Analysis Maternity and Birthing

What Is the Goal of the Doula Movement?

Miriam Pérez

Doulas have increased in number and popularity in recent years. But as a whole, what are we working toward? The goal of having a doula for every birth may not be feasible. It also may not bring about the radical change we seek.

It’s clear that the growing number of doulas in the United States have begun to significantly change the maternity care landscape. While many doulas still have struggles with doctors and hospitals and the medical system’s acceptance of their role, many more are finding providers to be willing partners who understand through patient demands and a growing body of scientific research that doulas improve the birth experience. But a question that came up at a recent university talk, and one I’ve been thinking about for years now, is: What is the end goal of the doula movement? What are we working toward? Many doulas would likely say—and I would have been among them just a few years ago—that the end goal is to have a doula at every birth. But I no longer believe that’s the right goal.

Last week I was invited to speak to a group of nursing and medical students at the University of Pennsylvania about my work as a doula and its connections to reproductive justice. The fact that I was invited alone shows how far the doula movement has come. Doctors and nurses, two groups historically (and presently) at conflict with the doula community, invited a doula to address them. Furthermore, when I asked if anyone in the room had also been trained as a doula, about half of the nursing students in the room raised their hands.

Though the formal concept of a doula was introduced in the 1970s, it’s seen tremendous growth in the last two decades. Doulas of North America (DONA), the largest doula training and certifying organization, grew from just 750 doulas trained in 1994 to more than 5,800 in 2004. And I would guess that in the years since then, we’ve seen tens of thousands more trained doulas.

Given that there are so many more doulas today than ever before, why do I no longer believe that having a doula at every birth should be the goal of the doula movement? For one thing, logistically, it’s still a pretty daunting task. We’d need to increase the number of doulas in this country exponentially to keep up with the demand—to be able to match each pregnant person with a doula for support during labor. Even if we could grow the doula ranks enough to meet this demand, what would be the cost? The majority of doulas who do this work professionally do it on a fee-for-service basis, charging anywhere from $300 to $3,000 per birth, depending on their experience, what services they offer, and where they live. In a system with already incredibly high health-care costs, especially in the arena of pregnancy and birth, where are these fees going to come from?

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Insurance reimbursement is increasing becoming an option, and some doulas hope that it will solve the question of fees. Last year a bill passed by the Oregon legislature recommended that the Oregon Health Plan include a waiver allowing doulas to be reimbursed for their services. From a cost/benefit standpoint, this could actually decrease costs for insurers because research has shown that the presence of a doula decreases the likelihood of interventions like cesarean sections, which increase costs.

The downside, though, is that insurance reimbursement will likely come with increased regulation and professionalization of doulas—more rules about what training is required and more standards about what doulas can and cannot do. I fear that these changes could dilute the power doulas have to fundamentally alter the pregnancy and childbirth experience. It’s a power I believe comes from being outsiders in the medical system, from being interveners, and from being independently trained.

This is where my biggest concern about the goal of a doula for every birth lies. It’s clear that the only way to reach everyone giving birth would be through institutional support, whether it’s insurance reimbursement or doulas being employed by hospitals, birth centers, and obstetrician practices (something we’re starting to see in the United States). We’ll never reach everyone if individuals are required to pay for doula care out-of-pocket, because in that scenario doula care will always be out of reach for low-income people.

What would institutionalization of doulas mean for our ability to make the radical change that doulas work to make, the change that could actually bring our maternity care system back toward patient-centered and non-interventionist care? I know there are other professions that at their inception saw themselves as actors with the ability to make radical change. I think about nurses, and how much of what doulas do was was at one time seen as part of the role of the nurse. Nurses are meant to be focused on patient needs, to be a more consistent presence during hospital stays. But the reality of nursing today, particularly in hospitals, is very different. Nurses attend to many patients at once, and at least in labor and delivery wards, do so more from the nurses’ station monitors than from the patients’ actual rooms. Social workers are another example of a well-intentioned profession whose ability to make major systemic change has been mediated by the institutions that support the profession.

I recently had a conversation about this with Jennie Joseph, a midwife and leader in the movement to address race-based maternal health disparities. In particular, we discussed how, despite the existence of Healthy Start, a decades-old government-funded program with millions of dollars in funding, infant mortality and low infant birth weight among African Americans in the United States remains extremely high. What is it about these institutional solutions that renders them ineffective, or at least keeps them from achieving their goals?

There is no easy answer to the question of where the doula movement is headed. It’s clear to me that doulas provide an important and potentially transformative intervention for our maternal health system. But it’s also clear to me that institutionalization and professionalization threaten the very model we’ve developed, a model that, because it is outside the medical system, allows us to shift the dynamic and improve outcomes.

An alternative that I think may be more feasible is working to bring the doula model of care to existing participants in the health-care system. How could the doula model transform the way current providers, like doctors and nurses, care for their patients? Rather than creating a vast doula profession, could we transform maternity care by turning everyone into doulas? Could family members, for example, be trained or shown how to provide the kind of support that doulas provide?

I think doula work is valuable and important, and I also don’t believe the essence of doula work—non-judgmental and unconditional support for pregnant and parenting people—needs to be locked away in a system that says only a certain amount of training, certificates, or other paperwork bestows upon someone the right to provide this support. We run the risk of replicating the model we’re trying to revolutionize. And I don’t think that is where real social change happens.

Joseph, for example, is trying to bring doula-like training to people already working in Healthy Start programs as community health workers. These folks are already working with at-risk pregnant and parenting people, tasked with improving their outcomes through education and support and navigating systems like Medicaid. Joseph’s educational program, called Community Outreach Perinatal Education, provides these community health workers with additional skill sets, based on the doula model, to transform their existing work. As Joseph explains, these people already have jobs, so she’s not trying to pull them out of the system and find work for them as doulas. Instead, she’s trying to give them skills to do better within the existing infrastructure.

If our goal is really to have doula support for every person who gives birth, we’re going to have to accept doulas in lots of different forms: nurse doulas, doctor doulas, family member doulas. We’ll need to tap into the existing networks of support and see what doulas have to teach everyone about supporting people through the journey of pregnancy and beyond. This doesn’t mean that professional doulas need not exist—they can and should continue to provide doula support. Rather, we need to look toward more flexible ways of bringing doula care to a larger number of people.

News Abortion

Anti-Choice Leader to Remove Himself From Medical Board Case in Ohio

Michelle D. Anderson

In a letter to the State of Ohio Medical Board, representatives from nine groups shared comments made by Gonidakis and said he lacked the objectivity required to remain a member of the medical board. The letter’s undersigned said the board should take whatever steps necessary to force Gonidakis’ resignation if he failed to resign.

Anti-choice leader Mike Gonidakis said Monday that he would remove himself from deciding a complaint against a local abortion provider after several groups asked that he resign as president of the State of Ohio Medical Board.

The Associated Press first reported news of Gonidakis’ decision, which came after several pro-choice groups said he should step down from the medical board because he had a conflict of interest in the pending complaint.

The complaint, filed by Dayton Right to Life on August 3, alleged that three abortion providers working at Women’s Med Center in Dayton violated state law and forced an abortion on a patient that was incapable of withdrawing her consent due to a drug overdose.

Ohio Right to Life issued a news release the same day Dayton Right to Life filed its complaint, featuring a quotation from its executive director saying that local pro-choice advocates forfeit “whatever tinge of credibility” it had if it refused to condemn what allegedly happened at Women’s Med Center.

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Gonidakis, the president of Ohio Right to Life, had then forwarded a copy of the news release to ProgressOhio Executive Director Sandy Theis with a note saying, “Sandy…. Will you finally repudiate the industry for which you so proudly support? So much for ‘women’s health’. So sad.”

On Friday, ProgressOhio, along with eight other groupsDoctors for Health Care Solutions, Common Cause Ohio, the Ohio National Organization for Women, Innovation Ohio, the Ohio House Democratic Women’s Caucus, the National Council of Jewish Women, Democratic Voices of Ohio, and Ohio Voice—responded to Gonidakis’ public and private commentary by writing a letter to the medical board asking that he resign.

In the letter, representatives from those groups shared comments made by Gonidakis and said he lacked the objectivity required to remain a member of the medical board. The letter’s undersigned said the board should take whatever steps necessary to force Gonidakis’ resignation if he failed to resign.

Contacted for comment, the medical board did not respond by press time.

The Ohio Medical Board protects the public by licensing and regulating physicians and other health-care professionals in part by reviewing complaints such as the one filed by Dayton Right to Life.

The decision-making body includes three non-physician consumer members and nine physicians who serve five-year terms when fully staffed. Currently, 11 citizens serve on the board.

Gonidakis, appointed in 2012 by Ohio Gov. John Kasich, is a consumer member of the board and lacks medical training.

Theis told Rewire in a telephone interview that the letter’s undersigned did not include groups like NARAL Pro-Choice and Planned Parenthood in its effort to highlight the conflict with Gonidakis.

“We wanted it to be about ethics” and not about abortion politics, Theis explained to Rewire.

Theis said Gonidakis had publicly condemned three licensed doctors from Women’s Med Center without engaging the providers or hearing the facts about the alleged incident.

“He put his point out there on Main Street having only heard the view of Dayton Right to Life,” Theis said. “In court, a judge who does something like that would have been thrown off the bench.”

Arthur Lavin, co-chairman of Doctors for Health Care Solutions, told the Associated Press the medical board should be free from politics.

Theis said ProgressOhio also exercised its right to file a complaint with the Ohio Ethics Commission to have Gonidakis removed because Theis had first-hand knowledge of his ethical wrongdoing.

The 29-page complaint, obtained by Rewire, details Gonidakis’ association with anti-choice groups and includes a copy of the email he sent to Theis.

Common Cause Ohio was the only group that co-signed the letter that is decidedly not pro-choice. A policy analyst from the nonpartisan organization told the Columbus Dispatch that Common Cause was not for or against abortion, but had signed the letter because a clear conflict of interest exists on the state’s medical board.

News Politics

Missouri ‘Witch Hunt Hearings’ Modeled on Anti-Choice Congressional Crusade

Christine Grimaldi

Missouri state Rep. Stacey Newman (D) said the Missouri General Assembly's "witch hunt hearings" were "closely modeled" on those in the U.S. Congress. Specifically, she drew parallels between Republicans' special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life.

Congressional Republicans are responsible for perpetuating widely discredited and often inflammatory allegations about fetal tissue and abortion care practices for a year and counting. Their actions may have charted the course for at least one Republican-controlled state legislature to advance an anti-choice agenda based on a fabricated market in aborted “baby body parts.”

“They say that a lot in Missouri,” state Rep. Stacey Newman (D) told Rewire in an interview at the Democratic National Convention last month.

Newman is a longtime abortion rights advocate who proposed legislation that would subject firearms purchases to the same types of restrictions, including mandatory waiting periods, as abortion care.

Newman said the Missouri General Assembly’s “witch hunt hearings” were “closely modeled” on those in the U.S. Congress. Specifically, she drew parallels between Republicans’ special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life. Both formed last year in response to videos from the anti-choice front group the Center for Medical Progress (CMP) accusing Planned Parenthood of profiting from fetal tissue donations. Both released reports last month condemning the reproductive health-care provider even though Missouri’s attorney general, among officials in 13 states to date, and three congressional investigations all previously found no evidence of wrongdoing.

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Missouri state Sen. Kurt Schaefer (R), the chair of the committee, and his colleagues alleged that the report potentially contradicted the attorney general’s findings. Schaefer’s district includes the University of Missouri, which ended a 26-year relationship with Planned Parenthood as anti-choice state lawmakers ramped up their inquiries in the legislature. Schaefer’s refusal to confront evidence to the contrary aligned with how Newman described his leadership of the committee.

“It was based on what was going on in Congress, but then Kurt Schaefer took it a step further,” Newman said.

As Schaefer waged an ultimately unsuccessful campaign in the Missouri Republican attorney general primary, the once moderate Republican “felt he needed to jump on the extreme [anti-choice] bandwagon,” she said.

Schaefer in April sought to punish the head of Planned Parenthood’s St. Louis affiliate with fines and jail time for protecting patient documents he had subpoenaed. The state senate suspended contempt proceedings against Mary Kogut, the CEO of Planned Parenthood of St. Louis Region and Southwest Missouri, reaching an agreement before the end of the month, according to news reports.

Newman speculated that Schaefer’s threats thwarted an omnibus abortion bill (HB 1953, SB 644) from proceeding before the end of the 2016 legislative session in May, despite Republican majorities in the Missouri house and senate.

“I think it was part of the compromise that they came up with Planned Parenthood, when they realized their backs [were] against the wall, because she was not, obviously, going to illegally turn over medical records.” Newman said of her Republican colleagues.

Republicans on the select panel in Washington have frequently made similar complaints, and threats, in their pursuit of subpoenas.

Rep. Marsha Blackburn (R-TN), the chair of the select panel, in May pledged “to pursue all means necessary” to obtain documents from the tissue procurement company targeted in the CMP videos. In June, she told a conservative crowd at the faith-based Road to Majority conference that she planned to start contempt of Congress proceedings after little cooperation from “middle men” and their suppliers—“big abortion.” By July, Blackburn seemingly walked back that pledge in front of reporters at a press conference where she unveiled the select panel’s interim report.

The investigations share another common denominator: a lack of transparency about how much money they have cost taxpayers.

“The excuse that’s come back from leadership, both [in the] House and the Senate, is that not everybody has turned in their expense reports,” Newman said. Republicans have used “every stalling tactic” to rebuff inquiries from her and reporters in the state, she said.

Congressional Republicans with varying degrees of oversight over the select panel—Blackburn, House Speaker Paul Ryan (WI), and House Energy and Commerce Committee Chair Fred Upton (MI)—all declined to answer Rewire’s funding questions. Rewire confirmed with a high-ranking GOP aide that Republicans budgeted $1.2 million for the investigation through the end of the year.

Blackburn is expected to resume the panel’s activities after Congress returns from recess in early September. Schaeffer and his fellow Republicans on the committee indicated in their report that an investigation could continue in the 2017 legislative session, which begins in January.


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