Women of color dying in childbirth is a crisis. Are doulas the answer?

• The death of sprinter Tori Bowie is raising awareness of a  maternal mortality crisis among women of color
• Michigan Medicaid on Jan. 1 began reimbursing doula services to provide support for women who are often unheard
• More work needs to be done to reduce disparities, achieve what advocates call birth justice

When Jennifer Heymoss became pregnant for the second time in 2019, she was determined to have a natural birth. But her experiences with doctors left her shaken and unheard.

She had her first son, Henry, in 2017 via cesarean because of complications. 

She wanted to avoid another surgery, so choosing a doula — professionals who provide physical, mental and spiritual support to pregnant mothers — was a no-brainer, Heymoss said.

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“My experiences with the medical field have been difficult in different ways,” said Heymoss, 40, of Kalamazoo, who is of Filipino ancestry. “I had just gotten a lot of grief through the years … when I knew I was healthy.”

“They kept saying I would have to get another C-section and I called …  my doula because I didn’t know what to do. I advocate for myself when I need it, but I was so tired. I was overdue (and) I was tired of fighting these doctors.”  

“I really think if I wouldn’t have called her, I would've had a repeat C-section.” 

Studies show women of color disproportionately have cesareans — not always by choice — and the procedure carries a far higher risk of complications and death.

Heymoss delivered her son Hugo, now 3, naturally, but her experience isn’t unique for women of color: Experts are sounding alarms about a spike in  maternal mortality rates among non-white women blamed in part on doctors failing to listen to patients.

The crisis is particularly acute among Black women, who are more than three times as likely to die from pregnancy-related causes than white women.

The discrepancy was highlighted most recently by an autopsy this week showing Tori Bowie, 32, a three-time Olympic medalist sprinter, died from childbirth complications.

Can doulas help prevent tragedy? Michigan thinks so.

‘Gold standard’ of labor care

In recent years, more women have become interested in midwife and doula services because of the disparities associated with hospital births.

But experts have said socioeconomic barriers and lack of funding make it hard to access these services, especially those who would benefit most from it. 

That may be beginning to change in Michigan, after state officials approved coverage of doula services through Medicaid. The Jan. 1 expansion covers six prenatal and postpartum visits and one during labor and delivery, reimbursing doulas $75 per visit and $700 for labor and delivery. 

Additional visits are possible with prior authorization.

Michigan also formed a doula advisory council of 26 members from 10 statewide regions to promote doula services by providing training and resources. In January, Michigan also created a registry of more than 160 state-certified doulas.

Advocates have sought the expansion for years, as many private insurance companies do not cover doulas because they don’t provide medical care. In 2022, Rhode Island became the first state to require private insurance companies to cover doulas, while several are considering reimbursing the service through Medicaid.

Midwives and doulas, “provides a golden standard for labor care and can inform physician approaches to care,” said Vanessa Moon, birth justice director for Rootead Enrichment Center, a Kalamazoo nonprofit that provides services to people of color.

“When continuous labor support is present from someone like a doula, rates of cesarean births are lower … and satisfaction with the entire process is higher.”  

The nonprofit’s doulas meet with clients one-on-one at least twice before the birth to develop a birth plan, provide the client with resources and empower women to advocate for themselves.

Birth doulas also coach women through the labor and will stay with the mother after the birth to work on breastfeeding and postpartum care.

Role of doulas is changing

Multiple factors contribute to the Black maternal and infant mortality rate including underlying health conditions, systemic racism and sometimes implicit bias, according to KFF, a nonprofit health policy group once known as the Kaiser Family Foundation. 

The stereotype that Black women have a higher pain tolerance may result in practitioners not taking their concerns as seriously, according to some research.

The U.S. Department of Health and Human Services published a study that concluded the presence of a doula decreased the likelihood of a cesarean birth and the use of an epidural.  

Since the Medicaid expansion, Community Health and Social Services Center in Detroit will begin offering doula services for the first time in years, after cutting the program due to lack of funding. 

“Doulas are specialized community health workers, and they focus on the pregnant woman leading up to becoming pregnant, through the pregnancy, through delivery and up until the first year of the baby's life,” said Dr. Felix Valbuena, chief executive officer for the center.

“We’ve been struggling over the years to get insurance companies to recognize that value and reimburse us for that.”

Women who have a high-risk pregnancy or other complications will be prioritized for doula services. The center will begin accepting clients in July.

The center also has programs for expecting mothers that address many of the social determinants that contribute to high fatality rates, including free transportation to clients. 

During the first 28 weeks of the pregnancy, women visit the doula every four weeks. After the baby is born, doulas will check in on the mother and the baby during the same visit because so many new mothers miss their first postnatal check up, Valbuena said. 

“I’m even willing to take a little bit of a loss on it because I know that the return on the investment of providing a doula is going to be significantly higher,” Valbuena said. “Moms are going to have better outcomes and babies are going to have better outcomes.”      

Overall, the use of doulas and midwives remains the exception in Michigan: Midwives attended about 10 percent of the 105,022 births in the state in 2021, and 182 of 2,018 home births according to state data.  

“There is a lack of understanding of the role of doulas and what they provide to women,” said Kari Beth Watts, a family physician at Western Michigan University Homer Stryker M.D. School of Medicine who works with a team of OB-GYNs and midwives to assist women with delivery. 

“Some of the assumptions are that the doulas will interfere with the plan of care,” or the doula would push back on medical intervention. 

“The role of the doula specifically … has shifted big time in a positive way,” Watts said. “Their value is more appreciated.” 

Better health outcomes

While many officials praise the Medicaid reimbursement for doula services, officials and birthing advocates say much more needs to be done to cut Black mortality rates.

Birth Detroit, a community-based maternal health practice, has worked alongside birth justice advocates across the state to pass a momnibus, a group of bills to improve maternal and infant health. 

Reimbursement for certified and professional nurse midwives and licensing for freestanding birth centers are among topics included in the momnibus. 

Michigan is one of nine states that doesn’t license or reimburse birthing centers, which could make the out-of-pocket costs lower and more accessible to women. Birthing centers are health care facilities specifically designed for childbirth. 

In October, state Rep. Laurie Pohutsky, D-Livonia, introduced legislation that would allow freestanding birthing centers to become licensed and expand access to these centers especially in rural areas. 

“There are better health outcomes particularly for Black birthing people in birth centers,” said Pohutsky. “We know that when somebody can go through a labor and delivery in a place where they feel safe, secure, supported, unjudged and listened to, they have a better outcome.”

Pohutsky told Bridge Michigan that she plans to reintroduce the bill after receiving input from midwives, doulas and other healthcare professionals. 

“There are also northern areas of Michigan … that also value birth centers just because of the limitation of access to healthcare in a lot of these areas,” she said. “Not only do I think that we have a real potential to move this bill this time, I also think it stands a good chance of being bipartisan.”