For those who are even aware of doulas at all, the term might bring up images of health-conscious moms-to-be, drinking cold-pressed green juices and flitting between yoga class and Lamaze. Further adding to their bourgeois appeal, the New York Times describes doulas—certified professionals there to assist and educate mothers through the various emotional and physical aspects of birth—to be "like personal trainers" and part of a "growing demand for personal service," akin to "the doorman, the yoga teacher, [or] Amazon Prime." Even the Wikipedia page for "doula" sites the service's class-specific tendency.
A new study, however, states that doulas should be for all—especially low-income mothers who are at higher risk for pre-term births and other complications. Researchers at the University of Minnesota analyzed Medicaid records across 12 states and found that "women with doula care had a 22 percent lower rate of preterm births compared to women who didn't have doula support," according to MPR News.
In other words, doulas can and do help facilitate healthier births. Preterm births, defined as a baby born before 37 complete weeks of pregnancy, are linked with a host of complications and the highest infant mortality rates. It's also the leading cause of neurological disabilities, according to the CDC.
The CDC also states that, in the United States, the preterm birthrate for black women is 1.5 times greater than the rate for white women. Unfortunately, according to a 2013 study published by the American Journal of Public Health, "most doulas are middle-aged, married, and well-educated White women from upper-middle-class households." The fact that 84 percent of doulas are white, they say, "may also influence the diversity of potential clients" and result in women of color and low-income women receiving unequal care.
Michele Giordano, the executive director of Choices in Childbirth, a maternal health advocacy organization, insists that all pregnant women should be able to access a doula. "The evidence shows that doulas improve the outcome for women who are at-risk. We know that low-income women, especially, have challenges accessing providers and getting the quality of care that they need," she tells me over the phone. "We really see doulas as a way to provide that additional support. I don't think there can be an argument made for women not having more support during labor and birth."
Doulas make financial sense, too; a recent report from Choices in Childbirth states that doulas can lower the need for premature, caesarean births by 28 percent. Since caesareans cost 50 percent more than natural births, that means that private insurance companies would stand to save $1.74 billion a year, and taxpayers would save $659 million a year in Medicaid costs.
I don't think there can be an argument made for women not having more support during labor and birth.
Right now, only two states, Minnesota and Oregon, currently provide access to doulas for low-income, expectant mothers on Medicaid through reimbursement programs. A federal program called Healthy Start provides access to doulas in "87 communities with infant mortality rates at least 1.5 times the national average and high rates of low birthweight, preterm birth, maternal mortality and maternal morbidity (serious medical conditions resulting from or aggravated by pregnancy and delivery)." That still doesn't cover every at-risk mother who can't afford a doula out-of-pocket, but it helps.
Healthy Start Brooklyn—a part of the Center for Health Equity, a division in NYC's Department of Health and Mental Hygiene—services families in Central Brooklyn (Bedford-Stuyvesant, Brownsville, Bushwick, East New York, and Flatbush), where rates of infant death, premature birth, and illness are high. They report that their client base is about 80 percent African-American and 14 percent Hispanic. In addition to providing parenting classes and other support, part of the program provides doulas to expectant mothers from pregnancy to postpartum. Anyone who qualifies for WIC would qualify for the program.
"We started the doula program to offer free support to pregnant women during childbirth," says Gabriela Ammann, director of Healthy Start Brooklyn's By My Side birth support program. "While there are lots of prenatal and postpartum services, there's a gap in care for the actual labor and birth. We realized that some moms didn't know if anyone would be with them when they gave birth, so we started the By My Side to fill that gap in central and eastern Brooklyn. We believe every woman should have access to a doula regardless of her circumstances."
Giordano, of course, agrees. "A doula can come to your house before labor, they can go to the place where you're having birth, and support you during the birth and afterwards," she says. "You're having a baby. That continuum of care is very critical."