Doulas, Racism, and Whiteness: How Birth Support Workers Process Advocacy towards Women of Color

: Systemic racism is embedded in healthcare settings and is linked to high maternal mortality rates for Black women in US Society. Doulas, or birth support workers, are uniquely positioned to advocate for women of color going through the birthing process, but little is understood on how doulas come to terms with race, racism, and whiteness in maternal healthcare settings. Using qualitative in-depth interviews with 11 doulas in northeast Florida, this research study found that doulas’ advocacy for maternal justice leads to an intersection with racial justice through their support of minority women clients. Doulas shared stories of racial injustice when they compared their white and Black client experiences, leading to shifting strategies to address racism in maternal healthcare settings. Doulas also grappled with their connection to whiteness through their own identities and interaction with white and minority clients. Many doulas shared a need for anti-racism training and recruitment of Black doulas to meet the needs of women of color going through the birthing process.


Introduction
Systemic racism is significant factor in the United States (US) healthcare system that leads to worse health outcomes for racial minorities [1,2]. In maternal healthcare, persons of color are often pressured to undergo medical interventions at a high rate leading to unsafe birth outcomes [3]. In fact, research has found that birthing people, in US hospitals, deal with disrespect, discrimination, abuse, and high stress through power dynamics in their interactions with medical personnel [4][5][6].
Currently, women of color disproportionately face poor maternal health outcomes and are particularly vulnerable to traumatic birth experiences, high rates of medical interventions during childbirth, and high rates of maternal mortality [7]. Many lack the support needed to effectively navigate the complex maternal health care system due to the historical suppression of advocacy and the pressure for institutions to prioritize speed and efficiency of labor and delivery [8]. The costs of birthing in the US are high and, without the needed advocacy of peers such as doula birth support workers, women are inadvertently silenced and undergo often unnecessary medical procedures, leading to a cascade of interventions that can potentially cause more harm [9].
The presence of a doula, or support person during pregnancy, birth, and postpartum, has been shown to alleviate the burden of accessing proper treatment, increase the quality of prenatal care, and improve confidence in and satisfaction of the birthing process, especially among families holding a low socioeconomic status [10,11]. Doulas often serve as advocates and proponents of social justice to those with limited experience or understanding of the complexities of pregnancies and childbirth within the many layers of the US healthcare system [12]. The informational, emotional, and physical support provided by doulas has contributed to lowered rates of cesarean births, decreased maternal distress, and appropriately mediated communication with providers between people of color and those who experience cultural or linguistic barriers [13][14][15][16][17].
Research has shown that the majority of birthing persons does not use doula services and, although there is a growing interest in hiring doulas, there continues to be financial and educational barriers on accessing these services [6,18]. Furthermore, studies have shown that the doula community is predominately white, often not covered by health insurance, and primarily serves white middle class women [6,19].
In more recent years, the doula community has become more diverse, with research finding that there is growing movement including Black and Latina doula support workers that serve their communities of color [20]. In fact, research has examined the multifaceted experiences of the benefit of doulas in the prenatal care, birthing experiences, and postpartum support in communities of color [4,5,7]. Research has also explored the impact of doulas on maternal health outcomes for women of color, including the ways doulas mediate racism and help contribute towards a sense of empowerment for these groups [3].
Limited research exists that focuses on the racial identities of white doulas and how they navigate their own whiteness in the context of their doula work and birth support. Whiteness plays an integral role in doula interactions, privileges, and access to resources for their minority clients. The interaction of doulas with diverse clients challenges the traditional homogeneity of social relationships among white groups and exposes them to the realities of the burdens in maternal health faced by women of color. Their understanding of their racial identity can be the source of allyship for improving the experiences, birth satisfaction, and availability of pertinent health knowledge and resources for their minority clients, so that they can truly have an advocate who recognizes the underpinnings of racial interactions and are cognizant of their roles in promoting justice. Historically, midwives have been the primary professionals that supported women going through the birthing process [21][22][23]. Midwifery traditions have existed across various cultures led primarily by women who were seen as healers and had participated in social births with traditions found in indigenous, African, and European variations, often commonplace in early America until the late antebellum period [21,24]. These midwifery traditions became heavily suppressed through the medicalization of birthing that favored white male doctors as proper credentialed professionals to oversee delivering pregnancies [24]. Scholars have termed this the emergence of the medical model in birthing, where pregnancy was viewed largely as a medical condition needing hospital-based interventions to ensure appropriate care [8,25]. It was not until the 1970s that a social movement focusing on women's health led to the reemergence of midwifery care during pregnancy and birth and challenged the need for unnecessary medical interventions-many of which were later recognized to be invasive, dehumanizing practices towards birthing persons [12].
Alongside the rise in midwifery, doula professionals also emerged as an essential part of the birth team. Doulas are trained and often certified birth support workers who provide nonmedical support during pregnancy, childbirth, and early postpartum care [12]. Doula workers are viewed as advocates for centering the needs of women during birth and as tied to social activism to empower women [2,12]. Their primary role is to provide emotional and physical support for birthing persons across various settings (e.g., home births, birth centers, and hospitals) and to help their clients vocalize their needs and encourage confidence and mental preparedness for the birth process.

Exploring Medical and Obstetric Racism
The midwifery and doula movement has been crucial in challenging obstetric violence through the way they mitigate the existing pressure on women to have medical interventions [26,27]. Obstetric violence [26] refers to frequent medical interventions aiming to alleviate women from the "ailments" of pregnancy consisting of invasive interventions that result in higher Cesarian section (C-section) rates and worse maternal health interventions [26]. Obstetric violence is very significant when considering the extent of race and racism in US medical history.
For instance, medical racism has been argued to be foundational for the way in which the US healthcare system has treated people of color [1,28]. In fact, the origins of obstetrics and gynecology are tied to medical violence preformed on enslaved Black women's bodies [28][29][30]. Racism has also been tied to the maternal healthcare outcomes of Black women that experience higher rates of medical interventions [3,31]. Davis (2019) conceptualizes obstetric racism to understand the way in which Black women are treated in these maternal clinical settings.
[Obstetric racism] includes, but is not limited to, critical lapses in diagnosis; being neglectful, dismissive, or disrespectful; casing pain; and engaging in medical abuse through coercion to perform procedures or performing procedures without consent. . . Obstetric racism emerges specifically in reproductive care and places Black women and their infants at risk [3]. (p. 562) These harmful conditions show that the treatment of Black women and other women of color is shaped through obstetric racism, creating specific conditions of racial inequality that must be significantly addressed by the medical community as well as by birth support workers. Davis (2019) finds that doulas can mitigate the conditions of obstetric racism through their support of Black women in these settings.
Fortunately, doulas already receive in-depth training to support birthing persons and take a holistic approach to center the non-medical physical, social, and emotional needs of their clients. They are acutely aware of the factors of obstetric violence and how to mitigate unnecessary interventions as well as helping their clients achieve the birth they are seeking [12]. Because of their background, doulas also have the potential to step in with the critical voice in support of women dealing with racism and mistreatment. Research has found that anti-racist advocacy, particularly amongst doulas of color, merges maternal justice with social justice to provide healthier birth experiences and outcomes [12].
Notably, the current birth justice movement has gained insight from Black doulas and midwives who have pushed to support awareness and accesses to birth support services for the Black community [32,33]. In fact, the term "reproductive justice" was coined by women of color who have significantly shifted the focus towards challenging racial inequality in maternal healthcare [34]. Efforts focused on empowering low-income women of color can be seen through midwife and doula organizations offering alternatives models to bring care to those who need it [35]. For instance, Jennie Joseph, in Florida, provides a non-profit organization that focuses on low-income women of color, a practical model for addressing their needs and overcoming the existing structures of racism, sexism, and classism that perpetuate these unequal outcomes towards birthing persons [35]. Research has also pointed to the community-based doula support models as able to reach these populations, especially during the COVID-19 pandemic era [36]. These alternative doula access models have made inroads with communities of color to help provide their birthing needs that overcome traditional and costly models out of reach for many birthing clients.
The emergence of Black-led midwife and doula services has made progress and offers potential to significantly impact the existing birth support community that consists mostly of white doulas. In order to maximize the access to doula support, it is important to consider that many white doulas, while active in the birth movement, may not have received the significant training on race and racism to support birthing persons of color. There is a need to understand how white doulas engage with race, how their focus on maternal healthcare justice can potentially translate into racial justice, and how they grapple with their own whiteness in clinical settings. As the predominate doula service providers, white women have an opportunity to challenge whiteness and disrupt the normalization of obstetric racism to better support birthing persons of color.

Doulas and Whiteness
While there are significant benefits to doula care during pregnancy and birth, the reemergence of midwifery and the rise of the doula movement have primarily taken place in the white middle-class community [37]. The majority of doulas are white women, their origin being tied to the second-wave feminism of the 1960s and 1970s that led to the reemergence of the birthing movement [12]. For all of the benefits doula services bring, the majority of their support is primarily going towards the white middle class community for several reasons. First, white women have led the return of midwifery and doula work and they are often the most certified birth support workers that focus on providing these services based on their existing networks in the white community [12,37]. Second, doula services are not often covered by insurance and require out-of-pocket expenses that lead to a concentration of white middle class women that can afford to retain these services [38]. Third, while there has been an emergence of women of color in the doula movement, many communities of color are not as aware of these doula services and are often outside of their financial reach due to insurance not covering doula support [37,38].
Therefore, the majority of doula work is seldom benefitting those with the highest need of support. Black women, in particular, face much higher risks and worse maternal healthcare outcomes than white women [5]. When white doulas bring support for white middle-class clients, they are often advocating for safer birthing and less medical interventions, yet their services are not as easily accessible for Black women. Due to racial segregation in US society [39], white doulas may not have access to social networks which include Black clients and may have less of a presence in advocacy efforts within communities of color.
Furthermore, there is little understanding of how white doulas view race, racism, and whiteness. Leading critical race perspectives point to color-evasive ideologies [40] as common in the healthcare industry [41,42], along with a poor understanding of health disparities as well as obstetric racism amongst healthcare workers [3]. In addition, there is a little understanding of how white doulas may practice antiracism perspectives along with critical reflections on white privilege. In order to spread the usefulness of white doula services towards racial minorities, these concerns must be addressed to understand how the white doula holistic birth support system can better support the Black community.
To explore these concerns, the present study focuses on examining the doula perspective on racial issues in their birth support of women of color. The research study is guided by the following questions: How do doulas navigate issues of race and racism to support women of color in maternal healthcare settings? How do doulas navigate whiteness through their advocacy towards supporting women of color giving birth in maternal healthcare settings?

Study Design
This is an exploratory study that used a qualitative methodological approach, consisting of in-depth interviews and thematic analyses. Interviews were conducted with 11 doulas to determine perspectives of race in maternal healthcare settings. Verbal consent was obtained for all study participants. This study was approved by the University of North Florida Office of Research and Sponsored Programs Institutional Review Board.

Research Team and Reflexivity
The interviews were coordinated by the first author (J.L.S.), an Assistant Professor of sociology, and by M.K., a graduate research assistant and practicing doula. As a white female with training in qualitative methodology and a certified doula, she was able to assist with the recruitment of doulas and encourage participation in this study. M.K. was involved in connecting with the doula participants in ways that made them feel comfortable sharing their racial views. The interviewer's positionality as a graduate research assistant and practicing doula, as well as a white woman, offered her unique connections on approaching often hidden topics of racial experiences and views from white doulas. These commonalities provided opportunities to co-construct knowledge through shared experiences in ways that allowed more informal discussions and connections on racial issues to be performed [43]. For instance, having to address race encouraged white doulas to share how they grapple with their own whiteness and racial inequality from a position of privilege in their doula experiences.

Recruitment and Setting
Doulas were recruited based on local community connections with varying levels of experience via snowball and convenience sampling. The eligibility for participation included adults (18 years and older) who were doulas or doulas-in-training, actively providing care and support to clients. While we highlighted the study's focus on advocacy for women of color, we opened the study to all doulas who were willing to speak about their challenges and perspectives on racialized encounters in healthcare settings.
Participants were contacted via phone or email based on local community organizations. Interviews were scheduled based on participant availability. Out of the fifteen individuals approached, eleven agreed to participate in the study and completed the interviews. Due to the COVID-19 pandemic, all interviews were arranged via audio teleconferencing through a secured, password-protected Zoom link. The interviews lasted from 1 to 1.5 h. No personal identifying information was collected from participants or the hospitals or organizations in which they were employed or provided services. All doula participants were women and there were 6 white doulas, 4 Black doulas, and 1 Latina doula in this study. The doulas were primarily working through the predominant model of doula services, which focus on providing doula birthing support for a fee that is not covered by medical insurance and often outside the reach of low-income birthing persons. All doula participants were given pseudonyms in order to keep their identity confidential.

Data Collection and Analysis
The in-depth interviews took place between July and October of 2020. Data saturation was considered reached after these eleven interviews were conducted. The design of the semi-structured guide with select questions found in Table 1 was guided by existing literature on racial identity and pilot interviews with local doulas. In-depth interviews allowed for doulas to express thoughts, opinions, and conceptualizations of their work and identities in their roles as a doula. The recorded interviews were transcribed verbatim using Otter.ai transcription software and analyzed using inductive code methodology through a qualitative approach [44,45]. Initial coding was determined independently by line-by-line coding by all study authors (J.L.S., M.S. and M.K.), who also met to discuss findings and resolve any discrepancies to maintain reliability. A codebook was developed and refined after each transcript was further coded by J.S. and M.S. Next, axial coding was used using constant comparative strategies to ensure data accuracy and agreement. Finalized results were synthesized through theoretical coding as major themes to capture the broader conceptual findings and patterns in the data which are reported in detail in the next section. What is the most important thing you do as a doula?
Racial Interactions

3.
Have you ever assisted a client in navigating a power struggle with a health care provider? Have you ever felt yourself in a power struggle with a health care provider? 4.
In general, in what ways do you feel race has an impact on your work and experiences as a Doula? 5.
What kind of influence do you feel race may have in your clients' healthcare experiences?
Is there anything doula organizations could do that would better help you or your clients in dealing with challenging births? 7.
What advice (personal and/or professional) would you give a new doula who wants to work primarily with minority clients in north Florida? 8.
In general, what are the biggest barriers women face in achieving the kinds of birth experiences they desire?
Ideally, what changes do you think would be necessary to improve birth in the area for women and families of color?

Results
Overall, this study explored the racial experiences of white and Black doulas through their support of birthing persons in maternal healthcare settings. They shared insights on the process of race, racism, and whiteness in these settings, along with recommendations for improving advocacy. The four major themes from the data findings include (1) anti-Black racism in maternal healthcare, (2) racial power struggles in clinical settings, (3) doulas navigating whiteness, and (4) doulas and the potential for advocacy.

Anti-Black Racism in Maternal Healthcare
In this first broad theme, doulas shared a consistent pattern of anti-Black racism in maternal healthcare settings coming from medical professionals such as doctors and nurses, along with medical staff. Although there are good intentions by medical personnel, doulas had numerous examples they shared regarding subtle differential treatment that led to worse outcomes for Black women.

Pushing Interventions onto Black Women
Doulas often spoke about differences they see in the way their Black clients are treated in maternal healthcare settings. They described doctors and nurses as having good intentions but not really centering the needs of Black women, often leading to more interventions than necessary. For instance, many doulas described doctors and nurses pushing the labor-inducing drug Pitocin to quicken up the process and, while both white and Black women were asked, it was Black women who are pushed more frequently. One doula described the following comparison: For my client, it was definitely, like, clear to me and the racial struggle that she was going through because none of my white clients had been pressured, like multiple times for something that they had already said that they didn't want. So that was very clear to me. (Pam, Black doula) There was a trend of Black women being pressured to take certain medications to hurry along the birthing process. This included nurses and doctors bringing up interventions more so than with white women, as if the concerns of Black women were not considered when making these decisions. The increasing forms of these intervention has led to higher rates of C-sections as well as more problems associated with the birthing process.
A Black doula explained that she felt her Black client felt it was necessary to schedule an early C-section, even though the doctor and doula felt that it was too big of a risk when the baby may not have been ready to be delivered. While trying to support the views of the mother, the doula noticed that the medical personnel too easily gave into the Black woman, as she explained in the following: You know, like, this was a mom that there was a lot of drama surrounding her birth, um, and her pregnancy. And I feel like she was very vocal to anybody that would listen to this, this situation. And I think that you know, like. . . (pause) I don't want to, I don't know if it was like that racism played a part in it, but I feel like it could have been a stereotype-(quietly) yeah that's racism. So, it was like, she was kind of being stereotyped into being like this loud, Black obnoxious woman who saw overly, you know, like, she's always bringing drama and problems, and so to satisfy her and not having to deal with her anymore. (Jenny, Black doula) The doula shared that she felt her client was seen as the stereotype of an angry Black woman and too little was done to counsel her and meet her needs in ways that did not promote risky interventions. This Black doula was conscious of the way the personnel was viewing and treating her client, giving in too easily to her demands for an early C-section as a way of moving on and neglecting their duty to provide a safe environment. The desires of the mother fell in line with the interventionist' perspective of the doctors operating out of the medical model and not enough was done to work with them to support a natural birth. The doula explained this as a form of racial inequality when compared to how white clients were treated where their needs were met.

Black Women Tolerate More Pain
Another perception among doulas was the idea that nurses often did not see Black women as being able to feel as much pain as white women. Doulas were very conscious of this process and saw trends in the way Black women were treated in these settings. One doula shared the following on the way Black women were treated concerning their pain during the birthing process: Yeah. And it goes back into like how Black women aren't given pain medication, like the lapse between men and women is significant, but then even more significant, or equally significant between white women and Black women. And so that I think has a lot to do with maybe the maternal death rate in the hospitals. It's just that there Like, oh, we're not going to respect her pain. We're not going to respect her. If she's noticing a sensation, we're going to dismiss it. (Sara, white doula) Doulas shared there were differences in the way pain was seen to impact minority women, connecting this to broader problems with maternal healthcare. They noticed that the perceptions of pain from Black women were not considered in the same way when compared to when white women shared their pain.

Racial Power Struggles in Medical Settings
In this second broad theme, doulas spoke about racialized power struggles in clinical settings, often resulting from tensions between the interests of medical personnel and the desires of the birthing person and their doula advocate. These power struggles were often racialized as they resulted in worse treatment towards minority women.

Tensions between Nurses and Doulas
Doulas shared experiencing racial tensions in clinical settings, often through the interactions with nurses, doctors, and personnel. There were different practices between nurses and doulas that led to tensions that were racialized through the way minority women were treated in these settings. A doula explained the following: I feel like I was prepared to an extent but the first experience that I witnessed, definitely it opened my eyes and is actually what like, made me like truly get into like anti-racism work. Just because I saw, you know, I was seeing in my work every day, the struggle that these women were facing just because of the color of their skin. So that is what was like my reality check of okay, this is something I need to look into. So that was what was really drawing me to start the work of, you know, just learning more about the marginalized communities and what way I could show up to serve them. (Olivia, Black doula) Doulas began to see a pattern of racial inequality and the need for anti-racist strategies in these settings. Going through the birthing process already brings social tension and stress and it is magnified through racism in maternal healthcare settings. The doulas were seeing the mistreatment through their Black clients and they linked this to the burdens faced by the Black community in the local area.

Doulas Advocating for Black Clients
Doulas also expressed how they handled racial power struggles by carving out a space against unequal treatment that exists in maternal healthcare settings that they were noticing when they compared their white and black clients. For instance, Pam, a Black doula, shared an experience on how she stepped in to ensure her Black clients received the same treatment from nurses as her white clients. Doulas are situated in a space where they can see the racial inequality occurring between their white and Black clients and can pick up on these subtle differences. Pam pointed to an "atmosphere" among the healthcare setting that could be detected in the preferential treatment of white clients who were taken more seriously as their needs were better met. It takes advocacy to bring in equal treatment and challenge medical personnel, even if it means breaking established social norms and existing power dynamics when nurses withhold equal treatment.

Doulas Navigating Whiteness
The third broad theme analyzed was a reflection on the conditions of whiteness in clinical settings, where doulas either had to navigate white clinical settings, or even reflect upon their own white identity in the spaces as they advocated for women of color. Both white and Black doulas shared their experiences dealing with whiteness as they interacted in these clinical spaces.

White Doulas Reflecting on Whiteness
Both white and Black doulas shared in-depth reflections on whiteness in maternal healthcare settings, exploring the impact of privilege and entitlement coming from white people involved in the birthing process. Many white doulas shared complex reflections on their own racial identities and the challenges that exist in advocating for Black women clients. One white doula shared the following: Sometimes as a white woman, I don't feel like I'm equipped to deal with, you know, the sensitivities that Black women have it harder they just do. And I come in with privilege and I don't, I feel sometimes like I'm out of my of my league like I don't know how to sympathize with certain issues and I can I can try it. But when it comes down to it, you know, it really is just about experience and about communication, and about putting yourself in those situations where you can gain the knowledge to serve people better. But in the system we have we I don't feel like I get enough of those opportunities. And I really do feel like doulas are sort of considered like elite. It's like something that rich white women do. And we don't have the reach out or the outreach to serve the people who really need it the most. (Stacy, white doula) White doulas were found to grapple with the impact of the whiteness and experience when it came to barriers towards supporting women of color. These doulas acknowledged privilege and racial inequalities in society, they saw that their clients tended to be more frequently elite and white, that they were being paid by wealthier communities and how the concerns of communities of color were not at the forefront when it came to their work as doulas. In another example, a white doula also shared that she felt that it was not her place to serve Black clients because she had not lived and experienced their perspective to provide them with the best support they needed.
I feel ill equipped. I feel like I, I can't experience what it's like to be a Black woman, and it's not part of our training. . . I would never not take on a Black client ever because of that. Yeah, but I know that would be in me that would be an insecurity of mine. Like, I would be like, Oh, no, what am I doing wrong? What if I can't support her in a way she needs like? So I, I guess it would if I'm being honest, I would feel more comfortable with the white client because of that, you know what I'm saying? Yeah, which is like, which is come but it would never ever never show outwardly. It would I would I would never it's not a real feeling in me. It's more of a like just that we are so like, segregated and we are so society. Yeah. . . it has revealed a huge empty spot where, you know, I always just sort of thought because I read the books, and I had heard the accounts and all of this that I had experience, but I actually really haven't with Black women and birth. You know what I'm saying? (Ivy, white doula) This doula was forthcoming with her feelings on supporting Black women and how she felt she was ill equipped. She came to terms with her own whiteness and began to articulate how more training is needed to understand how to provide the support women of color need in these settings. She was astonished at the gap of understanding she felt when asked these questions on racial inequality in maternal healthcare settings.

Doulas of Color Impacted by Whiteness
Black doulas explained the problem of having to manage their image in these white maternal health spaces. One shared the following experience: Race impacts my practice as a doula in how I am received at the hospitals um, I try to be as you know, like bubbly and open and you know, like helpful to the nurses as I can be so that they feel more confident in allowing me to do my work while I'm there. (Jenny, Black Doula) Having to change persona is a strategy to present oneself as likeable by nurse and staff. This is a way to maintain legitimacy in a space where one is not seen as acceptable to attend. In the next example, a Latina doula shared a sentiment about being white-passing in these settings and empathizing with the clients who had to stay more concerned with racism while being pregnant in these settings.
Because it's probably not just in midwifery it may be even in the medical world. I mean, I'm sure it's in the medical world. I'm sure it is absolutely. But these things are just like mind boggling. And really like. . . sad. that, like, when none of us choose how we're born, and none of us choose the color of skin we get into, and literally by choice chance, or luck or whatever, and it's not even lucky. Like it's not like I'm lucky because I have my color skin. I just happen to be living in a period of time that with this color of skin, I get treated a little bit better. Then a minority. . . had I looked like my cousins. . . then it would be a whole different world. (Sophia, Latina doula) This Latina doula discussed being "white-passing" and how she was often let into spaces where she felt others assumes she was white. She mentioned noticing differences in the way people spoke about racial issues when others believed she was white. She processed her connection to whiteness in these settings and empathized with women that were racialized that were experiencing a different world she was beginning to acknowledge. In the next example, a Black doula laid out how white women need to address racism and get into anti-racist work.
I think the layer of white women doing the work and truly addressing their racism and working to become anti-racist matters because I don't think it's fair to show up and serve a client that you don't have any connection to in any way of learning about how they've felt oppressed or not heard. (Zoe, Black doula) Black doulas were aware of the racial inequality that exists and explained that white doulas should engage in anti-racism and learn about the concerns about racial inequality faced by women of color.

Doulas and the Potential for Advocacy
The fourth broad theme was doulas and the potential for advocacy, as they were very committed to maternal healthcare justice; many emphasized the need to center Black doula leadership and engage in training to reduce racial inequality.

Centering Black Doula Leadership
Doulas advocated for increasing the involvement of Black doulas in positions of leadership to move the profession of birth support workers away from an exclusive white middle class community and begin impacting communities of color. Many shared ideas for how to bring about significant change in doula services.
Hopefully we will start seeing more Black women, you know, in these roles of doula trainers, not just in the classroom to be a doula. And I think that's something that will help change the narrative surrounding doula work in general, too, because that's something I think we face here with having such a, you know, there is such a population that needs to be served of young Black women here. And I think that if there were more Black doulas, who are accessible to them they would take that care so I think that's a layer to it that hopefully in our lifetime we'll start to see that shift on that scale I think would be huge. (Melissa, white doula) Doulas advocated for the presence of more Black doulas from the community. They saw less Black women involved in doula services and training, meaning concerns of racial inequality were poorly dealt with or remained unspoken topics in training. Another issue addressed is that not everyone could afford doula services and they were often not covered by health insurance. There needs to be more resources to support the work of doulas that work with minority clients from working class backgrounds.
Yeah. So outreach and then making it affordable. So doulas being willing to give their time for free or for cheap. Having a scholarship program set up and not even just for women to become doulas, but for women to acquire doulas even if it's like, you know, because like we said people need to live and if we want, if we can't expect something like just a person to take all free clients, so if there's some way that we could set it up where like the doula gets paid, even if it's just a little bit so that they can take on more clients. (Kate, white doula) Doulas are often coming from these same communities; they need this training and payment to support this career path. Often taking several clients per month, doulas provide support before, during, and post-birth, giving the necessary advice and support for birthing persons. It is difficult to navigate this system with free or low-cost services, creating a gap between who can afford doulas and who cannot.

Discussion
The findings in this study explore the racial experiences of doula workers as they support their birthing clients in northeast Florida in the United States. This research study contributes to the existing literature as it provides context on how doulas navigate race and racism in maternal healthcare settings as they process advocacy for Black women.
This study demonstrates that, through their advocacy, doulas can provide support against medical racism and improve the well-being of people of color going through the birthing process. Doulas became aware of racial inequality through their experiences with Black clients; they engaged in racial power struggles in their attempts to support the interests of people of color in these clinical settings. The findings from this study reaffirm previous studies that have shown that doulas provide a critical voice for Black women in maternal health settings that has the potential to disrupt existing patterns of frequent medical interventions, high C-section rates, and trauma from negative birth experiences [3,21].
This research study also found that doulas went through a racial journey when coming to terms with the extent of anti-Black racism that they began to notice when comparing the experiences of their white and Black clients going through the birthing process. Critical reflections on whiteness help towards conceptualizing paths towards antiracism for whites working in the healthcare industry [46,47]. Doulas already had a holistic perspective that supports maternal healthcare justice and tended to oppose the traditional hospital medical model, unnecessary interventions, and the suppression of voices that can lead to tragic birth experiences. Being committed to birthing justice advocacy led to conditions where doulas noticed subtle, yet significant mistreatment of their Black clients compared to white clients. Doulas noticed the dismissive attitudes towards the concerns of Black women, that they were treated as if they felt less pain, and the increasing pressure of interventions targeting this minority group. This is a similar finding from research showing that doulas encounter racialized beliefs from medical professionals who argue Black women are able to tolerate more pain than white women [3]. Furthermore, the doulas in this study also shared coming to terms with the conditions of medical racism when they noticed that their Black clients shared their fear and concerns about not surviving the birth experience, while white clients shared lighter concerns about their birth plans not being met. All of this exposure to the racial experiences of Black women caused white doulas to consider the importance of an antiracist approach in their commitments towards maternal healthcare justice.
The study has implications when considering the need for anti-racism training for doula workers and exposure to the extent of race and racism in clinical settings. Existing studies on anti-racism have focused on reaching out to healthcare professionals through education [48]. There is a need to promote anti-racism training to doulas to prepare them for how to navigate racialized clinical settings and provide tools for advocating for people of color. Some white doulas in this study shared being uncomfortable addressing race and that it is challenging taking on Black clients because of their lack of experience supporting them. Other white doulas shared in-depth understanding of medical racism and spoke candidly about white privilege in clinical settings that cause medical professionals to take them more seriously and meet their needs.
Major challenges exist for Black doulas having to navigate whiteness in doula work. First, most doula workers were white women and had an established network and community they work with. Second, Black doulas shared that white clinical settings were not welcoming, and they had to be highly conscious they were presenting their best selves or, otherwise, face racial stereotyping and mistreatment from medical personnel and staff. One Black doula shared she made sure to wear a wedding ring and present herself overly nice to dissipate anticipated tensions with doctors, nurses, and staff that may have occurred. These conditions led to significant barriers for Black doulas to be accepted and respected in white-dominant clinical settings that impaired their ability to administer birth support for women of color.
It is important to note that doulas had a multitude of experiences, trainings, and certifications as well as variations in hospital and homebirth experiences. The doulas in the study pointed out that each different hospital setting had their own informal culture on their willingness to accept doula workers, as well as individual medical personnel, such as doctors and nurses, who may be more or less welcoming of doula birth support. Therefore, these experiences shared are not all consistent with all clinical settings, the context of these medical institutions matter, along with the interactions of their medical personnel and doula workers as they support women of color.

Policy Recommendations
The research study has significant implications for policies for doula organizations, clinical settings, and the maternal healthcare industry. The findings show high recommendations for anti-racism training workshops for doula workers, specifically on racial inequality and health disparities, but also on best practices to support minority women. The various trainings and certifications tend to leave out these key aspects on race and racism education. Some doulas also brought up training for medical personnel, including doctors, nurses, and staff on how to work with doulas more collectively for birth support to alleviate some of the existing tensions and power struggles that often emerged.
Additionally, doula work is often not supported by the health insurance industry, despite health research showing the benefit of doula birth support for birthing persons [4,5]. The doula profession has continuously grown in recent years and more institutional support would benefit access to this crucial care. Many doulas struggle to maintain financial support, often offering donation or karma births to low-income women seeking their services. Access to insurance support would more consistently spread their care to minority women that need the most assistance to address health disparities.
There has been a doula service movement to support Medicaid expansion, especially as a way to reach out to the Black community and address alarming maternal healthcare issues [49]. Currently, there are five states that cover doula services through Medicaid, including Minnesota, New Jersey, Oregon, Indiana, and Rhode Island [50,51]. These expansions are highly needed to provide critical doula care across the nation. In the context of Florida, there have been limited doula services supported and, currently, only select providers cover some aspect of doula support [52]. Furthermore, US lawmakers have been considering allocating resources for midwives and doulas in the 2021 Build Back Better bill, showing growing support that is influencing policy [53]. These changes have the potential to expand support for maternal healthcare and provide, to communities of color, these resources.
Additionally, hospital settings would benefit from more partnerships with doulas due to their nonmedical physical and emotional support of birthing clients as well as their consistent continuation of care before, during, and post-birth. More formal connections with hospital clinical settings with birth centers, doula organizations, and communities of color would provide a higher access to birth support workers and institutional legitimization of this profession to bring the support to those who need it the most.

Conclusions
This study has significant contributions for understanding doula birth support workers and how they navigate racism and whiteness in clinical settings to support minority clients. Although white women largely make up the doula profession and their clients have tended to be middle class white women, there has been a shift in the utilization of doula workers to meet the needs of people of color going through the birthing process, for example, by having more doulas of color in positions of leadership, giving more racial inequality training to doula workers on anti-racism advocacy, and increasing the visibility and accessibility of doulas for communities of color that need it the most. Furthermore, the foundation of maternal healthcare justice informing the established doula workers would benefit from critical reflections on whiteness in the doula industry and clinical settings for the empowerment of women of color.