For Kayla Foxx, just knowing her doula, Shawna Howard, would be by her side during the delivery of her first child last month helped ease her anxiety about her pregnancy and labor.
Howard helped Foxx create a birth plan, an outline of preferences for how the birth would go. During labor, Howard reminded Foxx of affirmations to help her get through contractions, and reminded the medical team of Foxx’s needs when Foxx was in too much pain to talk.
Howard was part of the Black support system Foxx built around her as she prepared for the birth of her child.
“Shawna made sure to be an advocate for me and to be my voice when I couldn’t speak for myself,” Foxx said.
Doulas are not medical professionals, but support mothers during birth. Some doulas offer families emotional support and tips on infant care after babies are born.
The two women connected through a UNC program called the Alliance for Black Doulas for Black Mamas, which trains Black doulas and pairs them with Black patients. A $75,000 UNC grant that funds faculty projects launched the program. It then received a three-year, $525,000 grant from the Duke Endowment that allows for more doula training and more families to get the services, all for free.
Foxx called the program “amazing for young moms of color.”
Pushing back against a deadly trend
The United States has the highest maternal mortality rate among 10 of the world’s richest countries, according to a Commonwealth Fund analysis. Black mothers are more likely to die than white mothers from pregnancy-related complications.
The high Black maternal death rate has been in the spotlight for years, but that hasn’t stopped it from getting worse.
The racial mortality gap widened between 2019 and 2020.
The 2020 overall maternal death rate was 23.8 deaths for 100,000 live births, compared to a rate of 20.1 deaths for each 100,000 live births in 2019, according to the CDC.
The maternal mortality rate for Black women was 2.9 times higher than the rate for white women: 55.3 deaths per 100,000 live births for Black women compared to 19.1 per 100,000 births for white women.
With death rates so abysmal, communities, researchers, health professionals and parents are looking for ways to improve and are considering whether doulas are part of the answer.
Births attended by doulas are two times less likely to have complications for mothers and babies, according to a 2013 study. Mothers who receive doula support are less likely to have a cesarean section, are more likely to have babies born at healthy weights, and are more likely to breastfeed. C-section rates for Black women are higher than for white women. Studies have reported that doulas help reduce the impact of racial health care disparities and racial bias.
Venus Standard, an assistant professor of family medicine at the UNC School of Medicine, Jacquelyn McMillian-Bohler, an assistant clinical professor at the Duke University School of Nursing, and Stephanie DeVane-Johnson, an associate professor in the midwifery department at the Vanderbilt University School of Nursing, wrote the grant application for the program in 2018.
“This was developed by three Black certified nurse midwives who have been at the bedside, who’ve been in the trenches for the Black community,” DeVane-Johnson said.
The program augments the traditional doula training with information specific to Black women, DeVane-Johnson said. All the training is by instructors of color.
“We bring in aspects specific to the Black woman that other doula trainings do not incorporate,” she said. “That’s what is key to this program. We are tapping into things that uplift, inspire, educate Black women to be able to live and do another day in this really horrible world that we find ourselves living in.”
News about the training produced a flood of interest last year, with 125 people applying for 20 spots, Standard said. She pairs the doulas with parents who are planning to give birth at UNC. Talking about their experiences afterward, mothers sometimes say they told doulas things they didn’t tell the medical team.
“It’s because of the trust factor,” she said. “The doula looks like them. They may have similar backgrounds.”
Shawna Howard, Kayla Foxx’s doula, learned about Black maternal health while she was a student at Spelman College, a women’s HBCU in Atlanta, and about the shockingly high death rates for Black women.
“I heard the word ‘doula’ and I felt like that’s where I belonged,” she said. “I wanted to have some type of positive impact.”
She was in the second class of doulas that completed the program last year.
Howard has attended four births. She said her job is to focus on her clients and be a steady presence for parents.
“I let them guide me on what they need,” she said. She and Foxx had months to develop a bond.
That support is important, said McMillian-Bohler of Duke. Doulas help untangle medical jargon and make sure the medical staff is hearing patients’ concerns. “Having someone who understands, who listens, making sure you understand what’s available for you,” she said.
“As often is the case, people feel intimidated by the system,” she said. “The doula is there to make sure whatever the issues are, there is an echo for that, so they’re more likely to get exactly what they need.”
The insurance coverage hurdle
A 2012 study by the University of Minnesota suggested state Medicaid programs consider covering doula services as a way to save money, because it could result in fewer cesarean sections, which are more expensive.
Only a handful of states’ Medicaid programs cover doula services, according to the National Academy on State Health Policy. In North Carolina, Medicaid did not cover doula services before the state switched to Medicaid managed care.
Of the state’s five prepaid Medicaid managed care plans, two offer limited doula services. Blue Cross NC covers doula services for some of its Healthy Blue of North Carolina enrollees in the Greenville and Asheville areas, a company spokeswoman wrote in an email.
WellCare of North Carolina covers doula services for pregnant enrollees 13-20 years old who live in group homes or have “minimal parental support,” according to its online handbook.
Most insurance companies don’t offer doula coverage under their private plans, which means most people must pay out of pocket. Costs in North Carolina range from about $500 to more than $2,000 for a birth.
The Black doula program at UNC overcomes financial hurdles by providing both the training and the doula service at no cost.
State officials have considered providing doula services under Medicaid.
In an email, a state Department of Health and Human Services spokeswoman said the Medicaid office is evaluating coverage policies related to maternal mortality to determine the most effective strategies. The evaluation includes a fiscal review.
Doulas one piece of a larger puzzle
As part of a five-year, $10 million grant awarded in 2019 to improve maternal health, DHHS started a task force, run out of the North Carolina Institute of Medicine, to find solutions for improving maternal health. That task force suspended its meetings, but among the recommendations in the report is “a comprehensive analysis of doula support availability, standards, and coverage policies,” said Kathleen Colville, NC institute of Medicine president and CEO. The task force also wanted to recommend “looking at reimbursement strategies for Medicaid and private insurance to consider,” she said.
The task force was “very much in support of expanding and enhancing that workforce,” she said.
The state is using some of the federal grant to pay for two community health worker/doula programs, one based at the YWCA of High Point for Guilford County residents, and the other at Novant Health New Hanover Regional Medical Center.
The program at Novant Health contracts with two doulas who are paired with women through community health workers, said Sarah Arthur, community engagement manager. The program served 30 women in its first year. All are on WIC or pregnancy Medicaid.
Most of the women in the program are African-American, Arthur said, because the goal is to improve the health of Black mothers and their newborns. But some Hispanic and white mothers have received the service, too.
The doulas see the expectant mothers three times before a birth, during the birth and twice afterward. The community health workers see the parents more, and work with them for a year after their babies are born.
The UNC program is looking to serve broader purposes, in addition to improving the well-being of Black mothers.
One of the goals is to grow the workforce of Black doulas, some of whom may want to become labor and delivery nurses or certified nurse midwives.
And the enhanced training is meant to give doulas new perspectives on their lives that they then bring back to their communities.
“As they go into the community, they’re spreading this new outlook within their communities,” McMillian-Bohler said.
“The goal is not only to increase the voice of the birthing person, but to increase the voice of Black communities and give them the tools to do it.”
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