Growing Pains: Citywide Program to Expand Access to Doulas Hits a Crossroad

More than two years into a push by the Adams administration to expand access to maternal health, a program to provide free doula services to lower-income, pregnant New Yorkers is at a crossroads.

Taking steps to deliver on a campaign promise, Mayor Eric Adams announced the expansion of the Citywide Doula Initiative to 33 zip codes across the city in March 2022. Later that year, the City Council codified the program, passing a law that requires the city Department of Health to train doulas and provide their services for free to residents of “marginalized neighborhoods.”

That law is set to expire at the end of this month even as Adams touted in May that 1,900 families had doulas through the initiative. Currently, eight doula organizations, staffed by a little over 200 doulas, participate in the program, which the city says is funded through the next fiscal year even if the law expires.

Doulas offer a wide range of non-medical childbirth services, ranging from education for soon-to-be parents to physical and emotional support during delivery to information and assistance in the postpartum period. Community-based doulas who support higher risk pregnancies also advocate for patients as they navigate the medical system.

Community doulas who have participated in the initiative told THE CITY that while they appreciate the recognition of their work, they are also frustrated with aspects of the program, including with delays in payment.

The maximum amount reimbursed for a single client through the Citywide Doula Initiative is $1,600, but doulas are often reimbursed less if their clients don’t attend all sessions. (In the private sector, doulas can charge between $3,000 to $6,000 for a basic birth package.) Payment does not change regardless of how long a delivery lasts, and doulas interviewed for this story shared birthing experiences that ranged from four to 72 hours.

Adams has long said that expanding doula services is necessary to tackle yawning racial disparities in maternal health. The city’s own statistics show that Black women in New York City are four times more likely to die from pregnancy-related mortality issues, according to the most recent report .

Doulas participated in 4.1% of the city’s births in 2023, according to the Department of Health’s 2023 Doula Report, with the Citywide Doula Initiative providing doulas in nearly one-in-five of those births.

Department of Health data from March 2022 to May 2023 show that doula-assisted births often resulted in more favorable birthing outcomes, including lower cesarean and preterm birth rates.

“We need to give the program more time to grow,” said Councilmember Jennifer Gutierrez (D-Brooklyn), who sponsored the 2022 law. “Having had a doula I understand well how impactful it is to have an advocate in the room for you, the pregnant person,” she added.

Gutiérrez sent a letter, shared with THE CITY, to Department of Health Commissioner Dr. Ashwin Vasan on June 13, urging him to extend the doula program, something the law gives him the sole discretion to do.

The Department of Health says the program is currently not in jeopardy but didn’t offer information on its longer term plans. “This program is not expiring,” said a Department of Health spokesperson in an email to THE CITY. “Funding for doulas is baselined. The city’s health agenda, HealthyNYC, has reinforced our commitment to maternal health and birth equity. It is a core component of the administration’s health agenda.”

In a subsequent email the spokesperson clarified that the program is funded through fiscal year 2025.

‘You’re Not Just a Doula’

In interviews with THE CITY, doulas who found work through the Citywide Doula Initiative expressed a deep commitment to their clients, while also identifying challenges that come with serving lower-income birthing parents.

Christine George-Alexis, a doula for over two years, works with the Caribbean Women’s Health Association, which participates in the Citywide Doula Initiative. Her pregnancy support hours fall between 9 a.m. to 5 p.m. on weekdays, but she avails herself to clients calling about mysterious rashes, babies on sudden hunger strikes or just to vent at all hours, even if they’re several years postpartum.

“I tell my clients don’t text me, call me. It doesn’t matter if it’s four o’clock in the morning, if it’s important, call me,” George-Alexis said.

Pregnancy and birth are too glamorized, she said, adding that it’s her job to be real about the challenges that come along with having a baby under even the most privileged circumstances.

Community doulas like George-Alexis, who see clients from marginalized backgrounds, say they often support people who have faced violence during pregnancy or childbirth, housing insecurity, difficult medical histories, abusive partners or substance abuse disorders.

Community doulas spend significant unpaid time trying to help solve challenges faced by their clients, including connecting clients with housing assistance, benefits programs, childcare or job training.

Vickiana Peña, a doula who was part of the pilot program that evolved into the Citywide Doula Initiative, described the job as physically intense. Like many doulas, she works other jobs to make ends meet.

“When you’re a community doula, you’re not just a doula, you’re a therapist, a social worker, a big sister,” Pena said.

‘My Bills Are Due’

Doulas told THE CITY that the Citywide Doula Initiative and other government-funded programs have struggled to facilitate timely reimbursement for services, leaving them short on cash.

While the eight community organizations that form the Citywide Doula Initiative match doulas with clients, help facilitate paperwork and data collection, it is ultimately on the individual doulas to navigate the billing process with the city.

“If you really, truly cared, we shouldn’t be dealing with doulas not getting paid,” said Peña, who has since moved to a community doula collective in Bushwick, Brooklyn that’s not part of the Citywide Doula Initiative. Late last year, she took to Instagram to bring attention to the city’s months-long delays in payments.

“My bills are due and I need my money today,” she posted.

Peña called that moment her final straw, pushing her out of the program that she said struggled to scale up to meet the needs of both clients and doulas. She said the Citywide Doula Initiative was prone to losing paperwork and that she grew tired of “the same excuses.”

Reimbursement from the city for services rendered can take anywhere from two to three months to finally appear in the bank accounts of Citywide Doula Initiative doulas, according to program coordinators. At one point, reimbursement took as long as six to twelve months.

Reimbursement paperwork is tedious and can take hours to complete, as it’s often lumped in with extensive data collection used to track program metrics.

Coordinators say they set payment expectations from the outset, given the slow reimbursement schedule, and typically discourage doulas from relying solely on their income from that work.

“We let them know this isn’t like a job, you’re not going to get paid weekly or bi-weekly,” Nataly Morales, doula coordinator at Community Health Center of Richmond, said. “This is something different, you will get reimbursed for what you do but it’s not going to be right away.”

“We do this work from the heart,” said Morales, “and a lot of people are not complaining, because when you do it from your heart you’re not paying attention to how much you’re getting paid.”

The Caribbean Women’s Health Association floats payment to their doulas help keep their income consistent and morale high. But a budget shortfall in early 2022 forced the group to pause on taking on new clients, something Victoria St. Clair, of the group’s health department for women, said she hopes won’t happen again.

In early 2024, New York State expanded doula access to all Medicaid recipients, issuing a blanket referral to help streamline the process of connecting clients and doulas. But doulas told THE CITY that they worry that birthing parents who don’t qualify for Medicaid could be left out and unable to access free doula services, especially with the city law set to expire at the end of June.

The lengthy process for doulas to qualify as Medicaid providers has turned many off from accepting the payment in the first place. Others are hesitant to sign up for yet another reimbursement program given their previous experiences.

“I’m waiting to hear from other doulas about their experience with Medicaid before I sign up,” Peña said. “I know one doula who is fully certified to accept Medicaid but I don’t think they’ve taken on a client yet — it’s still so new.”

‘Two Peas in a Pod’

Without the help of her doula, Samantha Gordon, from Flatbush, Brooklyn, says she would have been lost. Searching online, she found the Citywide Doula Initiative, which in turn led her to Caribbean Women’s Health Association, just two blocks from her apartment, which matched her with George-Alexis.

“Luckily I found Christine because she was given to me and then we became two peas in a pod,” Gordon said.

Gordon’s daughter, Sunday, is just shy of a year old, with big eyes curious about every necklace worn by the women taking turns holding her.

Gordon continues to confidently grow into the role of Sunday’s mother, something she says would be impossible without a caring support structure.

“The other day she had a rash, I was like, Christine what can I do?” Gordon said.

Within seconds she had an answer.

“She’s still answering my phone calls and WhatsApp messages,” Gordon added.

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