The Doula Difference

U.S. Maternal Mortality Rates Send
Pregnant Women to Doulas

With three and a half months left to go in her first pregnancy, unexpected bleeding sent Nicole Buck and her husband Dave rushing to the emergency room where doctors recommended an emergency c-section.

"One of the most effective tools to improve labor and delivery outcomes is... a doula"
Consensus statement by the American College of Obstretricians and Society for Maternal-Fetal Medicine, 2014

But Buck wanted to give birth naturally and the couple had developed a birth plan with their doula, Dana Nassau.

So, for four days Nassau stayed at the hospital with Buck and her husband as they awaited the safe arrival of their first child. Now that the baby was arriving prematurely Nassau’s mandate was to help the couple follow the plan.

Nassau stayed with the couple day and night, only taking short breaks to sleep in her car. She worked hard to ease the couple’s anxiety and fear during the long and difficult labor.

“[I]t was really nice to have her there to pray with me, and... help me be calm and my husband be calm… [I]t seemed like everyone who walked in the room kind of got the vibe that was going on in there… So there was no panic, no drama,” Buck said.

Dana Nassau poses with her husband Scott and their three children. [Facebook]

In the delivery room, Nassau, Buck and her husband were in sync. “The three of us just kind of were one team,” Buck said. “He would mirror what Dana was doing… He would kind of be what I needed in addition to what she was doing. [I]f she was massaging my feet, he was holding my hand and making sure I had water.”

But it wasn’t until after Buck sent Nassau home for a much-needed break that her labor started in earnest. Within 15 minutes of her departure, baby Warren Buck was born naturally on November 15, 2017, weighing just 1 pound, 13 ounces. Even though she missed the birth itself, Nassau’s tireless work ensured that Buck was able to have the birth she wanted, and both mom and baby remained safe and healthy.

Like Nicole Buck, more and more women are turning away from Western medicine and embracing older, more traditional ways of having babies.

Doulas are part of the growing movement among families and birthing stakeholders to have a trusted advocate and friend on hand to tend to the family’s emotional needs during a time of increased fear and vulnerability. Changes in birthing have been spurred by statistics that show the presence of a doula can make a difference between a healthy new family and a mother at risk.

Maternal Mortality

The United States has the highest rate of maternal mortality in the developed world, averaging 17.8 maternal deaths per 100,000 live births as of 2009. In states like Minnesota, Oregon and New York, changes in Medicaid policy now pay for the services of a doula.

Women choose to engage doulas and their services for a variety of reasons. Some are aware of the dismal birth statistics in the US and want to get ahead of potential complications.

Various studies have shown that the increased prominence of doulas in birthing spaces is having a direct impact on improving birth outcomes.

In 2014, a consensus statement by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine affirmed that “one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”

And according to the March of Dimes, a non-profit working to improve the health of mothers and babies, “increased access to doula care [is] one tool to help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States.”

According to Buck, she didn’t even notice Nassau wasn’t in the room when her daughter was born. Because of her doula’s coaching, the couple was able to work through their birth plan without resorting to an emergency c-section.

For Gail Boggs, her doula was instrumental in making her feel supported in her birth.

Keya Nkonoki poses for her work as a doula and yoga teacher. [LinkedIn]

“In my first pregnancy I had a female doctor and I thought I was in good hands, but she was so rough I told her not to touch me again until my doula arrived,” Boggs said. “Doctors don’t have the same bedside manner. My doula made it more personal. My birth felt like a gathering. A special event.”

“A doula is a support person for a family in labor,” said Keya Nkonoki, a doula and yoga teacher working in Los Angeles. According to Nkonoki, a doula’s primary purpose is to “keep a pulse on the emotional state of mom and baby” to ensure that they have the tools and resources they need to have an empowered birth.

Unlike midwives, doulas are non-medical providers, so they do not take blood work, listen to heart tones or deliver babies. Their primary purpose is to advocate for mothers. And while doulas may seem like the latest trend, birth coaches have been around in various forms for centuries.

“[D]oulas actually exist in indigenous cultures all over the world. They're just not called doulas,” Nkonoki said. “They're aunties and grandmothers and extensions in the village. A mother in many indigenous cultures is elevated and supported and so many hands are there during the birth and in the postpartum to help out with the new baby and to ensure that the mother's getting proper care and nurturing.”

A big part of getting that care is helping new moms articulate their pain, stick to their birth plans and avoid unnecessary medical interventions, she explained.

For many, doulas are making a difference.

Nicole Buck and her daughter Warren bond through her first year of life.

Brandi Sellers-Jackson, a mother of three children, used a doula for the birth of her second and third child. Sellers-Jackson is aware of the fatal stats of mortality rates for black mothers giving birth, which is why she is an advocate for birth and postpartum doulas. To her, safety should be the number one priority for expecting mothers. Download link here

Brandi Sellers-Jackson plays with her youngest son, Jupiter

Keya Nkonoki, a doula and pregnancy yoga teacher, explains some key concepts about doulas and their work

Brandi Sellers-Jackson discusses the impact of doulas

Black Moms Are at Higher Risk

While maternal mortality is a problem across all demographics in the US, studies show the issue is nearing epidemic levels in black communities.

According to the CDC, black mothers are three times as likely to die from pregnancy complications as white mothers, and their children are twice as likely to die within a year of birth.

Evonne Smith talks about her role as a postpartum doula

In California, black moms are approximately four times more likely to die from preventable pregnancy-related causes than women in all other ethnic groups, according to the California Maternal Quality Care Collaborative.

The data shows that black mothers are subjected to increased levels of stress and “weathering” during their pregnancies, a process that causes their bodies to age faster than those of white women and increases their risk of pregnancy complications, as noted by the National Partnership for Women and Families.

According to the NPWF, weathering is caused by “exposure to chronic stress linked to socioeconomic disadvantage and discrimination over the life course” which makes pregnancy riskier at an earlier age.

“Racism is killing black moms,” said Brandi Sellers-Jackson, a mother and doula.

Additionally, “infant and maternal mortality rates are much higher, even when controlled for education and socioeconomic status,” said Evonne Smith, a Los Angeles doula and lactation consultant.

Imelda Padilla, the Community Outreach Director for the LA County Women and Girls Initiative said that the black maternal mortality disparity is in fact, a systemic issue caused by racial bias and a lack of adequate resource allocation. For black women, there is no amount of access or wealth that can mitigate these outcomes.

High Profile Cases

Many considered Serena Williams’ story as one high profile example of the risks black mothers face in childbirth, and how racial bias in medical institutions can contribute to substandard care.

In an interview with Vogue shortly after the birth of her first child, Williams disclosed that her initial concerns about her known health issues after giving birth were ignored. As an elite athlete, Williams was finely attuned to her body’s needs.

When she began experiencing shortness of breath, her history of blood clots meant that she was aware of the signs when they happened postpartum. But according to Vogue, after speaking with a nurse and specifically requesting the treatment she needed (in this case a CT scan with contrast and IV heparin), a doctor performed an ultrasound on her legs instead.

Williams, a wealthy, internationally known tennis star at the top of her game, had to fight to be heard by her treatment team. As Williams told Vogue in the same interview, when doctors eventually performed the CT scan as requested, they found several small blood clots in her lungs. Williams was right.

But the delay in treatment caused more problems.

According to the interview, the pulmonary embolism caused Williams to cough intensely which then led to a disruption in her C-section wound. During the surgery to fix the new issue, doctors discovered that a large hematoma had flooded her abdomen.

In a catch-22, heparin, a blood thinner used to treat the blood clots had caused her C-section to hemorrhage. According to Vogue, Williams had to have a filter inserted into a major vein in order to prevent further clots from traveling to her lungs.

Evonne Smith works at her home office.

Evonne Smith, a postpartum doula, outlines the roles of the two common types of doulas. Also a lactation consultant, Smith touches on her unique viewpoint on breastfeeding. She gives first-hand accounts of mothers she has worked with, and describes the various approaches she takes to set herself apart from other doulas. Download link here

Doulas Can Help

For black mothers, doulas can be integral to preventing the kinds of interventions that lead to further medical problems. A 2008 longitudinal study in Cleveland, Ohio conducted among a group of 420 middle-class women showed that the presence of a doula during birth decreased the rates of delivery via cesarean by 12 percent and decreased the need for epidurals by 11 percent. Most significantly, the rate of caesareans after induced labor decreased some 46 percent when a doula was present through labor and delivery.

In a 2018 position statement, the March of Dimes said that “the role of doula care in reducing c-sections is important because c-sections contribute to the risk of maternal morbidity and mortality in initial and subsequent pregnancies.”

“It’s abdominal surgery. If you don’t have to have [a C-section], I wouldn’t say do it,” said Sellers-Jackson. “Not only are you healing from birth but then abdominal surgery on top of that. That’s super intense, but there are people who will literally cut moms open because it’s time to go home.”

According to Sellers-Jackson, a doula’s role when these kinds of interventions are suggested is to slow the process down and ensure that the mother is knowingly giving informed consent to additional medical procedures. Their position as an outside family advocate means they have the knowledge and experience to help birthing families make decisions that are best for their long-term healthcare, rather than be pressured into procedures that are most convenient for a medical institution.

Insurance, Oversight and Access to Doula Services

Despite the growing evidence that doulas are improving birth outcomes for American women, most doula services are not readily covered by insurance.

"Patients with doulas are 22 percent less likely to have a premature birth and 56 percent less likely to have a C-section"
University of Minnesota

While some limited options do exist for doula services to be covered under Medicaid (as in Minnesota, Oregon and New York) doula services must largely be paid for out of pocket by mothers and families. Comprehensive doulas services can run into the thousands, which limits their accessibility to those who would most benefit from their services.

“Right now you can be covered under a health savings plan or a flexible spending account,” said Nkonoki. “We can invoice and fall under that coverage, but traditional insurance will not cover most doula work.”

This is significant, as patients with doulas are 22 percent less likely to have a premature birth and 56 percent less likely to have a C-section, compared to Medicaid beneficiaries without a doula according to the University of Minnesota.

Doulas have proven to be a necessary tool in fighting the high maternal mortality in the U.S., but some still perceive them as a luxury because of their potential high cost.

“There is always going to be a debate about [whether] people deserve a doula,” Smith said. “The two sides of the debate are, every birthing mother deserves to have a doula because doulas save lives. Doulas help improve birth outcomes. The other side is that doulas also deserve support. I deserve to be paid well.”

But as social attitudes catch up to the data, public officials are taking steps to integrate doula care into the range of services offered to birthing mothers, in recognition of their impact on a dire health crisis.

Though American exceptionalism elevates individualism as the most lauded ideal, the impact of the community-oriented work that doulas perform makes a compelling case that the old adage is true: it takes a village.