When Birth Becomes Bureaucratic

When Birth Becomes Bureaucratic

The doulas in Brooklyn are pissed off.

No one asked these birth workers for their opinion when legislators started pushing a new doula certification bill through the state government. No one asked if they wanted to be certified at all.

So for several months now, New York’s doulas have been writing, meeting, and calling local representatives in an effort to stop the bill from passing into law. From their work supporting women through childbirth, these doulas know how important it is to be a good listener. Now they’re asking lawmakers to do the same.

Meanwhile, the bill, which passed both the state Assembly and Senate, sits on Governor Andrew Cuomo’s desk, awaiting his signature.

Bill A364B is not long. But the page and a half speaks volumes. The requirements for certification include a $40 fee, “good moral character,” and a state exam administered by an unspecified “state commissioner.”

Assemblywoman Amy Paulin, a Democrat from Westchester, first introduced the bill in January. In the Senate, Representative Jessica Ramos, a Democrat from Queens, signed on as primary sponsor. The goal: to help address New York’s high maternal mortality rate by helping doulas get medicaid reimbursement for their work with low-income clients. It seemed like a fine idea.

But lawmakers didn’t realize that their actions would reverberate through the doula community with such force. It was only after the bill had already galloped through both chambers that the doulas’ cries made the lawmakers stop to consider the effect on those who did the work on the ground.

Some doulas felt that the medicaid reimbursement was not enough, that the language was not inclusive, and that certain doulas would be barred from their own community-based training programs and practices.

Paulin says that Ancient Song Doula Services, a community-based doula group in Bedford-Stuyvesant, contacted her immediately once they heard the bill was on the Assembly floor. She agreed to meet them at the back of the Assembly chamber, but at that point it was too late.

“We would have been happy to have this conversation beforehand if they would have reached out to us beforehand,” Paulin says.

When Denise Bolds answers the phone, there is a heaviness in the 55-year-old doula’s voice. A native New Yorker, she’s seen a lot in her five years working as a doula. A young woman Bolds knew died after giving birth to her second child the weekend before. It was a complication from her C-section. She was the daughter of a fellow birth worker. She was just 30 years old.

After giving birth, the woman told her doctors that she felt short of breath, a common symptom of pulmonary embolism. They told her not to worry about it. “It’ll pass,” Bolds said the doctors responded. They sent the woman home. She died soon after.

Maternal mortality is a serious health problem in the United States; the country ranked 33rd in maternal mortality in 2017, according to the OECD. The Harvard Business Review reports that despite increased attention, maternal mortality rates in the U.S. have climbed steadily over the years, doubling from 10.3 per 100,000 live births in 1991 to 23.8 in 2014. The article points a finger at high C-section rates.

Indeed, a Statista dossier on C-sections in the U.S. found that 56 percent of hospitals were overshooting the suggested C-section rate, and charging uninsured patients in New York on average $20,706—almost double what it costs when insured. Another report from Ariadne Labs found that 45 percent of C-sections were not medically indicated, and that C-sections reduced a doctor’s required labor from around 20 hours to two.

In other words, doctors get paid significantly more for procedures that require almost a tenth of the labor.

For people of color, the statistics are even worse. Bolds’ story has become a terrifying cliché for black and brown women in New York, where maternal mortality rates have soared.

According to the 2019 New York Department of Health report, black women in New York City are eight times more likely to die from pregnancy-related causes, and their babies are three times more likely to die within the first year than their white counterparts. Black women are also almost three times as likely to suffer life-threatening complications during childbirth.

The report also says that doula care has been associated with improved maternal and infant health outcomes—fewer c-sections, higher birth weight, less postpartum depression, to name a few. In essence, doulas seem to be effective in helping marginalized women advocate for themselves in sterile, chaotic hospital settings.

Doulas can help with those statistics, but they’re not the whole answer, the report argues. It says that will require “a range of strategies” that target systemic, deep-rooted racism.

Across the spectrum, black and brown women are dying at frightening rates during and after childbirth. Income and status are irrelevant.

“This is the same thing that Serena Williams was fighting about,” Bolds says, of the tennis great who suffered a pulmonary embolism after childbirth. “Being a multimillionaire, she was able to get heard. This woman was not heard.”

And understandably, interest in doulas has grown substantially in the past 10 years. DONA International, a major certifying body for doulas, reports that they have seen a 68 percent increase in birth doula certifications since 2013. Just this year, the organization said it has had an increase in the number of certification packages purchased by aspiring doulas.

Yet, doula supply is not meeting demand in New York because of doulas’ comparatively small workforce and the cost of hiring a doula—which can range from $225 to $5,000, the Department of Health report says. Lawmakers say the certification bill was an attempt to try to remedy these issues and make doulas more accessible. Medicaid reimbursements would encourage more doulas to serve low-income communities, and make their services more widely available to those communities.

The report estimates the number of working doulas in New York to be anywhere from 300 to 900. But it is difficult to determine exact numbers because there is no required training or certification to become a doula, and training methods can differ. The report found that just four percent of respondent doulas had no certification or affiliation with an organization.

When Nathalia Gibbs, a doula and Birth Coordinator at The Doula Project, heard about the bill through a Facebook group post in late June, she said it was a horrible surprise.

Gibbs herself is an uncertified doula, but she’s been trained by The Doula Project specifically to serve clients in New York and has worked as a doula in the city for two years. She says her training is important because it is very specific to the communities she encounters and allows her to work within a reproductive and social justice framework.

But doula anxieties are many when it comes to talk of certification. Some, like Gibbs, worry that state certification would give power to hospitals, making doulas beholden to the very institutions they try to supersede. They worry that hospitals will bar them from working if they don’t have the proposed state certification. Others, like Denise Bolds, fear that certification will discriminate against doulas who help at-risk communities.

“The doula bill is just— it’s there to keep barriers, to keep community doulas from doing this work,” Gibbs says. “Doulas are not medical staff, they don’t give medical advice, that’s not part of what they do.”

She doesn’t want to be regulated like a hospital staff member, which is exactly what happened to midwives in New York almost thirty years ago. In 1992, New York’s Professional Midwifery Practice Act mandated a new licensing process for midwives.

Gibbs points out that the wording of the doula bill is almost identical to the active legislation requiring midwifery licensure. This is not to confuse the two— midwives and doulas serve vastly different purposes, one medical, the other non-medical—but both represent a deviation from the physician-directed hospital birth.

When midwife licensure became required by the state, it made the path to the profession far more difficult and exclusive. A midwife had to pay to complete a master’s degree program in midwifery or its higher degree equivalent, and also pass a state licensing exam, among other stipulations like the “good moral character” clause. Economic and social barriers abounded.

Now, midwives are entrenched in the state system, but their numbers dwindling. It’s been the same for midwives around the world, including in Australia where Dr. Hannah Dahlen works as a higher degree research director and professor of Midwifery at Western Sydney University.

“I’m tired of feeling caught between the woman and the system,” Dahlen explains. With almost 30 years of midwifery experience under her belt, she has seen the impact of government regulation firsthand.

And this is exactly what some doulas worry about: becoming mandated reporters, beholden to the state, instead of to their clients. To them, that would defeat the entire purpose.

“All that [midwife] bill did was push midwives underground,” Gibbs says. “If you’re going to write a bill exactly like what has happened with nurse midwives, then we’re just repeating a cycle.”

While doulas have become regular fixtures in millennial childbirth lingo and the New York Times’ Style section, their job is far from a momentary fad. The role doulas play is as old as time.

They become fill-in mothers, friends, cousins, sisters, only there to look out for a woman’s best interests. Their agenda is this: a healthy mom and healthy baby. And for this reason, doulas have served an especially important role in the black community to help combat high mortality rates.

In fact, black women have been at the center of the modern gynecology movement in America since its inception, says Dr. Deirdre Cooper Owens, a professor of the history of medicine and director of the medicine in the humanities program at the University of Nebraska-Lincoln.

This legacy of black women and childbirth is a subject Cooper Owens has studied intensely in her book, Medical Bondage: Race, Gender, and the Origins of American Gynecology. Under Dr. James Marion Sims, the so-called “father of modern gynecology,” black slave women worked as assistants, and sometimes even became experimental subjects.

Cooper Owens explores the history that these black female “matriarchs” played in the creation of modern gynecology and obstetrics. But she also unveils the deep racism inherent in medical history. The black community, according to Cooper Owens, is still hesitant to trust doctors because of what she calls a deep “historical memory” of the ways in which doctors have exploited black bodies in the past.

Oddly enough, Cooper Owens used to live just down the street from Ancient Song. And she was able to watch as doulas gained strength and numbers in her own neighborhood of Bedford-Stuyvesant. One of her friends even trained with them. (Ancient Song has their own community-based training and certification process).

Although she hadn’t heard much about the bill, Cooper Owens strongly cautioned against government intervention, citing examples of traditional, cultural practices like hair braiding and midwifery that have struggled to thrive under state regulation.

“When they see that black women have diversified and democratized a field, all of a sudden there are these concerns that things have to be codified and there has to be this level of conformance,” she says, “but [the state] tends to not ever ask the desires of the community that they’re talking about.”

And it seems that some in doula community do not approve of this attempt to provide certification and medicaid reimbursement—at least not how it currently stands. What they do want is transparency. They want appropriate cultural training. They want to decide whether or not they want to be certified on their own.

“The more dysfunctional your system is, the larger the doula community will grow,” Dahlen explains. “Women are looking for humanized care and doulas are stepping into the gap. And who would you blame? I mean, a woman has a right to humanized care.”

Ancient Song Doula Services (seen above as the blue painted window front) is located on Halsey Street in Bedford-Stuyvesant. The organization has served as one of the major organizing bodies for doulas who have pushed back against the bill. | Photo by Currie Engel for The Brooklyn Ink

It didn’t take long for word in the doula of the bill to spread through the doula community—a call from a friend at home, a message here, a Facebook post there. One organization in particular jumped into action.

Ancient Song is an unlikely place for a resistance movement. Wedged into a block of buildings and shrouded by metal bars, the community-based doula organization is easy to overlook in Bedford-Stuyvesant. But what the organization lacks in its outward appearance, it makes up for in its prominent presence within the New York doula network. Almost every doula I spoke to about the bill mentioned Ancient Song’s advocacy efforts. They’ve been one of the major driving forces behind community discussions with Assemblywoman Paulin as they try to amend the bill.

Ancient Song’s founder and executive director, Chanel Porchia-Albert, is spearheading the activism. Since the bill’s introduction, she has been urging doulas to write to their representatives to oppose the bill on the grounds that its language was not inclusive enough and might present obstacles to doula work.

In a recent interview, Paulin says that when her office was crafting the bill she heard from individual doulas, but not from organized groups. She says she initially tried to seek out some kind of organized doula body to speak with, but couldn’t find an agency that represented doulas as a whole.

“We were hoping they would find us, if they chose to,” she says. “There was no uniform voice, which Ancient Song has attempted, to their credit, to try to remedy.”

Ironically, Paulin had advocated against stricter midwife regulations in a  2010 New York Times article, citing the experience of giving birth to her own daughter.

Paulin and Assemblywoman Michaelle Solages, a Democrat from Valley Stream who signed onto the bill as a co-sponsor, have since been talking with Ancient Song and other organizations to address the bill’s language and regulatory requirements, and to discuss possible amendments. But Paulin says they all wanted something different.

At a taped “community conversation” with Paulin and Solages in July, Porchia-Albert and other doulas raised their concerns. Porchia-Albert explained that about 85 to 95 percent of the people who come through Ancient Song are on Medicaid. These are clients whose care would be covered through medicaid reimbursement under the state’s plan. Yet, she said, doulas “want something better” than what legislators had come up with.

While the proposed medicaid reimbursement would be helpful for community-based organizations like Ancient Song that serve low-income populations, some doulas feel that the numbers the state suggested are too low. This plan was first introduced in a Medicaid pilot program that is now stalled in Brooklyn’s Kings County, but some of the pilot’s ideas and goals have been incorporated into the doula bill. In the pilot program, a doula could only make a maximum of $600 pre-tax per birth. That’s after overseeing four prenatal and postnatal visits as well as the birth itself. The schedule was demanding and the fees, critics charged, too low for a city like New York.

Porchia-Albert reminded the doulas at the meeting that even if they didn’t get an acceptable Medicaid reimbursement bill passed this session, the issue was not going away. Several other states currently have this type of legislation in the works, she claimed. Indeed, 13 states including New Jersey and Connecticut have introduced doula medicaid and insurance reimbursement bills, according to healthlaw.org. “This is not going to die because you veto a bill,” she told the doulas.

Despite repeated efforts, Ancient Song did not respond to an interview request.

While the specific complaints of various doulas differ, those opposed to the bill generally say the same thing: unless you’re going to listen to what we need, get your hands off of us. Methods may vary, but doulas feel they’re capable of training and regulating their own.

“The systemic ways that the state has intruded and intervened in black women’s lives in particular has been disappointing to say the least,” says Dr. Deirdre Cooper Owens. She explains that it seems like “they’re just telling these women what to do without consulting them.”

Dr. Hannah Dahlen would agree. She has studied the impact of doula work in Australia extensively, and understands the vital space they fill in medical systems worldwide. She used to think doulas should be more regulated, but after further study, changed her mind.

“My thinking has changed completely,” Dahlen says. “I actually really worry about us taking them into the system, and bringing them under our control, because I think they will start to work for the system and not for women.”

Concerned doulas expressed that the certification bill represented an unwarranted involvement in an issue that lawmakers simply don’t—and can’t—understand.

“I feel like the bill is seeking to fix a problem that doesn’t exist,” says Megan Davidson, 41, an internationally certified doula in Brooklyn.

Davidson has been working as a doula since 2003, and has assisted in 600 births. She sees the legislation as an attempt to get doulas and doula work to fit into a bureaucratic, legislative model to solve the maternal health crisis, and feels that that’s just not the answer. Davidson is not alone in this sentiment.

This kind of top down regulation is seen as a hindrance rather than a help, especially for doulas working within specific cultural and economic contexts.

In Nathalia Gibbs’ view, instead of allocating vast resources into building and maintaining a certification program, she feels it would be more effective for the government to just give those resources to community-based organizations. They’re the ones who directly help combat maternal morbidity, so why spend all this time trying to change the way they do things?

Even without the looming specter of government oversight, certification is already a tenuous subject. There are dozens of certifying bodies that serve different purposes and clientele. On doulamatch.net, there are over 100 different local and international certifying bodies listed. And doulas have their own reasons for wanting or not wanting to be certified.

Yet Jessica Stieger, advocacy director at DONA International, thinks certification can have important benefits. A certifying body can help establish foundational knowledge and can offer continuing education classes. She also suggests it can create a sense of accountability for the doula and their clients. “If something happens, and you need to reach out to an organization, we’re here to back our members,” she says.

Stieger does, however, think the choice to certify ultimately lies with the doula.

Carly Sargent-Knudson, a doula who identifies as non-binary, is DONA trained, but is not certified. Their certification packet is complete, but Sargent-Knudson never sent it in. Sargent-Knudson, now located in Colorado, worked in Brooklyn as a doula for a year, starting in 2017.

“I’m on the hunt for a truly culturally comprehensive and truly inclusive certifying body,” Sargent-Knudson explains. They want to be certified by an organization that is trans inclusive, one that supports all people of all kinds.

And besides, most of their clients don’t ask Sargent-Knudson if they’re certified. “Certification does not a great doula make,” Sargent-Knudson says.

While talking on the phone, Sargent-Knudson cradles their own baby at home in Colorado. The baby cries, demanding Sargent-Knudson’s full attention, but they remain serene, their voice only pausing to coo sweetly when the wails get too loud.

Despite the chaos, Amy Paulin feels confident that doulas and lawmakers will come to a resolution that will leave doulas feeling happy and supported.

“I think everybody’s heads and hearts are in the right place, so it’s just kind of working through these details,” she explains.

But some doulas are still hoping Governor Cuomo will just veto the contentious bill in December. They’d rather wait for a more comprehensive bill than hurriedly cut and paste amendments together. This kind of opposition to powerful lawmakers can be difficult for a decentralized group without a unified voice, but New York doulas are no strangers to long, arduous battles.

“I want the bill to be completely eradicated and destroyed and start all over again,” says doula Denise Bolds, “from the ground up with the right people at the table.”

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