical adjustments—meaning researchers accounting for factors like income, education, and access to healthcare. It also demands acknowledging the lived experiences of Black birthing people and how their intersecting identities—such as race, gender, and socioeconomic status—can increase their risk in traditional hospital settings.
“It’s not just about being Black in a medical system or being a woman in a medical system—it’s about what it means to be a Black woman in these spaces,” she says. “You’re invisible and hyper-visible at the same time. You’re too loud, but you can’t advocate for yourself enough to be heard.”
In addition to providing support during pregnancy and birth, Bailey and the Iowa Black Doula Collective engage in international learning to reclaim and integrate ancestral Black birthing practices. “I took a group of doulas to Ghana last year, and we brought back cloths,” Bailey says. “We went to learn and embrace traditional practices. Now, with our African families, we’re incorporating those traditions back into birth work—belly binding, prayer, herbs. These are things we’ve been doing for centuries that we stopped but are starting to bring back.”
But while birth justice advocates say this work is crucial to combat obstetric racism and the disparities in pregnancy and birth care, the financial reality of the work presents major challenges. Because doulas are often not covered by insurance, many provide extensive, culturally competent care without adequate compensation or structural support.
“A lot of states don’t cover doulas, or if they do, we have to jump through so many hoops just to get paid,” says Bailey. “Imagine you’re only being reimbursed $800 when the value of your work is $1,500 to $2,500. So now, doulas are doubling up on clients just to make ends meet.”
Her concern reflects a broader sustainability issue: As of 2024, only about twelve states offer some form of Medicaid reimbursement for doula services. Among those states, few have taken steps to ensure that doulas of color—who often serve the highest-need populations—receive equitable pay, access to training, or visibility within public health systems. According to Wildwood Birth, most birth doulas in the U.S. charge between $500 and $2,000 per birth. Yet when factoring in the more than 40 hours doulas often spend providing physical, emotional, and logistical support—including prenatal meetings, on-call availability, continuous labor support, and postpartum follow-up—their compensation often amounts to a modest hourly wage.
Belt emphasizes that while these conversations are gaining traction, much of the advocacy is still being led by grassroots efforts without sufficient government partnership.
“We’re seeing real movement—from postpartum Medicaid expansion to community grants—but there’s still a disconnect between what’s happening on the ground and what’s reflected in state and federal policies,” she says. “To sustain this work, policy must be created in collaboration with the very doulas and midwives who are doing it.”
While progress has been made in states like California, where legislation is expanding insurance coverage for infertility and in vitro fertilization (IVF) treatments, systemic gaps remain, especially for Black doulas and the communities they serve. Many birth justice advocates see supporting Medicaid expansion, increasing reimbursement rates, and investing in long-term infrastructure for community-based doulas as key steps in ensuring this work is both accessible and sustainable.
But the path to achieving these goals is steep. Currently, fewer than one in five births in the United States involve a doula, and access is even more limited in rural or underserved areas. And while programs like the Iowa Black Doula Collective are working to close that gap by sponsoring up to forty families per year, the need far exceeds current capacity.
At the same time, Bailey is cautious about the growing push to formalize and regulate doula work through insurance and policy. While expanding access is essential, efforts to include doula care in Medicaid programs across states like Minnesota and Maryland often require doulas to complete state-approved training programs, register with the state, and follow specific billing procedures. Bailey warns that too much oversight from state health departments or insurance regulators could dilute the very heart of what makes doula care powerful.
“This work is ancestral,” she says. “We’ve been supporting each other for centuries. Now, outsiders are trying to rename and reshape it, and that’s my biggest fear—that in trying to regulate doulas, they’ll push us out of the work altogether.”
But despite the challenges, Bailey says there is a profound sense of hope within the birth justice movement—one rooted in community, ancestral knowledge, and the unwavering determination of Black birth workers. She envisions a future where doula care is not seen as a luxury, but as a standard part of the pregnancy journey for every Black person who gives birth.
“Our goal is for someone to pee on a stick and their first thought be, ‘I need to get a doula,’” she says. “We want to make sure no one feels like they have to navigate pregnancy alone.”