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Doulas in Underserved Communities Are Fighting for Recognition

Often seen as a luxury service for the rich, doulas across the country are working hard to integrate affordable birthing care with Western medicine.

By Alizah Salario


(Photo: Jasonunbound/Flickr)

When Joni Gallman read an article on social media about birth doulas, she knew she had found her calling.

“I had heard horror stories about births not going the way the mom wanted it to go, no informed consent whatsoever, and moms being taking advantage of,” Gallman says.

Gallman, 31, lives in Raymond, Missouri, about 20 miles outside of Jackson. With a population just shy of 2,000, Raymond is “a little bit like your Mayberry town,” she says. Everyone knows everyone, there’s a Sonic Drive-In on Main Street, and an old Confederate cemetery. But until Gallman, the town did not have a doula. Nor were most people familiar with the profession — even Gallman’s doctor didn’t know what a doula was.

But Gallman was confident in her calling. She built up her business, Precious Feet Doula Services, by advertising at her local Women, Infants, and Children program and on, and by offering payment plans for expectant mothers who couldn’t meet her $500 fee. Eventually, the clients came.

For similar reasons, Chelsea Larsen, 26, decided to become a doula and remain in her hometown of Nampa, Idaho. Though she finds clients about 25 miles away in Boise willing to pay for her services (she calls people in Boise more “progressive” and “crunchy”), Larsen attends births for free in Nampa because she’s passionate about maternal health and education, and determined to bridge the gap between her rural hometown and the big city. Because fewer women in Nampa know doulas are an option, they’re less likely to even consider the “luxury.”

If doctors are like penicillin, then doulas are like chicken soup.

“Nobody needs a doula, but it’s a highly desired service in a lot of other areas,” Larsen says, “and it’s obviously beneficial, and it’s become more apparent that it’s worth the investment.”

For Johanna Goetz, a doula working in Regina, a city in the Canadian province of Saskatchewan, finding local clients able pay her full-price fee of $350 has also proven difficult. She’s new to the profession; to get experience, she often lowers her fee, leaving her with minimal profit. Goetz even attended one birth pro bono for a young, single mother who lacked a support system and ended up putting her baby up for adoption shortly after the birth.

“When you’re a single mom, and you’re younger, you’re not really taken very seriously,” Goetz says. “Not always — there’s a lot of really wonderful people who sort of take that time — but sometimes teenage and single mothers get trampled over and all the decisions get made for them, and it’s a hard thing to see.”

Boutique Births

A doula provides physical and emotional support for women during labor and delivery. Guiding a laboring woman through pain management exercises; calming a nervous spouse or partner; providing comfort measures like cold packs, soothing essential oils, or a hand to squeeze during contractions—all part of the doula’s job description.

Doulas, for the most part, do not advocate for or against particular birth interventions. Rather, they facilitate communication, provide information, and help support an expectant mother’s preferences, says Carol Sakala, director of childbirth connection programs at the National Partnership for Women & Families.

If doctors are like penicillin, then doulas are like chicken soup. Though they are not licensed clinicians or trained to deliver babies, their fortifying properties are understood and well-documented: Having a doula present during labor and delivery correlates with shorter labors, higher newborn APGAR scores, reduced caesarean rates and obstetric interventions, and an overall more positive birth experience.

Doulas like Gallman say each birth requires different support measures. One of the first births she attended was a vaginal birth after cesarean, which, due to the risk of uterine rupture, can be daunting for expectant mothers. Her client went in feeling petrified, Gallman says, after a prior traumatic birth. Gallman guided her through exercises using a peanut ball to open her cervix. Because her client knew she wanted an epidural, Gallman made sure she got one, but specifically a light epidural so the anesthesia wouldn’t block the sensations of delivery entirely. After the birth, Gallman helped ensure there was skin-to-skin contact between mother and baby.

“My role is to support the woman, to provide education, and to let them know they do have options, that they are allowed to say no, and they are allowed to have informed consent,” Gallman explains.

Gallman is referring to what’s known as the over-medicalization of birth — the increased rates of C-sections (roughly one in three babies are delivered by cesarean section in the United States), epidurals, and inductions — that can, in some cases, have a negative effect on the birth experience. This is particularly true for women who are unaware that such interventions are often choices, and as such the woman has the right to advocate for the kind of birth they want (though in certain circumstances, inductions and C-sections may be medical necessities). The increased popularity of doulas over the past decade has been seen as a backlash against the cascade of interventions, or the snowball effect that occurs when one medical intervention leads to another.

Yet doulas have come to be associated with a very specific milieu — wealthy, educated, usually white — and part of the “boutique birth” trend: think pricey maternity photo shoots, reiki practitioners and yoga instructors who moonlight as doulas, baby concierges, and celebrities gushing about their doulas after rubbing their haute couture-clad baby bumps for the camera.

There is a long, and much less publicized, history of doulas working in underserved communities.

The doulas who cater to this market don’t come cheap: In New York City, where about 5 percent of births are attended by doulas, the average out-of-pocket fee is $1,200. Though some doulas do operate on a sliding scale, rates can climb to $2,800 and beyond, depending on experience, according to a 2014 survey from Choices in Childbirth.

Yet there is a long, and much less publicized, history of doulas working in underserved communities, in both urban and rural settings. Those like Gallman, Larsen, and Goetz who work in rural areas must often compromise their own business goals to meet the needs of their communities, and wear multiple hats as information providers, educators, and business owners. In urban hubs like New York and Chicago, it is activist and community-based organizations that often work with volunteer doulas, rather than private practitioners who use a fee-for-service model, providing support at little to no cost for low-income women.

“Quite a few people get into this work as a kind of calling, because it’s very compelling, and they see that they make an enormous difference, and it’s very satisfying,” Sakala says. “It’s also unsustainable, in a way.”

Community-Based Doulas

Many doulas do find creative ways to work with women unable to afford their services, explains Melissa Harley, a spokesperson for DONA, one of the oldest and largest doula training and certification organizations. Some will barter with clients or offer payment plans. Expectant mothers sometimes put a doula on their registry, or they might qualify for insurance or health FSA (flexible spending account) reimbursements.

But focusing exclusively on private-practice doulas who charge steep standard fees doesn’t “reflect the bulk of doula care that’s going on,” according to Vicki Bloom, birth doula coordinator for the Doula Project, an activist organization that provides birth assistance to New York women with household incomes under $30,000.

Volunteer-driven organizations like the Doula Project work to address the persistent racial/ethnic disparities in access to maternal care. In New York City, for instance, African-American women face seven times the risk of maternal deaths as non-Hispanic white women.

“Having good care through labor and delivery is not a boutique thing. I believe it’s a basic right, so everybody deserves that. A lot of our clients are immigrants, the rest of their family may not be around,” Bloom says. “They’re in two-income families where things are tight enough that the support people can’t take off work, even at the birth of their baby. Dad might not be there because he can’t take time off from his job, or he’ll be fired.”

Volunteer doulas are generally trained or accredited by their supporting organizations, but they are often not officially certified. Still, many come to the practice with a commitment and calling equal to that of their certified counterparts.

Daisy Zamora, 31, works full-time in addition to volunteering with Chicago Volunteer Doulas. She sees herself first and foremost as a healer, and considers part of her job to make the laboring woman as comfortable as possible.

“I massage them, rub their shoulders, hold their hands, breathe with them, count with them, play music for them, and hold their powerful legs up when they are birthing,” Zamora says.

Zamora, who is Hispanic, has attended three births so far, all for women who identify as black or African American. As a woman of color living in Chicago, Zamora considers herself part of the same broader community as her clients.

In many ways, the role of the community-based doula harkens back to a time when knowledge of labor and delivery was passed down through the generations. That’s the premise behind HealthConnect One, a community-based organization that uses a peer-to-peer model to train women as health workers within their own communities.

“Women will depend on these doulas because they trust them, not because they have a certification,” says Rachel Abramson, a certified lactation consultant who provides leadership for HealthConnect.

HealthConnect uses a curriculum designed for women who don’t necessarily have a formal education. Trainings take place at local gathering spots, be it a community center or a laundromat. Ultimately, it’s community health workers, not outsiders, who do the in-person outreach, gathering information about who’s pregnant, and who needs help, often through old-fashioned word of mouth.

“Having good care through labor and delivery is not a boutique thing. I believe it’s a basic right.”

Abramson says community-based doula training is a way of “rebuilding the village,” since the move away from home-based births over the last century toward modern Western medical care. “I’m not saying take birth out of the hospital, but I am saying we need to build back that web of support, and make sure that it’s built back in a way that it stays in the community.”

Equity Issues

Uncertified volunteer doulas, those in private practice who lower their fees to meet the needs of their communities, and handsomely paid doulas in urban centers are both often fulfilling the same crucial needs during labor and delivery.

This raises a host of equity issues regarding certification and compensation. DONA certification, for instance, can run up to $700, plus additional fees for materials and coursework, making it extremely difficult for some women to afford.

“Many of the community-based doulas we’ve worked with, they either don’t have the money to go through certification, or they’re working full-time and don’t have the hours to go through that sort of process,” Abramson says. There’s also sometimes a language issue: The most qualified doula for a particular community might be a monolingual Spanish or Vietnamese or Somali speaker, and the requirements for traditional learning provide a barrier to certification.

There is some attempt to level the playing field, however. A handful of DONA certified trainers are affiliated with organizations that host doula trainings at a reduced rate in exchange for the doula working within that particular organization for a period of time, Harley says.

Reimbursement by insurance companies is another issue related to certification. It’s tricky, Sakala says, because doulas are not licensed clinicians — which insurance companies are set up to pay. However, some insurance companies will provide individual reimbursement upon request, and a handful of states, like Oregon and Minnesota, are trying to make doulas services more accessible through Medicaid coverage. In Minnesota, for instance, doulas can register with the Department of Health — but they must be first certified by a credentialing organization. And even for private-practice doulas, reimbursements may be so low they cannot afford to participate in the program, Sakala explains.

One possible solution, according to Sakala, is for doulas and other community health workers to play a larger role in the health-care system. Right now, however, their duties remain on the backs of women. Now, many wonder: Can the traditional, if not ancient, practices of providing comfort, sharing knowledge, and holding space be quantified in a Western medical system in the first place?

It’s a question that, particularly at a moment when the future of health care and reproductive rights are being called into question, feels particularly urgent. In the meantime, doulas like Gallman will continue to do the work.

“I think there is a great need for doulas. We get a lot of secondary births, and it’s because a woman has gone through trauma,” she says. “ But if women could know from the beginning, you have many options, I think that would help the overall birth experience.”