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.

Roundups Politics

Campaign Week in Review: ‘If You Don’t Vote … You Are Trifling’

Ally Boguhn

The chair of the Democratic National Convention (DNC) this week blasted those who sit out on Election Day, and mothers who lost children to gun violence were given a platform at the party's convention.

The chair of the Democratic National Convention (DNC) this week blasted those who sit out on Election Day, and mothers who lost children to gun violence were given a platform at the party’s convention.

DNC Chair Marcia Fudge: “If You Don’t Vote, You Are Ungrateful, You Are Lazy, and You Are Trifling”

The chair of the 2016 Democratic National Convention, Rep. Marcia Fudge (D-OH), criticized those who choose to sit out the election while speaking on the final day of the convention.

“If you want a decent education for your children, you had better vote,” Fudge told the party’s women’s caucus, which had convened to discuss what is at stake for women and reproductive health and rights this election season.

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“If you want to make sure that hungry children are fed, you had better vote,” said Fudge. “If you want to be sure that all the women who survive solely on Social Security will not go into poverty immediately, you had better vote.”

“And if you don’t vote, let me tell you something, there is no excuse for you. If you don’t vote, you don’t count,” she said.

“So as I leave, I’m just going to say this to you. You tell them I said it, and I’m not hesitant about it. If you don’t vote, you are ungrateful, you are lazy, and you are trifling.”

The congresswoman’s website notes that she represents a state where some legislators have “attempted to suppress voting by certain populations” by pushing voting restrictions that “hit vulnerable communities the hardest.”

Ohio has recently made headlines for enacting changes that would make it harder to vote, including rolling back the state’s early voting period and purging its voter rolls of those who have not voted for six years.

Fudge, however, has worked to expand access to voting by co-sponsoring the federal Voting Rights Amendment Act, which would restore the protections of the Voting Rights Act that were stripped by the Supreme Court in Shelby County v. Holder.

“Mothers of the Movement” Take the National Spotlight

In July 2015, the Waller County Sheriff’s Office released a statement that 28-year-old Sandra Bland had been found dead in her jail cell that morning due to “what appears to be self-asphyxiation.” Though police attempted to paint the death a suicide, Bland’s family has denied that she would have ended her own life given that she had just secured a new job and had not displayed any suicidal tendencies.

Bland’s death sparked national outcry from activists who demanded an investigation, and inspired the hashtag #SayHerName to draw attention to the deaths of Black women who died at the hands of police.

Tuesday night at the DNC, Bland’s mother, Geneva Reed-Veal, and a group of other Black women who have lost children to gun violence, in police custody, or at the hands of police—the “Mothers of the Movement”—told the country why the deaths of their children should matter to voters. They offered their support to Democratic nominee Hillary Clinton during a speech at the convention.

“One year ago yesterday, I lived the worst nightmare anyone could imagine. I watched as my daughter was lowered into the ground in a coffin,” said Geneva Reed-Veal.

“Six other women have died in custody that same month: Kindra Chapman, Alexis McGovern, Sarah Lee Circle Bear, Raynette Turner, Ralkina Jones, and Joyce Curnell. So many of our children are gone, but they are not forgotten,” she continued. 

“You don’t stop being a mom when your child dies,” said Lucia McBath, the mother of Jordan Davis. “His life ended the day that he was shot and killed for playing loud music. But my job as his mother didn’t.” 

McBath said that though she had lost her son, she continued to work to protect his legacy. “We’re going to keep telling our children’s stories and we’re urging you to say their names,” she said. “And we’re also going to keep using our voices and our votes to support leaders, like Hillary Clinton, who will help us protect one another so that this club of heartbroken mothers stops growing.” 

Sybrina Fulton, the mother of Trayvon Martin, called herself “an unwilling participant in this movement,” noting that she “would not have signed up for this, [nor would] any other mother that’s standing here with me today.” 

“But I am here today for my son, Trayvon Martin, who is in heaven, and … his brother, Jahvaris Fulton, who is still here on Earth,” Fulton said. “I did not want this spotlight. But I will do everything I can to focus some of this light on the pain of a path out of the darkness.”

What Else We’re Reading

Renee Bracey Sherman explained in Glamour why Democratic vice presidential nominee Tim Kaine’s position on abortion scares her.

NARAL’s Ilyse Hogue told Cosmopolitan why she shared her abortion story on stage at the DNC.

Lilly Workneh, the Huffington Post’s Black Voices senior editor, explained how the DNC was “powered by a bevy of remarkable black women.”

Rebecca Traister wrote about how Clinton’s historic nomination puts the Democratic nominee “one step closer to making the impossible possible.”

Rewire attended a Democrats for Life of America event while in Philadelphia for the convention and fact-checked the group’s executive director.

A woman may have finally clinched the nomination for a major political party, but Judith Warner in Politico Magazine took on whether the “glass ceiling” has really been cracked for women in politics.

With Clinton’s nomination, “Dozens of other women across the country, in interviews at their offices or alongside their children, also said they felt on the cusp of a major, collective step forward,” reported Jodi Kantor for the New York Times.

According to Philly.com, Philadelphia’s Maternity Care Coalition staffed “eight curtained breast-feeding stalls on site [at the DNC], complete with comfy chairs, side tables, and electrical outlets.” Republicans reportedly offered similar accommodations at their convention the week before.

News Law and Policy

Court Blocks North Carolina’s ‘Discriminatory’ Voter ID Law

Imani Gandy

“[T]he new provisions target African Americans with almost surgical precision," Circuit Judge Diana Gribbon Motz wrote for the court, describing the North Carolina GOP's voter ID law.

A unanimous panel of the Fourth Circuit Court of Appeals struck down North Carolina’s elections law, holding that the Republican-held legislature had enacted the law with discriminatory intent to burden Black voters and that it therefore violated the Voting Rights Act of 1965.

The ruling marks the latest defeat of voter ID laws passed by GOP-majority legislatures across the country.

“We can only conclude that the North Carolina General Assembly enacted the challenged provisions of the law with discriminatory intent,” Circuit Judge Diana Gribbon Motz wrote for the court.

HB 589 required in-person voters to show certain types of photo ID beginning in 2016, and either curtailed or reduced registration and voting access tools that Black voters disproportionately used, including an early voting period. Black voters also disproportionately lack photo IDs.

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Republicans claimed that the law was intended to protect against voter fraud, which has proven exceedingly rare in Republican-led investigations. But voting rights advocates argue that the law was intended to disenfranchise Black and Latino voters.

The ruling marks a dramatic reversal of fortune for the U.S. Justice Department, the North Carolina chapter of the NAACP, and the League of Women Voters, which had asked the Fourth Circuit to review a lower court ruling against them.

U.S. District Court Judge Thomas Schroeder in April ruled that plaintiffs had failed to demonstrate that the law hindered Black voters’ ability to exercise political power.

The Fourth Circuit disagreed.

“In holding that the legislature did not enact the challenged provisions with discriminatory intent, the court seems to have missed the forest in carefully surveying the many trees,” Motz wrote. “This failure of perspective led the court to ignore critical facts bearing on legislative intent, including the inextricable link between race and politics in North Carolina.”

The Fourth Circuit noted that the Republican-dominated legislature passed the law in 2013, immediately following the U.S. Supreme Court’s ruling in Shelby v. Holder, which struck a key provision in Section 4 of the Voting Rights Act.

Section 4 is the coverage formula used to determine which states must get pre-clearance from the Department of Justice or the District Court for the District of Columbia before making any changes to election laws.

The day after the Supreme Court issued its ruling in Shelby, the Republican chairman of the Senate Rules Committee announced the North Carolina legislature’s intention to enact an “omnibus” election law, the appeals court noted. Before enacting the law, however, the Republican-dominated legislature requested data on the use, by race, of a number of voting practices.

After receipt of the race data, the North Carolina General Assembly enacted legislation that restricted voting and registration, all of which disproportionately burdened Black voters.

“In response to claims that intentional racial discrimination animated its actions, the State offered only meager justifications,” Motz continued. “[T]he new provisions target African Americans with almost surgical precision.”

The ruling comes a day after the Rev. Dr. William J. Barber II, president of the North Carolina chapter of the NAACP and one of the primary organizers of Moral Mondays, gave a rousing speech at the Democratic National Convention that brought convention goers to their feet.

During a protest on the first day of the trial, Barber told a crowd of about 3,500 people, “this is our Selma.”