When Less Becomes the New Standard: The Problem With Replacing Nurses With Doulas in Postpartum Care

The right question is why the richest country on earth decided that trained nurses are optional for new mothers on Medicaid.

A new mother in Amsterdam goes home two days after delivery. A trained obstetric nurse visits her at home the next day. She checks blood pressure, inspects the wound, screens for depression, examines the baby, and reviews feeding. She is licensed. She is accountable. She is paid by the health system. She comes back several times in the first ten days.

Now consider a new mother in Boston. She may or may not get a six-week postpartum visit. If she is on Medicaid, she is statistically less likely to show up. Nobody comes to her home with a stethoscope. What the system offers instead, increasingly, is a doula.

A well-meaning doula. But not a nurse.

What the Paper Says

A viewpoint published in Pregnancy (Anghel et al., 2026) [the official journal of the Society for Maternal-Fetal Medicine] compares three postpartum support roles: doulas, community health workers (CHWs), and patient navigators. Not nurses. The authors from Brigham and Women’s Hospital and Harvard Medical School argue that these roles are distinct, underutilized, and potentially complementary. They use Massachusetts Medicaid as a case study and call for better standardization of training and reimbursement.

The tone is measured, the analysis thoughtful, and the intentions plainly good.

And yet the paper, almost entirely without meaning to, makes a case that should trouble us deeply.

The Central Problem: We Are Normalizing Less Care

The United States has one of the worst maternal mortality rates in the developed world. According to the CDC, the maternal mortality rate in 2022 was 22.3 deaths per 100,000 live births. In Germany it is 4. In the Netherlands it is 4. In Sweden it is 5. Many of those deaths happen in the postpartum period, not in the delivery room.

Now look at what those countries do differently after birth. In the Netherlands, the kraamzorg system sends a trained maternity nurse to every new mother’s home for 8 to 10 days after delivery. In Germany and other European countries, midwives and obstetric nurses provide structured home visits in the weeks after birth. These are not volunteers. They are not peer supporters. They are trained clinical professionals.

So what does American medicine do when postpartum care fails the most vulnerable patients? It does not ask why we cannot fund postpartum nurses. It proposes doulas.

I want to be precise here. Doulas can play a real role in emotional support, advocacy, and continuity of care. The data cited in this paper shows that among Medicaid enrollees, doula care is linked to a 47% lower risk of cesarean delivery and improved postpartum visit attendance. These are not trivial numbers. But those outcomes reflect a system so broken that the presence of any continuous human support produces measurable benefit. That is not an argument for doulas. That is an indictment of the baseline.

Medical Training Is Not Optional for High-Risk Patients

Here is the part of this conversation that almost nobody says plainly: postpartum patients are not low-risk until proven otherwise.

Preeclampsia can present or worsen after delivery.

Postpartum hemorrhage kills.

Postpartum cardiomyopathy is underdiagnosed.

Postpartum depression is missed at rates that should embarrass our system.

Sepsis does not wait for a six-week visit.

A doula is trained to provide emotional support, comfort, and information. Massachusetts requires doulas to demonstrate a basic understanding of maternal anatomy and common complications. That is a reasonable credential for an emotional support role. It is not a reasonable credential for identifying early signs of hypertensive emergency, evaluating wound dehiscence, assessing postpartum hemorrhage, or recognizing sepsis.

The paper itself acknowledges that doula competencies do not include clinical care coordination. Their role is explicitly described as non-clinical.

So why are we treating non-clinical workers as the solution to a clinical crisis?

The Equity Argument Cuts Both Ways

Proponents of this model frame it as an equity intervention. Rates of postpartum visit attendance are lower for Medicaid-insured and racially minoritized patients.

The system fails them.

Doulas and community health workers can help bridge that gap.

The argument has genuine merit, and I do not dismiss it.

But consider what we are really saying: the patients most at risk get the least-trained support.

Wealthy privately insured patients get board-certified obstetricians and nurses at every touchpoint.

Medicaid patients get a doula reimbursed at up to $1,700 for the entire perinatal period, with no standardized national competencies and no requirement for clinical training. The ones more at risk get less care.

This is not equity. It is a two-tier system given a compassionate name.

The paper rightly notes that the largest variations in postpartum care affect those with multiple disadvantaged identities.

The correct response to that finding must be to demand that Medicaid fund the same standard of clinical postpartum care available to well-insured patients. Not to build an elaborate non-clinical workforce and call it innovation.

What We Should Actually Be Demanding

The Netherlands spends money on kraamzorg nurses because Dutch society decided postpartum care is a clinical right, not a privilege. The result is a maternal mortality rate roughly five times lower than ours.

We should be demanding universal Medicaid reimbursement for structured postpartum home visits by trained nurses or certified nurse midwives in the first two weeks after birth.

We should be demanding parity between Medicaid reimbursement rates and private insurance rates so that qualified clinicians have the financial incentive to serve these patients. We should be demanding national standards that treat postpartum monitoring as the medical necessity it is.

Instead, the conversation has drifted toward how to credential a doula in Colorado versus Delaware, and whether patient navigators should be reimbursed separately from community health workers.

These are not unimportant questions.

But they are not the right question.

The right question is why the richest country on earth decided that trained nurses are optional for new mothers on Medicaid.

What the Paper Gets Right

To be fair to Anghel and colleagues: they are not arguing that doulas replace nurses. They are making the narrower case that if these roles exist, we should define them clearly and fund them appropriately. That is a reasonable argument within the constraints of a system that is not going to suddenly fund universal nurse home visits.

They are also right that CHWs and patient navigators bring real value in clinical navigation and referral, and that their competencies differ meaningfully from doulas. Better defining these roles is useful. The call for standardized training and cost-effectiveness data is sensible.

The problem is not this paper. The problem is the system this paper is trying to improve by working around it.

My Take

I have delivered more than 10,000 babies. I have watched more women leave the hospital without adequate postpartum follow-up than I care to count. I have been involved when women died postpartum. The fourth trimester is not a wellness concept.

Postpartum is a high-risk clinical period that kills women.

I am not against doulas.

I am against a medical system that uses them as a substitute for trained clinical postpartum care and then presents that substitution as progress for underserved communities.

The European comparison is not a fantasy. It is an existence proof. Postpartum nurse home visits work. They exist. They are funded by governments that decided maternal lives are worth the cost. We have decided something different, and we dress it up in the language of equity and innovation rather than call it what it is: a failure to fund adequate medical care.

The next time someone tells you that expanding the doula workforce is the answer to America’s maternal mortality crisis, ask them a simple question:

Would they be comfortable with their own spouse or daughter going home after delivery with only doula support or would they prefer that she be seen by a nurse?

Would you be comfortable going home after delivery with only doula support or would you prefer like in Europe to be seen by a nurse?

If the answer is no, then we should say so clearly, loudly, and without apology.

Reference

Anghel EM, Zera CA, Lara MC, Celi AC. Comparing postpartum support roles: Matching strengths to need. Pregnancy. 2026;2:e70269. doi:10.1002/pmf2.70269