Many Black women say their pregnancy-related concerns are dismissed by doctors, undermining their mental health and contributing to higher death rates. Doulas aim to change all that.
Jacquesta Michel’s baby shower was supposed to be themed around her favorite Disney movie, The Lion King. Then her blood pressure spiked. Instead of dancing and eating Simba cake, the Florida mom and licensed clinical social worker found herself in the hospital in July nearly three months before her due date. At night, she slept fitfully, worrying that she and her baby wouldn’t survive.
During those stressful weeks, her lifeline was Sabine Renois, a birth doula. Renois would show up at the hospital in Fort Lauderdale every day for hours at a time. Michel had a midwife, but it was Renois who translated and softened the alarming language from nurses and doctors. She massaged Michel’s neck and ears with essential oils and assured her that whatever happened, she could handle it.
With Renois’ help, Michel would fall back asleep, sending her blood pressure down. But over time, it crept back up and eventually she had to undergo an emergency cesarean section. While that wasn’t in her dream birth plan, Renois had already given baby Ezra more time to grow and eased Michel’s anxiety, making everything more bearable.
“This is the most traumatic thing I’ve ever experienced,” Michel said. “And I’m so glad Sabine was there. Her whole presence – her voice, the words she used – it was all very calming.”
Doulas like Renois are non-clinical health care workers trained to tend to the physical and emotional needs of women and other birthing people during pregnancy, childbirth and beyond. They’ve been around for centuries – the word comes from the ancient Greek and today means “one who mothers the mother.” In the U.S., they are slowly becoming more widely used, partly as a way to address longstanding inequities that lead to higher rates of premature births, pregnancy complications and maternal deaths among mothers of color.
While the first year after a child’s birth is a time of joy and bonding, it can also be a time of risk: Suicidality is now considered a leading cause of maternal mortality for women in the year after they give birth. Postpartum mood disturbance, although usually mild and short-lived, affects up to 85% of women, with 10-15% experiencing depression and anxiety and 1-2 women per 1000 developing postpartum psychosis.
But doula support not only leads to reduced birth complications and higher rates of breastfeeding, it also boosts new mothers’ mental health. A recent study found that women using doulas had a nearly 65% reduction in odds of developing postpartum depression and/or postpartum anxiety, provided doulas were present during labor and delivery.
Yet doula care is often unaffordable to low-income Black women and other women of color, who have the highest risk of birth-related complications and postpartum mental health conditions. That is starting to shift, as doulas become available in more communities. The Doula Network, an Orlando-headquartered company that provides health plans with credentialed doulas, has expanded doula services and pilots to 11 states.
While most people go through birth without a doula, more insurers now provide coverage. Bills passed, introduced or under consideration in California, Massachusetts, Missouri, Virginia and New York encourage private insurance plans to pay for doula care, and Rhode Island requires it.
Today, at least 12 states are paying for doula care through Medicaid, the joint federal and state health insurance program for people with low incomes, and eight are in the process, according to the National Health Law Center’s Doula Medicaid Project. In Florida, where about 100,000 Medicaid births occur each year, only Medicaid enrollees in managed care plans have access to the doula benefit. Recently, the Biden Administration approved Florida’s application to extend postpartum coverage from 60 days to 12 months.
“Doulas bring humanity back”
From its base in Miami, the nonprofit Southern Birth Justice Network (SBJN) trains and matches community-based doulas across the country and runs a mobile midwifery clinic that travels to historically Black neighborhoods in Miami.
Nadirah Sabir, a newly certified doula through SBJN, sees her work as providing care that once came from grandmothers and aunts. “Everything around pregnancy and childbirth is a ritual that requires community. It can’t be chilled down to some industrial, ice-cold experience,” Sabir says. “Doulas bring humanity back and put clients center, making them more aware of their rights and possibilities.”
Racial disparities in maternal care go back to slavery. In the 1840s, Jacob Sims, the “father of gynecology,” experimented on enslaved Black women without anesthesia. The gaps persist today for Black women, who are three to four times as likely as whites to die during or after delivery regardless of income or education level. They’re more likely to suffer life-threatening postpartum complications and to have cesarean sections, a surgical procedure that can lead to other complications and increase the chance for postpartum depression and anxiety.
Having a baby can compound the high levels of stress Black women already experience, says Andrea Clark-Horton, director of the Perinatal Mental Health Alliance for People of Color. Yet stigma and fear can keep them from seeking help postpartum.
She says Black women may be especially reluctant to admit it if they are feeling overwhelmed or having thoughts of harming themselves or their babies, because they’ve already experienced bias from health care providers.“ A lot of times we feel like we’re not listened to anyway so we don’t voice it,” Clark-Horton says. ”Or if we voice it, it’s dismissed.”
Doulas from organizations like SBJN pair tradition with Western medicine. They come from the communities they serve, and are trained to provide culturally reflective care for those who’ve experienced inequities. While every doula has a unique approach, sharing knowledge is key – such as how colostrum, the first breast milk, also known as “liquid gold,” is crucial for strengthening the baby’s immune system.
Doulas help clients advocate for themselves. Black women frequently report that when they try to raise or discuss a medical problem during or after birth, providers are less likely to believe them and and less likely to respond quickly than they are with white women.
Indeed, Black women are the least likely to be listened to when they raise an issue about their birth concerns, increasing the risk of death and complications for mothers and babies, according to 2018 survey in California Health Reports – a finding echoed in a 2022 issue of Women’s Health Reports. Research on U.S. pregnancy and childbirth by the World Health Organization backs up these reports.
“Sometimes I’m the only other person who looks like my client,” says Brianna Betton, chief operating officer of The Doula Network. “I’ve been in hospital rooms where I’ve had to repeat myself multiple times to the provider. Imagine what that would look like for my client if they were alone.”
Care with a doula is also more holistic, involving multiple prenatal and postpartum visits as well as connections to community resources for food, diapers, transportation, or mental health. Many doulas incorporate depression screening into their practice.
“I never want any woman to feel unimportant”
Renois, a nurse who trained as a doula through the Southern Birth Justice Network, sees her work as a calling. She worked previously at a psychiatric home for adolescents, which helped her to understand group dynamics and how that impacts mental health. She pays close attention to her clients and leans on her nursing skills to continually assess: How does their house function? Is the partner supportive? Do they have anxiety? She’s also available when needed , and sends check-in texts every other day.
“I’ve experienced being pregnant and feeling shame. I’ve been to the E.R. and the doctor has put me down. I’ve had postpartum depression. I’ve dealt with all of that and it doesn’t feel good at all,” Renois says. “I never want somebody to feel the way I felt.”
Michel’s pregnancy was a lonely experience in the beginning, and she knew she wanted more support. She’d dealt with morning sickness and couldn’t stand the smell of grass, which was especially challenging because she loved nature. She also was aware of the high mortality rate for mothers like herself and was fearful of not getting the right care. But instead of calming her fears, her OB-GYN told Michel that birth was going to be the worst pain she’d ever experienced and dismissed her request for a birth plan.
Five months into her pregnancy, Michel switched providers and a friend referred her to the Miami-based Metro Mommy Agency, where she found Renois. For $3,500 out of her own pocket, she got a package that included Renois’ services, massages, hypnobirthing classes, and other support. Her private insurance didn’t cover any of this – despite evidence that doula care improves outcomes and reduces risks. She was able to afford the cost and felt it was well worth it.
Ezra was born early at 28 weeks and remained in the NICU for more than three months for help with his breathing, getting stronger each day. Michel worried about him but she was hopeful. She went to the hospital daily, held Ezra skin-to-skin, and read a book of affirmations called “I’m a Little King.” Then, on October 15, the NICU held a rousing graduation party for him. His care team and family paraded around both floors of the unit so that all his respiratory nurses could join in the celebration. Renois, who had continued to check in with Michel regularly via phone, was thrilled. That evening, Ezra was home at last. “It was a beautiful day,” Michel recalled
Expanding access to doulas
Esther McCant is a doula and mother of four boys who grew up in a household of Haitian immigrants. Eight years ago, she founded the agency Metro Mommy. With funding from the Florida Department of Health, she’s working to build a sustainable doula workforce and improve maternity care for Black women in Miami-Dade County. She partners with the Southern Birth Justice Network to train doulas and has mentored Sabir, Renois, and others. She’s also working with Federally Qualified Health Centers to implement a new doula referral system.
Mental health support for her clients is top of mind for McCant, who regrets not having any herself until her third pregnancy. Her approach is holistic – she offers yoga, fitness classes, even therapy.
“Doulas are able to find a way to support families at all the in-between moments – whether at home, via text, virtually, in-person. And it just creates an easier way for people to open up,” she says. “Doulas can fill in the gaps that often a simple referral from a provider to a mental health therapist can’t. There’s still a lag time. Who’s going to check in with that parent and hold them accountable?”
About half of McCant’s clients come through Medicaid, which covers roughly 40 percent of all births in the U.S. Among Black birthing patients, that number increases to 65 percent. Advocates say that increasing Medicaid access can help alleviate the maternal health crisis by providing cost-effective, care for pregnant women and a sustainable wage for doulas who often feel overworked and underpaid.
“She made me feel seen and heard”
The Florida Association of Healthy Start Coalitions has been working with community partners and hospitals in 11 counties across the state to provide low-cost or free doula services. The association’s G.R.O.W. Doula program is supported by Medicaid health plans and has trained over 200 doulas.
During the weekend training, participants learn about everything from comfort measures that ease labor pain to a technique called B.R.A.I.N. – Benefits, Risks, Alternatives, Intuition, Nothing – that can help ground a pregnant person in difficult moments, like in the labor and delivery room. This is important, says doula director Bridgette Jerger, because traumas from past births often lead to future mental health issues.
“We want our Black moms to know they have control of their choices, that when they are talking to their providers, it should be shared decisions. It shouldn’t be the provider saying, ‘This is what’s going on,’” Jerger says. Once doulas are matched with a client, the doulas strive for five prenatal visits, support the family during labor until breastfeeding has been initiated, and do two to three postpartum visits. Clients pay on a sliding scale, though about 90% are free based on need. The most someone will pay out-of-pocket is $500.
Brittney Palmer reached out to G.R.O.W. because she wanted a doula as well as a midwife for the birth of her fifth child. A proponent of all things natural, she’d done mostly well in her previous births: no epidural, no screaming, no lengthy labor. But an emergency during a home birth led to her being transferred to the hospital with her fourth child, whose shoulder had gotten stuck. She was anxious about it happening again.
She’d gone the home-birth route because she had eight miscarriages between her second and third sons and felt dismissed by her doctors when she asked for an explanation for all the miscarriages. Nobody could figure it out, or seemed to care. Instead, they’d ask if she was done having kids and tried to get her on birth control.
With Jerger as her doula, Palmer no longer felt sidelined. “She made me feel seen and heard,” Palmer says. “I didn’t feel stupid about any of my concerns.”
When it came time for labor, Palmer had back pain so bad it felt like her spine was shattering. But Jerger was there by her side, hot pack in hand. She squeezed Palmer’s hips to relieve the pain and coached her husband to do the same. She whispered in her ear the affirmations they’d practiced: “I can do anything for one minute.”
This June, Palmer’s fourth son, Uriah, was born without complications. After his birth, Jerger visited regularly bringing items like a swaddle and breast pads. She’d also play with Palmer’s other kids. For the first time, Palmer says, she hasn’t lost a piece of herself.
In November, she plans to take the G.R.O.W. doula training. She feels a calling to reduce the maternal mortality rate for Black mothers by supporting others in the birthing process, a view she and Jerger share.
“Every birthing person deserves to have a doula,” Jerger says simply. “Nobody should birth alone.”
Support for reporting in this story was provided by the NIHCM Foundation.
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