How doula care can save mothers' lives

At eight months pregnant with her first child, Amelia Flynn Hamilton was in pursuit of a positive birth experience — and key to that was her doula, Makeetah Cochy.

The two worked together in a yoga studio on a recent Wednesday, stretching and talking — all in the quest for a better childbearing outcome in the face of research showing Black women nationally have a maternal mortality rate nearly three times that of white women, and that many confront discrimination in seeking care.

“The best investment that you can make is taking care of yourself during this process, and a doula is a surefire way to do that,” Flynn Hamilton said.

Doulas, trained professionals who give physical, emotional and other support before, during and after the birth of a child, are increasingly being tapped to help curb the nation's maternal health crisis.

New York will expand doula services under Medicaid next year to cover all enrollees. And last week, Gov. Kathy Hochul signed legislation to create a doula database to help promote their services to people on the public health insurance program, according to the measure. 

“So we will right the wrongs of the past and ensure that every mom and baby gets first-rate care, support from doulas, a state that understands their challenges, and finally, eradicate this insidious form of racism which has plagued our state for far too long,” Hochul said before signing the legislation.

A state report looking at maternal mortality found that Black women in 2018 had a pregnancy-related mortality rate five times that of white women in New York. Among the leading causes of deaths were hemorrhages and embolisms. But the report, which was released in 2022, also said that discrimination was a “probable or definite circumstance” surrounding more than 45% of pregnancy-related deaths. 

Moreover, 30% of Black women who took part in a 2023 survey said they experienced mistreatment in maternity care, according to the Centers for Disease Control and Prevention. Among all women in the survey, around 45% said they held back from “asking questions or discussing concerns with their provider during maternity care.” Other common reasons included “worrying that their maternity care provider might think they were being difficult.”

Although they do not replace physicians, midwives and other medical providers, doulas take on many roles, from helping to develop birth plans and giving breastfeeding support to guiding breathing exercises, and possibly going into the operating room with a pregnant person.

Doulas can work with women to identify symptoms of mental health conditions, a factor in pregnancy-related deaths, researchers said. In labor and delivery, birthing doulas can support a pregnant person’s voice in the face of possibly unnecessary medical intervention, and ask clinicians to better explain medical terms.

"They're basically there to make sure that the patient's concerns are heard and that there’s respectful care for the patients when they are in the hospital, or anytime they are in the health care system," said Dr. Dawnette Lewis, director of maternal fetal medicine at North Shore University Hospital and director of Northwell's Center for Maternal Health.

Cochy, who is Black and works with pregnant people of all backgrounds, said: “I became a doula so that I can be a voice to those who are voiceless.” 

When it comes to her Black clients, she said many of them are looking for someone who understands their needs, without having to explain their concerns about childbirth.

“You don’t have to explain to me what your fears are,” she said. “You know, you don’t have to explain to me what you’re nervous about because I know. I know the statistics.”

Flynn Hamilton, 35, said having a doula and a midwife helped alleviate her concerns about racial disparities in maternal deaths.

"But most of the time when you are healthy, and taking care of yourself, and have the right supporting cast in your birthing experience, it really can be positive more times than not," the Jericho resident said.

Research has shown that having a doula can lower the risk of a Caesarean section. One study looking at roughly 230 "socially disadvantaged mothers" who were at risk of "adverse birth outcomes" found that those linked with doulas had improved outcomes. The mothers who had doulas — and their babies — were "two times less likely" to have a birth complication, the study in The Journal of Perinatal Education found. They were four times "less likely to have a low birth weight" baby, the study said.

"Communication with and encouragement from a doula throughout the pregnancy may have increased the mother’s self-efficacy regarding her ability to impact her own pregnancy outcomes," the study noted.

While doulas have gained more traction over the years, a survey of 2,400 mothers who gave birth from mid-2011 to mid-2012 found that 6% of women received “supportive care from a doula” during labor, according to research in The Journal of Perinatal Education. It is unclear exactly how many doulas are currently working on Long Island.

Doulas can be costly

Securing support from a doula can be expensive, keeping the option out of reach for some who might benefit from the service. But there are efforts to change that.

Medicaid covered nearly 46% of all births in New York State in 2020, the March of Dimes reported. Now, with the state expanding Medicaid's doula coverage early next year to a statewide benefit, more pregnant people can access this care option.

In 2019, the state started a pilot program that offered people on Medicaid in Erie County — which is home to Buffalo — reimbursement for doulas. More than 90% of people who responded to a survey about their experience with the pilot program said "having a doula improved or somewhat improved their childbirth experience," the state Department of Health said in July.

However, a Kings County portion of the pilot program wasn't launched because not enough doulas signed up due to low reimbursement rates, the department told Newsday.

The state is holding virtual stakeholder meetings for doulas, with the next one scheduled for Thursday. As part of the proposed doula cost structure, eight prenatal or postpartum support visits at a minimum of 30 minutes could be reimbursed, totaling $750 in New York City and $675 outside the five boroughs. Additionally, the proposed structure would cover one encounter during labor and delivery.

And recently, Walmart, one of the largest employers in the country, said in a statement it would expand doula benefits to associates after it initiated a pilot program in Georgia, Louisiana, Indiana and Illinois.

Cochy, also a council member at the Long Island Doula Association, suggested that people who want a doula ask about financing options, such as a payment plan or a sliding scale.

Racial disparities persist

Though many see doulas as important in building knowledge and support on behalf of their clients, some experts and advocates point out that their efforts should be paired with implicit bias training for doctors, more significant usage of midwives and other interventions to see more gains in maternal health.

From 1999 to 2019, maternal deaths in the nation more than doubled, according to a study published in the Journal of the American Medical Association, which used estimates of maternal deaths per 100,000 live births for racial, ethnic and statewide breakdowns. Black people had the highest state median mortality rates per 100,000 live births, while American Indian and Alaska Native populations had the biggest increase in that measurement during those two decades.

According to the state Health Department, the mortality rate per 100,000 live births between 2016 and 2020 was 65.2 for Black people. The rate for white people, the next-highest group, was 14.5.

Still, researchers have said that maternal mortality is the "tip of the iceberg," with the larger portion of the "iceberg" being maternal morbidity. The CDC defines severe maternal morbidity as "unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health."

And there, too, disparities persist, state data shows. The rate of severe maternal morbidity for Black people was 153.1 per 10,000 delivery hospitalizations in 2019. For white people, that rate was 71.3, according to the state health department.

Martine Hackett, chair of Hofstra University's Department of Population Health and co-founder of the Birth Justice Warriors of Long Island, which fights for healthier pregnancies and babies, argues the disparities embody how Black women are more likely to experience barriers to equal, quality care. 

"The negative treatment transcends … you know, sort of the ability to have a higher education level or to have better health insurance," Hackett said. "And, that really is what we're talking about … a lot of interpersonal interactions that … have been influenced by society for a very long time."

A different approach

Anha Red Fox, a doula who specializes in caring for Shinnecock and other Indigenous people, said the pain and trauma of her first delivery inspired her to pursue the work.

Right after giving birth as a young mother in a hospital, Red Fox said she hemorrhaged and later had a bout of depression. Looking back, she said, some doctors acted like they knew her body better than she did.

Two years ago, when Red Fox had her second child, she took a different approach. She had the baby on her grandmother's land in the Shinnecock territory, in a birthing lodge built by her partner and his best friend. A doula and midwife were in attendance.

"And with my second birth, I was able to just really heal and learn so much and be able to offer that kind of experience to other people as well," said Red Fox, now  27.

Thaishah Riche, a doula of Afro-Caribbean descent who lives in Baldwin and has many clients of color, said many Black women come into the birthing experience with well-founded anxiety because of the maternal mortality rates.

They are concerned, she said, about not having advocates, not “knowing their rights” and feeling like they don’t have any say about having a positive birthing experience.

She works with these women on exercises such as breathing techniques and another where they are tasked to read their responses to questions such as: “What is it that you desire?"

“What do you have?” she says the exercise asks. 

And by the time of the birth, she said, they have reclaimed their power, and “I understand what’s their top priority.”

For Cochy, her work as a doula goes back to the mother of four's experience of being overwhelmed after the birth of her eldest son, now 24.

Later, for the birth of her eldest daughter, 10, she said that a doctor placed stitches in her with no numbing solution. "I still hold on to that because it should have never gone that way," Cochy recalled.

Cochy draws on those times to help clients have better births. That work can take many forms, from validating the parents' experiences to being a shoulder to lean on or giving a tight hug, even counseling one woman to see a physician because of unhealthy swelling.

She often asks clients what they would like their birthing experiences to look like; they answer but also say: "I want to make it out of the hospital. I want to go home, and I want to raise my child."

By Tiffany Cusaac-Smith

tiffany.cusaac-smith@newsday.com@T_Cusaac

Education: Howard University 

Tiffany Cusaac-Smith came to Newsday in 2023 after being a race and history reporter at USA TODAY, where she wrote enterprise and spot articles examining how the past shapes the present. Previously, she worked as the race and justice reporter at the USA TODAY Network of New York, covering issues such as criminal justice reform, housing, environmental justice, health care and politics. At The Journal News/lohud.com in Westchester County, she covered Yonkers, the state's third-largest city. She also worked at The Associated Press in Atlanta.

Honors and Awards: Criminal justice reporting fellowship with the National Press Foundation;  New York News Publishers Association award for distinguished investigative reporting;  Contributed reporting for Best of Gannett honor; Member of Table Stakes, a program funded by the Knight-Lenfest Local News Transformation Fund and managed by the American Press Institute to transform local news.