How Doulas Are Carrying Some Of The Black Maternal Health Weight

“I wish someone were there to explain everything to me,” Riveline Alexandre said, reflecting on the traumatic experience of giving birth to her son without a doula. Riveline has since become a full-time doula. Her primary motivation for training was to give back to women like herself, who may lack access to maternal healthcare and support.

New York City and State governments have spent the past several years creating legislation to address longstanding racial disparities within the healthcare system, specifically to make childbearing less dangerous for Black mothers. New York State’s 2023-24 Executive Budget expanded Medicaid coverage of preventative care, transforming doula services from the original 2019 Erie/Kings County pilot program into statewide, permanent coverage. As of March 1, 2024, New York State Medicaid covers doula services for pregnant, birthing, and postpartum people. To support access to services, the Department maintains a directory of doulas enrolled to provide covered services to Medicaid members.

Riveline Alexandre

Listed number eight in the doula directory is Riveline, who has been working as a doula for Medicaid recipients for one year in New York City. Riveline has witnessed firsthand the drastic changes in access to maternal care for her patients since the Medicaid cuts under the Trump administration. 

Riveline’s apprenticeship consisted of training courses and required her to attend three births. “Not only do doulas provide emotional support, but they can navigate you to different resources like prenatal education and postpartum care,” Riveline explained. Doulas provide critical education for expecting mothers who may not otherwise have access to such vital resources. Riveline shows pictures to her clients so they can see visuals and be prepared for cervical dilation, for example. Some clients may not be able to read or write, but doulas are well-educated enough to advocate for their patients and share critical birth and postpartum information.

Riveline emphasized that women need to know the signs of complications post-birth, a situation that can be life-or-death. “I have so many children, nieces and nephews,” Riveline said, referring to all of the children she has helped birth. Riveline enjoys small, simple acts of kindness, like bringing new mothers a plate of food after giving birth. After discharge, Riveline will carry their stroller, bags, and car seat down the stairs for them. 

“I do everything people never did for me. Just the other day, it was raining, and I was carrying all this stuff by myself down three flights of stairs,” Riveline said. Doula work is essential to provide vulnerable mothers with the relief of reliable support. “Whether you are the president’s daughter or somebody from the street, you are a woman and deserve quality care,” Riveline said.

Medicaid Funding Cuts

On July 4, 2025, President Trump signed the One Big Beautiful Bill Act (OBBBA) into law cutting nearly $1 trillion of Medicaid funding and restricting access to maternal healthcare. More than 2 million New Yorkers are expected to lose coverage over the next year—1.3 million will lose Medicaid due to new eligibility and verification hurdles, an additional 730,000 non-citizens will lose Essential Plan coverage as over half its federal funding is being eliminated. On July 1, nearly 450,000 New Yorkers became uninsured. 

The Greater New York Hospital Association (GNYHA) and The Healthcare Association of New York State (HANYS) estimate that cuts total roughly $8 billion to hospitals and threaten 34,000 hospital jobs which leaves “non-mandatory” Medicaid benefits (including doula coverage, which many states treat as optional) vulnerable in future budget cycles.

NYC’s Citywide Doula Initiative

In September of 2022, Mayor Eric Adams signed legislation providing doula services across the five boroughs to strengthen the city’s approach to maternal healthcare. It remains unclear whether the Adams-era Citywide Doula Initiative remains a budget priority under Mayor Mamdani. Mamdani’s first major public health project is a $20 million effort to expand the Nurse-Family Partnership (NFP) program. NFP aims to connect more families to visits from registered nurses that support healthy pregnancies and provide mental health resources.

Barriers to Care

Reimbursement rates for doula services remain an access barrier. Hiring a birth doula costs $1,500 per pregnancy in NYC and $1,350 elsewhere in the state, and doulas report this doesn’t match the time and effort required, causing some to opt out of Medicaid and only serve clients who can pay out-of-pocket—which disproportionately hurts the low-income, often Black clients the benefit was designed for. 

It took two months for Riveline to receive the payment for the doula services she provided to one Medicare patient. “You come home at the end of the day, and you’re too tired to fight the corporations. We are fighting everyone: doctors, residents, attendings, for clients…we can’t fight for ourselves,” Riveline said. 

Preventative Care

Riveline’s traumatic birth story, inspiring her to become a doula, reveals serious issues within the United States healthcare system, which often fails patients, particularly women of color. Traditionally, healthcare professionals are trained to provide physical labor and to effectively diagnose and treat a huge variety of conditions. But Riveline’s story exposes the critical need to improve preventative healthcare, patient education, and counseling. 

“The healthcare system has failed me tremendously,” Riveline said. Before the birth of her son, Rieline had never heard of a doula. Now trained as a doula, she’s even thinking of becoming a doctor so that she can have more control over decision-making during the birthing process. Riveline expressed that as a working doula, she often finds herself fighting with doctors for the rights of their patients. 

Faith

“It’s because of my faith in God that I do this,” Riveline said, “When you see the faces on the mothers holding their babies, and they tell me, ‘if you weren’t here, I don’t know what I would do.’” When Riveline gave birth to her son she had no confidence to speak up for herself; she had no voice. For Riveline, doula work is incredibly rewarding because she can help women avoid birth trauma, especially first-time mothers who have no prior knowledge or experience. “This is important because it’s like me giving back to the person I used to be,” Riveline said. Despite the unpredictable hours and delayed compensation, Riveline continues doing doula work every day because it puts her at peace, and she finds it fulfilling. 

The U.S. has one of the highest maternal mortality rates among high-income countries in the world, and over 80% of these maternal deaths are preventable. Birth outcomes are significantly worse for Black women, who are three to four times more likely to die from pregnancy-related complications compared to white women, according to the CDC. When vulnerable, expecting mothers see a passionate, confident doula like Riveline walk into the sterile hospital room, the energy starts to shift; mothers find courage and resilience within themselves. “I gain a new strength from them. I always iron my clothes,” Riveline said.