The baby’s heart rate was fluctuating for minutes—more than the natural ebbs and flows that Natasha Sobers, a doula of seven and a half years based in San Antonio, was used to seeing in the delivery room. “My gut was telling me I needed to walk out and say something,” she said. “You always want to straddle this fine line of not wanting to tell someone how to do their job,  but it was enough to be concerned.”

A nurse who had stepped in during a shift change had increased her client’s levels of the labor-inducing drug Pitocin. When Sobers alerted the on-duty nurse about the concern, she was met with gratitude, and the nurse immediately lowered the drug level. In a postpartum birth conversation, Sobers learned that the client had also felt that something was going wrong. “But she said she saw my face, and she said, ‘I knew you were on top of it already.’ She was able to just refocus on her laboring and breathing.” Today the client is healthy; her baby will turn four this year.

Doulas are not medical professionals, and they don’t deliver babies. They provide continuous informational, emotional, and physical support for their pregnant clients. They play the roles of both coach and advocate before, during, and after birth. “Sometimes [clients] just want to be heard and listened to—and a lot of times in the hospital they’re not,” said Britney Harris, a member of the San Antonio Black Doula Collective. “And they feel overlooked, they feel like a number, they feel like nobody’s listening to them. The hospitals deal with so many different people; they don’t have the time to build a connection with the mother.”

And, as Sobers experienced, that connection can prove essential for the health of both mother and baby. “Ninety percent of [maternal] deaths here in Texas are preventable,” said Nikia Lawson, the previous president of DONA International, a leading doula-certification organization. “That prevention comes from interaction, engagement, and support.”

According to the CDC, Texas’s maternal mortality rate between 2018 and 2020 was 22.9 per 100,000 live births—the United States’ was 20.4. The Texas Maternal Mortality and Morbidity Review Committee’s 2022 report found that non-Hispanic Black women faced the worst mortality outcomes, with a rate of delivery hospitalizations involving severe maternal morbidity more than twice that of non-Hispanic white women. Research over the past decade has shown that having a doula in the room results in less need for medical interventions during birth, like cesarean sections and usage of pain medication, with some correlations suggesting lower risk for health complications. Harris, who goes by Coy Serenity in her doula work, argues that the informational support doulas provide is invaluable too.

“When I gave birth six years ago, I was uninformed,” said Harris. She thought she did everything she was supposed to do, listening and attending every doctor’s visit, but she didn’t realize how out of the loop she felt until after she had given birth. “I went home and my brain was everywhere. I went through postpartum depression, because there were so many things I didn’t know.”

Depending on location and experience, doula services can cost parents-to-be thousands of dollars; an Austin doula group‘s lowest full-service package starts at $1,000, while a Dallas collective‘s packages range from $1,900 up to $2,800. While some insurance companies across the country are starting to cover doula services—Rhode Island requires all insurance based in the state to reimburse up to $1,500, for example—the people who could benefit from doula care the most are often those without private insurance. Fourteen percent of non-Hispanic Black women in Texas are uninsured, and according to the CDC, Black women nationwide are three times more likely to die due to pregnancy complications than white women, due in part to inequitable quality of or access to health care, susceptibility to chronic health conditions, and structural racism and implicit bias in care.

“The number one issue on the reports that have come out from the maternal mortality review committee has always been access to care. Doula services are a way to tackle that issue,” said Democratic state representative Armando Walle, of Houston, who passed legislation in 2013 to create the state’s MMMRC and this session filed a bill that would provide statewide reimbursement for doulas through Medicaid. In 2020, Medicaid recipients accounted for half of the total births in Texas. With Medicaid coverage, an unprecedented number of women of color would have access to doula care.

According to the National Health Law Program’s Doula Medicaid Project, more than half of all states have taken or are in the process of taking statewide action to implement Medicaid-funded doula care. Democratic state representative Shawn Thierry, of Houston, this session sponsored House Bill 465, which would establish a pilot program for Medicaid coverage in two counties in the state: Harris, the state’s most populous county, and one yet to be determined that has the greatest maternal health support needs. The bill, which passed the House in mid-April and is now stalled in the Senate, is one of several Thierry filed this session concerning maternal health. “Doula care typically has been something that’s available based on your socioeconomic status,” she said. “We want to make sure that the most vulnerable population that we’re seeing would have access to this level of additional maternal care.”

While many doulas volunteer their services when they can or offer a sliding scale, those measures are often not sustainable. Sobers had to take a hiatus from doula work for a few years after the birth of her own child. Despite having another remote job at a digital health start-up and a large community of support, she couldn’t provide care that was affordable enough for lower-income clients while also building a sustainable practice. “If I had two degrees, a career, a community, and I still needed help—what about the people who don’t have those resources?” she said.

Without insurance reimbursement, “we’re doing it for pennies,” said Morgan Miles, a board member of the recently formed advocacy group Texas Doula Association. “We deserve to have a living wage to support our own families—to be able to support the families we work with.”

Maternal health–related legislation has been on the docket in Texas before, but this is the first session Texans are grappling with the reality of a state where almost all forms of abortion are illegal. A Medicaid extension of postpartum care from two months to six months passed out of the Senate last session, but movement has been paused by federal concern over some of the language in the extension request in regard to abortion. A new twelve-month extension proposal passed out of the House this month, but it has stalled in the Senate. “We can’t have a healthy baby without a healthy mom. It’s just vitally important that we support that mother if we claim to care about life,” Walle said. Even if you boil down doula reimbursement to just a fiscal standpoint, Thierry says it’s a no-brainer. “My number one goal is to improve maternal health outcomes and infant health outcomes, but for those who are only looking at it from a financial standpoint, bottom line, it makes good fiscal sense,” she said. “The healthier the mother, the baby, the less time they’ll be in a hospital setting, and that will drive down costs in our health-care system.”

Sobers went to the Texas Capitol in late April, joined by doulas from across the state, to meet with lawmakers and help carve a way forward. “We love this work,” she told them. “We know what the studies show: we’re saving lives, and we’re saving money for the programs and insurances.”