The United States has a penchant for being different even when different isn’t necessarily better. Though midwives are widely recognized around the world as the primary source of maternal health care, they only account for 8% of U.S. birth workers

What is a midwife? What is a doula? And how do these services differ? 

Midwives are medically trained and certified birth workers in maternal and prenatal health care. Depending on the state and its regulations, midwives can work in birthing centers, at homes, or under the supervision of physicians in a hospital setting. Pregnant individuals may also be interested in hiring a doula. Doulas are community-based, birth-workers who advocate for the mental, emotional, physical and spiritual wellbeing of the pregnant individual during and after the pregnancy. Unlike midwives, doulas are not medically trained in prenatal care and cannot deliver an infant, however, they are essential in connecting pregnant individuals with maternal health resources and information. Due to exhaustion, medication, intimidation, confusion, and many other reasons, pregnant individuals may not be able to advocate for themselves before, during and after childbirth. That is where a doula might come into play. Studies suggest doula and midwifery services lead to better maternal and infant health outcomes and reduce risk for medical interventions. Some of these health outcomes include, lower rates of c-sections, lower risk of preterm births and infant mortality, and increased breastfeeding at birth. Due to their community-based training, doulas have emerged in recent years as an essential factor in combating structural racism in the medical field and decreasing maternal health disparities for Black, Latinx, Indigenous, and other communities of color. 

The Crisis: Black women are dying in childbirth

The health care system has a crisis at hand. There is a history of harm that contributes to generational trauma and distrust in the medical field. Black women die in childbirth 3-4 times the rate of their white counterparts. The difference in maternal mortality rates between Black and white pregnant individuals can be attributed to racism and not race

Black mothers experience high rates of separation from their infants after birth and do not receive consistent breastfeeding education nor consistent evaluations of health concerns through high blood pressure checks and cervical checks; they also experience more complications after receiving medical interventions such as epidurals, pitocin, and caesareans. (Destine, Brooks, Rogers, pg. 605)

Midwives and doulas may be part of the solution due to their highly personalized style of care and community-based training, but there are issues with doula and midwifery accessibility. According to the National Partnership for Women and Families, 55% of US counties do not have a registered certified nurse midwife. Even in counties with certified nurse midwives, accessibility can be difficult as their services are often pricey. Although midwifery services are fully funded by Medicaid, doula reimbursement programs only exist in Oregon and Michigan. Depending on the region and the doula, doula support may cost anywhere from $500 to $3,500. Since doula services are not reimbursed through Medicaid, pregnant individuals who hire a doula are often paying that fee out of pocket. Although studies have shown that all pregnant individuals benefit from having a doula at their side, middle to upper income individuals already have access to a plethora of resources that puts them in an advantageous position relative to low-income individuals when seeking pregnancy support. 

This creates a conflicting paradigm. All pregnant individuals can benefit from doula support, but only some can access it, and those who can access doula services are often not the individuals who need it the most. At the same time, doulas can volunteer their time in low-income, communities of color and rural communities, but they still need to make money to support their families. 

COVID-19 and Doula/Midwifery Accessibility 

During the pandemic, pregnant individuals have encountered additional barriers to accessing midwifery and doula services. Some pregnant individuals elected to give birth at home to minimize exposure to the virus. Others gave birth in hospitals but were forced to choose between having their partner or their doula in the delivery room in order to comply with COVID-19 regulations. The choice between a partner, close family member or doula can be a difficult decision for pregnant individuals. COVID-19 creates an atmosphere of stress that did not previously exist and it is important for pregnant individuals to have access to their support systems.  

As previously mentioned, doula support is especially important for Black women who have historically been neglected by doctors during pregnancy and childbirth. COVID-19 has only exasperated existing health disparities between Black pregnant women and their white counterparts. Black people are more likely to be hospitalized with COVID-19 and more likely to die from a COVID-19 health related condition. Black mothers have also reported feeling more stress and distrust in the medical field due to the virus. 

Due to COVID-19 there have been permanent closures of community health clinics and this may lead to long-term consequences for low-income communities of color. Like doulas, community health organizations share a specialized set of skills and knowledge pertaining to the communities they serve. Permanent closures only add to existing issues of health care accessibility in low income communities of color. 

The Momnibus Act: Improving Black Maternal Health

So, what’s the solution? Introduced by Rep. Alma Adams (D-NC) and Rep. Lauren Underwood (D-IL), the Momnibus Act of 2021 aims to improve Black maternal health by investing in community health organizations, improving data collection, diversifying the field of health workers, and increasing postpartum coverage to one year. The name of the act is a play on the word “omnibus” which is used to describe legislative packages that include multiple bills. The Momnibus package includes 12 separate bills, including the Kira Johnson Act. The Kira Johnson Act is important because it provides funding for prenatal community health organizations and these organizations often enlist the support of doulas and midwives. 

“NWHN is proud to support the Black Maternal Health Momnibus Act because the U.S. fares worse in preventing pregnancy-related deaths than most other developed nations and this bill aims to improve maternal health in the U.S.” -M. Isabelle Chaudry, National Women’s Health Network

Through the work of Kalena Murphy, the Senior State Advocacy Manager for Raising Women’s Voices (RWV), and RWV regional coordinators, the NWHN continues to support Black maternal health initiatives. Through the RWV campaign, we also provide financial and technical support to Black-led organizations in their respective states. RWV has supported The Afiya Center, our Dallas-based regional coordinator, to address maternal mortality in Texas through doula training and launching a doula collective  which offers a full spectrum of doula care to Black women, women of color, and low-income women. In 2018, RWV teamed up with Black Mamas Matter Alliance (BMMA) in a campaign to raise awareness on Black maternal mortality rates in the US.  In 2020, RWV signed in support of the Momnibus Act and engaged in a social media campaign to spread awareness. Last year, RWV joined BMMA in a campaign to support community-driven policy advocacy and health systems change aimed at improving Black maternal health outcomes. 

Black Maternal Health week (April 11th-April 17th) is just around the corner and BMMA will be hosting their annual Black Maternal Health Virtual Conference on April 16th and April 17th. The Black Maternal Health Conference provides a space for activists, researchers, health experts and Black women to convene, learn and discuss issues pertaining to Black maternal health. It is an incredibly important event. 

 The NWHN recognizes this is a complex issue. There is no one policy solution that can decrease Black maternal mortality rates, but increasing funding for doula and midwifery services is a step in the right direction.