Fox T. The integration of doulas into the pregnancy care teams of women of color in the United States. HPHR. 2021;34.
The United States has one of the highest maternal mortality ratios of any country in the Organization for Economic Cooperation and Development (OECD) at 17.4 per 100,000 live births as of 2017, far more than Canada, Sweden, Australia, or Germany (OECD.Stat, 2021). A primary reason for this considerable difference between the U.S. and other OECD countries is the racial disparity in maternal mortality. One intervention aimed at addressing this racial disparity is the integration of a doula, a professionally trained companion who provides birth support, into a woman’s biomedical care team (Gilliland, 2002). The doula works with their client throughout pregnancy, through delivery, and in the postnatal period, providing guidance and encouragement to the mother while also working within the healthcare system to advocate for, and in some cases to protect, her. This paper will provide a general background on maternal death in the United States, highlighting the historical and modern instances of racism and its impact on maternal health; examining the use of doulas as an intervention for reducing maternal death, using New York City as a case study; and discussing the potential implications of a national expansion of Medicaid reimbursed doula programs aimed at improving maternal outcomes countrywide.
Disparities in maternal health outcomes are deeply rooted in racism, from the historical implications of James Marion Sims to modern, systemic issues such as the quality of care women of color receive; the ways they are treated by their care team during delivery; and the overt racism they experience in daily life. James Marion Sims is lauded as the “Father of American Gynecology” for his work repairing the vesicovaginal fistula, a tear between the vagina, the bladder, and/or the rectum (Washington, 2006, p. 66). However, Sims perfected this technique solely through experimentation on enslaved women, three of whom were named Anarcha, Lucy, and Betsy (Cooper-Owens, 2017). The surgeries and the recovery were incredibly painful, as Sims did not provide anesthesia to the women (he later administered anesthesia to his white patients) because he claimed the procedure was “not painful enough” to warrant it and that “Blacks did not feel pain in the same way as whites” (Washington, 2006, p. 65). After five years of experimentation and on Anarcha’s thirtieth surgery, Sims perfected the procedure and was able to close Anarcha’s fistula with silver sutures (Cooper-Owens, 2017). The creation of a procedure to close vesicovaginal fistulae launched Sims to the forefront of gynecological medicine at the time and also made him exceptionally wealthy (Cooper-Owens, 2017).
The historical implications of vesicovaginal fistula repair need to be highlighted along with the modern ones. While the repair of this birth injury was, and remains, important to return all women to full health, “the repair of any medical condition that could render an otherwise healthy slave woman incapable of bearing children further strengthened the institution of slavery” (Cooper-Owens, 2017, p. 39). This experimental procedure, created by the Father of American Gynecology, offers a window into how the institution of slavery in the United States was inscribed into the bodies of Black women, perpetuating stereotypes of sensory deprivations. Indeed, Sims founded the field on the pain and suffering of enslaved women, touting medical myths that Black women could not feel the excruciating pain despite their screams during surgery (Washington, 2006). These historical legacies still continue today, as a study from Hoffman et al. demonstrated in 2016 that half of a sample of white medical trainees subscribed to the myth that Black patients felt less pain than white patients, and this ultimately impacted their treatment recommendations (Hoffman et al., 2016).
Numerous determinants of health can be further tied to structural racism and other laws and policies. According to Crear-Perry et al. (2021), “Jim Crow, the GI Bill, “redlining”, [and] mass incarceration are historically based features of an overtly oppressive U.S. society that … continue to shape contemporary access to health-promoting resources and opportunities necessary for optimal Black maternal and infant health outcomes” (p. 231). A few key instances of this can be seen in the quality of care received by women of color during delivery and mistreatment of this population by healthcare staff.
One study by Vedam and colleagues focuses on mistreatment and quality of care in the United States. Globally, women delivering in hospitals in high- and middle-income countries have cited negative experiences, including “being ignored, belittled or verbally humiliated by healthcare providers, having interventions forced upon them, and being separated from their babies without reason or explanation” (Vedam et al., 2019, p. 2). Women in the U.S. share in these experiences. For example, women of color with pregnancy complications in the U.S. cited a higher rate of mistreatment (37%) than white women (22%) and this remained the case when controlling for socioeconomic status (Vedam et al., 2019). The highest percentage of mistreatment reported, however, was from women who “had a difference in opinion” from the care provider – essentially a disagreement with how to proceed with care (Vedam et al., 2019, p. 12). More than 80% of women of color and 75% of white women in this instance reported mistreatment (Vedam et al., 2019). The women that experienced mistreatment by healthcare providers were more likely to be women of color, young, of low socioeconomic status, have social risk factors, or pregnancy complications (Vedam et al., 2019). Many of these social determinants of health described by Vedam et al. have direct ties to the structural racism outlined in Crear-Perry et al.
These determinants, among many others, have had drastic impacts on the disparity of maternal death in the U.S. Non-Hispanic Black women are more than three times as likely to die from a pregnancy-related complication as non-Hispanic white women in the United States (Petersen et al., 2019). Similar trends are also seen in non-Hispanic American Indian and Alaska Native women, whose pregnancy-related mortality ratio is more than twice that of non-Hispanic white women (Petersen et al., 2019). One intervention increasingly used to address the disparities in maternal mortality and morbidity outcomes is the integration of a doula into a woman’s pregnancy care team.
A doula, according to Thomas et al. (2017), is “a trained childbirth professional who provides emotional, physical, and informational support to women during labor, delivery, and the immediate postpartum period” (p. 60). Doulas provide a “constant presence” for the mother throughout labor and are typically someone familiar with the woman and her family, having met with the family numerous times by the delivery date to aid in pregnancy and to discuss a birth plan (Gruber et al., 2013, 50; Thomas et al., 2017). Doulas serve five overall roles, according to Gilliland (2002), throughout the labor process: “providing specific labor support skills, techniques and strategies; offering guidance and encouragement to laboring mothers and their families; building a team relationship with nursing staff; encouraging communication between patient and medical caregivers; and assisting mothers to cover gaps in their care” (p. 763). A key argument cited within Gruber et al.’s literature review is that the birthing process has become increasingly medicalized and is “highly interventionist,” thus removing much of the control from the mother (Gruber et al., 2013, 50). Doulas are there to support the mother through labor, but also to aid in the dismantlement of a rigid, biased, and, at times, overtly racist medical system to ultimately provide the best possible birth outcomes for their clients.
Arguably, one of the most important roles for doulas is to advocate for their client during the stress of delivery. Gruber et al. (2013) highlighted this standard of care, stating that “Medical providers sometimes prefer women to be compliant and recommend procedures to ward off pain and discomfort” (p. 50). These interventions, however, may negatively influence the birthing process and lead to bad outcomes as the mothers are encouraged by care providers to focus on their own comfort instead of the possible complications that could arise for themselves or the baby due to these interventions (Gruber et al., 2013). A doula should empower their client to make the best possible decisions for themselves and their baby, while also being nonjudgmental if the mother ultimately decides, after consideration, to go along with the plan outlined by the care provider (Gruber et al., 2013; Gilliland, 2002). The doula is purposefully challenging the power dynamics present in the delivery room, aiming to question the overarching authority of the physician and their staff, to ensure the decision about care ultimately lies with the mother, and to ensure the mother’s voice is appropriately heard.
The use of doulas has also proven to have positive birth outcomes ranging from lower rates of Caesarean section to a shorter amount of time a woman is in labor to a reduced need for oxytocin for labor induction (Gruber et al., 2013). In four studies, where groups of underinsured, low-income women were randomized between those who received doula support and those who received the standard delivery care, those receiving continuous support from a doula had “significantly shortened labor duration, double the rate of spontaneous vaginal birth, and a reduction by half in the rate of caesarean delivery, forceps delivery, and oxytocin use” (Campbell et al., 2006, p. 458). Also associated with the continuous support of a doula is higher newborn Apgar scores and higher rates of satisfaction with the delivery process among women (Gruber et al., 2013). These outcomes demonstrate the need for specialized support from a doula, especially during the labor process.
While doula support during labor is associated with better birth outcomes for all women, the support during labor is especially key among women of color in the U.S. One example of this is seen in an intervention providing doula support to women in New York City’s Brownsville, East New York, Bedford-Stuyvesant, and Bushwick neighborhoods – called the “By My Side Birth Support Program” – which highlights the positive impacts birth support can have on maternal health outcomes for moms of color (Thomas et al., 2017, p. 60). These neighborhoods became the focus of this program due to the high rates of comorbidities and poverty present, with more than 30% of adults diagnosed with obesity, 15% with diabetes, and with 30% living below the federal poverty line (Thomas et al., 2017). It has also been found that Black women are 12 times more likely to suffer from a pregnancy-related death compared to whites in New York City, a disparity about four times higher than the national maternal mortality disparity (Howell and Zeitlin, 2016; Petersen et al., 2019).
Launched in 2010, growing out of the Healthy Start Brooklyn program, the By My Side Birth Support Program focused primarily on Black women, as this group had the highest infant mortality rate in the program area (Thomas et al., 2017). The women were assigned a doula who would conduct three home visits, which cover topics ranging from prenatal care to a birth plan, and the doulas also screen for depression, food insecurity, intimate partner violence, and medical risk factors (Thomas et al., 2017). These home visits also allow rapport to build between the doula, the mother, and the family (Thomas et al., 2017). One of the primary roles served by the By My Side doulas is to assist women and families in “navigating the hospital environment during labor [and] facilitating communication with the medical staff” (Thomas et al., 2017, p. 61). The By My Side Birth Program subcontracts with 12 doulas and provides mentorship for incoming doulas to ensure high quality care for clients (Thomas et al., 2017).
The program has been highly successful. More than 80% of mothers stayed in the program through completion, which is defined by the By My Side Program as completing at least two postpartum visits (Thomas et al., 2017). Mothers in the program also experienced much lower rates of preterm birth and having low birthweight infants – nearly halving the rates experienced by those in the project area (Thomas et al., 2017). It is important to note that the mothers receiving doula support during labor did not have significantly lower rates of Caesarean section and the authors stated the importance of further study in this area (Thomas et al., 2017). Positive findings were also reported during qualitative interviews, many of which outlined the advocacy work performed by doulas in the delivery room. One client stated that, “When [the hospital staff] would say I needed certain things, she let me know that it was my decision if I wanted it or not, and that I didn’t have to do anything I didn’t want to. She let me know that I had a voice and a choice” (Thomas et al., 2017, p. 63). These findings further demonstrate the importance of providing doula support to women, especially those potentially vulnerable to maternal death.
The evidence indicating the usefulness of doulas within labor and delivery rooms is overwhelming. These care providers have been shown to reduce rates of Caesarean section, the use of oxytocin, and preterm delivery, while also demonstrating shorter periods of delivery among women. Importantly, doulas fight for their clients, pushing back against the assumed authority of physicians to ensure women have a voice in their own deliveries. These positive health outcomes have pushed policymakers to consider Medicaid coverage expansion, thus allowing doula services to be reimbursable expenses through the Medicaid program (Mehra et al., 2019).
While Medicaid expansion would be an excellent step forward in reducing maternal mortality and other maternal health disparities, it is critical to provide sufficient and easy reimbursement to doulas to make the practice equitable and to ensure those who need doula support the most can afford it. Two states – Minnesota and Oregon – have pioneered the legislative process of making doulas Medicaid reimbursable, though considerable work still remains (Chen, 2018).
According to Platt and Kaye (2020), “state Medicaid programs must cover a set of mandatory benefits, but states can, within federal guidelines, also choose to offer optional benefits” (p. 4). One of the outlined federal guidelines to qualify for Medicaid reimbursement is that a service needs to be provided or recommended by a licensed provider (Chen, 2018). While there are numerous professional organizations that provide training and licensure, including DONA International and The Association of Labor Assistants and Childbirth Educators, there are currently no formal mandates in terms of licensure or certification in the United States (Chen, 2018). Though a single, national set of guidelines for training and licensure would simplify making doulas Medicaid reimbursable, it is also important to consider that a lack of formal medical certification “gives them credibility as more independently minded patient advocates,” separate from the biomedical care system (Chen, 2018, p. 6).
To place this group of professionals within the federal Medicaid guidelines for reimbursement, Oregon and Minnesota have each used a different approach. Both states require a doula to comply with state-level certification and registration requirements, but Minnesota also mandates that a doula practice under the supervision of a physician or another qualified health care professional to receive Medicaid reimbursements (Chen, 2018). In Oregon, doulas register for their own individual National Provider Identifier number (which is how payment for their services is made), “enroll as an Oregon Medicaid Provider, and enroll with or become a state-approved Medicaid billing provider” in order to be reimbursed through the Medicaid program (Chen, 2018, p. 10). As more states pass legislation to make doula services reimbursable, each will need to navigate the positive and negative aspects associated with current practices, wait for a national training or certification mandate so doulas become eligible for Medicaid reimbursement under federal guidelines, or create their own requirements.
While both avenues taken by Oregon and Minnesota allow a doula to be Medicaid reimbursable, there are also significant hurdles associated with each. As of 2018, doula registration fees in Minnesota were $200 and mandated training costs were an additional $800, creating a significant obstacle to low-income doulas practicing (Chen, 2018). Oregon also faced a similar dilemma, as the Oregon Health Authority approved training program cost $800 as of 2018 (Chen, 2018). In order for doulas to most effectively treat their patients and provide culturally appropriate care, “they must be recruited and trained in greater numbers from the same communities in which their services are most urgently needed” (Chen, 2018, p. 8). Both Oregon and Minnesota must provide measures to reduce certification and registration costs that are preventing low-income doulas from becoming Medicaid reimbursable.
The cost barrier also impacts the uptake of doula services in Oregon and Minnesota. Both states provide small reimbursements for few visits (Mehra et al., 2019). Minnesota, for example, only reimburses $411 for seven visits with a doula, with one of these visits being for labor and delivery (Mehra et al., 2019). Mehra et al. (2019) points out that uptake in these states has “been minimal because reimbursement rates are below the cost for doulas to provide services” (p. 217). This has two unfortunate outcomes: the low rates of reimbursement further exclude low-income doulas from practicing; and the high cost of services (which can range from $400 to $2000 in New York City) present a barrier to access for those who could benefit most from doula support (Mehra et al., 2019).
The maternal health outcomes for women of color, especially non-Hispanic Black women in the U.S. are abhorrent. The U.S healthcare system has continually failed these women, both historically and in modern times. James Marion Sims founded gynecology on the pain and suffering of Anarcha, Lucy, and Betsy, as well as upon myths about Black bodies from Antebellum America, which continue to influence patient care today. The effects of Jim Crow still have a drastic impact on the health and wellbeing of people of color, creating the backbone of the social determinants of health. Racism is still clearly evident in health care, and a prime example of this can be seen in the disparity in the maternal mortality ratio. The integration of doulas within a woman’s pregnancy care team can help alleviate this disparity, as these health workers provide key support and advocacy throughout pregnancy and delivery. Crucially, however, doulas operate within a healthcare system that is systematically racist, devotedly working to dismantle the power structures that are effectively killing women of color.
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Tyler C. Fox is a public health professional at the Global Health Education and Learning Incubator (GHELI) at Harvard University and is interested in studying racial health disparities in the United States and interventions to address these disparities. He graduated from the University of North Carolina at Chapel Hill with a degree in Anthropology, concentrating in medical anthropology. Tyler’s global public health interests include health equity, maternal and child health, and the U.S. opioid epidemic.