The program led to reduced rates of C-sections, pre-term births, and low birth weights among Black & Hispanic birthgivers, who account for over 3 out of 4 pregnancy-related deaths
Ahead of Mother’s Day, New York City Comptroller Brad Lander unveiled a new audit of the NYC Department of Health and Mental Hygiene’s (DOHMH) Citywide Doula Initiative (CDI), which revealed that the program successfully improves birth and health outcomes for Black and Hispanic women and birthgivers.
The CDI program was launched to address longstanding inequities—including socioeconomic barriers, structural racism, and bias in healthcare services—that drive high rates of maternal mortality and adverse birth outcomes in communities of color. The audit underscores that doula services, long championed by reproductive justice advocates, can narrow racial disparities. Black and Hispanic participants in the program saw lower rates of C-sections, pre-term births, and low birth weights, compared to the general population of births in New York City.
“The Citywide Doula Initiative is working,” said Comptroller Brad Lander. “By providing doula services at no-to-low costs, the city is making progress toward closing the racial gap in maternal health outcomes and on its way to eliminating maternal mortality. Providing equitable care access for all is the first step toward building a thriving and healthier city to start and raise a family.”
Rates of maternal mortality and health complications are dramatically higher amount Black and Hispanic women. According to DOHMH, Black non-Hispanic women and birth givers accounted for 17.7% of all live births in the city, but a staggering 39.7% of all pregnancy-associated deaths. Black and Hispanic women and birthgivers made up over 3-out of-4 deaths, despite accounting for less than half of all live births across the five boroughs.
To address these disparities, New York City has increased access to doulas in recent years, leading to passage of Local Law 85 of 2022, sponsored by New York City Councilmember Jennifer Gutiérrez, establishing a pilot program to train doulas and provide free doula services to resident of marginalized neighborhoods. Doulas provide non-medical physical, emotional, and informational support to pregnant individuals and families before, during, and after childbirth. Throughout pregnancy, doulas also advocate for clients’ health decisions and help them navigate the challenges of childbirth.
Auditors from the NYC Comptroller’s office used citywide birth outcome data from 2022 (published in the most recent Annual Summary of Vital Statistics) and birth outcome data for the period of March 2022 through June 2024 for CDI clients, and also surveyed CDI participants and doulas. Auditors identified meaningful improvements in health outcomes for women and birthgivers.
Key Findings from the Audit:
- Increased doula access: DOHMH’s efforts are increasing doula access and support in underserved neighborhoods. Prenatal visit, doula-attended births, and post-partum visits all increased significantly, with over 2,000 clients receiving services through the CDI program.
- Improved maternal health outcomes: Black and Hispanic CDI clients saw significantly better maternal health outcomes, including lower rates of C-sections, preterm births, and low birth weights, compared to citywide averages. No pregnancy-associated deaths were reported for CDI clients, indicating that doula support may help reduce maternal mortality.
- Strong client satisfaction: Participants expressed satisfaction with the program, with 77% rating their pregnancy/birthing experience with a doula as good or excellent. One respondent stated “having a doula was life changing and more clinics/hospitals should offer it to all patients.”
Areas for Improvement:
The audit also identifies areas for improvement, including expanding access in shelters, advancing doula-friendly hospital policies, and increasing non-English speaking doula provider capacity.
- Hospital barriers: Doulas reported that some hospitals prevented them from providing comfort measures, such as assisting their clients in using the restroom (17% of respondents), supporting mobility out of bed (25% of respondents), and staying with their clients during delivery (13% of respondents). During a Doula-Friendliness meeting attended by auditors, CDIs encouraged hospitals to promote policies that would better enable doulas to provide care.
- Shelter access: Shelter residents faced inconsistent doula access due to delays in caseworker approvals or outright denials by shelter staff. Doulas experienced difficulties gaining access to clients living in shelters, with 33 (49%) of the 68 doula respondents saying that their clients were difficult to access or inaccessible.
- Language gaps: While six of the seven CDI vendors stated they could provide services in Spanish, less than half of the vendors could provide services in other languages; only 3-out of-7 CDI vendors offer services in Haitian Creole, 2 in French, and 1 each in Cantonese and Mandarin—limiting access for non-English speakers.
To address the findings and continue to improve this successful program, the auditors propose that DOHMH:
- Improve data collection to ensure more timely and efficient data reporting to identify the effectiveness of doula services on the reduction of negative birth outcomes and maternal mortality.
- Increase the number of non-English-speaking doulas.
- Continue to work with DHS to increase doula access to clients in shelters.
- Continue to promote doula-friendly policies in hospitals and expand doula incorporation into hospital birthing teams.
- Incorporate client satisfaction surveys into their data collection procedures and evaluate satisfaction by vendor, analyzing differences in practice that may affect satisfaction.
Read the full audit: https://comptroller.nyc.gov/reports/audit-report-on-the-new-york-city-department-of-health-and-mental-hygienes-oversight-of-doula-programs-in-underserved-neighborhoods
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