Pregnant Black women feel lost in the medical system. Doulas offer guidance – and a voice.

Marquisa Gaines-Nickelson’s labor was accompanied by an unexpected soundtrack: the voices of R&B titans like Mary J. Blige, Al Green, and Anita Baker. Her husband and “labor DJ” Mazi Nickelson diligently curated the music that reverberated through the delivery room in Cambridge, Massachusetts. The playlist was part of a birth plan that they prepared with the help of their doula, Melody Cunningham.

For the first-time parents, those details mattered a great deal, and Ms. Cunningham was essential to making them a reality. The pair wanted their daughter, Sanaa, to get a taste of their personalities even as she drew her first breath. “Some of the smallest details can turn out to be big ones,” Mr. Nickelson says. “Having Melody there to help us navigate that space … we appreciated that a lot.” 

Empowering expectant parents to ask for what they want is just one, albeit important, piece of what Ms. Cunningham does as a birthing doula, an advocate trained to provide guidance and support to pregnant people and their families. The care doulas offer isn’t like that given by an OB-GYN or midwife. Instead, they provide nonmedical help: counsel on what to expect; advocacy during delivery and doctor’s appointments; and a place to express emotions ranging from excitement, to, for many Black families, fear.

That fear comes with a history. The United States has the worst maternal outcomes in the developed world, driven in part by stark racial inequities. According to the Centers for Disease Control and Prevention, Black women died of pregnancy complications at rates 2.6 times higher than their white peers in 2021, the most recent year for which data is available. 

As Black expectant mothers try to navigate a medical system in which they have little confidence, Black doulas have become trusted members of their pregnancy teams. 

Black Americans across the board eye American health care warily. In a 2020 poll by the Kaiser Family Foundation and The Undefeated, only 56% of Black respondents said they trusted their local hospitals, compared with 70% of white ones. 

That mistrust is earned, says Dr. Allison Bryant, an OB-GYN and associate chief health equity officer at Massachusetts General Brigham. She points to a long history of medical mistreatment still felt by Black people and other groups. Indeed, doctors forcibly sterilized Black, Latina, and Indigenous women well into the 1970s. 

“We in the medical system have not done a great job of earning that trust back,” Dr. Bryant says. “So people come into the delivery rooms with that sort of context.”

Research shows that doulas can significantly reduce negative outcomes and lower anxiety among expectant mothers.

Doula work is steeped in a deep sense of community and a history that stretches back hundreds of years. Dr. Bryant points to “granny midwives” – highly skilled Black women who, for centuries during slavery and following emancipation, provided obstetric care for women living in the rural South. Though they laid the foundation for modern doula work and midwifery, they were pushed out as obstetrics became institutionalized in hospitals.  

To Stephanie Crawford, a Boston-based doula, part of that model’s success came from the women’s deep connections to the people for whom they cared. The midwives were familiar members of their communities – mothers, sisters, friends, and cousins. Ms. Crawford says that sense of collaboration is an essential building block for the deep, trusting relationships she relies on to care for her clients. 

During the initial meeting, the first thing she does is listen. It’s not her job to tell mothers and their families how a pregnancy should go, she says. Her job is to work with them, to guide them, and to make them feel informed enough that they can make decisions about their own care.

Ms. Crawford understands the importance of feeling ownership over a pregnancy. She’s been in her clients’ shoes. She’s Black. She’s given birth twice. She knows that hospitals and doctor’s offices can feel intimidating, that it can sometimes feel as if decisions are not yours to make. More than that, she understands how heartbreaking a pregnancy can be. Her first one, in 2011, ended in a stillbirth.

In some ways, her second pregnancy was remarkably similar to her first. It was another boy, and his birthday ended up being a mere three days from her first son’s. But having a doula made all the difference – so much so that she became one herself.

“I would do the birth 10 times again,” she says. Her son turned 5 in February. “My goal as a doula is just creating that same kind of experience for others, so that people can be more informed, intentional, and just own their journey a little bit more.”

Ms. Crawford says it comes down to the details. Mothers and their families don’t always know what they can ask for in the delivery room. But those small things – like not wearing a hospital gown or playing a favorite song during labor – can make people feel empowered. “That means something to people,” Ms. Crawford says. “Being able to have things that feel good to you.”

Joanne Dorgilus, another Boston-based doula, wants clients to feel as if they’re talking to a family member or a close friend. “I’m one of your girlfriends,” she says, chuckling while she talks about her work. Letting her clients see her naturally cheerful, “jokey-joke” personality is her way of easing anxiety and creating camaraderie.

Beyond that intentionally cultivated closeness, having a knowledgeable Black advocate in the room can be comforting. Research has shown that people are more satisfied with care from doctors who share their race. 

“Cultural competency cannot be bought,” says Ms. Cunningham. “It cannot be taught. It’s just something that is there. And it makes for a more comfortable experience, which makes for … the increased likelihood of a healthy and happy birth.” 

Sanaa, Mrs. Gaines-Nickelson and Mr. Nickelson’s daughter, will be 2 in July. The couple is hoping to have a second child soon, perhaps without the help of a doula this time. “I feel more confident in knowing what I know a little bit now,” Mrs. Gaines-Nickelson says. “I think I can guide myself.” 

Ms. Cunningham and other doulas interviewed emphasize that they value the expertise of physicians. The issues are more systemic than any one doctor. And even when clinicians are treating their patients equitably, they can sometimes struggle to break through entrenched power dynamics that make it difficult for Black women to speak up. 

Even though they don’t “catch the baby,” Ms. Dorgilus says, doulas are “putting their feet down and making the changes that we need to do to help women around the world.”

Black women “feel like they hadn’t been heard, and their voices haven’t been included in some of the decision-making process,” Dr. Bryant says. “In some instances that I’ve seen with my own eyes, the doula can sort of understand where the patient is coming from, and sometimes be able to be an advocate and a voice for that individual.”

Dashanna Hanlon, a doula based in the Greater Boston area, hopes that she can leave a legacy that leads to more joyful births, like Sanaa’s. “We talk so often about the awfulness of, you know, Black maternal health,” she says. “But there is so much joy in those rooms.”