Black expectant mothers need allies. We found some helpmates resurging.

Episode transcript

Clay Collins: In a relentlessly fast-forward age like ours, there are plenty of motivations for reaching back. They can reflect simple preference, like nostalgia for old forms of physical media. Or pragmatism: Pre-industrial agricultural practices, for example, have seen a renaissance. 

Sometimes, the stakes can be high. Maternal-health care has historically lagged for Black women in the United States. Mortality rates – both maternal and child – remain elevated for them.

The Monitor’s Cameron Pugh, whose portfolio includes the “Points of Progress” franchise as well as explorations of education, technology, social justice, and art, recently looked into the revival of birth doulas. 

Like midwives, doulas apply holistic, practical wisdom to obstetric care. Their resurgence is giving some Black women a new sense of trust in the healthcare system, broadly. 

Welcome to “Why We Wrote This.” I’m Clay Collins. Cameron joins me in the studio today. Hey, Cameron.

Cameron Pugh: Hi, Clay.

Collins: First of all, this isn’t about some negligible gap in quality of care. You described the racial inequities, historically, as being stark. Could you talk about that a little?

Pugh: I think it’s been broadly known, at least anecdotally among Black women and Black people, that you don’t necessarily receive equal treatment or equal care when you go to the doctor. And maternal health is just one example of that.

The stat in the story is that Black women die in pregnancy or of pregnancy related complications at 2.6 times the rate at which white women do.

And I think it wasn’t really until the late 2010s I’d say, that I think that entered the public consciousness because journalists did a lot of reporting to sort of uncover that, like ProPublica and NPR did a big series that uncovered that. But it has been, I think, broadly known among doctors and Black women for quite awhile. 

Collins: So, Cameron, I think most of our listeners and readers are familiar with the concept of the midwife. How are doulas different?

Pugh: So, two of the doulas I talked to both said the funny phrase “we don’t catch the baby.”

And it’s a good description of the difference between doulas and midwives. Midwives are highly trained medical professionals who specialize in delivering healthy children. They can basically care for someone who’s pregnant all the way from when they realize they’re pregnant to birth, as long as everything is going according to plan. If things get more complicated then a doctor would probably step in. 

Doulas don’t provide the same level of medical care. They’re more advocates. They’re in the room with patients during appointments and asking questions. They have some medical knowledge, of course, because you sort of have to, to serve in that role. But they’re not providing the same level of medical attentiveness that a midwife would be doing. They’re doing things like advocating for patients. They’re doing things like giving them tips on breathing exercises. They’re doing things like providing support for them and their families throughout the pregnancy.

Collins: Doulas specifically are about easing transitions. So there are end-of-life doulas, there are gender doulas, and there are birth doulas. You have maternal health as an issue, child health as an issue, there’s a lot of need. How widespread is the birth doula movement now, and how accessible is it for women?

Pugh: I think in terms of accessibility, it sort of varies. Massachusetts is unique in a handful of states. Doula care [here] is covered by Medicare and Medicaid, which means that if you have Medicare and Medicaid, you can get a birth doula, and that’ll be something that your insurance will cover it to some degree, at least.

But that’s not true in a lot of cases. In a lot of cases, insurance plans don’t cover doula services, and they tend to be pretty expensive, because when you think about what a doula does, they’re working with somebody from, basically, oftentimes from the earliest stages of pregnancy all the way through birth, and sometimes after, which is a long stretch of time. That’s a lot of work that they’re doing, and so their services cost a fair amount of money. 

So I think accessibility can vary, and I think historically it’s been a privilege that was only accessible to very rich women, and that’s sort of changing now, I think, as the medical system sort of recognizes that doulas are actually a scientifically proven, like, effective way to reduce these really stark maternal mortality rates.

And I think in terms of popularity, anecdotally, I think that doulas have gotten much more popular in recent years. I mean, I was pretty surprised during my reporting by just how many doulas there were in the greater Boston area. And maybe that’s partially because Boston is such a medical hub in general, but there were quite a few, and I think that’s probably true of other places too. And you know, a lot of the doulas I spoke to talked about how before they even knew that doula work was a sort of professional thing that they could pursue and get paid for, they were sort of doing the work already with their friends and with their family members and whatnot.

So, I think when you take into account those more informal doulas, so to speak, access sort of broadens.

Collins: In your piece, you lead with an anecdote about the work of a doula. I wonder, a.), how you got that kind of access, and b.), you know, what it was that you saw unfold?

Pugh: So I wasn’t actually present at the pregnancy, but I talked to the family afterward, and I met them through the doula I had spoken to.

And I really love this story. I mean, the anecdote goes, throughout the whole pregnancy they had created a birth plan, which is pretty standard when you’re working with a doula. You make a very detailed plan of how exactly you want your pregnancy and your birth to go, and you try to follow that.

And part of their birth plan was: They wanted their daughter to come into the world hearing the music that they listen to because they’re very musically inclined people, they like to dance, they like to sing. And so, throughout the birth, from the beginning, when they got to the hospital, and through their daughter’s birth, they were listening to R&B, so it’s like Anita Baker, and Al Green, and all of these, classic songs that they know and love, and they talked about how important that little thing was for them, to have their daughter get a sense of the kind of world she was coming into and the kind of family she was coming into from the very beginning. And, you know, that was something that a couple of the doulas I talked to emphasized, is how important those little things are, because they make people feel more comfortable, and they make people feel like they have agency and control over their birth and that’s really important to feel during something as significant as childbirth.

Collins: And what a great way to enter the world, from a kid’s point of view! 

Pugh: Yeah.

Collins: Hmm. It’s specialized, it seems to me in a way other than just medically. You write about “cultural competence” in particular and the notion that the caregiver’s background and life experience matches that of those in their care. How important a factor would you say you found that to be?

Pugh: I think it’s very important. All of the doulas I talked to sort of emphasized how it’s not even necessarily that doctors are doing anything wrong, it’s just there’s a power dynamic implicit between when you’re a patient and when you’re talking to your doctor.

It feels like your doctor is in control of everything like they’re the boss like you have to listen to them. You have to do what they say. You can’t ask questions. I think that’s related both to historic issues of medical racism and also just to sort of an inherent difference in how people interact with someone they view as a very educated, highly learned professional who they want to trust.

It’s also important to note that there have been a lot of studies that show that, even among doctors, people tend to prefer having a doctor of their own race. And that’s, that’s not necessarily even because of like a language barrier or anything like that. I think it’s just a comfort thing. It’s comforting to have someone in the room that looks like you, that understands your experience, that understands where you’re coming from. And so I think for a lot of Black women, because there are so few Black obstetricians, it can be really helpful to have just another Black professional in the room who knows what they’re talking about and can sort of interpret some of the medical speak for you, so you don’t don’t necessarily have to probe your doctor with all of your questions.

You can instead ask someone that you’ve been working with for a long time and you have this more one on one relationship with, and you spend a lot more time with in some cases, and that feels more comfortable to people.

Collins: So, Cameron, would you say that in any way the birth doula movement is kind of a refuge for women who in some cases might have had, not-positive experiences with the medical health community around obstetrics? 

Pugh: I think that’s definitely true. I mean, many of the doulas I talked to spoke about having children of their own and not having positive experiences and how they wanted to provide better experiences for other women and that’s why they were doulas in the first place and there is some science that talks about how as reproductive rights get constrained, the people who are most affected by that tend to be those who are already at the bottom of the food chain in that regard, so that’s Black women. And so I think for a lot of Black women, doulas can serve both as a refuge from negative experiences in obstetrics that were separate from the sort of recent political divides we’re seeing, and also now that things like that are getting more stark, can also be a refuge for that. 

Collins: Yeah. You make the point in your story that there’s not necessarily an us/them between people in the medical community and people in the doula community or, you know, frankly, in any of the holistic, non-medical or extra-medical arenas.

I’m just wondering, what’s your sense of how that respect dynamic is shaping up and, you know, is it mutual?

Pugh: I think it is mutual, from the doulas I talked to. I mean, many of them emphasize that they don’t blame doctors for the problems. The issues are more systemic. In addition to being like, there being instances of implicit and explicit bias, it’s also related to differences in access to healthcare and differences in access to education.

That’s part of it. I mean, if you drill down into the stats, it’s also true that even the most wealthy Black women die more frequently than the poorest white women. So that’s not the entire story, but it’s part of it. And so I think there’s recognition on doulas’ part that it’s deeper than any one doctor.

And I think they respect what doctors do and recognize that their expertise is obviously important and needed. When you think about pregnancy, I mean, there’s a lot of focus given on doctors, but it really is a team effort, like any medical thing. But pregnancy especially, you have the doctors, you have midwives, you have nurses, you have all these people working together to make sure that this goes smoothly and I think doulas sort of fit in and become a part of that.

While I was working on this story, I went to my first physical in Boston. So I had never met this doctor before and she asked me what I did for a living and I told her that I was a journalist and that I was working on this story and her face lit up when she heard about doulas. 

And she talked at length about how doulas are a great way to reduce maternal mortality and how they’re scientifically proven and they have all this research behind them showing that just having a doula in the room can be really helpful. And so I think doctors, as they’re looking for ways to sort of reckon with these really stark inequities, they’re, they’re becoming increasingly accepting of doulas as one of the things that might help.

Collins: Yeah. It’s encouraging that there’s a two-way level of acceptance there. The Monitor frames most of its stories, in terms of kind of a revolving series of universal values, and this one ended up carrying a “trust” tag. 

So I wonder if you could talk about the point in the story, where you and your editor sat down and said, “let’s do this as a trust story.”

Pugh: Mm. It’s interesting, because that’s actually related to my other big job here, which is writing Points of Progress. The story actually started as, in some ways, as a point of progress. It was one that we passed on you know, it’s a little, it’s a little too complicated to do in that distilled space, but my editor for that, Angela, said, “well, what if you did it as a fully reported story?”

Pugh: I mean, it seems like it’s about trust. And she was right. When you drill down into it, the entire issue is about trust. It’s about Black women and Black families not feeling like they can trust their doctors for a variety of reasons, because of personal experiences, because of history, because of these statistics, because of the scary stories in the news. 

And that trust affects every aspect of medical care, especially something as drastic as pregnancy. I mean, it’s really important when you go to the doctor, when you are working with a professional on your health, you want to feel like you can trust them. That adds a level of comfort and that adds a level of security that I think is really important, just for people’s psychological health, but also, I think, for their physical health. The doctor I talked to and the doulas I talked to, talked about how, like, when women are relaxed and when they’re at ease, the pregnancy tends to go better. 

So I think it was a trust story from the beginning and from the outset. But I found it really gratifying to be able to look at it through that lens and feel like I was really getting at the root of what the problem was, beyond just reporting that the numbers are scary and horrible and that women have terrible experiences, I found it gratifying to ask why and to see if there’s some way that people are trying to address that.

Collins: Right. Because there are elements of cultural recognition and reverence, even, in this story, it does set up as progress. I was going to ask you, actually, how it fit into the matrix of progress because as the Points of Progress editor, ideally you show credible progress. This is one anecdotally that’s strong. Is your sense that this will begin to bear out in the data and that the birth doula movement could be seen as more credible because of the outcomes?

Pugh: I think so. It’s funny … finding credible progress, so to speak, is like one of the perennial problems of writing Points of Progress. But I think in this case, it’s pretty clear that the progress is credible just because beyond even, like, the anecdotes that I gathered, there is a lot of scientific research that has shown the benefits of doulas and how they help women and how outcomes improve across the board. Not just for Black women, but for everyone who has a doula. And so I think there are strong elements here that make me think that this is something that will, in the long term – as it grows and becomes more popular and becomes more accessible – will actually lead to some progress. And of course, I don’t want to, I don’t want to overemphasize doulas because that was another thing they talked about is that the problems facing maternal health care are vast and complicated, and we don’t want to put all the pressure on doulas to sort of solve those things or to say that if you’re Black you have to have a doula or you’re going to die. That shouldn’t be how things are. 

There needs to be broader structural change and there need to be more Black doctors and there need to be all of these different things that will lead to really measurable progress. But I think doulas will end up being a pretty significant part of that.

Collins: Yeah. Powerful influence, on a very important time.

Thanks so much for writing about it, Cameron, and for coming on to talk about it and for all your Monitor work.

Pugh: Thank you for having me.

Collins: And thanks to our listeners. You can find more. Including our show notes with links to the story we just talked about, and to more of Cameron’s work at CSMonitor.com/WhyWeWroteThis. This episode was hosted by me, Clay Collins, and produced by Mackenzie Farkus. Jingnan Peng is also a producer on this show. Our sound engineers were Jeff Turton and Alyssa Britton. With original music by Noel Flatt. Produced by the Christian Science Monitor. Copyright 2024.