Audit Report on the New York City Department of Health and Mental Hygiene’s Oversight of Doula Programs in Underserved Neighborhoods

Audit Impact

Summary of Findings

The audit found that under the Department of Health and Mental Hygiene’s (DOHMH) administration of the Citywide Doula Initiative (CDI), underserved neighborhoods have increased access to doula services. Using citywide birth outcome data from 2022 published in the most recent Summary of Vital Statistics and birth outcome data for the period of March 2022 through June 2024 for CDI clients, the audit found that among both Black and Hispanic women, CDI clients experienced better birth outcomes than those in the general population, including for C-sections, low birth weights, and pre-term births. Asian American/Pacific Islander (AAPI) and White CDI outcomes were less positive overall, but participation rates, and therefore available data, were also much lower.

Respondents to surveys distributed by auditors expressed general satisfaction with the program, the doulas, the vendors, the training, and overall support that CDI provided to both doulas and vendors. However, survey results also indicate that clients residing in shelters are not receiving doula services with the same level of consistency as CDI clients not residing in shelters, either because doulas are delayed waiting for case worker approvals or because some shelters outright deny doulas access to their clients. Vendors and doulas also indicated a need for additional non-English-speaking doulas and translation/interpretation services when providing doula services on behalf of the CDI.

Regarding key performance data for CDI, the audit found that while doulas capture important information during their visits, DOHMH stores the data among multiple datasets rather than a single one, hindering the agency’s ability to conduct a comprehensive analysis of program effectiveness.

Intended Benefits

The audit identified the impact that access to doula services can have to improve birth outcomes for women in general and specifically those from underserved populations.

Introduction

Background

New York City is one of the most diverse cities in the world, with a population of more than 8 million people. It is also one of the most racially and economically segregated cities in this country. The New York City Department of Health and Mental Hygiene (DOHMH) is one of the largest public health agencies in this country. It has a yearly budget of roughly $1.6 billion and over 7,000 employees across the five boroughs. The responsibilities of DOHMH are to protect and promote the health of all New Yorkers against a broad range of diseases and health-related issues such as diabetes, obesity, heart diseases, HIV/AIDS, bioterrorism threats, and maternal health.

Disparities in Pregnancy-Associated Health

Historically, women of color in New York City have experienced higher rates of maternal and infant mortalities as well as higher percentages of births that result in negative outcomes than White women.[1] Negative outcomes include Cesarean sections (C-sections), low birth weight (babies born weighing less than 2,500 grams [5.5 lbs.]), and pre-term births (babies born prior to the completion of the 37th week of pregnancy). Low birth weight and pre-term births are associated with a higher likelihood of infant mortality. According to the CDC, several other factors are associated with negative birth outcomes such as access to healthcare, income level, and race/ethnicity.[2]

Certain neighborhoods in New York City have less access to primary care as well as prenatal or maternal health care. These neighborhoods also correspond to areas with lower average incomes and health insurance coverage rates and higher populations of people of color. These factors are associated with increased negative birth rates and infant and maternal mortalities.

According to DOHMH, Black non-Hispanic women accounted for 17.7% of all live births in the city in 2021 but accounted for 39.7% of all pregnancy-associated deaths, and Hispanic women accounted for 28.9% of all live births but 36.2% of all pregnancy-associated deaths.[3] This means that the share of pregnancy-related deaths among Black non-Hispanic and Hispanic women far exceeded their share of total live births over the same period.

The reverse is true for White non-Hispanic and AAPI women, who accounted for 36.3% and 15% of live births in NYC during this period, respectively. These populations experienced proportionately far lower rates of pregnancy-associated deaths: White non-Hispanic women accounted for 8.6% of pregnancy-associated deaths and AAPI women accounted for 12.1%.

According to the Bureau of Vital Statistics’ Summary of Vital Statistics 2022 for New York City (the most recent set of statistics available), the highest rates of infant mortality by mother’s race/ethnicity were Non-Hispanic/Latino Black at 7.6 infant deaths per 1,000 live births, and Hispanic at 4.7 infant deaths per 1,000 live births.[4] [5] [6] White non-Hispanic mortality rates were 2.7 infant deaths per 1,000 live births, and AAPI infant mortality rates were the lowest, at 1.9 infant deaths per 1,000 live births.

Geographically, these statistics correlate closely to 33 neighborhoods predominantly comprised of people of color and identified as underserved by the City’s Taskforce on Racial Inclusion & Equity (TRIE).[7] [8] (A listing of these neighborhoods is found in Appendix I.)

The auditors’ analysis of data provided in NYC’s Bureau of Vital Statistic’s Summary of Vital Statistics 2022 showed that neighborhoods identified by TRIE experienced higher rates of negative birth outcomes, including C-sections, low birth weight, and preterm births.

Doula Support as Healthcare

The U.S. Department of Health and Human Services, the New York State Department of Health, and the American College of Obstetricians and Gynecologists have identified doula support as one way to reduce racial inequities in accessing pregnancy and maternal health care and reduce negative birth outcomes in these populations.

Doulas provide non-medical (emotional, physical, and informational) support to pregnant people and their families before, during, and after childbirth, and advocate for their clients’ health and wellness decisions. Doula support can help families handle the physical, emotional, and practical issues that surround childbirth.

Studies have shown that doula support leads to better labor and birthing experiences, as well as better birth outcomes. For instance, according to Doula Care and Maternal Health: An Evidence Review (a report issued by the U.S. Department of Health and Human Services in December 2022), people giving birth with support from a doula are less likely to have an instrumental vaginal birth or C-section, have their labor induced, or receive pain medications, and they are more likely to experience a shorter labor, initiate breastfeeding earlier and breastfeed longer, express positive feelings about their birth experience, and bond better with their babies.

There are four types of doulas:

• “Birth doulas” meet with clients before and after childbirth to help prepare them for birth, breastfeeding, and parenting.
• “Postpartum (i.e., following birth) doulas” work with families to provide evidence-based information and support on physical recovery from birth, emotional well-being, infant feeding, and parent-infant bonding.
• “Full spectrum doulas” train to provide comprehensive emotional, physical, informational, and educational support during pregnancy, delivery and labor, and following birth
• “Community-based doulas” conduct home visits and offer a wider array of services and referrals for people who need more support. Community-based doulas are trained to address all the needs of their clients, including referrals to food pantries, housing programs, and sources for free diapers.

Additionally, according to DOHMH, all doulas may provide advocacy that incorporates cultural awareness as well as reproductive and birth justice.

The Citywide Doula Initiative

The New York City Council passed a series of laws collectively requiring that DOHMH (1) create a plan to expand access to doula services and publicly report its efforts in that regard, and (2) report certain birth-related data in the City. Specifically:

• Local Law 187 of 2018 (LL187): requires DOHMH to “post on its website a plan to increase access to doulas for pregnant people in the city” and “post on its website a report on […] city and community-based programs that provide doula services.” The report must also include “areas or populations within the city in which residents experience disproportionately high rates of maternal mortality, infant mortality, and other poor birth outcomes.”
• Local Law 85 of 2022 (LL85): requires DOHMH to “establish a program to train doulas and provide doula services to residents of marginalized neighborhoods in all five boroughs at no cost to the resident.”

DOHMH has implemented several programs aimed at increasing access to maternal care and reducing the racial disparities in maternal and infant mortalities and pregnancy outcomes. One such program is the DOHMH’s Citywide Doula Initiative (CDI). CDI provides free doula support for people living in underserved communities, as well as people living in shelters or foster homes.

To be eligible to receive doula services under the initiative, a resident must be income-eligible for Medicaid, live in a zip code designated by TRIE as underserved, or in a shelter or foster home anywhere in New York City. Additionally, pregnant teenagers who are income-eligible for Medicaid are also able to receive services.

DOHMH contracted with seven vendors to provide doula services under CDI across TRIE neighborhoods: Ancient Song Doula Services (ASDS), Community Health Center of Richmond (CHCR), Caribbean Women’s Health Association (CWHA), Hope and Healing Family Center (HHFC), Mama Glow Foundation (MGF), Mothership Doula Services (MDS), and the Northern Manhattan Perinatal Partnership (NMPP). New York City residents can also obtain doula services through the By My Side Birth Support Program which DOHMH operates.

The total approved amount for services and training provided during the period of March 1, 2022 through June 30, 2024, was $4,066,429.32.

Additional Resources that Support CDI

Prior to the establishment of CDI, DOHMH created programs that continue to interact with and provide supplemental support to CDI. For example, DOHMH introduced the By My Side Birth Support Program (BMS) in 2010, and in 2016, the New York City Council began funding the Healthy Women, Healthy Futures (HWHF) program.

BMS aims to reduce inequities in birth outcomes by providing no-cost, comprehensive doula support to pregnant people living in underserved neighborhoods of Brooklyn. BMS is funded through the federal Healthy Start Brooklyn grant and thus only provides doula services within certain areas of Brooklyn and refers clients to CDI vendors when necessary.

The goal of HWHF is to provide women with health resources—including access to maternal healthcare and doula support—and it is composed of three community-based organizations: Caribbean Women’s Health Association (CWHA), Community Health Center of Richmond (CHCR), and Brooklyn Perinatal Network (BPN). BPN also provides community health worker services, birth and postpartum doula services, public health insurance enrollment, family and youth peer support, health and nutrition education, and distribution of baby supplies.

In 2019, DOHMH also established the Maternity Hospital Quality Improvement Network (MHQIN) in partnership with 14 maternity hospitals.[9] The MHQIN initiative is part of the City’s plan to promote equity in maternal care by working with NYC maternity hospitals to prevent and reduce disparities in maternal mortality and severe maternal morbidity. The objectives of the MHQIN as they relate to creating doula-friendly hospitals are to (1) improve hospital staff collaboration with doulas, and (2) strengthen healthcare system connections to community-based resources, such as no- or low-cost doula programs.

Objectives

The objectives of this audit were to assess DOHMH’s administration of the Citywide Doula Initiative to ensure that underserved neighborhoods are receiving doula services and the extent to which the initiatives goals are being met, including increased access to doula services and reduction in negative birth outcomes for CDI clients from March 1, 2022 through June 30, 2024.

Discussion of Audit Results with DOHMH

An Exit Conference Summary was sent to DOHMH and discussed with DOHMH officials at an exit conference held on April 16, 2025.  On April 24, 2025, we submitted a Draft Report to DOHMH with a request for written comments. We received a written response from DOHMH on May 6, 2025. In its response, DOHMH agreed with six recommendations and disagreed with one.

DOHMH’s written response has been fully considered and, where relevant, changes and comments have been added to the report.

The full text of DOHMH’s response is included as an addendum to this report.

Detailed Findings

DOHMH has complied with Local Laws 187 and 85 in its implementation of the Citywide Doula Initiative, and the impacts are notable. The audit found that all 33 TRIE neighborhoods now have access to CDI doula services, and residents in these neighborhoods are increasingly using them—the number of CDI doula visits conducted during the second quarters of Calendar Years 2022 through 2024 has increased an average of 75% each year.

CDI is also meeting its goal of increasing access to doula services and is taking steps to improve data collection and share data with the public on doula programs and services. The audit attempted to compare the rate of negative birth outcomes for people who received CDI doula services with citywide rates, but 2022 was the most recent year for which citywide birth data was available.[10] This was before the implementation of CDI and the audit’s scope period (March 2022 through June 2024), so a direct comparison was not possible.

Nonetheless, using birth outcome data from 2022 published in the most recent Summary of Vital Statistics and birth outcome data for the period of March 2022 through June 2024 for CDI clients provided by DOHMH, auditors found that among both Black and Hispanic women, CDI clients fared better than those in the general population in all three categories of negative birth outcomes relating to C-sections, low birth weights, and pre-term births.

Auditors found that Black and Hispanic women experienced significantly better birth outcomes as CDI clients than citywide birth outcomes for Black and Hispanic women generally. Birthing outcomes for White CDI clients did not show the same level of improvement, and AAPI CDI participants experienced worse outcomes than Citywide rates.   As noted above, however, the participation rates, and therefore available data, for AAPI and White women were much lower.

To gain further perspective on doula services and the CDI program, auditors distributed satisfaction surveys to clients and doulas. Most respondents expressed general satisfaction with the program, the doulas, the vendors, the training, and overall support that CDI provided to both doulas and vendors. Levels of satisfaction with doulas varied among providers, with the highest rates of satisfaction with Caribbean Women’s Health Association (CWHA) (81%) and Ancient Song Doula Services (ASDS) (77%).

However, survey results also indicate that access to doula services has not increased for all underserved populations. Clients residing in shelters are not receiving doula services with the same level of consistency as CDI clients not residing in shelters, either because doulas are delayed waiting for case worker approvals or because some shelters outright deny doulas access to their clients. These clients are being denied the access they should have based on the New York Standards for Respectful Care at Birth.[11]

Survey responses from vendors and doulas also indicate a need for additional non-English-speaking doulas and translation/interpretation services when providing doula services on behalf of the CDI. Increasing language access would represent another important step in ensuring equitable access to doula services.

Finally, regarding the collection and storage of key performance data for CDI, while doulas capture important information during their visits, DOHMH does not compile the data into a single dataset; instead, the agency produces reports of multiple datasets which can then be combined into one comprehensive dataset. This hinders the ability of agency staff to conduct an efficient analysis of program effectiveness.

DOHMH’s Efforts Are Increasing Doula Access and Support in Underserved Neighborhoods

The audit found that all 33 TRIE neighborhoods had access to CDI doula services.  However, the degree to which residents used those services varied significantly by neighborhood. As of June 2024, vendors reported that 283 doulas were retained to provide services to CDI clients, and CDI data showed that 2,158 clients received at least one visit from a doula during the period covering March 1, 2022 through June 30, 2024. Of the 2,158 clients, 2,017 (93%) came from TRIE neighborhoods. (The remaining 141 clients were in foster care or resided in shelters located throughout the City.) Table 1 below presents a breakdown of the number of clients served by neighborhood.

Table 1: Number of Clients Served by TRIE Neighborhood

As shown in the table, none of the clients came from the Elmhurst/Corona (Queens) neighborhood. The most represented neighborhood was Bedford Stuyvesant (Brooklyn) with 237 clients, followed by Morningside Heights (Manhattan) with 146 clients; Mott Haven/Melrose (Bronx) with 141 clients; St. George/Stapleton/Port Richmond (Staten Island) with 122 clients; and Williamsbridge/Baychester/Edenwald (Bronx) with 113 clients.

DOHMH contracted with seven vendors to provide doula services across TRIE neighborhoods: Ancient Song Doula Services (ASDS), Community Health Center of Richmond (CHCR), Caribbean Women’s Health Association (CWHA), Hope and Healing Family Center (HHFC), Mama Glow Foundation (MGF), Mothership Doula Services (MDS), and the Northern Manhattan Perinatal Partnership (NMPP). (A list of the neighborhoods and assigned vendors can be found in Appendix I.)

In addition, both the number of clients accessing services and the number of visits conducted by doulas has been increasing, as shown in Table 2 below. The impacts of the increased use of doula services may account for the decrease in some negative birth outcomes among CDI clients, as discussed later in the report.

The audit also found that CDI is executing the plan DOHMH developed to comply with Local Laws 187 and 85, detailed below. (See Appendix IV for full details regarding CDI’s compliance.) As a result, access to doula care in New York City increased significantly during the scope period.

The Number of Women in Underserved Neighborhoods Receiving CDI Doula Services Has Increased Every Year

Since March 2022, the number of doula visits provided to CDI clients has increased, indicating that residents in underserved neighborhoods have more access to doula services and are making use of those services. Auditors assessed and compared the number of client visits conducted from April 1 to June 30 in 2022, 2023, and 2024 as a sample to assess program performance since formation of the CDI. Table 2 below shows increases across all categories in the number of prenatal, labor, and postpartum visits CDI clients received from April 1 to June 30 in 2022, 2023, and 2024.[12]

Overall, prenatal visits increased by 37% for the period tested in 2022 to 2023 and increased by 23% from 2023 to 2024. Doula-attended births increased by 107% for the period tested in 2022 to 2023 and increased by 31% from 2023 to 2024. Post-partum visits increased by 209% for the period tested in 2022 to 2023 and increased by 42% from 2023 to 2024. The number of doulas providing at least one visit increased by 36% for the period tested in 2022 to 2023 and increased by 25% from 2023 to 2024.

The increase in the number of visits clients received during the selected periods indicates a greater use of CDI-provided doula services since the launch of the program. As shown in the table, the number of doulas that provided at least one visit from the establishment of the CDI in 2022 through June of 2024 also increased by 70% over the period, going from 77 in 2022 to 131 in 2024.

Table 2: Tracking of CDI Doula Visits

CDI Is Building Doula Capacity and Support through No-Cost Training, Apprenticeship Program, and Engagement with Statewide Coalition

CDI seeks to train residents of TRIE neighborhoods to become doulas and provides professional development to all doulas working in the initiative. Residency in a TRIE neighborhood is not a requirement to become a CDI doula; however, residency in a TRIE neighborhood is a factor in promoting culturally-sensitive care—a key principle of a community-based doula program. Initial doula training is provided by ASDS at no cost to anyone who is accepted for CDI training. After completion, CDI staff train community members and experienced doulas who are new to the program in the CDI model of care, at no cost. Doulas are compensated at a rate of $35 per hour for attending the CDI training course and any other additional optional trainings.

According to the 2024 State of Doula Care report, 47 community members were trained to become full-spectrum/community-based doulas in 2023. For the period covering March 2022 through November 2024, six training sessions were conducted and 151 doulas were trained. Auditors attended one such training in November 2024, and reviewed sign-in sheets and materials for the other trainings and verified that the subject matter required by LL85 was covered. This included prenatal, birth, and postpartum doula training, intimate partner violence training, infant and pregnancy loss training, and training on the CDI model of doula care.

Newly trained doulas are further supported by CDI’s doula apprenticeship program, through which doulas can improve their professional skills, achieve certification, and increase their capacity to work as community-based doulas. As stated in the 2024 Doula Care report, 108 apprentice doulas were participating in the program as of March 2024. Auditors attended nine continuing professional development training sessions that covered the LL85-required topics mentioned above.

CDI also engages with the New York State Coalition for Doula Access (NYCDA), which seeks to expand access to perinatal support for all, with a particular focus on communities at greatest risk of negative outcomes. Current priorities of the coalition are to set standards for a living wage for doulas through Medicaid reimbursement and to develop a plan for a doula-friendly hospital designation. The audit found that NYCDA convened 11 meetings to develop guiding tenets for a doula-friendly hospital designation and 12 meetings to establish reimbursement of doula services through Medicaid. NYCDA also provided testimony in Albany regarding the need for doulas and an equitable reimbursement rate.

Auditors reviewed the doula-friendly hospital guidebook that is based in part on NYCDA’s Principles of Doula Support in the Hospital, attended 12 virtual NY State doula Medicaid townhall meetings between May 30, 2023 and March 12, 2024, and reviewed transcripts of DOHMH, NYCDA, ASDS, and BPN representatives’ testimony before the Senate Standing Committee on Mental Health, and were able to reconcile the information reported. Auditors attended eight CDI vendor monthly meetings. During four of these meetings, doulas and vendors’ staff informed auditors that CDI was providing them with support to register as Medicaid doula service providers. Specifically, at one meeting hosted by NMPP, the vendor provided instruction on registering as a Medicaid provider.

CDI’s Surveys Show that Some Doulas Experience Difficulties in Providing Services at Hospitals

The audit found that CDI conducts outreach to hospitals to promote doula-friendly policies. However, surveys distributed by DOHMH to doulas revealed that a significant portion of them still experience difficulties in providing services at hospitals.

The Maternity Hospital Quality Improvement Network (MHQIN) initiative is a part of the City’s plan to promote equity in maternal care. The initiative works with NYC maternity hospitals to prevent and reduce disparities in maternal mortality and severe maternal morbidity. The objectives of the MHQIN as they relate to creating doula-friendly hospitals are to (1) improve hospital staff collaboration with doulas and (2) strengthen healthcare system connections to community-based resources, such as no- or low-cost doula programs.

CDI conducts outreach to MHQIN hospitals to promote doula-friendly policies. These policies include: increasing patient awareness of doulas and no-cost doula services; increasing hospital staff knowledge of doula support; developing a centralized referral system; incorporating doulas into the birthing team; encouraging better communication between hospital staff, clients, and doulas; and allowing the presence of doulas during birth and labor.

DOHMH contracts with four local community organizations (Ancient Song Doula Services, BxRebirth, Caribbean Women’s Health Association, and Brooklyn Perinatal Network) to conduct outreach and provide support during presentations to MHQIN hospitals. Presentations began prior to the launch of the CDI program.

Vendors and CDI staff also provided technical assistance to nine hospitals (Jacobi, Kings County, Lincoln, Metropolitan, Elmhurst, Jamaica, Montefiore, St. Barnabas, and SUNY Downstate).[13] Auditors reviewed presentation files associated with 37 meetings at these hospitals, along with an associated 20 invoices and supporting documents vendors submitted for those meetings to ensure vendors met their obligations to provide training to hospital staff about the nature and benefits of doula care.  Auditors attended four “doula-friendly hospital” meetings at St. Barnabas, SUNY Downstate, Jacobi, and Jamaica hospitals and observed DOHMH CDI staff (1) providing instructions to hospital staff on how to incorporate doulas in the hospital birthing teams and (2) distributing flyers to patients on the role of doulas.[14]  During the meetings with St. Barnabas, SUNY Downstate, and Jamaica hospitals, CDI staff credited hospitals with incorporating doula friendly policies discussed at previous Doula-Friendliness Meetings, while also noting some areas for improvement.

Auditors also conducted eight unannounced onsite observations at Metropolitan, SUNY Downstate, Kings County, Jamaica, Elmhurst, Jacobi, Lincoln, and Montefiore hospitals and their associated women’s health clinics, where they interviewed hospital staff in the OB/GYN clinics (including administrative staff, nursing staff, and receptionists). The auditors found that hospital staff were aware of DOHMH’s doula programs and were able to refer clients to such services. Auditors also noted the presence of pamphlets, flyers, and posters in English, Spanish, French, Bengali, and Haitian-Creole on display in publicly accessible locations within the OB/GYN clinics that informed patients of the availability of CDI and other free doula services. The OB/GYN clinics and hospital entrances displayed signs stated that patients have the right to free translation services at no cost.

DOHMH created a survey and the Doula Support Assessment Tool that it uses to identify patterns in the practices employed by hospitals that potentially hinder the effectiveness of doula support for patients. Once identified, the intent is to take corrective measures to make hospitals more doula friendly. DOHMH distributed the Doula Support Assessment Tool to doulas working with CDI vendors, By My Side (BMS), and Healthy Women, Healthy Futures (HWHF).[15] As of December 2023, 429 surveys had been completed.[16]

DOHMH’s assessment and the audit’s review of the Doula Assessment survey found that a significant portion of doulas were prevented from providing certain care. Doulas reported that hospitals prevented them from providing comfort measures, such as assisting their clients in using the restroom (17% of respondents), supporting mobility out of bed (25% of respondents), and staying with their clients during delivery (13% of respondents). During a Doula-Friendliness meeting attended by auditors, CDI encouraged hospitals to promote policies that would better enable doulas to provide care. CDI also encouraged hospitals to adopt policies that would give doulas greater access to their clients, such as incorporating doulas into birthing teams, allowing for increased client mobility during labor, increasing access to the restroom, and providing comfort measures.

CDI Is Promoting Standards for Birthing Care and Equity

CDI strives to provide technical assistance and training to MHQIN hospital staff to support the NYC Standards for Respectful Care at Birth (NYC Standards).[17] The NYC Standards include receiving education, quality of care, decision-making, informed consent, dignity and nondiscrimination, and support. They also specifically state that individuals deserve to be educated about the nature and availability of doula care and deserve to have the support of a doula during delivery.

CDI distributed brochures and informational material to inform the public about the NYC Standards and availability of doula services. Auditors visited hospitals, clinics, and local community events, and noted that pamphlets, flyers, brochures, and palm cards were present. In addition to the previously mentioned unannounced visits to hospitals, auditors attended five community outreach events attended or organized by CDI, including a Community Baby Shower hosted by the New York City Police Department in Manhattan and Staten Island, a Community Baby Shower hosted by CWHA, and an HHFC Diaper Bank. Auditors also attended a doula training informational and recruitment event hosted by CDI. At each event, hospital, and clinic, auditors observed evidence that either the vendor or the CDI was promoting the Standards of Respectful Care and the availability of free doula services.

DOHMH also posts information about the NYC Standards, how to obtain doula care, and a directory of no-cost doula service providers on its website.[18]

The Neighborhood Birth Equity Strategy was developed to promote the availability of doula services and provide opportunities for residents to learn about the opportunity to become a doula.  DOHMH operated Family Wellness Suites-hosted events during which vendors promoted doula care as well as other maternal health and birth justice topics.

Auditors attended CDI training at one such Family Wellness Suite event and attended similar events, such as community baby showers, diaper distribution events, and informational outreach events that promote the benefits and availability of no-cost doula services and the opportunity to register for CDI doula training. Additionally, auditors confirmed with vendors that they were scheduled to attend similar events at Family Wellness Suites and other local health centers.

DOHMH Is Improving Accessibility

DOHMH posts directories of NYC Doula Providers and NYS Medicaid Doula Providers. Auditors confirmed that the agency collected information about organizations that provide doula training and no-cost doula services and posted directories of those organizations online.[19] DOHMH’s website has a translation feature that can translate into over 100 languages to ensure equal access to non-English-speaking New Yorkers who may need free doula services.

DOHMH’s plan also calls for assessing which City-based insurers cover doula care. As stated in the 2024 Doula Care report, DOHMH intends to assess the need to create a directory of private insurers that cover doula care. Similarly, the New York State Department of Health has created a directory of doulas who provide services through Medicaid.[20] DOHMH includes a link to that directory on its website, informing potential clients of the availability of free or low-cost doula services from a number of sources.

Doula Support Appears to Improve Birth Outcomes, Infant Health, and Maternal Mortality Outcomes for Certain Demographics

The steps taken by CDI are having direct and positive impacts on the communities that doula services are intended to support. However, the extent to which these efforts have resulted in better birth outcomes for target populations (primarily Black and Hispanic women in underserved neighborhoods) has not been fully determined.

Demographic Breakdown of CDI Clients

Most CDI clients identify as either Black or Hispanic.[21] (CDI clients can self-identify as more than one race or ethnicity.) A racial/ethnic breakdown of the clients who received at least one prenatal visit between March 1, 2022 and June 30, 2024, is shown in Chart 1 below.

Chart 1: Racial/Ethnic Breakdown of Clients Who Received Doula Services from March 2022 through June 2024

As shown in the chart, 1,298 (60%) of the 2,158 clients served identified as Black and 864 (40%) identified as Hispanic. (Clients can self-identify as more than one ethnicity or race, so it is likely that some of these clients identified as both Black and Hispanic.) Of the 2,661 ethnic/racial self-identifications, 2,162 (81%) were Black or Hispanic. White women represented the third largest ethnicity, accounting for 182 self-identifications, while AAPI (Asian and Native Hawaiian/ Pacific Islander) women collectively accounted for 67 (50 + 17) self-identifications. Native American/ Alaskan and Arabic women accounted for 42 and 12 self-identifications respectively.

Fewer Negative Birth Outcomes for CDI Clients

As stated previously, the rates of negative birth outcomes (such as C-sections, low birth weight, and preterm births) have been higher among women of color than the citywide average.

The audit attempted to compare the rates of negative birth outcomes for people who received doula services against citywide rates. However, the latest available citywide data is for 2022 published in the Summary of Vital Statistics 2022 and the audit scope covered March 2022 through June 2024, so a direct comparison is not possible.[22]

Nevertheless, using the available data—birth outcomes published in the most recent Summary of Vital Statistics containing birth outcome data for Calendar Year 2022 and birth outcome data covering March 2022 through June 2024 for CDI clients provided by DOHMH—auditors were able to compare the percentages of live births that resulted in negative birth outcomes.  Black and Hispanic women represent a significant portion of CDI clients, accounting for 1,298 (60%) and  864 (40%) respectively of all clients, while White and AAPI women represent a very small portion of clients, numbering 182 (8.4%) and 67 (3.1%) respectively.[23]. (See Charts 2 through 4 below for a breakdown of CDI and citywide rates.)

The comparisons showed the following:

• Low birth weight rates were lower for CDI clients than citywide rates for Black and Hispanic women but higher than citywide rates for White and AAPI women, as well as the overall citywide population.
• Rates of C-section births for CDI clients were lower than the citywide rates for Black, Hispanic, and White women but higher for AAPI women. Rates of C-sections for CDI clients were lower than citywide rates overall.
• Rates of pre-term births were lower for CDI clients than the citywide population for White, Black, and Hispanic women, and higher for AAPI women. Rates of pre-term births for CDI clients were lower than citywide rates overall.
• Black and Hispanic women experienced significantly better outcomes as CDI clients compared to citywide birth outcomes for Black and Hispanic women generally.
• Birthing outcomes of White CDI clients varied when compared to citywide birth outcome rates while birthing outcome rates for AAPI CDI clients were higher when compared to citywide rates.
• Rates for CDI clients were slightly lower than rates for all women citywide in two of the three categories.

Chart 2: Comparison of Citywide and CDI C-section Outcomes

Chart 3: Comparison of Citywide and CDI Low Birth Weight Outcomes  

Chart 4: Comparison of Citywide and CDI Pre-Term Birth Outcomes  

Auditors also looked at data related to breastfeeding, which has known health benefits, such as supporting growth and development of the baby as well as protection against certain illnesses and diseases. CDI doulas are trained to encourage their clients to breastfeed and provide clients with information and education about lactation. The Summary of Vital Statistics 2022 states that 40.4% of citywide live births recorded exclusively breastfeeding. During the period from March 1, 2022 through June 30, 2024, 53% of live births to CDI clients were exclusively breastfed, 31% higher than the rate of breastfeeding among non-CDI births, indicating that the additional information, education, and encouragement provided by doulas may have contributed to higher rates of breastfeeding.

Together, these findings suggest that doula support may be an effective way to reduce the percentage of live births that result in negative birth outcomes in the most at-risk populations. (See Table 3 below.)

Table 3: Birthing Outcome Rates for CDI Clients as Compared to Citywide Rates

As shown in the table and charts above, Black and Hispanic women experienced significantly better birth outcomes as CDI clients than citywide birth outcomes for Black and Hispanic women generally. Birthing outcomes of White CDI clients varied when compared to citywide birth outcome rates, while birthing outcomes of AAPI CDI clients were worse than citywide birth outcome rates.[24] For pre-term births and C-sections, White CDI clients had a lower rate when compared to the citywide rate for White women.  Overall, CDI clients had lower rates of pre-term births and C-sections when compared to the citywide rates.

At the Exit Conference, DOHMH stated that White and AAPI women were significantly underrepresented among CDI clients. As stated earlier, only 182 CDI clients self-identified as White and 62 self-identified as AAPI. (The audit notes that the CDI is primarily targeted to women in TRIE neighborhoods, which have significant Black and Hispanic populations). DOHMH should nonetheless explore this issue more fully, to determine why CDI seems to impact AAPI and White women to a much lower extent.

Maternal Deaths Not Identified among CDI Clients

The most recent maternal mortality report issued by DOHMH states that, in 2021, there were 99,262 live births and 58 pregnancy-associated deaths of women and birthing people. For the period of March 1, 2022 through June 30, 2024, no pregnancy-associated deaths of CDI clients were reported by doulas collecting data on behalf of DOHMH/CDI, indicating that doula support may help reduce the rates of negative birth outcomes, such as those resulting in C-sections, which are a contributing factor in maternal deaths.

Survey Results Indicate Positive Experiences with Doula Services and General Satisfaction with CDI

To determine how the various parties view the doula program, auditors distributed satisfaction surveys to 2,458 clients, 317 doulas, and each vendor contracted to provide doula services on behalf of the CDI.  Auditors received 164 responses from clients, 112 responses from doulas, and responses from each vendor surveyed. Key portions of the results for client, doula, and vendor surveys can be found in Appendices V, VI, and VII respectively.

Overall, those participating in the program view it favorably. However, the level of satisfaction varied among providers, 81% (22 of 27) expressing satisfaction with the doula provided by CWHA, and 77% (24 of 31) expressing satisfaction with the doula provided by ASDS.

Client Survey Responses

Survey questionnaires were emailed to 2,458 clients on DOHMH’s client outreach database (those who registered to receive information about obtaining a CDI doula or did receive doula services through the CDI). The surveys were issued in the top three most-reported languages spoken by CDI clients who received doula services—English, Spanish, and Haitian Creole. The surveys included questions about client demographics, including preferred language, client satisfaction with the doula and vendor, and information and social service recommendations provided to the client by the doula.

Auditors received 164 responses. The number of questions answered varied among respondents. Responses were anonymized.

Key takeaways from the client survey are as follows:

• 122 of 159 (77%) respondents rated their pregnancy/birthing experience with a doula as good or excellent.
• 56 of 81 (69%) respondents who had been pregnant before but were working with a doula for the first time rated their doula experience as better than without.

Clients were also asked to provide comments about their pregnancy and birthing experience with a doula. Auditors received 71 comments, 50 (70%) of which were positive. One respondent stated, “I honestly think my labor would’ve been a bad experience if it wasn’t for my doula advocating for me.” Another stated that “having a doula was life changing and more clinics/hospitals should offer it to all patients.”

Results of the client surveys are shown below in Charts 5, 6, and 7.[25]

Chart 5: Clients’ Overall Satisfaction with Doulas

 

Chart 6: Clients’ Overall Satisfaction with Provider Agencies

Chart 7: Client Ratings of Pregnancy/Birthing Experience with Doula

Doula Survey Responses

Auditors also emailed survey questionnaires to 317 doulas who had provided doula services on behalf of the CDI; 112 responses were received. The survey included questions related to doula training, languages spoken, information and social service recommendations to clients, and general perception of the CDI program.

Key takeaways from the doula survey are as follows:

• 66 of 108 doulas (61%) who responded to a question asking them to rate their experiences supporting their clients during labor in hospitals rated their experience as good or excellent.
• Of the 106 doulas who responded to a question asking them to rate the level of engagement and support they receive from the agency that provides them with clients, 77% rated the level of service as good or excellent.
• Of the 105 doulas who responded to a question asking them to rate the level of engagement and support they receive from the CDI, 74% rated the level of service as good or excellent. Doulas were asked to explain their ratings. Some of the responses mentioned the availability and responsiveness of mentors, vendor staff, and CDI staff; the level and availability of training; and monthly meetings.
• Of the 63 doulas who said that they speak a language other than English, 43 (68%) said that they spoke Spanish, seven (11%) said that they spoke Haitian Creole, and five (8%) said that they spoke French. Five (8%) said that they spoke another language, and one doula each said that they spoke Chinese, Arabic, or Polish.

Vendor Survey Responses

Finally, auditors emailed survey questionnaires to the seven contracted vendors and Brooklyn Perinatal Network to assess vendor satisfaction with DOHMH support. (Detailed survey results are included in Appendix V).) The question topics included client and doula recruitment, languages spoken, doula training, and general support received from CDI. All eight vendors stated that DOHMH/CDI provides them with assistance to achieve their goals.

The surveys identified two areas where improvement is warranted, as discussed in the following section of this report.

Survey Respondents Cite Barriers to Doula Services at Shelters and for Non-English-Speaking Clients

Limited Access to Doula Services in Shelters

Doulas expressed difficulty in gaining access to clients living in shelters, with 33 (49%) of the 68 doula respondents saying that their clients were difficult to access or inaccessible.  Additionally, two of the 12 (17%) clients who said they were living in a shelter during any one of their doula visits said that the shelters did not permit the doula to visit them.

Clients living in homeless shelters who lack access to doula care or information are being denied their rights in accordance with the New York Standards for Respectful Care at Birth. Further, doulas reported additional barriers to access, such as being forced to contact a DHS caseworker to communicate with their client, thus delaying critical services.

Doulas who rated their access to clients as difficult or inaccessible reported that some shelters do not have adequate space to provide doula services. Others stated that clients may not feel comfortable due to privacy issues, or because shelters themselves may bar entry.

CDI officials informed auditors that they have begun a dialogue with the New York City Department of Homeless Services (DHS) to increase doula access to clients residing in shelters.

Need for Doulas Proficient in Other Languages

Vendors that responded to the survey reported a need for non-English-speaking doulas. While six of the seven CDI vendors stated they could provide services in Spanish, less than half of the vendors could provide services in other languages—two in Haitian Creole and French, and one each in Cantonese Chinese and Mandarin Chinese.

According to the data CDI submitted to auditors, CDI clients requested services in a language other than English 321 times. Of the 164 client survey responses that auditors received, 47 stated that English was not their preferred language, with Spanish receiving the most responses (37 responses), followed by Haitian Creole and French with three responses each.

Auditors spoke to DOHMH officials about this issue, and they stated that they are actively prioritizing the recruitment of non-English-speaking doulas during outreach and recruitment events.

CDI Procedures for Producing a Comprehensive Data Report Are Inefficient

DOHMH has implemented several measures to more accurately track the use and effectiveness of doula support. However, the agency does not maintain a single comprehensive dataset containing key data (e.g., doula services provided, clients served, birth outcomes) relating to the CDI.

DOHMH implemented the following measures to improve data collection and accessibility:

• In 2021, DOHMH modified the NYC Birth Certificate and Mother/Parent Worksheet so that it now indicates the presence of a doula during labor and delivery. This information can be used to better assess the extent to which doula services are available in the City.
• CDI doulas collect data related to doula services and client demographics. CDI provides doulas with forms and questionnaires to complete either during or after each visit to collect data about clients’ general physical and mental health, birth outcomes, breastfeeding, and client needs, such as food security, housing, and social service assessments. The collected data can be used to assess the effectiveness of doula care on reducing the rates of negative birth outcomes among CDI clients.

However, because data is collected during different visits and recorded in different datasets (and because not all clients receive the same number of visits or doula care during pregnancy), there is no dataset that captures all the data that can be run in one single report for analysis.

CDI staff review data from multiple datasets to prepare reports showing birth outcomes, services provided, and demographic data. This process is labor intensive and hinders the aggregation of key performance data. This, in turn, makes it very difficult for CDI staff to determine the extent to which the program is achieving its intended outcomes and more readily identify areas where increased support is warranted.

Auditors used several different datasets to determine if the rates of negative birth outcomes had been reduced. Auditors informed DOHMH/CDI that the data collection and reporting procedures needed to be improved to better understand the effectiveness of the program.

DOHMH/CDI informed auditors that they “plan to supplement our program data with more rigorous, multi-year analyses of outcomes by matching CDI clients to more complete datasets (i.e. OVS or Medicaid claims data), which will allow us to more effectively compare outcomes for individuals who received doula support through the CDI to those who have similar characteristics but did not receive doula support.”

Recommendations

To address the findings, the auditors propose that DOHMH:

1. Make all reasonable efforts to collect or use available provisional citywide birth outcome-related data, to facilitate a timelier comparison between the rates for CDI clients and the rates for other target populations in the City.

   DOHMH Response: DOHMH agreed with this recommendation.

2. Consolidate data collection to ensure more efficient data reporting to determine the effectiveness of doula services on the reduction of negative birth outcomes and maternal mortality.

   DOHMH Response: DOHMH agreed with this recommendation.

3. Increase non-English-speaking doula capacity.

   DOHMH Response: DOHMH agreed with this recommendation.

4. Continue to work with DHS to increase doula access to clients in shelters.

   DOHMH Response: DOHMH agreed with this recommendation.

5. Continue to promote doula-friendly policies in MHQIN hospitals and expand doula incorporation into hospital birthing teams.

   DOHMH Response: DOHMH agreed with this recommendation.

6. Incorporate client satisfaction surveys into their data collection procedures and evaluate satisfaction by vendor, analyzing differences in practice that may affect satisfaction.

   DOHMH Response: DOHMH agreed with this recommendation.

7. Conduct additional studies focused on outcomes for Asian [AAPI] and White women to gain an understanding of the apparently lower impact of CDI on birth outcomes.

   DOHMH Response: DOHMH disagreed with this recommendation. The agency indicated that the focus of the CDI program was Black and Hispanic birth outcomes and cited the very small sample size for AAPI and White women to question the comparison to Citywide rates.  The agency also stated that it plans to conduct “a rigorous analysis of outcomes once the sample sizes across all categories have increased and comparison data for the relevant years becomes available. This analysis will include all racial and ethnic sub-groups, as well as other factors that could influence outcomes, including age, previous births, and health conditions such as hypertension, diabetes, and obesity. This will likely shed some light on the question the auditors raise.”

   Auditor Comment:  The positive outcomes for Black and Hispanic women in the program, and the promise of more detailed analysis in future, are very welcome.  However, the fact that AAPI CDI clients apparently experienced higher rates in all 3 categories of negative outcomes, and White women in the program experienced higher rates of low-weight births, should not be dismissed without closer consideration.

Scope and Methodology

We conducted this performance audit in accordance with Generally Accepted Government Auditing Standards (GAGAS). GAGAS requires that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions within the context of our audit objectives. This audit was conducted in accordance with the audit responsibilities of the City Comptroller as set forth in Chapter 5, § 93, of the New York City Charter.

The scope period was from January 1, 2019 through April 24, 2025.

To achieve the audit objectives, auditors performed the following:

• Reviewed relevant criteria including:
  • NYC Administrative Code, Title 17, Chapter one, § 17-199.3 Maternal mortality annual report (Local Law 55 of 2017)

• • NYC Administrative Code, Title 17, Chapter one, plan to increase access to doulas, § 17-199.10 (Local Law 187 of 2018)

• • NYC Administrative Code, Title 17, Chapter one, § 17-199.3 Maternal mortality and morbidity annual report (Local Law 188 of 2018)

• • NYC Administrative Code, Title 17, Chapter one, § 17-199.10 (Local Law 85 of 2022)

• Created compliance checklists to assess DOHMH’s compliance with LL187 and LL188.
• Reviewed reports released as required by LL187, LL188, and LL85 and analyzed data contained in the reports.
• Attended virtual New York State Doula information sessions on doula care and Medicaidreimbursements from May 30, 2023, and March 12, 2024, and reviewed pdfs of presentations from January 9, 2024, to December 10, 2024.
• Reviewed testimonies before the New York State Senate Standing Committees on Health and on Mental Health by Ashwin Vasan, MD, PhD (Commissioner DOHMH), Michelle Zambrano, MPH (Co-lead, NYCDA), Ngozi Moses (Executive Director BPN), Chanel L. Porchia-Albert (CEO: ASDS)
• Conducted eight virtual interviews and walkthroughs with key DOHMH personnel involved with the administration of doula related programs between October 27, 2023, and December 19, 2024.
• Conducted seven site visits, interviews, and walkthroughs at all seven community-based doula service providers contracted to provide doula services to qualified clients participating in the CDI program between January 29, 2024, and March 24, 2024.
• Conducted eight site visits, interviews, and walkthroughs at MHQIN hospitals who had agreed to participate in doula-friendly policy expansion programs between June 26, 2024, and September 16, 2024.
• Attended four Grand Rounds/Doula-Friendliness meetings in person and virtually between June 24, 2024, and November 18, 2024, to ensure vendor and CDI promoted doulas friendly hospital policies.
• Conducted five site visits and walkthroughs of community outreach events to increase awareness of doula services and training between March 8, 2024, and September 10, 2024.
• Attended nine vendor conducted monthly meetings with doulas to determine support for doulas between April 25, 2024, and December 10, 2024.
• Attended ten in-person and virtual training sessions to ensure doulas received adequate training in areas required by LL85 between January 25, 2024, and December 11, 2024, including:
  • birth equity,
  • CDI Model training,
  • Client Needs Assessment,
  • Comfort Measures training,
  • Full Spectrum Doula training,
  • trauma-informed care (Intimate partner violence and infant and pregnancy loss training),
  • navigating the hospital environment and support services.

• Reviewed and assessed DOHMH reimbursement procedures to ensure DOHMH was properly approving vendor invoices.
• Reviewed supporting documents received from DOHMH such as:
  • 22 Vendor contracts for services provided from November 2021 through June 2024
  • 215 Invoices from vendors for all services provided from November 2021 through June 2024
  • Doula Guidebooks (CDI Handbook, Hospital Doula-Friendliness Guidebook)
  • CDI promotional materials (pamphlets, flyers, palm cards)
• Reviewed and analyzed DOHMH provided demographic and birth outcome data for the period of March 1, 2022, through June 30, 2024, collected by doulas during visits to clients to assess effectiveness of doula services on reducing negative pregnancy outcomes and improving satisfaction with birthing experience.
• Reviewed the 2021 and 2022 New York City Department of Health and Mental Hygiene’s Summary of Vital Statistics reports, released in 2024 and 2025 respectively, to compare with CDI data and birth outcome rates.
• Conducted participatory surveys to assess the general opinion of DOHMH programs to increase access to doula services in underserved neighborhoods. Surveys email to seven CDI contracted vendors and BPN (all seven vendors and BPN responded), 317 doulas (112 responded) and 2,458 clients (164 responded).

Appendix I

Map and Listing of 33 Underserved Neighborhoods as Identified by TRIE

Appendix II

List of Boroughs and TRIE Zip Codes Served by Vendors

Appendix III

List of Vendors and Contract Amounts by Fiscal Year

Appendix IV

Components of Plan to Increase Doula Access Underserved Neighborhoods per LL187

Appendix V

Client Responses to Auditors’ Survey of CDI Participants

See the attachment.

Appendix VI

Doula Responses to Auditors’ Survey

See the attachment.

Appendix VII

CDI-Contracted Doula Vendors’ Responses to Auditors’ Survey

See the attachment.

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Endnotes

[1] For the purposes of this report, the term “women” includes persons who self-define as birthing people.

[2] https://www.cdc.gov/maternal-infant-health/preterm-birth/index.html

[3] Pregnancy-associated deaths include deaths from any cause during pregnancy or within one year from the end of pregnancy, regardless of the outcome of the pregnancy.

[4] The Summary of Vital Statistics 2022 was released in 2025 but contains vital statistics, including birth outcome data, from 2022.

[5] Infant mortality tracks the death of an infant before their first birthday.

[6] For the purposes of this audit, the infant mortality rates for Puerto Rican and Hispanic/Latino (not Puerto Rican) were combined.

[7] TRIE was launched in April 2020 in response to the disproportionate impact of COVID-19 on communities of color, for the purpose of addressing racial and economic injustices in communities that have a high percentage of health and socioeconomic disparities.

[8] For the purposes of this audit, the terms “TRIE neighborhoods” and “underserved neighborhoods” may be used interchangeably. Underserved neighborhoods are defined as neighborhoods that have high rates of socio-economic and health and healthcare disparities.

[9] The 14 hospitals consist of nine public hospitals and five private hospitals. The public hospitals include SUNY Downstate and eight NYC Health + Hospitals (H+H) hospitals—South Brooklyn/Ruth Bader Ginsburg (formerly Coney Island), Elmhurst, Jacobi, Metropolitan, North Bronx Central, Woodhull, Kings County, and Lincoln. The private hospitals include Jamaica, Montefiore, Long Island Jewish Medical Center, New York Presbyterian Allen, and New York Presbyterian Sloane.

[10] The citywide birth outcome data used in this report is taken from the Summary of Vital Statistics 2022. The most recent Summary of Vital Statistics at the time this report was written was published in 2025 and contained data from 2022.

[11] According to New York Standards for Respectful Care at Birth, patients have a right to have persons of their choice—such as family members, friends, or doulas—present during delivery and other procedures.

[12] Auditors analyzed data from March 1, 2022 (the establishment of CDI) through June 30, 2024, to correspond with the end of vendors’ contract term, which was Fiscal Year 2024.

[13]  Subsequent to the initial launch of the MHQIN, St. Barnabas Hospital and SUNY Downstate were added in 2023.

[14]  Hospital doula-friendliness meetings are CDI-sponsored meetings in which CDI staff meets with vendors and hospital officials to develop hospital policies designed to increase staff knowledge of doula support, develop a centralized referral system, incorporate doulas into the birthing team, encourage better communication between hospital staff, clients, and doulas, and allow doula presence during birth and labor.

[15] BMS is a federally-funded program that provides no-cost doulas, and HWHF is a City Council-funded program that provides no-cost doulas.

[16] Use of the Doula Assessment tool began in 2019 and was paused during the COVID-19 pandemic. Distribution resumed in 2021.

[17]  In 2019, DOHMH developed the New York City Standards for Respectful Care at Birth to inform and educate people giving birth about their reproductive rights.

[18]https://www.nyc.gov/health/doula

[19] https://www.nyc.gov/site/doh/health/health-topics/citywide-doula-initiative.page

[20] https://www.health.state.ny.us/health_care/medicaid/program/doula/directory/directory.htm

[21] Summary of Vital statistics report disaggregate data by Puerto Rican and Hispanic separately.  For the purposes of this report, Puerto Rican and Hispanic data has been combined.

[22] The most recent Summary of Vital Statistics contains data for birth outcomes that occurred in 2022.

[23] CDI clients can self-identify as more than one race/ethnicity.  The percentages here represent the rates at which CDI clients chose to self-identify with a given option.  Percentages may exceed 100% when added up because some clients self-identified as more than one ethnicity.

[24] The population of both Asian and White CDI clients is significantly smaller than the population of Black and Hispanic population of CDI clients and make up a disproportionally small share of pregnancies with CDI doula support.

[25] Clients served by CHCR, HHFC, and NMPP are not included due to the low number of client responses.