Health and wellness touch each of us differently. This is one person’s story.
Groggy and half-asleep, I turn to my nightstand to check my cell phone. It had just made a cricketlike chirping noise — a special ringtone I reserve only for my doula clients.
Joanna’s text read: “Water just broke. Having mild contractions.”
It’s 2:37 a.m.
After advising her to rest, hydrate, pee, and repeat, I go back to sleep — though it’s always hard to drift off when I know a birth is near.
What does it mean to have your water break?
When a soon-to-be mother’s water breaks, it means her amniotic sac has ruptured. (During pregnancy, the baby’s surrounded and cushioned by this sac, which is filled with amniotic fluids.) Usually, the bag of water breaking is a sign that labor is near or is beginning.
A few hours later at 5:48 a.m., Joanna calls to tell me her contractions are intensifying and occurring at regular intervals. I notice she’s having trouble answering my questions and is moaning during contractions — all signs of active labor.
I pack my doula bag, filled with everything from essential oils to vomit bags, and head to her apartment.
Over the next two hours, Joanna and I perform the labor techniques we’d been practicing for the past month: deep breathing, relaxation, physical positioning, visualization, massage, verbal cues, water pressure from the shower, and more.
Around 9:00 a.m., when Joanna mentions she’s feeling rectal pressure and the urge to push, we go to the hospital. After an atypical Uber ride, we’re greeted at the hospital by two nurses who escort us to a labor and delivery room.
We welcome baby Nathaniel at 10:17 a.m. — 7 pounds, 4 ounces of pure perfection.
Doesn’t every mother deserve to have a safe, positive, and empowered birth? Better outcomes should not be limited to only those who can pay.
In February 2018, I completed a 35-hour professional birth doula training at Natural Resources in San Francisco. Since graduating, I’ve been serving as an emotional, physical, and informational resource and companion to low-income women before, during, and after labor.
While doulas don’t offer clinical advice, I can educate my clients on medical interventions, the stages and signs of labor, comfort measures, ideal positions for labor and pushing, hospital and home birth environments, and much more.
Joanna, for example, doesn’t have a partner — the father is out of the picture. She doesn’t have family in the area, either. I served as one of her primary companions and resources throughout her pregnancy.
By encouraging her to attend her prenatal appointments and talking with her about the importance of nutrition and diet during pregnancy, I also helped her have a healthier, low-risk pregnancy.
The United States has the worst rate of maternal deaths in the developed world. It’s 24.6 deaths per 100 births, compared with 9.2 in the United Kingdom.
I felt an urge to get involved after doing extensive research about the appalling state of maternal care and outcomes in the United States. Doesn’t [SD1] every mother deserve to have a safe, positive, and empowered birth?
Better outcomes shouldn’t be limited to only those who can pay.
This is why I serve the low-income population of San Francisco as a volunteer doula — a service I strongly believe is much needed to improve the lives women and children in our country. It’s also why some doulas offer flexibility or a sliding scale when it comes to payment.
The maternal crisis in the United States
According to data from UNICEF, global maternal mortality rates fell by almost half from 1990 to 2015.
But the United States — one of the wealthiest, most advanced nations in the world — is actually trending in the opposite direction compared with the rest of the globe. It’s also the only country to do so.
A doula’s presence leads to better birth outcomes and reduced complications for both mother and child — we’re not just a “nice-to-have.”
During a long-term investigation, ProPublica and NPR identified more than 450 expectant and new mothers who have died since 2011 from issues that arose during pregnancy and birth. These issues include, but are not limited to:
What’s going on here?
After all, this isn’t the Middle Ages — shouldn’t something as natural and commonplace as childbirth be totally safe given advances in modern medicine? In this day and age, why are mothers being given a reason to fear for their lives?
Experts speculate these fatal complications occur — and are occurring at a higher rate — due to a wide variety of factors that may influence each other:
- more women giving birth later in life
- an increase in cesarean deliveries (C-sections)
- a complex, inaccessible healthcare system
- a rise in chronic health issues like diabetes and obesity
Plenty of research has shed light on the importance of continuous support, what about support from a doula specifically, versus a partner, family member, midwife, or doctor?
Many pregnant women — no matter their race, education, or income — are subject to these underlying factors. But maternal mortality rates are significantly higher for low-income women, black women, and those living in rural areas. Black infants in America are now more than twice as likely to die as white infants (11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies).
According to public mortality data from the U.S. Centers for Disease Control and Prevention, the maternal mortality rate in large central metropolitan areas was 18.2 per 100,000 live births in 2015 —but in the most rural areas, it was 29.4.
Needless to say, our country is in the midst of a frightening, serious health epidemic and certain individuals are more at risk.
But how can doulas — nonclinical professionals with perhaps only 35 hours or so of training, like me — be part of a solution to such an enormous problem?
The charted impact of doulas in the delivery room
Despite the fact that only 6 percent of women choose to use a doula during pregnancy and labor nationwide, the research is clear: A doula’s presence leads to better birth outcomes and reduced complications for both mother and child — we’re not just a “nice-to-have.”
2013 study from the Journal of Perinatal Education
- Study: Out of 226 expectant African American and white mothers (variables like age and race were similar within the group), roughly half the women were assigned a trained doula and the others were not.
- Results: The mothers matched with a doula were four times less likely to have a baby born at a low birth weight and two times less likely to experience a birth complication involving themselves or their baby.
Plenty of research has shed light on the importance of continuous support, but is support from a doula specifically, versus a partner, family member, midwife, or doctor different?
Interestingly, when analyzing the data, researchers found that overall, people who have continuous support during childbirth experience a 25 percent decrease in the risk of a C-section. But when doulas are the ones providing support, this percentage suddenly jumps to a 39 percent decrease.
The American College of Obstetricians and Gynecologists released the following consensus statement in 2014: “Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”
Case for continuous support for women during childbirth — 2017 Cochrane review
- Review: 26 studies on the effectiveness of continuous support during labor, which can include doula assistance. The studies included more than 15,000 women from a variety of backgrounds and circumstances.
- Results: “Continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score, and negative feelings about childbirth experiences. We found no evidence of harms of continuous labor support.”
- Quick birth terminology lesson: “Analgesia” refers to pain medication and “Apgar score” is how babies’ health is assessed at birth and shortly afterwards — the higher the score, the better.
But here’s the thing: According to this survey from the American Journal of Managed Care, black and low-income women are the most likely to want but least likely to have access to doula care.
This is possibly because they can’t afford it, live in a geographic area with few or no doulas, or simply have never learned about it.
Doulas may largely be inaccessible to those who actually need them the most.
It’s also important to mention that most doulas are white, well-educated, married women, based on results from this 2005 survey published in Women’s Health Issues. (I also fall into this category.)
It’s possible that these doulas’ clients match their own racial and cultural profile — indicating there’s a potential socioeconomic barrier to doula support. This could also underlie the stereotype that doulas are a froufrou luxury that only wealthy white women can afford.
Doulas may largely be inaccessible to those who actually need them the most. But what if more widespread usage of doulas — especially for these underserved populations — could prevent some of the complications that are behind the U.S.’s astonishingly high maternal mortality rate?
A hopeful future for doulas and mothers
This is the exact question the state of New York hopes to answer through its recently announced pilot program, which will expand Medicaid coverage to doulas.
In New York City, black women are 12 times more likely to die from pregnancy-related causes than white women. But because of the optimistic research on doulas, lawmakers hope this jaw-dropping statistic, coupled with the expansion of prenatal education programs and hospital best practice reviews, will improve.
Regarding the program, which will launch this summer, Governor Andrew Cuomo says, “Maternal mortality shouldn’t be a fear anyone in New York should have to face in the 21st century. We’re taking aggressive action to break down barriers that prevent women from getting the prenatal care and information they need.”
Right now, both Minnesota and Oregon are the only other states that allow Medicaid reimbursements for doulas.
Many hospitals, like San Francisco General Hospital in the Bay Area, have created volunteer doula programs to address the issue.
Any patient can be matched with a pro bono doula who’s there to guide the mother prenatally, during birth, and afterwards. Volunteer doulas can also work 12-hour hospital shifts and be assigned to a laboring mother needing support, perhaps if she doesn’t speak fluent English or arrived at the hospital alone without a partner, family member, or friend for support.
Additionally, San Francisco’s Homeless Prenatal Program is a nonprofit that offers doula and prenatal care to the city’s homeless population.
As I continue to learn and serve as a doula, I hope to focus my efforts on these high-risk populations by volunteering with these programs and taking pro bono clients like Joanna.
Each time I hear that familiar sound of crickets chirping from my cell phone in the wee hours of the morning, I remind myself that though I’m only one doula, I’m doing my small part to improve women’s lives, and perhaps even helping to save some, too.
English Taylor is a San Francisco-based women’s health and wellness writer and birth doula. Her work has been featured in The Atlantic, Refinery29, NYLON, LOLA, and THINX. Follow English and her work on Medium or on Instagram.