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Doulas Are Key to Curbing Maternal Mortality — But They’re Drastically Underpaid

Doulas for low-income women fight rising maternal mortality rates, but are often not compensated for their work.

Doulas for low-income women fight rising maternal mortality rates, but are often not compensated for their work.

The first time doctors saw Laginne Gianina Walker’s ultrasound, they accidentally read it backwards. They told her the boy’s organs were all upside-down. An ob-gyn counseled her to consider an abortion.

It was a frigid day in early February 2016 in downtown Manhattan. Walker, a 36-year-old computer science teacher, drove home to her studio apartment on the 21st floor of a building on Grand Concourse in the Bronx, and sat on her couch. She spent the next two weeks mulling what to do with her pregnancy.

The second time Walker went for an ultrasound, in early March, her doctors realized they’d made a mistake. They called their colleagues into the room to double-check the scans. Walker lay sprawled on the doctor’s bed as they prodded her bare watermelon belly with implements covered in cold gel. When the doctors finally reached a conclusion, it was a complete reversal of what they’d told her in February. “They had just made a mistake,” she recalled.

The next time she went to a doctor’s appointment at Mount Sinai Doctors West on 59th Street, roughly two weeks after the second appointment, Walker — who is Black — brought a white friend of hers. “So they would listen,” she explained.

She felt the white woman’s presence might make the doctors take her more seriously and answer more of her questions. She was right — she said she felt the doctors treated her in a meaningfully different way in her friend’s presence. This experiment was so telling that she started researching what other kinds of support were available for other low-income, single, women of color and first-time moms like her. When Walker got pregnant, she lived alone. Three months into her pregnancy, she still hadn’t told her own mother. She was feeling alone.

That’s when a pregnant woman in the waiting room of the Mount Sinai clinic told Walker that Bronx residents had access to free doulas. Walker had no clue what a doula was but said that if the service were free, she wanted to take it.

Walker learned, from her search on the internet, that doulas are birthing coaches who help people before, during and after they give birth. She diligently filled out the forms to request a doula from a center called Healthy Women, Healthy Futures.

Walker waited the remaining five months of her pregnancy for her doula assignment to come through. She was told that the agency was short on funds and that help would arrive when the new fiscal year began.

She never heard back, and forgot about it.

At 6 p.m. on August 22, 2016, Walker was getting to the hospital for her scheduled C-section, which she had decided would be her preferred method of birth because she did not want to go through a painful labor. But while in the cab, her contractions started as if for a vaginal birth, so she agreed to try a vaginal birth instead of proceeding with the planned C-section.

But once she was lying in the hospital bed, she couldn’t think. Her temperature and blood pressure shot up instantly. She couldn’t inhale. She trembled with fear. The doctors were coming in and out, apparently unconcerned. Everybody gets a fever, they told her. “Don’t worry.” High-blood pressure happens, they told her. “Don’t stress.”

Eight hours passed. The baby still hadn’t come.

“They weren’t responsive to the fact that I was in so much pain,” said Walker. Everything was happening so quickly. The rest of her thoughts melted into one another, leaving her powerless to piece together what was happening.

How Doulas Support the Birthing Process

However, at 3 a.m., Walker’s birth experience began to change. As she lay sweating in her hospital bed, an energetic woman with a big smile stumbled through the door. Evelyn Alvarez, the doula she had requested five months earlier, had arrived out of the blue. Alvarez was the co-founder of Black Magic Doulas, a small, New York City-based doula group, and had over 20 years of experience.

Like a Mary Poppins of birthing, Alvarez produced one piece of paraphernalia after the next from her backpack: lotion, oils, blankets, a tennis ball to support Walker’s back on the hospital bed, a scarf, a laptop and lip gloss so that Walker’s lips would not look chapped when taking a picture with her baby after hours of dehydrating labor. Then she started to work her magic. She played relaxing music, a special R&B selection from Walker’s streaming account that features artists like D’Angelo and Angie Stone. She massaged Walker’s temples and guided her through breathing exercises. She stretched out the expectant mother’s back to help her regain flexibility. She presented a trove of colorful bottles full of elixirs — she’d just gotten into aromatherapy, she explained — and let Walker choose which one to use.

“She was everything I needed but I didn’t know I needed,” Walker said.

Alvarez spent the next 12 hours beside Walker, holding her hand and calling out the doctors when she felt they were ignoring Walker. She insisted the doctors do something about Walker’s fever and was adamant that they keep her blood pressure in check, since complications can arise from neglecting such conditions.

“Women, especially Black women, sometimes are scared to ask questions, because of the racism they’ve experienced their whole life,” Alvarez said. “Sometimes it’s just a matter of asking, ‘Yes, but what are the other options?’ when a doctor says to do something.”

Alvarez’s undivided attention is something neither doctors nor a family can give. “When somebody you love is in a lot of pain, you want to take that pain away from them,” said Alvarez. “Parents and partners also have a right to experience the birth on their own skin, taking in everything it means to become a father or to become a grandma.”

Mothers often wonder: Aren’t doulas just doing what nurses should do? Research on doulas shows, however, that the positive effects occurred specifically when support was provided by someone other than a nurse. Often, mothers expect that nurses will spend more than half of the birth process offering support such as coaching and explaining, when, in reality, it’s on average just 6 to 10 percent.

Despite all of Walker’s contractions, there was no sign of the baby. It had been 10 hours since she’d gone into labor, yet she was only five centimeters dilated, and it usually takes at least 10 centimeters to deliver.

They reverted to the initial plan of a C-section, finally, as Walker was crying from the pain. The doctors cut through her abdomen and made a small incision in her uterus to reach in and pull the baby out.

At around 6 p.m. on August 23, Garvey’s head emerged. As the doctors stitched the layers of her abdomen together, Walker’s temperature began dropping back to normal, from over 102 degrees to under 100, as the doctors gave her some pills. At last, she could rest.

Could Access to Doulas Reduce Maternal Mortality Rates?

Like Alvarez, doulas are precious assistants during the time of a birth because of all the oft-overlooked strains and risks of pregnancy.

In 2016, nearly 900 women died from pregnancy-related complications in the U.S. With maternal mortality increasing 26.6 percent in the past decade, women here are now more likely to die in childbirth than their mothers were.

The United States is the only developed nation in the world where these numbers are increasing, from 18.8 to 23.8 deaths per 100,000 births in the period from 2000 to 2014. And according to medical investigations, more than half of all maternal deaths in the U.S. could have been avoided.

Experts note that risks have increased because women are getting pregnant later in life. But most evident maternal deaths in recent decades were caused by heart problems, hemorrhages, blood clots, infections and the pregnancy-induced form of hypertension known as preeclampsia. All of these conditions can be easily detected and treated in a hospital, especially if mothers receive regular checkups.

The medical community has made great strides in fetal research, but has made less progress recently in studying maternal issues, partly due to a false impression that the U.S. has solved birthing problems according to Mary D’Alton, a specialist in high-risk Maternal-Fetal Medicine at Columbia University. In her paper “Where is the ‘M’ in maternal-fetal medicine?,” she notes that 20 American hospitals have launched care centers for infants, but only one — New York-Presbyterian/Columbia University Irving Medical Center — has a research center concentrating on maternity research from a mother’s standpoint.

Social factors, including access to health care, race and income also affect the growing death rate. In the United States, Black mothers die at three to four times the rate of their white counterparts, and college-educated Black mothers are more likely to suffer pregnancy-related complications than white women who never graduated from high school, according to the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. And even when it comes to age-related medical complications, there’s still a disparity; a Black woman in her thirties will encounter comparable numbers of health issues to a white woman in her forties.

To fight this disparity, in late June 2018, the United States Senate Committee on Appropriations requested $50 million to prevent the pregnancy-related deaths of women in the U.S. Six months later, both houses passed the Preventing Maternal Deaths Act. If signed by President Donald Trump, it would fund the establishment of Maternal Mortality Review Committees in every state, along with research to track — and standardize strategies to prevent — maternal deaths.

State governments have also proposed laws to provide greater access to doulas, because of how helpful they are in mitigating the risks of pregnancies.

The continuous support of doulas shortens labor times and decreases the likelihood of cesarean births, according to the Journal of Perinatal Education. Doulas also protect women from what is formally known as “obstetric violence”: disrespect, coercion, bullying, physical abuse and, most importantly, lack of consent for examinations or treatments, including C-sections. They are linked to healthier newborns and higher maternal satisfaction rates, notes Kenneth J. Gruber, a research psychologist at the University of North Carolina.

Doulas Provide a Service and Receive Poverty

Because of doulas’ scientifically proven benefits, federally funded pilot programs have started to emerge across the U.S., with more than 10 states proposing bills for allocating resources to increase doula access for populations whose rates of maternal mortality are disproportionately high. Some states, like Indiana, Minnesota, and in this case New York, are granting some form of Medicaid coverage for doula services.

Though the programs granting access to doulas save lives, they also perpetuate an unhealthy cycle. The generous doulas who participate in serving low-income mothers earn far less than the private doulas who serve middle- and upper-class women who pay full fees, and they often slip into the same low-income bracket as their clients.

Medicaid covers an average of $500 for doula services. That single fee covers up to seven prenatal and postpartum sessions plus the actual birth, which could last anywhere from a couple of hours to more than three days. A doula contracted under Medicaid would have to assist 50 women a year to make $25,000, which doesn’t come close to providing a living wage in New York City. Meanwhile, private doulas often make upwards of $1,200 per client (which is certainly not a decadent salary itself).

Many doulas who do community-based work are hired as independent contractors, taking private clients on the side to make ends meet. Or they only work as doulas part-time, though the nature of the job means they’re on call all day, every day, with clients who could go into labor at any second.

“I always pray that my clients deliver at night,” said Megan Aebi, a program manager at the New York University School of Medicine who works as a doula on the side. “Sometimes it’s best not to even tell your boss you’re also a doula, so you can pretend to be — cough, cough — sick.”

Carmen Mojica, a New York-based doula who used to work for federally funded programs, left them five years ago because of the painfully low wages. “They’re continuing to create this poverty cycle by not paying the doulas the money they deserve for this crisis they oh-so-desperately wanted to solve,” said Mojica, who now works with the Uptown Village Cooperative in Harlem, which runs off donations. “The government just throws money at this problem, but they’re not listening to the people who are actually doing the work.” She added that her sense based on anecdotal evidence is that doulas in government-funded programs often wait as long as a year to get compensated, or they don’t get paid at all.

“I was never paid for Laginne’s birth,” said Alvarez, referring to Walker. The check simply did not come through. And the lack of government compensation didn’t surprise her: “Doulas often get invited to the baby’s first birthday, second birthday, and still haven’t been paid for the birth!” Alvarez said. The only money she got came from Walker’s mother, who felt she deserved to be compensated at least a little, and handed her a loose $40.

Meanwhile, Alvarez gives talks in schools, hosts workshops and helps organizations dealing with maternity issues in low-income areas to make ends meet. “I do a delicate dance,” she said. “It can go both ways. Some doulas might think, ‘we’re just not gonna do it; pay us more,’ but some might stick it out to prove that there will be an improvement.”

Doulas Provide Support After Birth

On January 20, 2019, Walker and Alvarez met again for the first time after more than two years.

Garvey opened the door. He was two and a half. He was jumping around the living room, restless and excited to see somebody new was visiting, waving at Alvarez. “Garvey, baby, Evelyn was one of the first people to see you alive,” said Walker, in her talking-to-her-baby voice.

Alvarez and Walker hug and laugh. They pour themselves large glasses of red wine. They slouch on the sofa to catch up, like friends who haven’t seen each other in a while, even though they have only met three times.

“Nobody ever talks about how hard to is to recover from a birth,” says Walker. “And you cannot say anything about it because people will brand you as ungrateful,” she says.

In fact, in the United States, 7 percent of maternal deaths are due to postpartum depression leading to suicide. Doulas like Alvarez also help new mothers restore pieces of themselves they may feel they’ve lost in childbirth, and manage expectations when they’re not able to live their lives like they want to, just yet.

Walker and Alvarez talked for almost four hours. They ordered sushi to the apartment, drank more wine, and talked about motherhood.

Alvarez shared that she is still a doula. She’s been leading doula workshops all over the state, helping two or three moms give birth every month, even officiating weddings whenever she can.

As they talked, she checked her phone, in case a client was abruptly going into labor and needed her help.

This article was provided to Truthout through StorySquare, a platform connecting freelancers with media outlets.

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