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Delivery Room Advocacy: How doulas can mitigate the effects of medical sexism and racism

The internet is littered with harrowing stories of childbirth gone awry. In The New York Times, Tara Haelle chronicles Tamoyia Hashim’s experience with her third child, in which she lost three quarts of blood and needed a hysterectomy. A. Rochaun Meadows-Fernandez similarly wrote in The Washington Post about post-birth complications that nearly killed her. What do these stories have in common? These women had no one to champion their needs in the delivery room and subsequently became advocates for doula presence during labor.

Each year, 700 women die in the United States as the result of pregnancy or delivery complications. The United States has the worst maternal mortality rate in the global North, and it is also the only country where this rate is still rising. A staggering 135 women per day endure traumatic and life-threatening complications during and after childbirth, including extensive blood loss and permanent infertility. The numbers are more shocking still when accounting for racial disparities. The Centers for Disease Control and Prevention report that the pregnancy-related mortality rate for Black, American-Indian, and Alaska Native women older than 30 is four to five times higher than it is for white women. Heartbreakingly, almost two-thirds of these pregnancy-related deaths are preventable.

Doulas are one essential component in combatting this maternal mortality crisis. Most basically, a doula is a pregnant woman’s advisor, a laboring mother’s advocate, and a parent’s guide to taking care of a newborn. Beyond offering critical emotional support, doulas can have a significant impact on facilitating positive birth outcomes and improving laboring mothers’ experiences. Numerous studies have shown that working with a doula leads to fewer birth complications, greater success with breastfeeding, and a decrease in the length of labor. Further, the presence of a doula has been shown to lower rates of cesarean deliveries, a surgical procedure which can cost twice as much as a vaginal birth. Considering the crisis of maternal mortality in the United States, which is deeply intertwined with medical racism and sexism, reimbursing doula services for Medicaid beneficiaries is one small step toward achieving reproductive justice for all.

Hiring a doula is one way to navigate a medical system in which a woman’s pain is taken less seriously than a man’s. In comparison to men, the average woman experiences longer wait times in emergency rooms, decreased access to pain medication, and dismissal of symptoms by health professionals. In fact, physicians often belittle women’s pain, in some cases telling patients that they are fabricating their discomfort or that it is “a normal part of being a woman.” Doulas can help mitigate the effects of this kind of medical sexism, which are especially acute for minority women, by advocating for the mother in the delivery room and ensuring that her pain is taken seriously.

Beyond these valuable health-related impacts, working with doulas is associated with cost savings for private insurance companies and state Medicaid programs. Because doulas significantly decrease rates of cesarean deliveries, they simultaneously help to circumvent preventable deaths and save costs for mothers. Critically, however, the costs of hiring a doula are high, ranging from about $800 to $2,500, and not all insurance companies will pay for a doula. Due to this significant financial barrier, doulas represent one of the fundamental challenges to reproductive justice: access.

Because of the ways in which doulas improve a woman’s laboring experience, their services must be made readily accessible, particularly to women of color. Studies have shown that doulas are especially equipped to aid low-income and Black women, as they are uniquely capable of minimizing the impact of medical racism by recognizing bias and providing culturally sensitive, patient-centered advocacy. However, doulas can be cost prohibitive. While some women can pay for doulas out of pocket without worrying about the expense, low-income women o en struggle to afford these services. Though local nonprofit organizations sometimes fill these gaps, coverage under Medicaid is necessary to make sure all women are able to access this vital resource.

Rhode Island is currently considering a bill that would require that doula services be eligible for reimbursement throughout the state under private insurance and Medicaid. The bill, entitled “The Rhode Island Doula Reimbursement Act,” previously passed unanimously in the State Senate. It is a huge step forward for low-income women who may otherwise be unable to access a doula and are therefore at an inordinately high risk of experiencing severe complications during labor. This bill, however, would not only benefit these women; the state would also likely save money due to a lower predicted rate of cesarean procedures among laboring mothers. Rhode Island would be only the fourth state to expand Medicaid coverage to include doulas, following the lead of Indiana, Oregon, and Minnesota. This is an opportunity for Rhode Island to establish itself as a leader in the reproductive rights sphere, potentially prompting its liberal neighbors to follow suit.

This measure is particularly necessary in Rhode Island because the state legislature spends a staggering 23.4 percent of its budget on Medicaid, a larger allocation than any state except New York. Though recent reports have concluded that outsized spending on Medicaid overall is a “worthwhile investment,” with nearly one-third of Rhode Island residents served by the program, any opportunity to decrease expenditures and route savings to other programs would certainly be welcome.

The Rhode Island Doula Reimbursement Act must be passed as soon as possible, and other states must follow suit in order to ensure that all women have access to physical, emotional, and informational support before, during, and after childbirth, regardless of their income. Doulas are indispensable in helping women navigate the daunting, confusing, and sometimes violating process of giving birth. They are especially valuable for women who are already predisposed to face disadvantages in our medical system due to racism and sexism.

Though doulas are poised to mend critical disparities in maternal health, they alone cannot fix inequities in the health system. Standing up for the rights of pregnant women must go beyond the delivery room and extend into other spheres of advocacy related to disproportionate access to housing, lack of nutritious food, deficient public transportation systems, inadequate sexual education, and even voter suppression. Nonetheless, by investing in doulas as a means of helping pregnant women—especially low-income women and women of color—access support systems that assist in the pre- and post-partum processes, policymakers can contribute to a more equitable healthcare system.

Editor’s Note: If you are interested in getting involved with advocacy around this bill, please contact Zander at alexandra_blitzer@brown.edu

About the Author

Zander Blitzer '22 is a Staff Writer for the US Section of the Brown Political Review. Zander can be reached at alexandra_blitzer@brown.edu

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