_Sarita Hendrix entered what she and her fellow doulas call “the birth world” after moving to Arkansas from her home state of California in 2010. Already a mother to one young child, she wanted to focus her career on supporting new mothers and their babies. She started working as a breastfeeding peer counselor with the Arkansas Department of Health in Little Rock. “I saw all kinds of women coming in for services, breastfeeding help,” she said. 

The women Hendrix counseled told her their stories. “Horror stories,” she said, “about their birth experiences.” Many spoke about the trauma of delivering by cesarean section. “Especially women of color,” she said. “Black and brown women . . . were coming in with more of the C-section stories than their white counterparts.” Hendrix knew that C-sections create a greater risk for postpartum complications, and she was dismayed by the volume of women she met daily who had delivered this way. She also knew that her observations reflected the broader landscape of healthcare disparities in Arkansas and in the United States. According to the Arkansas Center for Health Improvement, the C-section rate among first-time Black mothers is 32.5 percent. For first-time white mothers the rate is 26.7 percent. The National Bureau of Economic Research, in a 2024 study of nearly one million births, reported that healthy Black mothers are almost twenty-five percent more likely to deliver by unnecessary C-section. 

Recognizing these discrepancies in care, Hendrix hired a doula when she and her husband became pregnant with their third child. She had delivered their first baby back home in California, surrounded by family and under the care of a provider who supported her birthing plan. “I didn’t know what a doula was with my oldest,” she said. She didn’t know because, at the time, knowing wasn’t necessary. She hadn’t needed the kind of physical, emotional, and informational assistance that doulas are trained to provide. But in Arkansas, with a smaller support network and immersed in the field of maternal health, Hendrix saw the value of hiring a doula. She had even wanted to hire one with her second child, three years earlier, but she and her husband couldn’t afford the service. In Arkansas, the cost of a doula can range widely, but on average runs between five hundred and two thousand dollars, depending on the doula’s experience and location. (Last month, the governor signed a bill aimed at improving maternal care, part of which includes pathways to reimbursement for doulas and other community health workers. To date, though, most insurers, including Medicaid, do not reimburse doula services in Arkansas.) 

The delivery of Hendrix’s second child had been difficult, resulting in an emergency C-section that found her unprepared for what her body endured. “I was terrified,” she said. In Arkansas, Black women are nearly twice as likely to die from pregnancy-associated causes. Hendrix, who is Black, understood the statistical deck that was stacked against her. Even though she was educated in matters of labor and delivery, even though her experiences with her providers had been mostly positive, even though she and her second child had thrived after the emergency C-section, Hendrix insisted upon hiring a doula to help her navigate the complexities of her third pregnancy, which she wanted to deliver vaginally.

_According to the American Pregnancy Association, ninety percent of women who have delivered by C-section are candidates for vaginal delivery in the future. Although Vaginal Birth After Cesarean, or VBAC, rates in Arkansas have been rising, reaching 11.1 percent in 2023, the state still trails the national average of 15.1 percent. Research by the Arkansas Center for Health Improvement (ACHI) also indicates that where a pregnant person lives is directly correlated with the likelihood that she will deliver by C-section, with the rural southeastern corner of the state reaching rates as high as 45.6 percent. The varied rates by county are likely associated with disparate health risks among women as well as “the journey they experience through their pregnancy,” according to ACHI President and CEO Joe Thompson. That journey is heavily informed by access to consistent care and to providers who clearly communicate their patients’ options. “It’s just a matter of women having autonomy, being educated and talked to instead of talked at,” Hendrix said. “[If] you want to have a vaginal birth, there are certain questions that your provider should ask you. . . . But those questions aren’t necessarily being explored or asked of all patients.”  

Knowing that she wanted to pursue VBAC with her third child, Hendrix hired Nicolle Fletcher, a midwife and doula based in Conway, who helped her select a provider and hospital with a strong history of supporting VBAC birthing plans. Though doulas provide individualized care, their scope of work encompasses a range of non-medical interventions, including advocacy, emotional support, physical assistance during labor and delivery, lactation counseling, and informational help related to medical care and resources, among other things. In Hendrix’s case, Fletcher not only helped her choose her birthing location, she also informed her about a safe way to avoid an epidural. “She educated me about intermittent monitoring,” Hendrix said. “I didn’t have any health implications that required continuous monitoring of my baby, so the intermittent monitoring allowed me to be more mobile through labor, so I could get through pain management easier.” Fletcher also helped her secure a hospital room with a bathtub, which aligned with Hendrix’s birthing plan, and she attended the birth.

In the days and weeks after Hendrix returned home from the hospital, Fletcher called and visited based on the terms of their contract. These check-ins involved questions about Hendrix’s physical health—How was her bleeding? Was she experiencing headaches, dizziness, or tightness in her chest? Was she in pain? Was she sleeping when the baby slept?—but they also focused on her emotional wellbeing. “She was really there to be like, ‘Hey, just wanting to check in to make sure you’re not sad today. How are you adjusting? Who made you food today?’” This kind of holistic, community-based postpartum care is a significant aspect of a doula’s role in improving overall maternal-health outcomes. According to Arkansas’ Maternal Mortality Review Committee, the majority of pregnancy-associated deaths in the state occur after a woman has given birth—with 6.5 percent occurring in the first week postpartum, 14.5 percent occurring between seven and forty-two days postpartum, and 50.7 percent occurring between forty-three days and one year postpartum.

The benefits of doula-based care on maternal health are well documented. Studies have linked doulas to improved health outcomes among Medicaid patients, a reduction in cesarean births by thirty-nine percent, and an increase in spontaneous vaginal births by fifteen percent. Doula-based care has also been associated with reduced odds of postpartum depression and improved breastfeeding, which is linked to stronger infant health outcomes. These findings are pronounced among marginalized women, who are underrepresented in supervisory healthcare roles. A 2023 review of sixteen primary studies found that doulas helped diminish health disparities experienced by Black, refugee, and low-income women, while a Georgia-based study the same year found that matching doulas with clients from similar racial and ethnic backgrounds had a positive overall impact on client outcomes. Taking a more cynical perspective on these widespread benefits, researchers in 2023 modeled the cost-saving potential of integrating doula programs into the traditional healthcare system and projected up to $185 million saved in healthcare costs nationwide. To account for all this evidence pointing toward the efficacy of doula-based care, some scholars have started using the phrase, “the doula effect.”

_On an individual level, Hendrix immediately felt the advantages of her doula’s guidance, and she wanted to provide the same support to other women, particularly women of color. She was still breastfeeding when she began training with Fletcher and several other local doulas, in 2018. She also trained with DONA International, the world’s largest doula training and certification organization. Later the same year, Fletcher and Hendrix co-founded the Ujima Maternity Network, in Conway, with the goal of training more doulas who could bring care to at-risk communities around Arkansas. “Our focus is Black women and increasing the survival rate in our moms and babies,” Hendrix said. “Right now, Black women are afraid to have babies in the hospital, because we’re dying at a higher rate in the state. . . . A lot of my clients are scared they’re not going to go home.”

Though Ujima trains and serves women from all communities and ethnic backgrounds, the organization was founded in direct response to Arkansas’ poor maternal-health outcomes, which disproportionately affect people of color. “Our goal is to train women that look like us, to help women that look like us, because that’s also a part of the puzzle . . . we fare better with women that look like us.” Ujima is also responding to a critical demand. In 2024, the University of Arkansas for Medical Sciences (UAMS) identified fewer than fifty trained doulas in the state. To address this void, UAMS partnered with Ujima as well as the Doula Alliance of Arkansas—a coalition of doulas, midwives, OBGYNs, and maternal-health experts that includes both Hendrix and Fletcher as co-founding members—to provide scholarships that will train eighty new doulas in 2025 and two hundred by the end of 2026. All trainees who matriculate through the scholarship program will complete forty hours of in-person training with Ujima—offered in Conway, Springdale, Jonesboro, and Arkadelphia—virtual training with Birthing Beyond, as well as training in breastfeeding support, HIPAA, and CPR. 

Krista Langston, the executive director of community programs at UAMS who helped launch the training initiative, said that in addition to growing the number of doulas in Arkansas, a key goal of the project is to establish doula resources in areas of the state with low or no access to maternal care. “One question on our application is, ‘Where do you live?’ And then, ‘Where do you plan to serve?’” she said. “We’ve actually started to map that out as we begin to accept applicants, to make sure that . . . we’re choosing candidates who can serve some of those counties without birthing hospitals.” 

Nearly half of Arkansas’ counties are maternity-care deserts—areas without obstetric providers and without hospitals or birthing centers that offer obstetric care—according to the March of Dimes. Increasing the number of community-based doulas within these regions can help women without a consistent provider to better understand their physical and emotional needs. Community-based doulas can even help women improve their access to medical care by providing informational support. But they cannot be viewed by the state as replacements for adequate access to birthing facilities in rural areas. “The important thing to remember about a doula is that they do not provide any medical care,” Langston said. “Their role is very specific to providing emotional, physical, and informational support before and after pregnancy.” 

Some Arkansas doulas, including Hendrix and Fletcher, have also trained to become licensed midwives in the state, allowing them to provide medical interventions and facilitate home births. Though the line between doula and midwife is well defined. “I do not doula and midwife at the same time,” Hendrix said. When she is working in a midwifery capacity, Hendrix is also filling a void in care in Arkansas. According to the Department of Health, there are thirty-two licensed midwives and fifteen apprentices in the state.

In their capacities as doulas, and through the Ujima Maternity Network, Hendrix, Fletcher, and their team of more than fifteen doulas have built a robust training and mentorship network that centers community. In addition to the six-month, hands-on training required for certification, the group hosts free monthly gatherings for pregnant and postpartum women as well as community-outreach events open to anyone interested in learning more about the services doulas provide. Ujima also facilitates weekend retreats for doula trainees, during which they engage in role-playing exercises that help prepare them for their doula certification exam. “Everybody’s connected to a mentor,” Hendrix said. “At the end, you have a whole community. You have the whole Ujima Maternity Network to lean on.” This approach fosters professional collaboration. When one of Hendrix’s clients wants to establish a fitness plan, for example, she calls the colleague who prioritizes working out with her clients. When another doula in her network wants to connect a client with lactation support, she calls Hendrix.

_Recently, one of Hendrix’s clients visited her OBGYN for a routine appointment. The doctor instructed her to go to a nearby hospital for observation, without informing her further. Her husband was at work and her phone was quickly losing its charge, so she drove herself to the hospital. Upon her arrival, she was told that her doctor had instructed the hospital staff to prepare her for a C-section.

Alone at the hospital, feeling confused and frightened by the surprise news that she would need major surgery, she used the last of her phone’s battery life to call Hendrix, who was able to talk her through what would happen during the procedure. “[I was] able to articulate firsthand on what that process looks like,” said Hendrix. She told her client, “Your legs might start itching when you’re on the table to get a C-section. You might feel, you know, overwhelmed with all the stuff on you, but you’re okay. The anesthesiologist can see your breathing and your heart rate.” When she hung up, Hendrix alerted her client’s husband and mother, then rushed to the hospital. “It’s situations like that where having a doula makes a huge difference,” she said.