Maternal health in Massachusetts: The potential for culturally-concordant doula care to improve maternal health outcomes

Despite spending significantly more per capita on health care each year, the United States continues to report the highest rate of maternal mortality, and one of the highest rates of severe morbidity, among high-income, industrialized countries.

Each year, hundreds of birthing people in the U.S. die from pregnancy and birth-related complications, with tens of thousands more experiencing severe, and potentially life-threatening, pregnancy and birth-related complications, termed Severe Maternal Morbidities. These maternal deaths and morbidities, the vast majority of which are preventable, disproportionately affect non-Hispanic Black birthing people nationwide. 

The Centers for Disease Control and Prevention reported that between 2018 and 2021, the maternal mortality rate (MMR) for all birthing people in the United States nearly doubled, rising from 17.4 maternal deaths to 32.9 maternal deaths per 100,000 live births. In the same time period, the MMR for non-Hispanic Black birthing people alone was more than double the national MMR each year, rising from 37.3 maternal deaths to 69.9 maternal deaths per 100,000 live births.

While the national MMR dropped in 2022, and provisional CDC data shows that it continued to decrease in 2023, experts agree that this drop may not indicate that the maternal health crisis is lessening. The 2020 to 2021 MMR surge, experts speculate, had to do with the COVID-19 pandemic, and it is likely that the MMR is returning to its pre-COVID rates. Sobering maternal health disparities remain, with 2022 data showing that Black birthing people had a maternal mortality rate more than 2.5 times higher than white birthing people. 

Severe maternal health disparities exist in all corners of the U.S., including here in Massachusetts – a state which consistently tops rankings on health care performance across the country and is home to several of the country’s highest-ranked hospital systems. A 2023 Massachusetts Department of Public Health (DPH) report indicated that rates of severe maternal morbidity doubled between 2011 and 2020, with the highest rates reported for non-Hispanic Black birthing people. In its 2023 to 2024 Health of Boston analysis, the Boston Public Health Commission (BPHC) reported that Black residents, and neighborhoods with higher populations of Black residents, report far worse maternal health outcomes than other residents and neighborhoods.

Social determinants of health, or environmental conditions that affect the health of populations, play a significant role in driving rates of maternal mortality and severe maternal morbidity in minoritized populations. Implicit bias, discrimination, and structural racism directly rooted in a history of anti-Black racism and xenophobia in U.S. policy affect disparities in healthcare access, quality of care, and health outcomes, regardless of socioeconomic status, insurance type, and more. For example, the most recent Health of Boston report cites a 2022 study by Kennedy-Moulton et al. indicating that “low birthweight and preterm birth rates for infants of Black women in the highest income bracket were significantly higher compared to white women in the lowest income bracket” (p.8).

Thought leaders, scholars, activists, community workers, health care providers, and politicians across Massachusetts continue to sound the alarm on these persisting and dramatic racial inequities in maternal health outcomes. Leaders at a recent Boston-area panel event, “Birthing Justice: Finding a New Way Forward,” discussed – among other key topics and themes – the need for increased diversity in the healthcare workforce as a means of improving access to racially and culturally concordant care, mitigating structural racism in health systems, and ultimately, improving maternal health outcomes in minoritized populations (We recommend watching the full recording of the GBH-sponsored program here).

At Accompany Doula Care, we strongly agree that every birthing person should have access to and autonomy in choosing perinatal support concordant with their primary language, culture, and race. The benefits of cultural concordance on health outcomes in minoritized populations are documented in the literature. In a 2022 study, Jetty et al. found that racial concordance between patients and their physicians led to improved health outcomes and lower healthcare expenditures.

Combining cultural concordance with the proven positive impacts of continuous labor support and advocacy via doula care is an even greater step toward more positive birth outcomes. Birthing people with doula support experience lower odds of cesarean intervention, lower odds of preterm birth, shorter labors, lower risk of postpartum depression, and more. Evidence also shows that access doula support is particularly beneficial to birthing people of color and can address birth inequities. Making doula care affordable, accessible, and concordant is crucial, particularly for the 40% of births currently covered by MassHealth in the state. About 17% of MassHealth patients identify as non-Hispanic Black individuals. 

While doula coverage is not the sole solution to the current state of maternal health in Massachusetts and across the country, it is a crucial step in the right direction. Increasing equitable access to racially and culturally concordant doula care across the Commonwealth is one vital component of a much larger conversation and systems-level changes that ensure that pregnancy, childbirth, and the postpartum period are safe for all birthing people.