Dr. Natalie Hernandez-Green

Dr. Natalie Hernandez-Green, executive director at the Center for Maternal Health Equity at ߣƵ addresses the graduates during a commencement ceremony at the Albany Civic Center on Saturday, April 27, 2024 (Matthew Pearson/WABE).

Rural Communities in Georgia Are Losing Access to Maternity Care. Can Training More Doulas Help?

ߣƵ recently graduated its first cohort of rural doulas, called Perinatal Patient Navigators, hoping to help address a shortage of maternal health services in southwest Georgia.

By Jess Mador, WABE News

When Bristeria Clark went into labor with her son in 2015, her contractions were steady at first. Then, they stalled. Her cervix stopped dilating.

After a few hours, doctors at Phoebe Putney Memorial Hospital in Albany, Georgia, prepped Clark for an emergency cesarean. Phoebe Putney Health System operates the only hospital in the area. 

It wasn’t the vaginal birth Clark had hoped for during her pregnancy.

“I was freaking out. That was my first child. Like, of course you don’t plan that,” she said. “I just remember the gas pulling up to my face and I ended up going to sleep.”

She remembered feeling a rush of relief when she woke up to see that her baby boy was healthy and well.

Clark, a 33-year-old nursing student who also works full time in Southwest Georgia county government, had another c-section when her second child was born in 2020 — this one planned.

She said she’s grateful the physicians and nurses who delivered both of her babies were kind and caring during her labor and delivery.

But looking back, Clark said she wishes she had had a doula for one-on-one support through pregnancy, childbirth and the postpartum period.

Now, she wants to give other women the option that she didn’t have.

Clark is part of ߣƵ’s first cohort of rural doulas, called Perinatal Patient Navigators.

The program recently graduated its first dozen participants, all Black women from southwest Georgia. They have completed more than five months of training and are slated to begin working with pregnant and postpartum patients this year.

“We’re developing a workforce that’s going to be providing the support that Black women and birthing people need,” said ߣƵ Associate Obstetrics and Gynecology Department Professor Natalie Hernandez-Green, executive director of the Center for Maternal Health Equity, speaking at the program’s commencement ceremony in Albany, Georgia.  

This is ߣƵ’s second Perinatal Patient Navigator program site. The first is already up and running in Atlanta.

Georgia has one of the highest rates of maternal mortality in the country, according to an analysis by health policy and research organization KFF. 

And Black Georgians are more than twice as likely as white women to die related to pregnancy.

“It doesn’t matter whether you’re rich or poor. Black women are dying at an alarming rate from pregnancy-related complications,” Hernandez-Green said.

“And we’re about to change that one person at a time.”

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies have also linked doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals.

They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the healthcare system and provide emotional and physical support before, during and after childbirth.

MSM’s program is among a growing number of similar efforts popping up across the country as more communities look to doulas as one way to help address maternal mortality, morbidity and poor maternal health outcomes in the United States, particularly for Black women and other women of color.

Now that she’s graduated, Clark said she’s ready to help other women in her community as a doula. And, her training has inspired her to become an advocate for maternal health issues in southwest Georgia.

“To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect,” she said. “The ultimate goal is to make them feel comfortable and let them know, I’m here to support you.” 

MSM’s $350,000 per year Perinatal Patient Navigator program is grant-funded. It pays graduates a $2,000 training stipend and includes funding to place five of the new graduates with healthcare providers practicing in the area.

Grant money will pay the doulas’ salaries, but only for one year. 

“It’s not sustainable if you’re chasing the next grant to fund it,” said Rachel Hardeman, Blue Cross Endowed Professor of Health and Racial Equity, Division of Health Policy and Management at the University of Minnesota School of Public Health.

She has studied what happens when Medicaid covers doula services.

More than a dozen states cover them, according to the National Health Law Program. Minnesota’s Medicaid program has been doing it for around a decade. 

“We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries. And we found that there’s a cost savings there,” she said.

Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in healthcare costs.

That’s because doulas can help reduce the number of expensive medical interventions during and after birth. They can even reduce the likelihood of preterm birth.  

“An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive,” Hardeman said.   

A coalition of advocates pushing for Georgia’s Medicaid program to cover doulas says it could save the state a lot of money and reduce racial disparities in maternal mortality at the same time. 

There is growing demand for doula services in Georgia, said Fowzio Jama, director of research for Healthy Mothers Healthy Babies Coalition of Georgia.

Her group recently completed a pilot study offering doula services to roughly 170 Georgians covered under Medicaid.

“We had a waitlist of over 200 clients and we wanted to give them the support that they needed, but we just couldn’t with the given resources that we had,” Jama said.

Doula services can cost hundreds or thousands of dollars out of pocket, putting the care out of reach for many low-income people, rural communities and communities of color that are also harder hit by shortages in maternity care, according to the March of Dimes.

The Healthy Mothers Healthy Babies Coalition of Georgia study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive impact on patients. 

“There was a reduced use of pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birthweight,” said Jama.

Still, she and other advocates acknowledge that doulas alone can’t fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Hardeman said.

“I think it’s important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool,” she said. “They are a piece of the puzzle that is helping to impact a really, really complex issue.”  

In the meantime, ߣƵ program graduate Joan Anderson, 55, said she’s excited to get to work supporting patients, especially from rural areas around where she lives in Albany.

“I feel like I’m equipped to go out and be that voice, be that person that our community needs so bad,” Anderson said. “I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned.”  

And someday, she wants to open an independent facility to offer a type of maternity care patients in Albany can’t currently get.

“A birthing center, because we do not have one here in southwest Georgia — at all.” 

In addition to providing support during and after childbirth, Anderson and her fellow graduates are also trained to assess patients’ daily needs and connect them with any other services they need to stay healthy, such as food assistance, mental healthcare resources, transportation to prenatal appointments, or breastfeeding assistance.

Their work is likely to have far-reaching ripple effects across the largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs a nonprofit organization in Southwest Georgia called SOWEGA Rising.

“So many of the graduates are part of church networks, they are part of community organizations, some of them are our government workers. They’re very connected,” Byrd said. “And I think that connectedness is what’s going to help them be successful moving forward.”