This piece is published in collaboration with Echoing Ida, a Forward Together project.
While the Affordable Care Act has significantly improved access to health insurance and preventive care, some important types of care for pregnant women were left out of the health-care reform law, namely doula care.
A new report from Choices in Childbirth, a New York City-based health nonprofit, shows that doulas not only improve maternal health outcomes, but the maternal care and support they provide also empowers women to overcome discrimination in the health-care system, ultimately improving health outcomes.
Yet, doula care is not nationally covered in public and private health insurance plans. This new report, Doula Care in New York City: Advancing the Goals of the Affordable Care Act, adds to a body of evidence that doula care should both be included in health plans and be made available to all women, particularly women of color, who face disproportionate rates of maternal and infant mortality in the United States.
The report highlights how doulas can help reduce health disparities—one of the key goals of the health-care reform law—by supporting positive outcomes. Doula care contributes to a reduction in medical interventions like cesarean sections, which can put women at additional risk for complications associated with a surgical procedure. Most births are low-risk and will progress naturally without surgery or intervention. By encouraging and allowing time and space for the body to do what it was designed to do, doula care also reduces the need for forceps and vacuum births, lessens the need for anesthesia, and is associated with positive outcomes like better newborn health indicators. Additionally, doula care is good for mothers during and after labor. Mothers assisted by doulas report having more positive feelings about their birth, and 80 percent said they felt more empowered.
In communities of color, where discrimination and disempowerment in the health-care system is prevalent, doula care can make a big impact. As Samantha Griffin, a doula with Mamatoto Village in Washington, D.C., explained to Rewire via email, “There are so many things designed to take our power away in these situations: historical power dynamics, the way the health-care system is set up, the unknowns we have around our bodies and birth in particular. And then you have the vulnerability of labor and birth.”
This disenfranchising power dynamic is apparent in previously published stories—shared in various reports over the past few years—of Black women in labor being ignored, having their desires disregarded, and left without adequate information about their health status or health care. For example, the Reproductive Injustice report, published by the SisterSong Women of Color Reproductive Justice Collective, the National Latina Institute for Reproductive Health, and the Center for Reproductive Rights, explains how when one woman, Tiffany, “went into labor with her third child, she was forced to wait in the hallway of the public hospital in Jackson [Mississippi] because there were no available beds.”
[Tiffany explained:] “Not only was [the delivery ward] in the basement, women were lined up on the wall, in the hallway, in labor, I mean full out labor in the hallway.” … Despite her sister’s pleas for the nurses’ attention, Tiffany was ignored until the baby started to crown. Even then, the nurses told her, “Hold her. Don’t push.”
Deadly Delivery describes the consequences when women don’t receive the care they need:
“She was talked down to, things were not explained. She told me she was stunned by the way she was treated … She had to struggle to get the information she needed.” The woman eventually lost her baby.
These anecdotes are supported by data showing that Black women and other women of color are more likely to experience racial discrimination and receive lower quality care within the health-care system. But doula care can help shift power during labor and childbirth by providing mothers with information, tools, and confidence to speak up and advocate for the care, time, or attention they need. Griffin added, “I think that for many of the first time mothers, and women of color generally, my presence empowers them to ask questions of their providers and get information they may not get otherwise.”
Chanel Porchia, founder and executive director of Ancient Song Doula Services in New York City, further explained: “I don’t think doulas empower women as much as a woman empowers herself when she realizes her voice is being heard and she can make a decision [about how she wants to give birth] based in knowledge rather than fear.”
With doula assistance, women are empowered to be proactive in realizing their reproductive, health-care, and birth goals. Effectively, doulas are helping to achieve reproductive justice.
The report goes on to share that despite these proven benefits, only one-third of privately insured women knows about doula care, and only 6 percent of expectant mothers in the United States have benefited from doula care. Data from a survey of 2,400 women shows that 39 percent of the more than 300 Black women surveyed would have liked to have doula care, the highest proportion of respondents in the study.
But even if women do know about and seek doula care, they still may not be able to afford it. Nan Strauss, director of policy and research at Choices in Childbirth, told Rewire in a phone interview, “The biggest barrier that prevents women from using doulas is cost. It’s great if you can afford to pay for it out of pocket, but even for middle income families, childbirth is one of most expensive health events in a family’s life.”
The average cost of doula care in New York City is $1,200—an expense that can be prohibitive when families may be paying for prenatal care and preparing their home for a new arrival on top of their usual expenses.
“Given the challenges with reimbursement, it’s hard to expand access to doulas because it means a real out-of-pocket expenditure for a lot of women. I think the biggest thing we could do is to make it affordable by making it reimbursable,” added Strauss.
Doula care is not typically reimbursed under Medicaid, but there is opportunity within Obamacare to change that. In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a ruling allowing states to reimburse for preventive services that have been recommended by a licensed medical provider but that may be provided by a variety of professionals, including doulas. So far, two states—Oregon and Minnesota—have taken steps to reimburse doula care under Medicaid. All states should do the same.
“Our policy is to never turn anyone away,” said Chanel Porchia, “but the reality is that by opening the door to Medicaid coverage of doula care, more families would be able to get assistance.”
State leaders must take the opportunity to expand Medicaid under Obamacare so more women can have access to the essential preventive care doulas provide. Sadly, some of the states where politicians refuse to consider Medicaid expansion are the states that need it most. For example, Georgia has the second highest maternal mortality rate in the country, but instead of working to expand access to care, politicians have actively worked against it.
While improving insurance coverage for doula care could go a long way, it’s also important for organizations advocating for doula care expansion to provide communities with the resources they need to take their health into their own hands. “It will have to be for us by us,” explained Samantha Griffin, noting that Black women are the key to increasing the use of doula care in the Black community. “We have to make sure that regardless of age, income, education, sexuality, we all get access. The health of Black mothers and babies is too important to leave to chance.”