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!!)

Lawmaker may propose cutting epidurals, C-sections from medicaid

A bit of a delayed response on this bit of news, but it's still worth sharing.  Lawmakers in Utah are considering a proposal to overhaul Medicaid, starting with cuts in the most interesting of places- epidurals and elective Cesareans.  The move would be an attempt to minimize the spending the state says it makes for out-of-state college students "freeloading" on Medicaid (because apparently Utah has an epidemic of pregnant college girls) since they might not technically be employed, yet still dependent on wealthy parents residing elsewhere.  However, despite there being examples of how the rates of these procedures go down when insurance refuses to pay the high price for them, the motivation of this particular move is troubling.  

I agree with the response this has incited that denying a woman an epidural she is desperate for based on her insurance provider is classist and totally misogynistic.  On the other hand, exclaiming epidurals an issue of choice just doesn't sit well with me.  I guess it's that old feminist line of thought that says we have the right to escape the pain of childbirth, as if the pain of birth was, in fact, meant to punish us for being women.  It's not going far enough for me.  The right to a healthy, normal, empowered birth is a feminist issue.  This argument to protect Medicaid-sponsored epi's reeks of the sentiment that lower class women aren't capable of a normal, non-intervened birth (which is suspiciously useful to the state- can you imagine if poor women everywhere started having supported, empowering births?  Watch out!)  I agree that women who are systematically denied education and resources contributes to the lack of informed consent, and therefor the cascade of interventions, which makes an epidural sound pretty nice.  But nobody here is talking about providing the women effected in this situation alternatives (such as implementing hospital midwifery programs, like this one, and this one).  They're just fighting to protect the epidural.

This is a classic case of a few bad apples spoiling the bunch, because sometimes an epidural can be a useful tool, not every college kid has wealthy parents, and the overwhelming majority of pregnant women on Medicaid are there for a damn good reason.  It's just disappointing for me to see that the biggest reaction to this has been so unimaginative and classically self-blaming.  We should really be taking this opportunity to talk about how to empower the women this would effect, to look at the evidence, and try to create something positive out of a poorly motivated, yet opportunistic, change.  The question here should be, "Do we need the epidural?"

Of unquantifiable value- radical doula services in a capitalist society.

I'm beginning the process of putting together a sort of childbirth education discussion group with my back up doula and a yoga teacher I'm friends with.  I really appreciate it when things just come together organically, as far as organizing things goes.  There have been so many times I've tried to put things together after sitting on it for a long time, only to find that the idea was so much better than actualizing it will ever be.  But this morning was refreshing.  No second guessing, no hang ups.  It's a really sweet thing to find an effective, efficient group of folks who are passionate about getting something done.    

It's making me consider my feelings about charging for my services, though.  As an anarchist, I am definitely cost-prohibited (in reality as much as in theory), not to mention that I think doula services are something that every mama has a right to.  I know that this is something that other radical doulas have struggled with.  What are the implications of applying the capitalist system to childbirth?  Beyond just the thought that health care is a right, but is it appropriate for me to adhere to a hierarchical cash exchange over something with unquantifiable value?  Does that make sense?  I just feel a little hypocritical sometimes with the thought of engaging my sisters in a system that is often oppressive to us (especially mothers).  My practical, mothering mind says, though, that this is what I've got to work with, and that my time and skills are valuable- I am an intelligent, gifted woman who wants to help others- and until we are set up in a different framework, I have to find someway to make my life sustainable now.  I just always feel like I have one foot in and one foot out with a lot of this stuff.

Oh, and to update, I got lazy with the emmenagogues.  I guess I just get to a point where I ultimately trust my body to do what it needs to do, instead of trying to control it or coerce it to doing something that's comforting or convenient.  That's what it's all about, anyway.