COMMUNITY-BASED DOULAS
WHAT ARE COMMUNITY-BASED DOULAS AND WHY ARE THEY IMPORTANT?
Community-based doulas are trained social service professionals who provide non-clinical emotional, physical, and informational support to expectant parents, starting during pregnancy and continuing throughout the postpartum period. Community-based doulas specialize in culturally competent care that reflects the values and lived experiences of their clients, working in tandem with doctors, nurses, and midwives to provide care throughout the perinatal period.1 Doulas support their clients by providing childbirth education, helping them navigate the health care system, advocating for them throughout the perinatal period, and connecting them with community resources.
Support During the Perinatal Period Improves Wellbeing
Community-based doulas act as a buffer to decrease the influence of stressors during pregnancy, birth, and early parenthood by providing information to clients, helping to navigate complex health care systems, and acting as advocates for the wellbeing and wishes of clients.
Information provided to expectant parents includes risk factors and warning signs for issues that affect maternal and infant health outcomes. Community-based doulas teach expectant parents about monitoring a fetus’s movements in utero, sleeping patterns, and positions. They also provide information after delivery by modeling developmentally appropriate behaviors such as responding to an infant’s cues and emotional needs.2 Parenting and child development education provided by doulas can also help foster nurturing parent-child relationships and increase safe feeding practices for infants.
Community-Based Doulas Provide Unique Care
Community-based doulas go beyond the scope of care given by physicians to help their clients navigate complex health care systems and social service providers. Traditional healthcare providers spend an average of 5.75 hours with patients.3 In comparison, community-based doulas are on call 24/7 for their clients and spend an average of 76 hours with each client throughout their perinatal journey.4
This aid can start as early as initial contact in the prenatal period and expand into the postpartum period to help parents provide thriving environments for their children.5 Connections to community resources can mitigate social drivers of health, such as a lack of health literacy or social support issues that are the root cause of health disparities and negative outcomes.6
Community-Based Doulas Can Improve the Birthing Experience as Client Advocates
Community-based doulas act as advocates for their clients and affirm the client’s experience. For example, a community-based doula can recognize and affirm the pain or concern clients feel as they go through the perinatal period and ensure those concerns are taken seriously by medical staff.7 This support is vital for Black expectant parents who are marginalized by the traditional healthcare system and have an increased chance of complications due to racial bias.8
Expectant parents who have a doula acting as an advocate during labor and delivery experience less stress, and are less likely to experience medical interventions, such as cesarean deliveries and labor induction, and have a lower risk of the associated adverse birth outcomes.9,10
Culturally Competent Care Is Critical to Address Disparities
Community-based doulas incorporate reproductive justice and birth justice frameworks and use strategies to address structural racism, intergenerational trauma, and implicit bias. Doulas have served their communities during the perinatal period for centuries, but recently, support of community-based doula care has become a popular policy option for states in response to the recognition of discrimination experienced by people of color in healthcare systems, and the resulting disparities in birth outcomes by race and ethnicity.11 The culturally competent care provided by community-based doulas can be one element of a larger comprehensive system of care that reduces maternal and infant health disparities.12
Community-Based Doula Care Can Be Cost-Effective
Limited research suggests community-based doulas may help states save money in the long run. One study of community-based doulas covered by a Medicaid managed care organization in Minnesota showed that the potential cost savings of doula care averaged $986 per patient, and total predicted savings were estimated at $58.4 million each year.13
A simulated cost analysis that compared data from Medicaid births without doula support nationwide and Medicaid births with doula support in Minnesota found that states could save at least $2 million a year.14 Furthermore, a nationwide cost-benefit analysis determined that the estimated decreases in preterm birth caused by doula care can result in $1.6 billion in annual savings.15
Search the Prenatal-to-3 Policy Clearinghouse for an ongoing inventory of rigorous evidence reviews, including more information on community-based doulas.
WHAT IMPACT DO COMMUNITY-BASED DOULAS HAVE AND FOR WHOM?
Strong causal evidence of community-based doula programs has demonstrated that doula support increases attendance at medical appointments and education classes, encourages responsive parenting behaviors, and enhances child health and developmental outcomes such as breastfeeding initiation rates and safe sleep practices. Additionally, there is evidence that participation in community-based doula programs improves important birth outcomes including preterm birth, low birthweight, and neonatal intensive care unit visits.
More Research Is Needed to Determine the Potential of Community-Based Doulas to Reduce Racial and Ethnic Disparities
Because community-based doulas are specifically trained for culturally sensitive care and to focus on expectant parents who are more likely to experience discrimination and racism in traditional healthcare settings, evidence suggests that the involvement of a community-based doula may decrease disparities in birth outcomes for mothers and infants. Rigorous research on community-based doulas demonstrates beneficial impacts on diverse groups of parents, including mostly people of color, but to date, no strong causal studies directly test for differences by racial and ethnic groups, making it impossible to draw conclusions about whether parents of color benefit at the same or different levels as White parents.
Additionally, studies on other types of birth doulas do not use representative samples and consist mostly of White women. Although there are some rigorous studies showing mixed results, the evidence from these studies is not conclusive regarding the benefits of lay and other birth doulas for diverse populations.
Future research must focus on examining the differential impacts of community-based doulas by race and ethnicity, and socioeconomic status.
For more information on what we know and what we still need to learn about community-based doulas, see the evidence review on community-based doulas.
WHAT ARE THE KEY POLICY LEVERS TO SUPPORT COMMUNITY-BASED DOULAS ACROSS STATES?
The current evidence base does not identify a specific policy lever that states should implement to increase access to community-based doula services to all parents who want this type of care.
We identified two key policy levers that states can implement to increase access to community-based doula services in their state:
- Cover and reimburse community-based doula services under Medicaid, and
- Provide financial support for doula training and workforce development.
As of September 1, 2025, 26 states reimburse for doula services under Medicaid, and 14 states provide financial support for doula training and workforce development. Six new states (Connecticut, New Mexico, Ohio, Pennsylvania, South Dakota, and Washington) implemented Medicaid coverage, and six new states (Connecticut, Delaware, New Mexico, New York, Oregon, and Washington) implemented workforce supports in the last year. In total, 12 states have implemented both key policy levers to increase access to community-based doulas.
Key Policy Lever: Cover and Reimburse Community-Based Doulas Under Medicaid
To foster access to community-based doulas among families with low incomes, states can cover and reimburse doula services during the perinatal period for families enrolled in Medicaid. Without Medicaid coverage, out-of-pocket costs for doula services may be unaffordable for many families who wish to have doula support. Medicaid covers 41% of all live births in the US, therefore including doula services as a covered service expands access to a significant portion of families nationwide.17
In the past year, six new states (Connecticut, New Mexico, Ohio, Pennsylvania, South Dakota, and Washington) began reimbursing doulas under Medicaid. In total, 26 states (including the District of Columbia) actively cover doula services under Medicaid, including community-based doulas.
As of September 2025, an additional seven states were in the process of implementing coverage of doula services under Medicaid with coverage expected to be effective in 2026 or later. These seven states include Arkansas, Louisiana, Maine, Montana, New Hampshire, Utah, and Vermont. States can use direct reimbursement or provide reimbursement through managed care organizations (MCOs).
Changes to Medicaid funding at the federal level may impact Medicaid coverage and services of evidence-based programs such as community-based doulas. Work to determine the full impact of federal Medicaid changes on state offerings is ongoing.
States vary in the number of visits covered by Medicaid (e.g., up to eight total visits) and any requirements on when those visits occur (e.g., Oregon requires a minimum of two prenatal visits and requires two postpartum visits). Rates per visit also vary. As of September 2025, reimbursement rates for the total cost of doula care including prenatal visits, labor and delivery, and postpartum care range from $450 for one patient in Florida to $3,500 in Washington.
Setting fair Medicaid reimbursement rates requires states to recognize the long hours community-based doulas spend with their clients and the true cost of the care they provide. Key factors include market rates for doulas, cost of living, scope of services, supplies, and time spent on clients during and outside of visits, including emotional support, connections to social services and community supports, and 24/7 on-call availability.
To help ensure that rates are sufficient as a sustainable source of income, states can set up a formula or minimum threshold to determine rates. Timely reimbursement is critical for community-based doulas, whose wages often rely on payment from individual clients or health insurance providers.
States also make policy choices around who can become a Medicaid provider and take steps to make policies affecting who is considered a doula more inclusive. To recognize the experience and skills of doulas in the state and encourage participation in Medicaid, states can collaborate with doulas to set requirements on who qualifies as a doula (e.g., certification and core competency requirements).
State certification requirements do not always accurately reflect the diverse backgrounds and expertise of community-based doulas. Rather than requiring certification from a specific organization, states can provide pathways for doulas to meet criteria to become Medicaid providers through demonstrated expertise or experience based on a list of core competencies.
Including community-based doulas in the policymaking process is vital to creating equitable and efficient policies for doula Medicaid coverage. States can involve community-based doulas through advisory boards, listening sessions, or workgroups. Creating policies that are reflective of the doula community, and informed by their expertise and experience, can increase doula participation as Medicaid providers.
Key Policy Lever: Provide Financial Support for Community-Based Doula Training and Workforce Development
States can also implement policies that support the community-based doula workforce by increasing access to education and training opportunities. Financial support can ease the financial burden of obtaining necessary trainings for both current and future doulas.
As of September 2025, 14 states provide financial support for doula training and workforce development. Arkansas, Delaware, Missouri, New York, Oregon, and West Virginia fund grant programs, California, Michigan, and New Mexico fund financial support programs, and Colorado and Connecticut fund scholarship programs to increase access to doula training and education.
Additionally, the New Jersey Department of Health provides grant funding for the New Jersey Doula Learning Collaborative operated in partnership with HealthConnect One that provides assistance for Medicaid billing and enrollment, workforce development, and training opportunities. Similarly, Washington uses states appropriations to fund a doula hub to provide technical assistance, development, and training. Finally, Nevada has an education loan repayment program for health care providers, including doulas enrolled as Medicaid providers.
State Policy and Administrative Choices Affect Access to Community-Based Doulas
States can enact policies that increase access to community-based doulas beyond Medicaid reimbursement and financial support for training and workforce development. Requiring private insurance to cover doula services is one way to further expand access to doulas beyond those covered by Medicaid. Currently, five states (California, Colorado, Louisiana, Rhode Island, and Virginia) require private insurance coverage of doula care. Arkansas will require private insurance coverage by December 31, 2025 and Illinois will require private insurance providers to cover doula services by January 1, 2026.
States can also issue statewide standing recommendations for doula services, which would eliminate the need for expectant parents to seek individual referrals for doula services. Typically, to receive doula services through Medicaid, recipients need a physician recommendation. Seven states (California, Illinois, Massachusetts, Michigan, Minnesota, Ohio, and Washington) have issued statewide standing recommendations to eliminate this barrier to care.
Furthermore, states can increase access to community-based doulas by maintaining statewide doula registries or directories. A registry or directory lists various contact and care information about community-based doulas in the state to allow families to easily find a provider. The lists can be optional for doulas to join and can be funded by the state to remove financial barriers to participation for doulas. As of September 2025, a total of eight states (Louisiana, Michigan, Minnesota, Missouri, New Hampshire, New Jersey, New York, and Vermont) offer a statewide registry or directory for doulas.
States vary considerably in their level and type of support for community-based doula services. These policy choices can lead to variation in the number of people who have access to this effective strategy. However, no single source of national data exists to understand and compare access to community-based doulas. Data are needed to explore access to doula care and to better understand the availability of doulas and workforce challenges they face.
For more information on the state policy levers to maximize the reach and effectiveness of community-based doulas see our State Policy Lever Checklists.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO INCREASE ACCESS TO COMMUNITY-BASED DOULAS?
During the 2025 legislative session, more than half of states introduced legislation related to support for community-based doulas. Among the 35 states that introduced legislation related to doulas, 14 states successfully enacted legislation.
6 States Newly Implemented Medicaid Coverage for Doula Services
In the last year, six states (Connecticut, New Mexico, Ohio, Pennsylvania, South Dakota, and Washington) fully implemented Medicaid coverage for doula services through state plan amendments (SPA) approved by the Centers for Medicare and Medicaid Services (CMS). The states have varying requirements for coverage and reimbursement rates.
The states that newly implemented coverage this year enacted legislation or took administrative action to require coverage in previous years. Connecticut and South Dakota implemented coverage by administratively changing covered services in their existing Medicaid perinatal care programs. New Mexico, Ohio, and Washington appropriated funds in their state budgets to mandate Medicaid coverage of doula services in Fiscal Year 2025. Finally, Pennsylvania enacted legislation in 2024 that mandated state agencies to seek approval from CMS for a doula Medicaid benefit.
6 States Made Progress Towards Medicaid Coverage for Doula Services
Six states took meaningful steps towards implementing Medicaid coverage for doula services this year.
- Arkansas enacted legislation to implement Medicaid coverage for doula services by December 31, 2025. The bill also requires private insurance providers to cover doula services.
- Louisiana enacted legislation to implement Medicaid coverage for doula services by January 1, 2026. Medicaid coverage will include at least five prenatal visits, three postpartum visits, and attendance at labor and delivery.
- Maine enacted legislation to implement Medicaid coverage for doula services by January 1, 2026. Medicaid coverage will include at least four prenatal visits, four postpartum visits, and attendance at labor and delivery.
- Montana enacted legislation to implement Medicaid coverage for doula services by January 1, 2026.
- Utah enacted legislation to implement Medicaid coverage for doula services by October 1, 2025.
- Vermont enacted legislation to implement Medicaid coverage for doula services by July 1, 2026.
Additionally, New Hampshire is working towards implementation of doula Medicaid coverage after appropriating funds for a new benefit in 2023. As of September 2025, no state plan amendment has been approved for the states working on implementation.
8 States Introduced Legislation to Cover Doula Services Under Medicaid
Eight additional states (Indiana, Iowa, Kentucky, North Carolina, South Carolina, Tennessee, Texas, and West Virginia) introduced, but did not enact legislation to cover doula services under the state Medicaid program. Georgia introduced, but did not enact, legislation for a pilot program for doula Medicaid reimbursement.
2 States Enacted Legislation to Expand Covered Doula Services
Furthermore, Virginia enacted legislation that will increase the number of doula visits covered by Medicaid. Allowable visits will increase from eight visits to 10 total visits throughout the perinatal period. Oregon also enacted legislation this year to increase the number of hours of doula care eligible for Medicaid reimbursement to 24. The maximum Medicaid reimbursement rate for doula services in both states will likely increase to reflect the changes. Maryland is also in the process of increasing its maximum Medicaid reimbursement rates. As of September 2025, no SPA has been approved.
Multiple States Enacted Legislation to Support Doula Workforce Development
In the last year, six states (Arkansas, Delaware, Missouri, New Mexico, New York, and Oregon) enacted legislation to support doula workforce development. The states appropriated funding in budgets for Fiscal Year 2026 to doula organizations, programs, and funds that provide grants and scholarships for doula training, continuing education, and technical assistance.
- Arkansas appropriated $2 million in the Fiscal Year 2026 budget to the Maternal Health Workforce Trust Fund at the University of Arkansas for Medical Sciences. The fund can be used for doula certification opportunities.
- Delaware appropriated $5,000 to the Do Care Doula Foundation which provides low-cost doula support, community outreach, and doula training and development.
- Missouri continued funding for the Cora Faith Walker Doula Training Program, appropriating $500,000 for the program.
- New Mexico appropriated $600,000 to establish a doula fund used to create guidelines for voluntary doula certification, support the doula workforce, and establish a doula credentialing advisory council.
- New York continued funding for the Doula Expansion Grant Program which provides funding for doula training, recruitment, and development. New York appropriated $250,000 for the program.
- Oregon appropriated $1 million to establish a Community-Based Perinatal Services Access Fund which will provide grants to organizations increasing access to community-based perinatal care, including doula services.
Additionally, Massachusetts and North Carolina introduced legislation to establish grant programs for the perinatal and/or doula workforce. The bills did not pass in North Carolina; as of September 2025, Massachusetts was still in session, but the bill had not passed.
States Continue to Invest in Doula Registries
In the last year, Arkansas enacted legislation to create a statewide doula registry or directory. Along with implementing Medicaid coverage for doula services, the Arkansas Department of Health will upkeep community-based doula certification and the state registry. Implementation will be effective December 31, 2025.
Missouri and New Jersey continued funding for existing statewide doula directories. Missouri appropriated $100,000 and New Jersey appropriated $450,000 in FY 2026. Two states, Hawaii and Missouri, introduced legislation to require statewide doula registries. The bills did not pass this session.
States Focus on Integrating Doulas into Health Care Facilities
In the last year, five states (Connecticut, Illinois, Maryland, New York, and Virginia) enacted legislation relating to the integration of doula care in hospitals and birthing facilities and the ability to accompany patients through labor and delivery.
Illinois passed legislation that, in part, will require hospitals and birth centers to adopt public written policies and procedures to allow doulas to attend to Medicaid patients with limited exceptions. Maryland also enacted legislation that will require hospitals to have a public policy allowing doulas to attend to patients.
Connecticut enacted legislation which will create a workgroup to investigate hospital doula policies and complete a study on integrating doula-friendly hospital policies. A final report on the findings of the workgroup will be due by January 1, 2027.
Virginia enacted legislation which will require birthing facilities to allow doulas to accompany patients during births and cesarean deliveries. However, New York enacted legislation to amend existing policies that allow doulas to accompany patients during delivery. The enacted amendments allow birthing facilities to deny doulas access to accompany patients in emergency situations or operating rooms.
Four states (Indiana, Michigan, Nevada, and West Virginia) introduced legislation relating to doula integration in hospitals and birthing facilities. The bills did not pass in Indiana, Nevada, and West Virginia; as of September 2025, Michigan was still in session, but the bill had not passed.
Federal Changes to Medicaid May Impact State Medicaid Offerings
In the last year, the federal government passed the 2025 Federal Budget Reconciliation Bill making cuts to federal funding for Medicaid.18 Work to understand the implications of federal policy changes on state budgets is ongoing, though changes are anticipated to have a detrimental effect on state support for evidence-based policies and strategies such as community-based doulas.
For more information on each state’s progress on community-based doulas, find our individual state summaries under Additional Resources below (and here).
ADDITIONAL RESOURCES
View our Policy Impact Calculator, which illustrates how policies, such as state minimum wage, paid family and medical leave, out-of-pocket child care expenses, taxes and tax credits, as well as federal nutrition benefits, interact to impact overall household resources.
View a summary of community-based doula policies across states here. (PDF)
NOTES AND SOURCES
- Mallick, L. M., Thoma, M. E., & Shenassa, E. D. (2022). The role of doulas in respectful care for communities of color and Medicaid recipients. Birth, 49(4), 823–832. https://doi.org/10.1111/birt.12655
- Hans, S. L., Thullen, M., Henson, L. G., Lee, H., Edwards, R. C., & Bernstein, V. J. (2013). Promoting Positive Mother-Infant Relationships: A Randomized Trial of Community-based doula Support For Young Mothers: Community-based doula Randomized Trial. Infant Mental Health Journal, 34(5), 446–457. https://doi.org/10.1002/imhj.21400
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Chen, A., & Robles-Fradet, A. (2022, March 2). Challenges Reported by California Doula Pilot Programs. National Health Law Program. https://healthlaw.org/resource/challenges-reported-by-california-doula-pilot-programs/
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Kozhimannil, K. B., Vogelsang, C. A., Hardeman, R. R., & Prasad, S. (2016). Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. The Journal of the American Board of Family Medicine, 29(3), 308–317. https://doi.org/10.3122/jabfm.2016.03.150300
- Salinas, J.L., Salinas, M. & Kahn, M. (2022). Doulas, Racism, and Whiteness: How Birth Support Workers Process Advocacy towards Women of Color. Societies, 12(19). https://doi.org/10.3390/soc12010019
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Masten, Y., Song, H., Esperat, C.R., & McMurry, L.J. (2022). A maternity care home model of enhanced prenatal care to reduce preterm birth rate and NICU use. Birth, 49, 107-115. DOI: 10.1111/birt.12579
- Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7. https://doi.org/10.1002/14651858.CD003766.pub6
- Salinas, J.L., Salinas, M. & Kahn, M. (2022). Doulas, Racism, and Whiteness: How Birth Support Workers Process Advocacy towards Women of Color. Societies, 12(19). https://doi.org/10.3390/soc12010019
- Bakst, C., Moore, J.E., George, K.E. & Shea, K. (2020). Community-Based Maternal Support Services: The Role of Doulas and Community Health Workers in Medicaid. Institute for Medicaid Innovation. https://www.medicaidinnovation.org/_images/content/2020-IMI-Community_Based_Maternal_Support_Services-Report.pdf
- Kozhimannil, K. B., Hardeman, R. R., Alarid‐Escudero, F., Vogelsang, C. A., Blauer‐Peterson, C., & Howell, E. A. (2016). Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth, 43(1), 20–27. https://doi.org/10.1111/birt.12218
- Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., & O’Brien, M. (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health, 103(4), e113–e121. https://doi.org/10.2105/AJPH.2012.301201
- Eastburn, A., Hubbard, E., Mitchell, A., & Chen, A. (2024). A Cost-Benefit Analysis of Doula Care from a Public Health Framework. National Health Law Program. https://healthlaw.org/resource/a-cost-benefit-analysis-of-doula-care-from-a-public-health-framework/
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- KFF. (n.d.) State Health Facts: Births Financed by Medicaid, 2022. https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/
- KFF. (2025). Health Provisions in the 2025 Federal Budget Reconciliation Bill. KFF. https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/
