Editor’s note: Every mother deserves a safe pregnancy, but there are vast disparities in maternal health care based on where a mom lives, her ability to pay and the color of her skin. That's unacceptable, and it's why we started #BumpDay. Our goal is to raise awareness about the need for equitable care for every mom, everywhere, and to urge elected representatives to take action to support safe pregnancies and healthy babies. This article was originally published as part of our #BumpDay 2021 package, but it continues to be relevant today. To learn more about the critical issues impacting moms in 2022, visit our #BumpDay 2022 editorial package here.
When Melanney Beckles was 40 weeks pregnant, her obstetrician performed a membrane sweep to induce labor. Beckles had an uncomplicated pregnancy up until that point, and her doctor did the procedure without asking permission, explaining whether it was medically necessary, or sharing what the benefits or risks might be.
A slew of unexpected and unexplained interventions followed, and Beckles was given Pitocin and an epidural, the latter which hadn't been part of her birth plan.
"I'm grateful that it didn't get to a point where I needed an emergency C-section, but labor was rough, let's just put it that way," she says.
Beckles, who lives in Laurel, Maryland, feels grateful to have left the hospital healthy and with a healthy baby, but disappointed to have felt like a bystander to her own birth experience.
“It just got to the point where I felt like things were still out of my control,” she says. “I was determined that I wanted a different birthing experience with my second baby, so I trained for it.”
During her second pregnancy, Beckles immersed herself in birthing classes and books. During her research, she realized her birth plan was missing something. Although Beckles has a husband, she felt she could benefit from additional support on her prenatal care team. That’s when a friend recommended Beckles hire a doula.
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Beckles searched Facebook and used referrals to find a professional who felt like a good fit. For Beckles, it was important to find a Black doula, in large part due to the shocking racial and ethnic disparities in the U.S. maternal mortality rate.
“I wanted a Black doula because I'm a Black woman, and I know the terrifying infant mortality rates and Black women dying at disproportionate rates or receiving subpar care just because of the color of our skin,” she says.
Black women are two to three times more likely to die in childbirth or of pregnancy-related complications than white moms, while American Indian and Alaska Native women are about two-and-a-half times more likely, according to the Centers for Disease Control and Prevention (CDC). Black infants are also more likely to die during and shortly after childbirth.
A number of factors are thought to contribute to the heartbreaking maternal mortality rate, including pregnancy and postpartum complications that disproportionately affect Black women (such as postpartum hemorrhage and preeclampsia) as well as institutional racism.
All parents can benefit from working with a doula, but many experts believe that increased access to doulas for Black, Indigenous and People of Color (BIPOC) parents in particular is one way to reduce the maternal mortality rate and improve birth outcomes.
What role do doulas play?
Doulas are trained professionals who provide emotional and physical support to parents and parents-to-be during pregnancy, childbirth and the postpartum period. Brandi Hawthorne, a full-spectrum birth doula in Yorktown, Virginia, says that as more BIPOC parents become aware of the alarming maternal mortality statistics, they are increasingly seeking out doulas to support them during labor and delivery.
“One of the first things that I hear a lot of moms express is they don't want to die giving birth," Hawthorne says. "They want to make sure that they’re being told everything they need to know to make an informed decision. They don't want to be bullied. They want to know that there's someone who can help them navigate that system." Very often, she adds, BIPOC moms feel like this system is not for them.
There are different types of doulas; some are specifically trained to assist parents during the postpartum period, helping with common challenges such as breastfeeding, sleeping and swaddling, while a birth doula specifically assists during pregnancy, labor and childbirth. Full-spectrum doulas like Hawthorne support families at every stage.
While doulas don't provide medical care during labor and delivery, they are well-versed in the childbirth process and can help you advocate on your behalf to your prenatal care team. “We’re not there to replace a care provider, but we can give them the information to help them make informed decisions,” Hawthorne explains.
Doulas can also help with relaxation techniques and breathing exercises, suggest labor positions and generally make moms (and their partners) feel supported and at ease.
What are the benefits of having a doula?
Doulas give women, especially BIPOC women, someone who can communicate effectively with and for them, says Sirina Keesara, M.D., an OB/GYN and director of women’s health at West Oakland Health in Oakland, California.
“You only go through childbirth maybe a few times in your life and the people providing for you do this every day, thousands of births a year, so communication between them can be difficult,” she says. “Doulas give women the translation from someone they trust.”
Beckles recalls how her doula acted as a liaison with hospital staff, a role that she believes was crucial in allowing her to focus on her labor. While her midwife and nurses were in and out with other patients to take care of, her doula was by Beckles' side for the entire 24 hours and 21 minutes she labored — guiding her into comfortable positions with yoga balls, helping her into the shower to ease contractions, even bringing food for her husband.
“From beginning to end, she provided me with direction,” Beckles says.
Beyond communication, birthing people also need security. Dr. Keesara notes that it can be difficult for women to labor when they don’t feel safe in their birth setting. Beckles’ doula helped with pain management techniques and developed a birth plan, which Beckles says gave her a sense of peace at the hospital.
All women can benefit from this kind of support during labor — research has shown that doulas can reduce time spent in labor, lower anxiety of mothers, lower the rate of medical interventions and health care costs, and improve birth outcomes.
The support doulas provide lead to fewer birth complications, research shows, and many experts believe that widespread access to doulas would help address racial maternal health disparities.
Studies also show that doulas can help mitigate the negative effects of racism and classism for Black birthing people, as well as reduce the rate of C-sections, which are performed more often on Black women. Though they can be medically necessary, C-section procedures are linked to postpartum hemorrhaging, one of the leading causes of maternal death for Black women.
The benefits of doulas during childbirth also extend to the baby. One study found that babies born in doula-assisted births were less likely to have low birth weight — a condition that Black infants are almost four times more likely to die from.
How can we increase access to doulas?
In addition to wanting to find a culturally competent Black doula, Beckles needed to find one she could afford. When she gave birth to her first child, insurance covered Beckles' entire hospital visit and stay. When she started her search for a doula during her second pregnancy, however, she discovered that the services were not covered by her insurance.
Beckles' experience is not unusual: Out-of-pocket doula services can range from $800 to $2,500 (or even more) depending on location, and most are not covered by insurance. Fortunately, Beckles had enough money in a flexible spending account to pay for the cost of her doula, but 25 million women in America rely on Medicaid for their health care expenses.
Black women ages 15 to 44 disproportionately rely on the program, with about 37 percent covered by Medicaid. According to the Harvard Chan School's Maternal Health Task Force, only three states have legislation allowing reimbursement for doula services through Medicaid as of 2020. Slowly, however, this may be starting to change.
“Some states are now accessing federal funds through Medicaid to cover doula services for eligible moms,” says Megan Carolan, director of policy research at the Institute for Child Success. “When this is done right, which means adequate reimbursement and reducing bureaucracy, it allows for local providers who know their communities best to leverage a new funding source and potentially save lives.”
A bipartisan resolution acknowledging the crucial work of doulas recently passed through the Senate, and 21 states and Washington, D.C., have proposed legislation related to doula access working its way through Congress. Recently, Illinois, where a significant number of Black women live in maternal care deserts, signed into law a bill that provides Medicaid coverage for birth doulas and postpartum home visits. Wisconsin and Nevada are among the states with bills still hoping to pass.
In Hawthorne’s home state of Virginia, where 1 out of every 3 birthing people is covered by Medicaid, advocacy groups are pushing to get doulas recognized and paid for by the program. Hawthorne believes that such legislation could save lives, as could ensuring that doulas become a more accepted and recognized part of prenatal care teams.
"We have a long way to go, but we've made progress," Hawthorne says.
How to find a doula
The following organizations can help parents connect with a doula:
- Childbirth and Postpartum Professional Association (CAPPA)
- International Childbirth Education Association (ICEA)
- DONA International
- Birthing From Within
- DoulaMatch.net
- Hypnobabies, which certifies doulas who specialize in hypnobirthing
- National Black Doulas Association (NBDA), a nonprofit organization connecting Black families to certified Black doulas throughout the U.S.
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