Thursday, August 9, 2012

Disparities in the Doula Model of Care

After the Community Health Worker training that ended today, I'm faced with the reality of how many gaps there are in not just health care, but doula care.  Health disparities are everywhere, and there are amazing organizations and agencies out there gathering funding to provide free preventative health care to the under- and uninsured.  When it comes to doula care, however, access is limited to those who can pay out-of-pocket.  Painfully ironic is the fact that those who can afford it are in need of it the least.  

That's not to say that the privileged pregnancies that are on the receiving end of a doula do not deserve it.  But populations, particularly teens and women of color, who see the most health disparity and the worst maternal and infant health outcomes, are the most underserved by doulas.  How do we, as doulas, approach this?  Many of us offer our services for much less than what we should be making even for our full-paying clients.  If we have a particular interest in working to solve health disparities and applying social justice to our work, we work for next to nothing.  I've done many births where, in the end, I was getting paid a shocking hourly wage for expert advise, 24 hour on-call availability for weeks on end, and physically strenuous overnight hours- much less than minimum wage in the end.  This is not rare.  Ask the doula next to you if this is the case and you will likely get an emphatic "YES".  

What is the root of this?  My belief is that it stems from doula care existing in a for-profit model (as much of health care is, but that's another blog post).  That doulas have settled on charging their clients directly undercuts the potential of doula care- applying the benefits of doula care on populations that see the worst outcomes in order to make the most amount of change.  Taking a new approach is critical in improving outcomes.  But it will require doulas rejecting the for-profit model that so much of us have accepted.  We need to explore new options in receiving funding for our work, to generate public and private interest in doula care from stakeholders in maternal and infant health, and to work together, and not in competition like so much of the for-profit model encourages, to make our work sustainable for not only our clients but ourselves.

We know the benefits of our work.  It's time for doulas to get out of our comfort zones, advocate for those benefits, and start creating change.  We are at the forefront of improving outcomes with our unique advantage to spend time educating and empowering patients.  A public health approach to doula care is desperately needed if we actually want to see our work make a difference.

(If you know of a fabulous community doula project, or have seen doulas used by public health agencies, please leave some information in the comments!!)


Wendy said...

Thought-provoking post, Stephanie! Open Arms Perinatal Services in Seattle is a non-profit and doing amazing work:

hanna russo said...

I live in Michigan, and how i got my doula training was through a program called doulas care. Where they paid for most of my training, but i now volunteer for them for 5 free births. They then offer all the doulas who go through this programs services to low income women! There is also a local group called doula connection, that offers a list of doulas who provide free services to women who need them. AND

Miss Q said...

I agree with your post from the bottom of my heart!! I started a facebook page called Volunteer Doulas Network, and we try to connect moms with doulas that are doing volunteer work, some of them are the ones that are working for their certification, and some are, like myself, the ones that just have a hard time seeing a mom not having a doula because they can't pay for it. For me, they have become the best advertisement too, and many of them want to become a doula, to give back what they received. I think that I might never be rich, but I am happy knowing I am making a difference, one mommy at the time
Please visit and like our page

ebruno said...

I volunteer at a local hospital that pairs moms in need with doulas in the community. I work those moms into my normal schedule and generally do 2-4 volunteer births every year. Depending on the year, there are often a few other doulas volunteering with me. We are currently working on making an "on call" portion of the program for women that come in to have their babies and need some extra support (right now, we're working with the mothers one-on-one starting a couple months before their due dates).

It should come as no surprise that even though this hospital is a teaching hospital and serving our cities most underserved populations, they have the lowest rates for episiotomies, c-sections, and the highest breastfeeding rates.

Unknown said...

I feel the same way about homebirth- it is very elitist. The nonprofitbirth center is a good model for extending midwifery care to all women and could easily incorporate a doula program.

Vicky, CNM homebirth midwife

Christy said...

Please check out the work of HealthConnect One in Chicago ( They have been pioneers for 25 years in replicating their Community-Based Doula Program and I am a doula working with an organization in Nicaragua working on building a Community-Based Doula Program to complement the work of trained community health promoters in remote, rural communities with some guidance and support from HealthConnect One. There is some exciting stuff going on out there but we are not all connected. Thanks so much for your post. It really resonates with me and many issues that I am struggling deeply with as a doula. Let's keep up the conversation!

Judy said...

My doula training was with Boston Medical Center's Birth Sisters program ( The program aims to offer trained labor support by women from the mom's own community. So they recruit AND PAY primarily African American and immigrant women to work as Birth Sisters.

I'm a white woman who speaks fluent Spanish, so I wasn't a peer. I struggled a lot with my own internalized privilege, and to become more vigilant for internalized racism that the women I supported had learned, manifesting in ways they looked up to me as a formally educated white woman and up to American culture and hospital birth. This wasn't in the curriculum for those of us who weren't peers when I was a Birth Sister. Is it in your programs?

The program uses the name Birth Sisters, by the way, because doula comes from the ancient Greek word for female handservant, and the African-American women who founded the program felt it had enough connotations of slavery that it was inappropriate. We need to talk about that more.

I believe women who can't afford to pay for prental, labor, and postpartum support deserve an experienced birth worker. Yes, we need to get our experience somehow, but let's be aware of the power dynamic when we offer our services for free to get practice. Let's not stop offering when we have our experience.

Birth Sisters is paid for by the hospital, largely through breast feeding grants and I think some funds from March of Dimes intended to improve birth outcomes. It's starving for funds, and has had to cut back the number of births it's been able to support. Some of the Birth Sisters have no longer been able to keep their schedule open to be on call for the decreasing number of births and have had to leave for other jobs. If public insurance paid for Birth Sisters, we wouldn't be in this boat.

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