Better Births
How doulas could improve Black maternal and infant health
As a doula since 2005, Jeaonna Hodges has attended more than 900 births. But one in particular sticks out in her mind. A few days after she assisted in a delivery, the client was bleeding heavily. The woman called another doula, who told her to go to the hospital immediately.
She was having a postpartum hemorrhage, a rare condition that affects just 1% to 5% of women but is a leading cause of maternal death. The woman spent several days in the intensive care unit, but she survived.
“I truly believe that having a doula saved her life,” said Ms. Hodges, lead doula at UPMC Magee-Womens Hospital.
Doulas are trained, non-medical professionals who provide emotional, physical, and informational support and guidance to pregnant and postpartum people. As the United States and the region grapple with higherdeath rates among Black women and their babies, doulas have emerged as a way to help Black women advocate for better care. Locally and across the state, doula services are becoming more available.
About 700 women a year in the United States die from pregnancy or delivery complications — the highest rate of maternal deaths among high-income countries — and Black women are nearly three times more likely to die from childbirth than white women are.
Black mothers in Pittsburgh are at particularly high risk. A 2019 report by the city’s Gender Equity Commission found that they’re more likely to die from pregnancy than their peers in 97% of U.S. cities. Black babies born in Pittsburgh also die at a higher rate than white babies — 18 out of every 1,000 Black pregnancies end in a fetal death, compared to only 9 out of every 1,000 white pregnancies.
Black women also have worse pregnancy outcomes, higher rates of cesarean sections and report lower birth satisfaction than white women.
That was the case for Ms. Hodges, who describes the birth of her third child in 2002 as “traumatic.” She said that her doctor didn’t listen to her concerns and was dismissive of an existing medical issue noted in her health records. Her birth lasted an agonizing 39 hours and afterward, she suffered postpartum depression.
“If I would have had someone who advocated for me,” she said. “Then bonding with that child would have been much easier than it was.”
Three years later, during her fourth pregnancy, she found a new doctor and had a completely different experience. She felt like her doctor respected her and spoke up on her behalf. That was when she decided to train to become a doula.
Bridging the gap
“Not only do Black women have disparate pregnancy outcomes, but they report disparate experiences, and that is reflective of how our medical systems are failing our Black women,” said Demia Tyler, director of strategic initiatives at Healthy Start, a Pittsburgh organization that aims to improve maternal and child health and to reduce poor birth outcomes and infant mortality in AlleghenyCounty.
“That is one of the reasons that Black women should have doulas, so that they can have that extra layer of advocacyand support,” she said.
Advocates say several factors contribute to ongoing maternal and infant disparities, including structural racism and implicit bias baked into the health care system. Factors such as economic stability and educational access, known as social determinants of health, often contribute to Black patients having less access to quality health care and higher rates of certain chronic conditions, which also make them more vulnerable to pregnancy complications.
Discrimination during medical appointments is also a common experience among Black patients. They may feel that they can’t vocalize their needs or disagree with their doctor. Doulas can act as a bridge between the pregnant person and the health care team.
“Our clients will tell us
things that they will not tell their provider,” said Ms. Hodges.
Doulas often spend more time with patients than providers do. They accompany pregnant individuals to appointments, answer questions about pregnancy and offer comfort during labor. After birth, doulas can provide mental health support and locate community resources for those experiencing perinatal or postpartum depression.
“The kinds of services we provide include teaching birthing people how to advocate for themselves, letting them know what their best practice choices are, giving themthe evidence to support their birth and just giving thempermission to advocate for the birth that they want,” said Ms. Hodges.
UPMC’s Birth Circle doulas program has doulas that speak several languages to help immigrants and refugees, who are also at higher risk of worse birth outcomes than white women.
This level of trust may help explain why studies have shown that doulas can help improve health outcomes for both mothers and babies. In one doula program that launched in 2008 in Greensboro, N.C., for
high-risk women, doula-assisted mothers were four times less likely to have a baby with a low birth weight, two times less likely to experience a birth complication, and significantly more likely to begin breastfeeding. The findings, published in the Journal of Perinatal Education in 2013, were based on 226 expectant mothers — 129 who gave birth without the assistance of a doula and 97 who worked with a doula.
A 2017 study found that women who gave birth with the assistance of doulas were less likely to have a cesarean birth and less likely to have pain-relief medications administered. Women also reported having a more positive childbirth experience.
UPMC is gathering data on whether its program can help decrease rates of cesarean sections, increase breastfeeding rates and improve patient satisfaction.
Expanding doula access
Recognizing the health crisis for Black mothers and infants, local organizations are working to make doulas more accessible.
UPMC Magee ramped up its doula program during the pandemic. Previously, the health system offered doula services for UPMC health plan holders only. In October 2020, it brought on the Birth Circle, formerly a community-basedorganization, to offer free doula services at Magee to anyone. In that time, the program has served morethan 400 women.
Local nonprofits Healthy Start and the MAYA Organization also provide free doula services. But growing demand means that free doula programs often have waiting lists, and the cost of hiring a doula can be prohibitive to the people who could benefit from them the most. Doula services can range from around $500 to several thousands of dollars.
The PA Doula Commission, which formed in December, is working on a proposal to get the state’s Medicaid program to cover doula services.
“We want to make sure that, in time, there will be a doula for everyone and that it will be affordable for everyone,” said Gerria Coffee, presidentof the group.
Ms. Coffee’s doula business, Genesis Birth Services, has partnered with Pennsylvania’s state prisons to bring doula services to incarcerated women through a pilot program. Funded through the Tuttleman Foundation, the program will start by providing doulas to pregnant inmates at SCI Muncy in Williamsport. The governor’s office estimates that there are around 30 to 50 pregnancies a year within Pennsylvania’s state correctional facilities.
Where to find a doula
Mastersofmaternity.com provides a directory of doulas across Pennsylvania, among other resources.
The following local organizations provide doulas free of charge: Healthy Start; Birth Circle Doulas of Magee; and MAYA Organization.