Commentary Maternity and Birthing

We Need Doula Care to Achieve Reproductive Justice

Elizabeth Dawes Gay

A new report from Choices in Childbirth adds to a body of evidence that doula care should be included in health plans and made available to all women, particularly women of color, who face disproportionate rates of maternal and infant mortality in the United States.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

While the Affordable Care Act has significantly improved access to health insurance and preventive care, some important types of care for pregnant women were left out of the health-care reform law, namely doula care.

A new report from Choices in Childbirth, a New York City-based health nonprofit, shows that doulas not only improve maternal health outcomes, but the maternal care and support they provide also empowers women to overcome discrimination in the health-care system, ultimately improving health outcomes.

Yet, doula care is not nationally covered in public and private health insurance plans. This new report, Doula Care in New York City: Advancing the Goals of the Affordable Care Act, adds to a body of evidence that doula care should both be included in health plans and be made available to all women, particularly women of color, who face disproportionate rates of maternal and infant mortality in the United States.

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The report highlights how doulas can help reduce health disparitiesone of the key goals of the health-care reform law—by supporting positive outcomes. Doula care contributes to a reduction in medical interventions like cesarean sections, which can put women at additional risk for complications associated with a surgical procedure. Most births are low-risk and will progress naturally without surgery or intervention. By encouraging and allowing time and space for the body to do what it was designed to do, doula care also reduces the need for forceps and vacuum births, lessens the need for anesthesia, and is associated with positive outcomes like better newborn health indicators. Additionally, doula care is good for mothers during and after labor. Mothers assisted by doulas report having more positive feelings about their birth, and 80 percent said they felt more empowered.

In communities of color, where discrimination and disempowerment in the health-care system is prevalent, doula care can make a big impact. As Samantha Griffin, a doula with Mamatoto Village in Washington, D.C., explained to Rewire via email, “There are so many things designed to take our power away in these situations: historical power dynamics, the way the health-care system is set up, the unknowns we have around our bodies and birth in particular. And then you have the vulnerability of labor and birth.”

This disenfranchising power dynamic is apparent in previously published stories—shared in various reports over the past few years—of Black women in labor being ignored, having their desires disregarded, and left without adequate information about their health status or health care. For example, the Reproductive Injustice report, published by the SisterSong Women of Color Reproductive Justice Collective, the National Latina Institute for Reproductive Health, and the Center for Reproductive Rights, explains how when one woman, Tiffany, “went into labor with her third child, she was forced to wait in the hallway of the public hospital in Jackson [Mississippi] because there were no available beds.”

[Tiffany explained:] “Not only was [the delivery ward] in the basement, women were lined up on the wall, in the hallway, in labor, I mean full out labor in the hallway.” … Despite her sister’s pleas for the nurses’ attention, Tiffany was ignored until the baby started to crown. Even then, the nurses told her, “Hold her. Don’t push.”

Deadly Delivery describes the consequences when women don’t receive the care they need:

“She was talked down to, things were not explained. She told me she was stunned by the way she was treated … She had to struggle to get the information she needed.” The woman eventually lost her baby.

These anecdotes are supported by data showing that Black women and other women of color are more likely to experience racial discrimination and receive lower quality care within the health-care system. But doula care can help shift power during labor and childbirth by providing mothers with information, tools, and confidence to speak up and advocate for the care, time, or attention they need. Griffin added, “I think that for many of the first time mothers, and women of color generally, my presence empowers them to ask questions of their providers and get information they may not get otherwise.”

Chanel Porchia, founder and executive director of Ancient Song Doula Services in New York City, further explained: “I don’t think doulas empower women as much as a woman empowers herself when she realizes her voice is being heard and she can make a decision [about how she wants to give birth] based in knowledge rather than fear.”

With doula assistance, women are empowered to be proactive in realizing their reproductive, health-care, and birth goals. Effectively, doulas are helping to achieve reproductive justice.

The report goes on to share that despite these proven benefits, only one-third of privately insured women knows about doula care, and only 6 percent of expectant mothers in the United States have benefited from doula care. Data from a survey of 2,400 women shows that 39 percent of the more than 300 Black women surveyed would have liked to have doula care, the highest proportion of respondents in the study.

But even if women do know about and seek doula care, they still may not be able to afford it. Nan Strauss, director of policy and research at Choices in Childbirth, told Rewire in a phone interview, “The biggest barrier that prevents women from using doulas is cost. It’s great if you can afford to pay for it out of pocket, but even for middle income families, childbirth is one of most expensive health events in a family’s life.”

The average cost of doula care in New York City is $1,200—an expense that can be prohibitive when families may be paying for prenatal care and preparing their home for a new arrival on top of their usual expenses.

“Given the challenges with reimbursement, it’s hard to expand access to doulas because it means a real out-of-pocket expenditure for a lot of women. I think the biggest thing we could do is to make it affordable by making it reimbursable,” added Strauss.

Doula care is not typically reimbursed under Medicaid, but there is opportunity within Obamacare to change that. In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a ruling allowing states to reimburse for preventive services that have been recommended by a licensed medical provider but that may be provided by a variety of professionals, including doulas. So far, two states—Oregon and Minnesota—have taken steps to reimburse doula care under Medicaid. All states should do the same.

“Our policy is to never turn anyone away,” said Chanel Porchia, “but the reality is that by opening the door to Medicaid coverage of doula care, more families would be able to get assistance.”

State leaders must take the opportunity to expand Medicaid under Obamacare so more women can have access to the essential preventive care doulas provide. Sadly, some of the states where politicians refuse to consider Medicaid expansion are the states that need it most. For example, Georgia has the second highest maternal mortality rate in the country, but instead of working to expand access to care, politicians have actively worked against it.

While improving insurance coverage for doula care could go a long way, it’s also important for organizations advocating for doula care expansion to provide communities with the resources they need to take their health into their own hands. “It will have to be for us by us,” explained Samantha Griffin, noting that Black women are the key to increasing the use of doula care in the Black community. “We have to make sure that regardless of age, income, education, sexuality, we all get access. The health of Black mothers and babies is too important to leave to chance.”

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.”