The Labor of Doulas
During the first year of the pandemic, maternal deaths increased by 14% in the U.S, from 754 deaths in 2019 to 861 in 2020, according to a report from the National Center for Health Statistics. Among Black women, the U.S. Centers for Disease Control and Prevention noted a significant increase during that time, from 241 maternal deaths in 2019 to 293 in 2020 — a 22% increase.
Just one month before Governor Gavin Newsom issued a stay-at-home order in March 2020, Majority Leader of the California State Assembly Eloise Gómez Reyes (D-Colton) introduced Assembly Bill 2258 which intended to lower maternal and infant mortality rates in 14 California counties, including Riverside and San Bernardino.
The bill never had a chance to move forward as priorities shifted to address the COVID-19 pandemic. Two years later, the Majority Leader is excited to witness the implementation of doula services as a Medi-Cal benefit.
“I’m sorry it didn’t happen sooner, but I’m very happy that it’s happening now. If we provide doulas, I think that there is going to be a reduction in birth complications,” Reyes stated. “There’s a long list of things: decreased rates of preterm births and low birth weight babies, 25% reduction in the likelihood of c-section, 14% reduction in newborn admittance to special care nurseries, increased breastfeeding rates.”
Reyes explained that one of the greatest benefits to providing doula services will be tackling the maternal mortality rate, especially as it impacts Black women. While traveling across the U.S. to learn more about the topic, co-sponsors of the bill and birthing people reminded Reyes that a lot of the disparities in outcomes have to do with racism in health care.
“Most doulas that I talked to were providing 24-hour a day service. They were always available to the women they were working with,” Reyes shared. “I think that the [Medi-Cal benefit] is also going to signal to the rest of society that we do value doulas and the work they do, and I hope it’s going to encourage an expansion of doula training, also certification and the availability, not just for women who can afford it, but for women who need it.”
Unlike doctors and nurses, doulas are almost always available to their clients through phone, texting, video chat and in-person check ups, and are not necessarily compensated for all of it. Doulas largely operate as independent contractors and set prices for services based on their own discretion.
Chantel Runnels, a doula who operates across the Inland Empire, described being a doula as being a concierge, attending to clients at any time and providing support without notice. While some doulas will take on about two to three birthing clients a year, keeping in mind the 9-month timeline and juggling other part-time work, Runnels takes on two to three clients a month.
“Last year, I had 21 births, and one was a set of twins, so I guess it’s 22 babies,” Runnels explained.
The number of clients a doula supports depends on the doula and their capacity. Runnels shared that the average doula may have less than 10 births a year, in part due to compensation and how demanding it can be to care for a birthing person and their family.
“In one week alone, we could be spending over 40 hours just caring for a client, in addition to whatever else is going on in our life, and so it can be very labor intensive,” Runnels said.
Runnels supports a variety of clients in the Inland Empire, including those who pay for her services out-of-pocket and those who receive free services through community-based programs like the Sankofa Birthworkers Collective which is supported by state-wide organizations like the California Black Women’s Health Project, a nonprofit organization that encourages women to be “active participants in improving their health status.”
The California Black Women’s Health Project works in partnership with the Sankofa Birthworkers Collective to fund doula programs and host birthworker events and educational forums.
The support provided by Runnels and doulas everywhere is highly valued, proven effective and according to many, grossly undercompensated.
Expanding doula compensation, coverage and support
Dr. Sayida Peprah-Wilson is a licensed clinical psychologist and birth doula with a specialty in multicultural psychology, trauma, suicide prevention and maternal mental health. She is one of the founding members of the Sankofa Birthworkers Collective and belongs to the doula stakeholder group involved in establishing doula services as a Medi-Cal benefit.
Like most of the doula stakeholders involved in the development of the State Plan Amendment, Dr. Peprah-Wilson was disappointed with the initially offered $450 reimbursement rate for doula services.
“It’s a token of appreciation. This is not an actual sustainable, respectable offering. That’s what California is putting on the table right now,” Dr. Peprah-Wilson said. The reimbursement rate has since been increased from $450 to $1,154.
Regardless of what the state offers, Dr. Peprah-Wilson advised that part of the conversation regarding equity and doula service expansion must also acknowledge that adding this benefit will not “change the trajectory for all Black women in California or anywhere else” because everyone is not a beneficiary of Medi-Cal.
In her role as Program Director of Frontline Doulas, a Perinatal Health Program, Dr. Peprah-Wilson said that they provide free doula services to women that do not have Medi-Cal and who may have subpar insurance through their jobs, like a health maintenance organization (HMO) that does not cover the cost of doula services.
In the 21st century as Black families continue to experience harmful and sometimes fatal outcomes, the historic role doulas have played in the care of Black birthing people is finally being recognized, mainstreamed and compensated as a viable option for the successful care of pregnant people, especially Black women, to help curb the tide of Black maternal death.
