A study across South Carolina and several other states is researching how the use of doulas can offer a possible solution to the maternal mortality crisis in the United States.
Maternal mortality in the United States is higher than any other developed country, according to health research nonprofit The Commonwealth Fund.
And, among that high mortality rate, Black women have a rate more than double that of white women, according to the Centers for Disease Control and Prevention.
Academy Health, the University of Pittsburgh and the Institute for Families in Society at the University of South Carolina are working on what's called Project DREAM, which stands for Doula Research for Equitable Advances in Medicaid Pregnancy Health.
Project DREAM will focus on the effectiveness of doulas in improving health outcomes in hospitals, specifically for people on Medicaid, a federal and state program that helps cover medical costs for low-income and uninsured individuals, and people with disabilities.
The S.C. Department of Health and Human Services reported that about 60% of births in the state are covered by Medicaid.
“We hypothesized that different strategies to implement doula care in Medicaid programs could improve health outcomes … particularly among folks who might have lesser access to health care,” said Marian Jarlenski, a project researcher and Pitt public health professor.
Doulas provide nonclinical support to people during pregnancy, birth, or postpartum.
That support can be physical, emotional or informational, and is available both for home and hospital births, Jarlenski said.
Kentucky, Maryland, Michigan, Pennsylvania and Virginia are also participating in the study. Jarlenski said these states are working with Medicaid agencies to combat maternal health issues.
“We hope to be able to take the data that we've collected on the different doula program implementations and connect that with the health outcomes data to understand which strategies work best,” Jarlenski said.
Project DREAM is in its third year and is expected to wrap up in 2027.
Researchers are currently looking for study participants on Medicaid who have given birth in South Carolina in the past six months. For more information, email AHDoulaStudy@gmail.com.
Maternal health care in South Carolina
Each year, the S.C. Department of Public Health publishes its S.C. Maternal Morbidity and Mortality Review Committee Legislative Brief to analyze the number of pregnancy-related deaths in the state and their causes.
The 2025 report said that in 2021, the last year of available data, there were 47.2 pregnancy-related deaths per 100,000 live births.
It's higher than the national average of 32.9 pregnancy-related deaths per 100,000 live births.
Of those pregnancy-related deaths in South Carolina, 65% of them were Medicaid patients, according to the public health department.
Black women were nearly twice as likely to die than white women in South Carolina, according to the state's maternal mortality brief.
South Carolina is trying to fix these numbers, said Ana López-De Fede, the associate director of the Institute for Families In Society at USC and an investigator for Project DREAM.
She’s worked with Medicaid offices for 30 years.
López-De Fede said South Carolina extended Medicaid for 12 months postpartum in May 2022, ahead of most states in the South.
And she said that South Carolina was the first state to cover immediate postpartum placement of long-acting reversible contraceptives, or IUD birth control, under Medicaid.
That is separate from global maternity payments, which bundle all birth costs together.
The state's health and human services department also received a grant in January from the Centers for Medicare and Medicaid Services to focus on improving maternal health care for people on Medicaid.
“There is movement within South Carolina … to test doula care within Medicaid before fully implementing (it),” López-De Fede said.
In South Carolina’s House and Senate, there are two bills that would require Medicaid to cover the cost of doulas under certain circumstances. Both bills still sit in committee. The Legislature returns for session in January 2026.
Part of the push for more doulas, López-De Fede said, is because of the lack of labor and delivery hospitals.
Since 2012, 13 labor and delivery hospitals have closed in South Carolina.
Most are in rural areas, she said.
"It's all about access to care," said Dr. Oscar Lovelace, who runs Lovelace Family Medicine in Newberry, South Carolina. "The second year I was here, the county's only OB-GYN died suddenly. During my second year of solo practice, I delivered 228 babies."
He said doula care does not solve the issue of the obstetrician shortage in South Carolina, and that hospitals should be required to have labor and delivery units.
Doulas can help people find available care, said BirthMatters Executive Director Amber Pendergraph.
BirthMatters provides community doula care for Medicaid patients in Spartanburg and Cherokee counties at no cost, with the goal of providing support and education to expecting mothers.
"We only have one delivery hospital between (Spartanburg, Cherokee and Oconee Counties), so we do refer," Pendergraph said.
She added that doulas help with transportation to doctor's appointments and hospitals, which is one of the biggest barriers in rural areas.
López-De Fede said a lack of quality care can hurt communities too.
“Our rural communities have always been challenged," she said. “However, what I can say about us in South Carolina is that we're clearly innovative. We're moving ahead, we're looking at strategies.”
She added that grant funding from CMS, attention to doula care and ongoing research and developments bring rural areas closer to getting adequate care.
López-De Fede is working to launch a website called Empower Palmetto Moms, which will allow users to ask questions to a chatbot about maternal health, as well as show the real experiences of those who have given birth in South Carolina.
The project is expected to launch in September.
“It's about ensuring that I as an individual with the ability to change, influence and determine the efficacy of whether something is working or not, can contribute to the larger dialogue about how we as a society must move forward,” López-De Fede said.
“As well as putting into place all of the resources that are necessary to achieve optimal birth outcomes.”
