Doulas Fill Critical Need in Black Maternal Care
Morehouse School of Medicine's Perinatal Patient Navigator Program helps expectant parents navigate the health care system to ensure better health outcomes for underserved populations.
By Shelia Poole, the Atlanta Journal-Constitution
Reona Porter gently rubs her lower belly as several contractions hit, but it was not yet time to grab her stuffed go bag from under the coffee table in her Stockbridge living room.
Instead, the expectant mother does stretching exercises, hip squeezes and gets a massage from Bashellia Williams, her birth doula. The two were matched a few months ago through Morehouse School of Medicine's Perinatal Patient Navigator Program, which helps expectant parents navigate the health care system to ensure better health outcomes for underserved populations.
It's all part of the process to prepare Porter mentally and physically. "Trust in the process and your body," Williams said.
Porter's baby arrived 11 days early at 5:30 a.m. on October 10. Williams drove her to the Atlanta Birth Center, where she had a "beautiful water birth" in a birthing pool. The baby was Porter's fourth and was a 6-pound, 11-ounce girl.
The concept of women assisting other women during pregnancy, birth and afterward has been around for centuries, but the modern-day notion of birth doulas picked up steam in the 1960s and 1970s in the United States.
More recently, the use of doulas has been embraced as a way to address maternal mortality and morbidity, especially in the Black community. The field has really been set ablaze in recent years, with more women using doulas and promoting it on social media, Williams said.
"Our understanding of and appreciation for doulas is finally approaching critical mass or, rather, getting the attention needed to place doulas firmly on the front lines of the birth care team," said Dr. Jennifer Barkin, an OB-GYN and professor of community medicine at Mercer University's School of Medicine.
Doulas provide expectant moms with emotional support, along with educating them on pregnancy, childbirth and breastfeeding. They also teach them how to advocate for themselves with their medical team. Some doulas may provide information about other necessary basics, like housing and transportation, which is one of the main deterrents to access quality health care.
Doulas differ from midwives in important ways.
Tiffany Bryant, manager of the women's patient, education and support services department for Wellstar Health Systems, said Wellstar's midwives have clinical training and can see regular gynecologic patients. "They (midwives) actually deliver the babies more times really than our physicians, but they do generally the nonsurgical deliveries," Bryant said.
"A doula wants what you want," said Robin Elise Weiss, president of Chicago-based DONA International, a credentialing organization. "You sit down and tell me what you want for your birth, and let's talk about how to get that."
While it’s not required, some doulas, like Williams, have clinical training or a medical background. She has been a trained doula for more than three years but has been involved in maternal health for more than two decades as an OB-GYN medical assistant.
She was the doula for one of her daughters and “caught the grandbaby” at delivery. She said she has been present at the births of nearly 100 babies: 70% in hospitals, 20% at home and 10% at birthing centers.
Because there’s no licensing requirement for doulas, it’s not known how many practice in Georgia and nationally.
Some doulas get training and certification offered through nonprofits and health organizations around the U.S., such as the 50-year-old Atlanta nonprofit Healthy Mothers, Healthy Babies Coalition of Georgia.
Kimberly Seales, executive director for the coalition, said it has seen a growing demand for doulas. “Before, doulas were a very boutique service that you only saw in certain income brackets,” she said. “Today, women, organizations and states are seeing positive outcomes associated with doulas. It saves money at the end of the day. There is more one-on-one care. Women will see their doulas more than their OB-GYN.”
Keeping Black Mothers Healthy
Georgia ranked among the top five states for poor maternal outcomes, according to data released by the Institute for Health Metrics and Evaluation at the University of Washington and Harvard University’s Mass General Brigham.
The data, published in the Journal of the American Medical Association, showed that in 2022, the U.S. maternal mortality rate for Black women was 49.5 deaths per 100,000 live births, significantly higher than rates for white (19), Hispanic (16.9) and Asian (13.2) women, according to the Centers for Disease Control and Prevention.
A pregnancy-related maternal death is a death that happens during pregnancy or within one year of the end of pregnancy, according to the state Department of Public Health, which tracks and evaluates these deaths.
A recent study published in the American Journal of Public Health found expectant moms with doulas had a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth. The study included 722 women who received doula care matched to those who did not. All were enrolled in Medicaid-affiliated plans.
In Georgia, among all races, there were 35.69 pregnancy-related deaths per 100,000 live births from 2019 to 2021, according to DPH statistics. The state’s Maternal Mortality Review Committee concluded that 85% of the state’s pregnancy-related deaths during that period were preventable. The most common reason for maternal deaths were cardiovascular, followed by COVID-19, hemorrhage, mental health — including suicide — and embolisms or blood clots.
“It’s very troubling,” said Kristina Cheek, a trained doula and founding executive director of the Sista Girl Birth Initiative, a Valdosta-based nonprofit that focuses on Black maternal health outcomes. “People hear ‘Black women,’ but it can affect everybody.”
“The spotlight is on Black women,” Cheek said, “but maternal mortality doesn’t discriminate regardless of a woman’s race, her income, her ethnicity or her marital status. No one should have to worry about losing her life during what should be one of the best experiences of her life.”
Multiple factors contribute to disparities in maternal health care, such as variation in the quality of health care, underlying chronic conditions and structural racism and bias, according to the CDC.
Doulas can help pregnant women overcome some of those challenges.
Doulas Used More Widely
The cost of a doula can vary. Typically, a birth doula can earn between $1,500 and $3,500 for their services, said DONA’s Weiss.
Rates may vary based on whether the client and doula are in a larger city or rural area or whether they are birth doulas or postpartum doulas, according to DONA. It may also depend on whether it’s private pay or third-party reimbursement. Some doulas use the barter system or offer payment plans.
“A lot of us here in rural South Georgia who are doing the work of doulas find ourselves doing it for free. It becomes a work of compassion,” Cheek said.
Across the country, some hospital systems, such as Wellstar, are beginning to employ doulas.
The program was set up to improve the birth outcomes of high-risk pregnancies, the underserved and marginalized populations and for those with Medicaid-based insurance in Cobb and Douglas counties. The program has been expanded and now serves all birthing families across Wellstar’s hospitals.
Since beginning the program about 18 months ago, Wellstar has received 394 inquiries and doulas have been involved in more than 170 births.
Harmoni McNair, 18, had a doula during both of her pregnancies.
Her first child, Laila, was underweight at birth and died two weeks later of what doctors said was sudden infant death syndrome. When McNair discovered she was pregnant a second time, she said it made her extremely nervous.
Sista Girl’s Cheek, though, kept up with McNair as her doula, both physically and emotionally.
Cheek taught McNair movements to help with her plan for natural childbirth and helped her prepare emotionally. “Her believing I could go unmedicated is really what helped me through it,” McNair said. “(The baby) came out faster, and it was a lot less stressful for her.”
Expanding Doula Programs in Georgia
Mercer’s Barkin also serves as director of South Georgia Healthy Start, one of 105 federally funded Healthy Start programs housed within the Center for Rural Health and Health Disparities at Mercer. She said the organization plans to establish a doula presence within the program as soon as possible under the Project Elevate initiative.
The program will provide doula training for existing case managers and hire trained doulas. “There is a strong evidence base indicating that doula care leads to better health and birth outcomes,” Barkin said.
Atlanta Doula Collective is also expanding to offer more doula services statewide. The nonprofit based in Clayton County will become the Georgia Black Doula Network, said founder and Executive Director Sekesa Berry.
Berry said while doulas have traditionally worked independently, they are now increasingly employed by health nonprofits and hospitals. The collective has 12 active doulas, with 14 more in training, Berry said. The collective has trained more than 300 doulas nationwide, either virtually or in person, since 2017.
Natalie Hernandez-Green, PhD, executive director at the Center for Maternal Health Equity at Morehouse School of Medicine, said so far more than 70 women have been trained at the school as doulas or health care “navigators,” who do work similar to doulas.
She pointed out the use of doulas might help reduce not only maternal deaths but “near misses” caused by women who experience poor health during their pregnancies.
“For every maternal death, there are 50 to 100 women who are estimated to experience severe maternal morbidity – and, from that, there are women who are considered maternal ‘near misses,’ meaning they almost died,” Hernandez-Green said. She added doulas can be part of wraparound services aimed at preventing maternal deaths.
Doulas or navigators “really serve as a voice and advocate for women who often feel unheard and not listened to,” Hernandez-Green said. “Our navigators are basically protectors of women’s voices.”
“When you protect the health of a mom, you automatically protect the health of a baby,” Hernandez-Green said, “… and not just a baby but a family and a community.”