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'The state needs to listen to Black women.' Why doulas aren't happy with California

Ariane Lange, The Sacramento Bee on

Published in Mom's Advice

SACRAMENTO, Calif. — Two doctors and four nurses bustled around a young indigenous mother as she lay in a hospital bed at Mercy San Juan Medical Center this summer. The woman was giving birth to her second child, and in the din of the brightly lit room, she heard that staff wanted to give her Pitocin, a synthetic hormone that increases contractions and can severely increase the pain of labor.

Through the small crowd around her, the 24-year-old locked eyes with her doula, who recounted the scene to The Sacramento Bee. The doula, Bahja Imaan Davis-Perkins, silently pointed to her wrist at an imaginary watch. Steadied by the signal, the woman asked the doctors if she could have a moment of quiet to think about what they were telling her, and they left the room.

She had been scared, but she talked it over with Davis-Perkins, and when the doctors returned, she was firm: No Pitocin. Late in the afternoon the next day, she delivered a baby boy, with Davis-Perkins still by her side after the 16-hour labor.

"She felt empowered," said Davis-Perkins, a Black and indigenous doula who works with Haven, a pregnancy and postpartum care nonprofit. In a turbulent moment, Davis-Perkins guided the young woman back to safety and stillness.

The mother's first birth had felt like something that happened to her as she lay there helplessly; it ended in a traumatic C-section, Davis-Perkins told The Bee. This time, she avoided surgery and labored the way she chose to.

"Birth should be sacred, is what she wanted to feel," Davis-Perkins said. She said the mother told her later that Davis-Perkins had protected her from being overwhelmed by doctors.

Doulas have long existed outside formal medical systems. Since professionalizing in the 1980s, these workers have improved people's experience of pregnancy and childbirth, preventing unnecessary C-sections and postpartum depression alike. They sometimes serve clients in a veil of aromatherapy and doctors' scorn, and they operate without a license or a governing body.

But now a group of doulas is facing a problem many in California have long endured: a byzantine health care bureaucracy that threatens to undermine access for people of color.

The state is poised to spend millions of dollars a year to provide doulas to low-income women through Medi-Cal, greatly expanding the number of people who can afford this care. One in three Californians make use of the insurance program, and half of births in the state are covered by Medi-Cal. Although the benefit is open to all pregnant Medi-Cal recipients and 2.5 million beneficiaries are white, the policy change is intended to help the most vulnerable birthing people, particularly those who are Black and indigenous.

But it will only work if doulas actually sign up as Medi-Cal providers, and 12 doulas from across the state told The Bee that issues over credentials, pay scales, billing processes and a federal Medicaid requirement for "supervision" could discourage the marginalized birth workers whose services BIPOC Medi-Cal recipients need most.

Furthermore, the Department of Health Care Services confirmed to The Bee that their initial working estimate for doula care was $450 per birth for services that include prenatal and postpartum visits as well as labor and delivery — a relatively low payment that foreshadows a clash.

The birth workers fear the new expanded benefit won't end up helping people of color receive a service that many have long been denied. And the doulas are gearing up for a Nov. 19 stakeholder meeting, the last forum scheduled before the state submits its proposal to the federal government.

"When the new benefits come out for people of color, they usually come out with a rub, with a trick," said Sayida Peprah, the doula and psychologist who co-founded Los Angeles' Frontline Doulas, which connects Black families with Black doulas.

"There's a really strong historical experience of systems coming out and dis-serving the people that they were supposed to serve," she said. "In this case, this is a double-whammy, because it's both the people that they're supposed to serve and the people doing the service with the same experience. We're the same."

This year, knowing that a bill championed and shaped by doulas was working its way through the state Legislature, Gov. Gavin Newsom surprised birth workers by including $403,000 in doula coverage for Medi-Cal beneficiaries in the state budget. That funding will increase to $4.4 million annually when the benefit is fully implemented.

Black doulas have pushed for this change since 2018. While California has improved maternal health overall, Black people and indigenous people are at the greatest risk of complications and death during and after birth.

The California Department of Health reports that the pregnancy-related mortality rate for white women between 2014 and 2016 was 9.4 deaths per 100,000 live births; for Black women, the rate was nearly six times worse, at 56.2 deaths per 100,000 live births.

The state did not release comparable numbers on Native women, but nationally, under a more restrictive definition of maternal mortality, they are more than twice as likely as white women to die of a pregnancy-related cause.

As a result of these disparities, Black doulas in particular feel the urgency of this crisis — and have the most to lose if a Medi-Cal benefit isn't rolled out equitably.

"Just in the last seven days, a doula reported a maternal death that she was able to witness," said Khefri Riley, the co-creator and co-director of Frontline Doulas. "It's happening right in front of our eyes, in our community, and it's so devastating. We have no choice but to take up arms and to make sure these changes happen."

Private insurance doesn't directly reimburse for doula care, so most birthing people who retain their services are women who can afford to pay the fee out of pocket.

"Doulas historically have been for rich white women," said Deidre Coutsoumpos, a founding member of the Black-led Sankofa Birthworkers Collective of the Inland Empire.

That's because the cost of a doula, who supports pregnant people before, during and after a birth, can range well over $1,500 for an experienced practitioner. Typically, adults on Medi-Cal make 138% of the federal poverty level or less — in 2022, a yearly income of $30,305 for a family of three. Some people who make more money but are uninsured or can't afford decent insurance qualify for Medi-Cal during and after pregnancy as well.

Doulas have a history of defiance

Professional doulas will point out that "auntie" figures have provided continuous support to pregnant and birthing people since time immemorial. When women gave birth at home, female relatives, friends or neighbors would naturally be there for them; a female midwife who learned her trade from other female midwives might also attend a home birth.

This remained true for the vast majority of people in the U.S. until the 1930s and 1940s. But as birth shifted into hospitals and shut out aspects of community care, labor became more alienating for birthing people. Birth became the realm of professional medical experts who were often male doctors.

With knowledge concentrated among doctors and nurses who were in and out of the room during labor, the women actually giving birth could feel estranged from their own bodies. At the same time, when medical experts were presumed to know better than their patients, women lost control over labor.

Still, it wasn't until the 1970s and '80s — when the rate of C-sections began increasing dramatically, and when the feminist movement was raising women's consciousness of the ways patriarchy disempowered and demeaned them — that the doula rose as a formalized job.

In 1970, five percent of births ended in a C-section; by 1996, it was 21 percent of births. Currently, the Centers for Disease Control and Prevention report that 31.7 percent of deliveries — about one in three — lead to a C-section, including more than a quarter of "low-risk" births that may not have required surgery at all.

Doulas emerged in opposition to these trends, staying by the sides of birthing people continuously throughout labor inside and outside hospitals. They attempt to shift the balance of knowledge and power back to women.

"Doulas exist because our maternity care system is crappy, it's dangerous and it kills pregnant people," said Samsarah Morgan, the founder of the Oakland Better Birth Foundation and one of the most senior Black doulas in the Bay Area. "This is not hyperbole: If you look at the mortality numbers, it's there."

While the maternal mortality rate overall is abysmal, Black women have worse outcomes than white women across education and income levels.

Black women face a tangle of disadvantage. A racist society leaves Black Americans more likely to have underlying health problems, including but not limited to severe stress. Doctors are less likely to take women's complaints seriously. And, as researchers wrote in the Proceedings of the National Academy of Sciences in 2016, "a substantial number" of white people, including white medical students and residents, "hold false beliefs about biological differences between blacks and whites," convinced that Black people feel less pain than white people.

Health practitioners' racist beliefs are not merely the result of so-called "unconscious bias." Racial distinctions are codified in the treatment guidelines circulated by governing bodies of the medical field. Doctors learn through these official guidelines that Black patients, including Black infants, must be sicker than their white counterparts to receive the same treatment for certain conditions. Resultant delays in treatment can, in turn, exacerbate or cause underlying health conditions.

Doulas alone can't undo medical racism or end the Black maternal health crisis. But having a supportive professional to advocate for a birthing person's needs before, during and after labor — a professional who is not working for a medical institution, but for their client — would help curb disparities, advocates say.

Because they've operated outside of institutions, doulas are wary of the obligations that will come with institutional acceptance.

The Department of Health Care Services, which administers Medi-Cal, held the first "stakeholder meeting" Sept. 16 to seek input from doulas, health care providers and advocates. By the second stakeholder meeting on Oct. 20, the department had already pushed the rollout of doula coverage from January to July 2022.

The delays, the department said, are coming because the state needs additional time to work with stakeholders on how to define a doula's services so they can be reimbursed; how much (and how often) to pay them; how doulas can prove they're qualified when they have no licensing system; and how to coordinate implementation with managed care plans

Lisa Murawski, the chief of the Department of Health Care Services' benefits division, opened the WebEx chat on Oct. 20 by thanking the participants who joined her on what she called the "journey to define this benefit." After introductions, that journey quickly took a turn for chaos.

At one point Murawski told the group that the Centers for Medicare and Medicaid Services require "supervision" for unlicensed practitioners.


Oakland-based Morgan cut in: "Forgive me for interrupting you, and with all due respect: What you're saying is not working," she said.

Medical providers do not understand what services doulas provide, and they aren't fit to supervise, she explained. Moreover, as Morgan put it to The Bee, "We are directly opposing the medical-industrial complex of which they are a part."

After more than an hour of fielding questions and comments, Murawski said, "I really appreciate the dynamism of this group and your self-facilitating process" as she attempted in vain to steer the stakeholders back to her forgotten agenda.

Doulas repeatedly asked for clarification on what "supervision" meant. No civil servant in the meeting provided a clear answer. Many doulas logged out of the meeting disappointed, and some were downright offended.

"There's so much work already done for them, but it doesn't seem like they've done their homework," Riley said. "That's frightening, considering that people are dying right now."

Riley's co-lead, Peprah, shared her concerns about this meeting and the next one, which is scheduled for Nov. 19. "You're only giving two sessions to solve the entire crisis of Black maternal health in California?" she said. "The level of disrespect with which they rolled this out is flooring to me."

Some doulas also found it ironic that an agency representing a medical establishment that leaves too many mothers sick, depressed and sometimes dead has asked them to prove their qualifications.

"Who's harming us now? People who are licensed," a frustrated doula of decades, Linda Jones, said at the meeting. "They're the ones who are harming us, not the lowly doula."

Officials at the October meeting wanted participants to hammer out a definition of what a doula is and what credentials or training they need in order to be considered a qualified doula. This in itself will be contentious for a group of workers who have never had to answer to any governing body.

"Generally, doulas are beholden to nobody but their client," Morgan told The Bee. "We want to keep it that way as much as possible."

The most widely-recognized doula certifying program is run by DONA International, formerly Doulas of North America. It's changing — the current president-elect is Black and the organization has adopted anti-racist policies — but it was long dominated by white people and is overcoming that legacy. Moreover, DONA's certifying workshops alone can cost $400 to $700, which could be prohibitively expensive for marginalized doulas.

Additionally, some of the most successful and experienced birth workers have never had any formal certification.

"I have been trained by wonderful doulas that have coined themselves as distinguished doulas that have been practicing for decades," said Marna Armstead, the co-founder and executive director of the SisterWeb doula collective in San Francisco. These senior doulas, she said, "Never took a training class, never certified anywhere, and it would be absolute disrespect to say that they need to go be trained."

Armstead and many other stakeholders are adamant that the qualifications be as flexible as possible and include those with fewer resources and those with years of experience alike.

However, Murawski barely broached the "qualifications" item on her agenda — the discussion mired in questions over supervision.

Likewise, the pay scale and payment process remain to be argued over.

The Sacramento Bee reached out to the Department of Health Care Services and requested an interview with Murawski about the agency's plans for the benefit. A spokesperson, Carol Sloan, said, "Unfortunately, staff are not available to discuss this."

California has a chance to lead the nation — only four other states actually reimburse doulas under their Medicaid programs. And despite a maternal health record that is the worst in the developed world by far, Congress has yet to set a national standard for ensuring access to doula care.

But Denise Bolds, president-elect of DONA International, cautioned that execution is everything. "Unfortunately, the mentality is that if we have Medicaid, it's gonna solve everything. No," she told The Bee.

While state legislators in Indiana, Minnesota, New Jersey and Oregon intended to help address a maternal health crisis for people of color in their states, their results have been weak. Medicaid coverage only helps if workers actually sign up to provide services, and these states have not made the bargain very enticing.

Indiana has a law requiring doula coverage for Medicaid recipients, but currently has no mechanism for paying them directly, which forces doulas to work under a licensed provider who bills for them. Some doulas see this as a conflict of interest.

And aside from the far more cumbersome billing process that comes with taking insurance, the reimbursement rates have been low. New Jersey, for one, wrote to the federal government proposing a relatively high rate — up to $1,166 — but that was for doulas who saw their clients on 12 separate occasions, and the labor and delivery fee was $235. Meanwhile, the American College of Obstetricians and Gynecologists says that the average first-time labor lasts 12 to 18 hours.

Working alone, a doula can typically support two to four births a month; the job requires significant time on-call and far more facetime than an obstetrician or a midwife would put in. With all this in mind, doulas across California who spoke with The Bee said they were concerned that Golden State officials hadn't learned from the problems with other programs.

In a statement to The Bee, the Department of Health Care Services spokesperson wrote, "For purposes of the Medi-Cal estimate, DHCS made an initial cost estimate of $450 per birth for that bundled rate based on data available to the Department at that time" — with the "bundled rate" including pre- and postpartum visits as well as labor. She added, "DHCS will also take under advisement other payment options presented by the stakeholders."

That estimated pay scale would leave full-time doulas unable to afford a standard one-bedroom apartment in any major city in the state, according to fair market rates set by the U.S. Department of Housing and Urban Development.

Throughout the Medi-Cal doula fight, Morgan has seen echoes of American history. She referenced the Black granny midwives who were effectively legislated and regulated out of birth work by white doctors and politicians, ostensibly in the name of making birth safer and more hygienic.

"As soon as doulas got trendy, I was like, okay, here comes the knife," said Morgan, who has attended more than 1,000 births. "Folks were like, 'Oh, you're so negative.' Oh, no, no, no. I am not negative. I'm just old now. And I've seen some things happen and the way this country works."

She said she expected doulas to be absorbed into the medical system and eventually be paid "a pittance."

'It's nothing that you can wave a magic wand over'

A few small community-based pilot programs in the state have already begun serving Medi-Cal populations in collaboration with insurance providers and health departments — with a great deal of success.

The Bee spoke with doulas from Sacramento, Alameda, Los Angeles, Riverside and San Bernardino Counties working on projects in which insurance companies reimburse them for agreed-upon services.

Coutsoumpos, a founding member of the Black-led Sankofa Birthworkers Collective of the Inland Empire, said that the Inland Empire Health Plan initially contracted her and her colleagues to serve 150 birthing families through the Doula Access Program. There was so much demand for doulas that the health plan expanded the program to serve 400 families. A separate, smaller health plan has contracted with them to serve 50 families.

"It's nothing that you can wave a magic wand over and be like, 'Boom! We wrote it in the bylaws and we made a budget and now you have a doula program! '" Coutsoumpos said. "It can take time ... to not only create something that is incredible as a benefit to patients, but that can be really sustainable for doulas."

In particular, doulas need "a livable wage," Coutsoumpos said.

Armstead, who leads the SisterWeb doula collective in San Francisco, said doulas need a billing system that is streamlined enough to be accessible. Payments need to arrive in bank accounts in a timely manner.

Black and brown doulas, Armstead said, are "probably in the same community experiencing a lot of the same things that their pregnant folks are dealing with," and they don't have "that leisure to get a payment later, to run it through a billing house or bill it monthly" that a white doula with more resources would have.

Jones, a co-founder of Black Women Birthing Justice who's been a doula for three decades, told The Bee, "The state needs to listen to Black women who have been doing this for a long time for this to be a successful program."

Ultimately, the doulas were hopeful — if extremely anxious — about the Medi-Cal benefit. But whatever happens in the gears of California state policy, they said they'll keep doing their work.

"There are lots of wonderful doulas who are doing a lot of work for free, and they were excited at the possibility of getting paid," said Morgan, the Oakland-based doula. "The folks who are doing it free are not gonna stop if they can't get Medi-Cal reimbursement, because women are dying. It's as simple as that. Birthing people are dying in this country that don't need to die."




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