"I want to serve those communities [but] my price tag is not what they can afford": The community-engaged Georgia doula study.

INTRODUCTION: In Georgia, maternal mortality is relatively high, and Black women are three times as likely to die from pregnancy-related causes as white women. Doulas can improve perinatal health and reduce disparities, but doula accessibility in Georgia is unclear. METHODS: This community-engaged mixed methods study surveyed and interviewed 17 doulas in Georgia. Surveys included structured questions on demographics, businesses, clientele, training, and challenges; we analyzed them using descriptive statistics. In-depth interviews included open-ended questions on doula care benefits, building their businesses, and improving access to doula care. We analyzed the content of transcripts using coding and memoing. RESULTS: Our diverse doula participants described providing life-saving services including education, referral to care, and patient advocacy. Yet they described numerous challenges to providing care and building their businesses. Almost all participants reported having fewer than their ideal number of clients and all reported being insufficiently paid for their services. Although training, mentoring, and networking help build their businesses, many doulas want to serve Black women, transgender men, gender non-binary individuals, and families living on lower incomes. Participants suggested Medicaid reimbursement and community health worker models as potential interventions for increasing equitable doula care access. DISCUSSION: Doulas can improve perinatal health outcomes and are urgently needed. Yet they face challenges in building businesses and finding clientele, especially from communities and groups at highest risk of negative outcomes during pregnancy, childbirth, and the postpartum period. Identifying avenues for supporting publicly-funded reimbursement, expanding equity-focused doula training, and fostering stronger doula networks with mentorship appears warranted.

"We really are seeing racism in the hospitals": Racial identity, racism, and doula care for diverse populations in Georgia.

INTRODUCTION: Poor birth outcomes are more prevalent for Black communities, but strong evidence shows that doula care can improve those outcomes. More evidence is needed to understand racial differences, discrimination, and equity in doula care. METHODS: The current study's objective was to describe the experiences of Black doulas as well as the challenges and facilitators of providing doula care to communities of color in Georgia. From Fall 2020-Fall 2021, 20 surveys and in-depth interviews were conducted with doulas as part of a community-based participatory study co-led by Healthy Mothers, Healthy Babies Coalition of Georgia and academic researchers. RESULTS: Doula participants were diverse in age (5% under 25, 40% 25-35, 35% 36-45, and 20% 46+) and race/ethnicity (45% white, 50% Black, 5% Latinx). Most (70%) Black doulas reported that more than 75% of their clientele is Black, while most (78%) white doulas reported that less than 25% of their clientele is Black. Doulas noted the alarming Black maternal mortality rate and how mistreatment causes Black clients to lose trust in medical staff, leaving them in need of advocates. Black doulas were passionate about serving and advocating with Black clients. Participants also described how language and cultural barriers, particularly for Asian and Latinx people, reduce clients' ability to self-advocate, increasing the need for doulas. Doulas also discussed the ways that race influences their connections with clients and their dissatisfaction with the lack of cultural humility or sensitivity training in standard doula training. CONCLUSION: Our findings indicate that Black doulas provide essential and supportive services to Black birthing people, and those services are more urgently needed than ever following the overturn of Roe v. Wade. Doula training must be improved to address the cultural needs of diverse clients. Increasing access to doula care for Asian and Latinx communities could also address language and cultural barriers that can negatively impact their maternal and child health outcomes.