By BirthMatters
South Carolina faces a devastating maternal health emergency.
With a maternal mortality rate of 47.2 per 100,000 live births in 2021, significantly above the national rate of 32.9, the state ranks 8th highest nationally for maternal deaths. Almost 90% of these deaths are preventable. For the third consecutive year, South Carolina earned an โFโ grade from March of Dimes for preterm birth rates (11.6%), ranking 44th nationally. The stateโs infant mortality rate of 6.8 per 1,000 live births exceeds the national average of 5.6.
Stark racial disparities compound these alarming statistics. Black women face maternal mortality rates nearly twice that of white women, while Black infants are more than twice as likely to die before their first birthday. Geographic inequities further intensify these disparities, with 10 counties designated as maternity care deserts and 11 classified as low-access areas. Rural mothers face a 62% higher mortality rate (55.4 per 100,000) compared to urban counterparts (34.2 per 100,000). One in five women receives inadequate prenatal care, and 8.7% live more than 30 minutes from a birthing hospital โ a figure that rises to 100% for women in rural areas.
These systemic failures disproportionately impact the most vulnerable populations. Medicaid patients represent 60% of total births but comprise a disproportionate share (65%) of pregnancy-related deaths. With 71% of rural deliveries paid by Medicaid, structural healthcare inequities intersect with geographic and racial disparities to create a perfect storm of preventable maternal and infant mortality.
Current Policy Context and Legislative Developments
Recognition of this crisis has galvanized bipartisan support for expanding doula services, driven in part by coordinated advocacy efforts. The South Carolina Doula Steering Committee (SCDSC), established in 2022, has led a collaborative, statewide effort to advocate for policies that provide equitable compensation for doulas in South Carolina. The committee has been studying how other states have built doula reimbursement policies to determine policy recommendations for South Carolina, providing crucial groundwork for current legislation.
While the SCDSC was not involved in the initial conception of House Bill 3108, introduced in January 2025, the committee organized and testified at legislative hearings in March. The legislative committeeโs decision to continue testimony at a later date has allowed the SCDSC to build broader community relationships and work towards ensuring doula voices guide the evolution of the billโs language.
House Bill 3108, sponsored by Rep. Kambrell Garvin (D-Richland) and Rep. Thomas โTommyโ Pope (R-York), would require coverage through both private insurance and Medicaid. The policy framework includes establishment of professional standards, doula certification organizations and statewide registries while recognizing alternative credentialing pathways for practitioners with documented community-based experience โ acknowledging the value of peer learning models integral to community-based approaches. Companion Senate Bill 42 extends coverage requirements to lactation services with implementation scheduled for January 1, 2026.
The Evidence Base: Why Doulas Save Lives
The growing body of research supporting community-based doula care provides a strong foundation for policy expansion, demonstrating that doula care represents a critical, evidence-based intervention that saves lives by significantly reducing maternal and neonatal morbidity and mortality.
A comprehensive Cochrane systematic review of 26 randomized controlled trials involving over 15,000 women found that continuous labor support provided by doulas reduces cesarean births by 22% (RR 0.78, 95% CI 0.67-0.91), decreases instrumental vaginal deliveries, shortens labor duration, and reduces epidural use by 10-60% across trials.
These clinical improvements directly translate to life-saving outcomes: fewer emergency cesarean sections reduce maternal risks of infection, hemorrhage and surgical complications, while shorter labors decrease fetal distress and neonatal intensive care admissions. Community-based doulas are particularly effective because they share cultural backgrounds and lived experiences with the families they serve, providing culturally responsive care that addresses health disparities.
Research shows that women who received doula care had 52.9% lower odds of cesarean delivery, 57.5% lower odds of postpartum depression/postpartum anxiety, increased breastfeeding success and improved overall birth satisfactionโwhile babies born with doula support have higher Apgar scores and reduced NICU admission rates, all factors that contribute to long-term maternal and infant survival and wellbeing.
The economic case for doula care implementation is equally compelling, with cost-benefit analyses demonstrating savings that far exceed program investments while simultaneously saving lives. Doula programs show substantial cost savings, with studies reporting potential savings associated with doula support reimbursed at an average of $986, through reduced surgical interventions, shorter hospital stays and decreased complication rates.
When scaled across population-level implementations, doula-supported deliveries among Medicaid beneficiaries could save $58.4 million and avert 3,288 preterm births annually. In South Carolina alone, where adverse maternal and infant health outcomes represent a substantial public health crisis with significant economic impacts, doula services costing $750-$1,500 per birth represent a highly cost-effective strategy that prevents medical emergencies and saves lives while achieving substantial healthcare system savings.
The American College of Obstetricians and Gynecologists now recognizes doula care as an evidence-based practice, stating that โcontinuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor,โ and even hospital-based programs are integrating community-rooted approaches, recognizing that doulas not only improve clinical outcomes but also empower mothers to advocate for themselves during one of lifeโs most vulnerable moments.
Reimbursement of doula care services represents a critical opportunity for South Carolina to simultaneously improve maternal and infant health outcomes while achieving significant healthcare cost reductions across the stateโs maternal health system.
Building a Sustainable Community-Based Workforce
The success of expanded Medicaid coverage will depend on developing a robust, culturally competent community-based doula workforce that is rooted in the communities most affected by health disparities. As South Carolina considers House Bill 3108 and companion legislation, the state has the opportunity to build on the innovative work already being done by community-based doula programs like BirthMatters, BEE Collective, and Family Solutions. These programs provide blueprints for culturally competent, community-rooted care that can be scaled through Medicaid reimbursement while maintaining the peer support and community connection that makes the model so effective.
Critical infrastructure investments are essential to ensure workforce readiness and sustainability. Training infrastructure must include standardized certification programs that incorporate cultural humility, trauma-informed care and community health worker principles, while providing pathways for career advancement and continuing education.
Adequate compensation structures that recognize the full scope of doula care, including prenatal education, labor support and postpartum follow-up, are fundamental to workforce retention, with reimbursement rates that reflect the comprehensive nature of the service and provide livable wages for practitioners who often serve low-income communities.
Support systems must address the unique challenges faced by community-based doulas, including access to affordable childcare during on-call hours, flexible training schedules that accommodate work and family responsibilities, and peer support networks that prevent burnout and secondary trauma.
Successful workforce development also requires robust mentorship programs that pair experienced doulas with new practitioners, creating pathways for knowledge transfer and community leadership development. Infrastructure considerations should include technology platforms for client communication and care coordination, transportation support for home visits in rural areas and liability insurance coverage that protects both individual practitioners and community-based organizations. Additionally, recruitment strategies must prioritize individuals from the communities being served, ensuring that the doula workforce reflects the racial, ethnic and socioeconomic diversity of South Carolinaโs Medicaid population.
By investing in these foundational elements, South Carolina can create a sustainable model that not only improves birth outcomes but also provides meaningful economic opportunities for community members while addressing the root causes of maternal health disparities through culturally responsive, community-led care.
National Context and Future Outlook
South Carolinaโs efforts align with a national movement toward community-based doula care expansion. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana and Montana, have passed laws to facilitate Medicaid coverage of doula services, with many specifically recognizing community-based models. All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so, with increasing recognition of the effectiveness of community-based approaches.
However, implementation challenges remain, particularly around ensuring adequate reimbursement for community-based doula programs that provide more comprehensive, long-term support. For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client, demonstrating the need for adequate and equitable compensation to ensure community-based program sustainability.
The Path Forward
The evidence is clear that doula care saves lives and improves outcomes, particularly for the most vulnerable populations.
Successful implementation of Medicaid reimbursement requires coordinated stakeholder engagement, adequate workforce compensation and comprehensive systems integration addressing social determinants of health. The established community-based doula programs provide implementation blueprints, while the SCDSC offers ongoing advocacy and oversight capacity. Policy advancement through legislative passage and systematic implementation can position South Carolina as a national model for community-based maternal health intervention.
BirthMatters seeks to reduce teen pregnancy through reproductive health education. We provide doula support services to expectant mothers 24 years old and younger in Spartanburg County.
References
South Carolina Department of Public Health. (2021). Pregnancy and Postpartum Health. Retrieved from https://dph.sc.gov/health-wellness/family-planning/pregnancy/pregnancy-and-postpartum-health
Centers for Disease Control and Prevention. (2021). Maternal Mortality Rates in the United States, 2021. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm
SC Maternal Morbidity and Mortality Review Committee (SCMMRC). 2025 legislative brief: CY 2018-2021 [PDF]. Retrieved from https://dph.sc.gov/sites/scdph/les/Library/00229-ENG-CR.pdf.
March of Dimes. (2024). 2024 March of Dimes Report Card for South Carolina. PeriStats. Retrieved from https://www.marchofdimes.org/peristats/reports/south-carolina/report-card
March of Dimes. (2024). Infant mortality rates: South Carolina, 2019-2022 Average. PeriStats. Retrieved from https://www.marchofdimes.org/peristats/data?reg=99&top=6&stop=91&slev=4&obj=18&sreg=45
March of Dimes. (2023). 2023 March of Dimes Report Card for United States. PeriStats. Retrieved from https://www.marchofdimes.org/sites/default/files/2023-11/MarchofDimesReportCard-UnitedStates.pdf
University of South Carolina Title V Maternal and Child Health. (2024). South Carolina โ 2024 โ III.C. Needs Assessment Update. Health Resources and Services Administration. Retrieved from https://mchb.tvisdata.hrsa.gov/Narratives/III.C.%20Needs%20Assessment%20Update/a933ee78-b3e1-42ff-bda0-09cba7e29967
South Carolina Department of Health and Human Services. (2024). SCDHHS Receives Grant to Invest in Maternal Health Care. Retrieved from https://www.scdhhs.gov/communications/scdhhs-receives-grant-invest-maternal-health-care
ACOG Committee Opinion No. 766. (2019). Approaches to limit intervention during labor and birth. Obstetrics & Gynecology, 133(2), e164-e173. doi: 10.1097/AOG.0000000000003074
Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7(7), CD003766. doi: 10.1002/14651858.CD003766.pub6
South Carolina Institute of Medicine & Public Health. (2025). Improving Maternal and Infant Health: Increasing Access to Care in Rural South Carolina. Retrieved from https://imph.org/wp-content/uploads/Maternal-and-Infant-Health-Report-2025.pdf
Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., & OโBrien, M. (2013). Doula care, birth outcomes, and costs among Medicaid beneficiaries. American Journal of Public Health, 103(4), e113-e121. doi: 10.2105/AJPH.2012.301201
Kozhimannil, K. B., Hardeman, R. R., Alarid-Escudero, F., Vogelsang, C. A., Blauer-Peterson, C., & Howell, E. A. (2016). Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery. Birth, 43(1), 20-27. doi: 10.1111/birt.12218
Ogunwole, S. M., Bennett, W. L., Williams, A. N., Bower, K. M., Wan, G., Lau, B. D., โฆ & Dalcin, A. (2022). Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. eClinicalMedicine, 50, 101531. doi: 10.1016/j.eclinm.2022.101531