The Power of Doulas in Underserved Communities
How doulas help lower maternal mortality rates
June Eric-Udorie remembers the exact moment she decided to become a doula — a trained professional who provides physical, emotional, and educational resources for women throughout the spectrum of pregnancy, birth, and early postpartum.
Eric-Udorie, a 21-year-old student at Duke University majoring in African and African American Studies, was distraught after reading that college-educated black women were more likely to suffer major complications in pregnancy or childbirth than white women without high school diplomas. But the issue of racial disparity in maternal mortality became more pressing to her in 2018 when Serena Williams publicly shared her birth story.
“This superstar with all these resources almost died because her provider didn’t listen to her when she said something was wrong,” she said. “What about poor women, queer women, undocumented women, refugees, and women of color? What happens to them?”
Eric-Udorie’s concerns reflect a broader public health issue facing the United States: While the U.S. is one of the richest, most medically advanced countries in the world, it also has one of the highest maternal mortality rates, especially for birthing people of color.
A 2017 investigation found that American women are more than three times more likely to die during pregnancy, birth, or in the postpartum period than Canadian women, and six times more likely to die than Scandinavians. Maternal death is far more common in marginalized communities, particularly among African Americans and low-income or rural women. According to the Centers for Disease Control, most of these deaths are preventable.
Reasons for maternal mortality are multifaceted, but research shows a strong link between the stress of systemic racism and negative pregnancy outcomes. The support of a doula is one way to empower women to have more positive birth experiences.
Doulas don’t provide medical care for moms or babies like OB-GYNs or midwives (women’s health practitioners who work with low-risk pregnancies). Instead, they work together with moms and their health providers to improve physical and mental health outcomes by supporting mothers to make informed decisions about their pregnancy and birth. For example, many doulas meet with mothers throughout pregnancy, educating them on what to expect during birth. During labor and delivery, a doula is present to offer emotional support and comfort measures like massage or breathing techniques, and after delivery, a doula might offer breastfeeding support or help a mother acclimate to life at home with a baby.
Medical experts agree that a doula’s support can improve physical and mental health outcomes for babies and mothers. The research around doula support and the corresponding positive effects is robust, too. One 2013 study shows doula-assisted mothers were four times less likely to have babies with low birth weight and significantly more likely to breastfeed since doulas empower women to make informed decisions in the interest of maternal and fetal health throughout both pregnancy and birth. These positive effects are even greater for socially disadvantaged individuals.
While there’s no direct scientific research on the impact of doulas on maternal mortality, there is promising evidence that the presence of a doula can positively impact maternal health. Not only are parents with doulas two times less likely to experience birth complications; the support of a doula is also associated with decreased C-section rates.
“The vision behind community-based doula programming is to make sure every woman has a healthy pregnancy because she has an advocate and champion by her side.”
While doulas provide emotional support for pregnant and birthing women, they also can empower women to communicate their needs in prenatal appointments and in the delivery room.
“Doulas can play a really critical advocacy role. That’s what they’re trained to do — to advocate for the patient, to support her birth plan, to help provide information for her to understand what’s happening, and to help her speak up if the hospital providers aren’t hearing her concerns,” says Melissa Nothnagle, family medicine physician at Natividad and co-author of a 2019 paper on hospital clinicians’ perceptions of doulas.
Because most hospital clinicians are focused on achieving medically safe outcomes, which could lead to potentially unnecessary interventions, Nothnagle says doulas can be a helpful mediator, encouraging providers to explain their thinking and helping to promote shared decision-making between patients and clinicians.
Advocacy can be pivotal during birth and delivery when a mom and baby’s health are on the line, but Samantha McClellan, a birth doula and owner of Carolina Doula Collective says this advocacy is most effective when it begins during pregnancy.
“We do a lot of childbirth education, informing them on what normal physiological birth looks like, and the other complications that might arise, and when other interventions might be necessary, giving them all the information they need to understand what’s normal and what’s not normal during pregnancy and birth,” says McClellan. “We want them to have a firm foundation before they even go into labor.”
Eric-Udorie is in the process of receiving her doula certification through a social justice-focused organization called Cornerstone Doula Trainings, which involves a series of three courses followed first aid and CPR certification, a hospital tour, and required reading and essay-writing. Then she began offering doula services in and around her home city of Chapel Hill, North Carolina. She’s committed to providing totally free doula services to birthing people of color in a region where hiring a doula for pregnancy and birth can cost anywhere from $700 to $1,500. Currently, she’s booked with clients through April 2020.
Despite their benefits, doulas are vastly underused — especially by the people who need them most. While research estimates some women just aren’t aware of doula care, cost is the greatest barrier to hiring a doula. In many communities, subsidized doula programs like McClellan’s seek to bridge the gap.
For example, the Brooklyn-based By My Side birth support program has served more than 1,000 mothers with free doula services since 2010. Focused on three predominantly black zip codes in Brooklyn with infant mortality rates at least 1.5 times higher than in other parts of the country (and generally worse health outcomes), By My Side provides three prenatal home visits, support during labor and delivery, a post-birth visit in the hospital, and three home visits during the early postpartum period.
Mary-Powel Thomas, director of Healthy Start Brooklyn at the New York City Department of Health and Mental Hygiene, says the program has resulted in a robust reduction in preterm birth and low birth weight. While they don’t have statistics on maternal mortality, program participants reported doula support helped “give them a voice in consequential childbirth decisions.”
“If you have an ally by your side, encouraging you to speak up and trust your body, that can be really powerful,” says Thomas.
Other communities are launching similar programs based on local maternal mortality rates. In Oklahoma, for example, African American women are nearly three times more likely to die during or shortly after pregnancy than white women. In response, the local YWCA is launching a community doula initiative focused on supporting pregnant high school students. (Oklahoma also has nearly the highest teen pregnancy rate in the country.)
“The vision behind community-based doula programming is to make sure every woman has a healthy pregnancy because she has an advocate and champion by her side,” says Julie Davis, CEO, YWCA Tulsa.
The program, set to officially launch in November of this year, will also partner with other organizations, like hospitals and clinics, to ensure health accessibility and equity for disadvantaged mothers. “Our main goal is that we will start to see reductions in the disparities, and that more women will be empowered to have a healthy and safe childbirth,” says Davis.
McClellan recognizes that hiring a doula is often a marker of privilege for white women who want to achieve a “beautiful, natural, unmedicated birth.” But for disadvantaged birthing people, doula access can be a matter of life or death.
“My job as a doula is to help you achieve a healthy and positive birth, whatever that looks like. You can have a positive birth in any number of scenarios, but the biggest piece to that is feeling like you have the support you need to navigate the process. It’s about coming away from birth feeling like you had some type of control,” she says.
