Part 8: Window Washing: Doulas, Bias Training, and the Politics of Avoiding Hard Fixes

Part 8 of Structural Inequity in Prenatal Care

The April 2026 JAMA Network Open systematic review of 21 doula care studies found the strongest associations were with reduced maternal anxiety and improved breastfeeding initiation. Not maternal mortality. Not severe morbidity. Meanwhile, 26 states now reimburse doulas through Medicaid, some requiring only 16 hours of training. A Medicaid patient in Manhattan cannot see a faculty obstetrician. She can get a doula. This is what substitution looks like when we are unwilling to address the actual problem. obmd.co

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I want to introduce a term that I think captures what is happening in the policy response to Black maternal mortality: window washing.

Window washing is the practice of cleaning the visible surface of a building while leaving the structure unchanged. The building looks better from the street. The people inside it are in the same building. The metaphor is not original to me, and the phenomenon it describes is not unique to maternal health policy. But it is a precise description of what is being built: a set of visible, politically tractable, institutionally convenient responses to a crisis whose root causes are structural and whose structural solutions require changing the economics of how obstetric care is financed and delivered.

Implicit bias training is window washing. I made the case for that in the previous post. This post examines the second major element of the current policy response: doula care. And it examines the specific mechanism by which both of these interventions serve an institutional function that is about managing the appearance of the problem rather than solving it.

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