Editor’s note: For this piece we chose to use the gender neutral term “pregnant people,” unless we are quoting or paraphrasing information from research. This story first appeared on palabra, the digital news site by the National Association of Hispanic Journalists.

By Yesica Balderrama

In a South Bronx apartment a few blocks away from the New York Botanical Garden, Estee Mills, a Black immigrant from St. Kitts, lives with her two children and husband. Inside the warmly-lit home, a TV blares the evening news as Mills soaks her feet in a tub of water while her bundled three-week-old baby sits by her side in a car seat. Mills, a clerical associate for the city’s Human Resources Administration, is on maternity leave, and her doula (a person that provides guidance and support before, during, and after childbirth), Jasmin Fortunato, is here for a postpartum visit to check in on the progress of her client’s recovery. “It’s good to have mobility,” Fortunato says, “but you’re not straining yourself, right?”

Mills searched online for doulas and spoke to three before ultimately choosing. Afro-Dominican Fortunato is a contractor for New York’s groundbreaking Citywide Doula Initiative program, which pays for doula services for low-income people. The city program, which was signed into law last September, has stirred hope that doula services could become more accessible to pregnant people of color beyond New York. There is also a nationwide movement at work in other states to cover doula services through Medicaid.

An essential part of making doula services accessible to marginalized communities are increased affordable or free education opportunities for people who want to become doulas. In a major health policy shift, in addition to funding doula care for low-income families, the Citywide Doula Initiative has made birth work education more accessible for people of color by funding trainings at community organizations for those who may not be able to afford doula training fees and materials. The city has so far hired about 200 doulas, the majority of whom are Black and Brown, according to Mary-Powel Thomas, director of the Citywide Doula Initiative and Healthy Start Brooklyn.

Advocates and experts hope that doula training will become more affordable beyond New York City soon, not only benefiting Black, Indigenous, and other patients of color, but practitioners themselves.

Financial barriers are a major factor in the lack of access to doula education for aspiring birth workers, as a doula course in New York City not funded by the Citywide Doula Initiative ranges from $1,000 to $1,500 or more. Fortunato used her savings from previous jobs to start her career as a part-time doula. Otherwise, she wouldn’t have had the financial backing to start her own business.

Fortunato’s work exemplifies the importance of educational opportunities for doulas of color. Her care of her clients is informed by the history of birthing and structural racism in her field, which she learned about while training at a Black-owned doula education program. “The reason why it’s important to have Black and Latino doulas in the workspace, is to be able to provide care for Black and Brown mothers birthing in a system that wasn’t really created for them,” says Fortunato.

“Doula services have traditionally been available to people who can afford to pay,” says Thomas. Those have mostly been,”middle class families that can pay out of pocket” for private doulas charging $800 to upwards of $2,000, depending on the client’s needs.

Fortunato works full time as a hotel sales coordinator and as a full-spectrum doula on nights, weekends, and whenever her clients need her (If a client goes into labor while Fortunato is at her day job, she either leaves work to assist or has a backup doula work with the client until she can leave work.). Fortunato is currently supporting Mills through her recovery after a traumatic C-section. “I expected them to be more understanding and more patient,” Mills says of the hospital staff. “So many different things were forced on me.”

According to a Journal of Perinatal Education study, access to doulas not only ensures the safety and wellbeing of the parent and child, but mothers who had doula care reported greater levels of satisfaction with the birthing process. Pregnant people like Mills need the extra support doulas provide, as research shows they are at increased risk due to health disparities caused by socioeconomic inequality and structural racism. Black, non-Latina mothers in the United States are eight times more likely to die from pregnancy-related causes than their white, non-Latina counterparts, and their babies are 3.3 times more likely to die before birth. In contrast, doula support prevents birthing complications such as preterm births and reduces the chances of C-sections, both of which are leading causes of maternal mortality.

In the study, Latinas and their babies had similar outcomes as white mothers and babies, “despite experiencing increased access barriers and social and economic challenges typically associated with poorer health outcomes.” This finding is called the ‘Latino health paradox,’ the authors noted, with Latinos in general often having similar or better health outcomes to whites– although some Latinos have worse health outcomes, especially those from marginalized origins, birth countries, and races.

The next generation of doulas of color

An important aspect of accessibility is increasing diversity in the field of birth workers.

Although people of color have long helped their community members during birth, it was a white American anthropologist who coined the name ‘doula’ to refer to this work. (The origin of the word itself can be controversial with BIPOC doulas, as it comes from the Greek word for a female slave.) After a group of white women and white male physicians founded Doulas of North America–now called DONA International–in 1992, doula work became more recognized and more institutionalized as DONA became the world’s largest doula certification organization.

Not only has training and certification often been financially out of reach of many doulas of color, but BIPOC doulas have also experienced “cultural insensitivity, disregard for (their) concerns, and even overt racism” within DONA and its training programs, according to a September 2020 DONA community open letter. (Current DONA president Hillary Melchiors told palabra that the organization’s diversity and inclusion efforts include increasing BIPOC representation on the board of directors and as-yet-unannounced initiatives to be unveiled later this year.) Others have complained that, as a culturally white organization, DONA isn’t culturally competent nor focused on the needs of the communities they serve.

Nikia Lawson, a past DONA president and International Doula of Color Trainer Fellow, says that remote courses expanded educational opportunities for birth workers in areas where the organization did not offer in-person classes. “Now we are in different parts of the world we didn’t have access to before.”

Since 2019, DONA has offered the Improving Maternal Health Practices & Advocacy through Certification & Training full scholarship to 20 doulas per year, with persons of color who want to work with their communities prioritized. (DONA-approved training normally costs from $700 to $1100 for certification.) The scholarship “has been a game changer,” Lawson says. “So many people need this opportunity, and desire to be trained. Many just don’t have the resources.”

Some community organizations have moved to accept more doula training programs focusing on social justice and health equity, rather than just DONA training.

In New York City, Ancient Song Doula Services trains doulas of color and is one of eight doula organizations comprising the Citywide Doula Initiative.

In 2008, self-taught Black doula Chanel Porchia-Albert created Ancient Song, which offers a work-study program and full scholarships to make their classes accessible to low-income students, as well as high-quality doula care for Black and Latinx clients regardless of their income.

The mission of providing care for people of color at Ancient Song piqued Fortunato’s interest. Fortunato trained there in 2021, where she learned to support clients physically and emotionally during all stages of pregnancy, including after an abortion or a pregnancy loss.

“The most important skill is listening–it’s showing empathy. It’s important to meet people where they are, not where we want them to be,” says Anabel Rivera, a bilingual perinatal coordinator at Ancient Song.

Some organizations in New York are also striving to meet doula trainees where they are at through virtual platforms. MaternityWise International offers an international online certificate.

On a Saturday in March, Anne Wallen, director and cofounder of the organization, led a two-hour in-person and virtual workshop in the noisy heart of Williamsburg with a diverse group of doulas and students.

“The reason that we really want to make sure that women of color are in our training is because the mortality rate among women of color is a lot higher than for white women,” says Wallen.”It’s more beneficial for someone of their community to be supporting women in labor, to have Latino women, to have Black women in a training like this doesn’t just really impact future clients, but it can really impact the entire community.”

Bilingual doulas are urgently needed, says Dr. Sheela Maru, Assistant Professor of Global Health and Obstetrics, Gynecology and Reproductive Science at New York’s Icahn School of Medicine at Mount Sinai and head of the Helping Promote Birth Equity through Community-Based Doula Care (HoPE) program. Maru says that patients who aren’t fluent in English may have trouble articulating concerns or communicating with their medical provider, so HoPE trained 25 doulas in concert with Ancient Song and Caribbean Women’s Health. Half speak Spanish, while the rest speak a variety of languages including Haitian Creole, Mandarin, Hindi, and Bengali.

Movement for Medicaid to increase access

The legislation for the Citywide Doula Initiative is part of a growing national trend of states adding doula care education and certification requirements, as well as coverage for recipients, to Medicaid programs. Doulas are typically not covered by Medicaid or health insurance, a barrier that limits access for low-income communities and pregnant people of color.

The latest states to include doula services as part of Medicaid are California and Michigan. Eight other states including Virginia, Oregon, Nevada, and New Jersey, plus the District of Columbia, provide state-covered doula care services.

Raising Medicaid rates would remove significant financial barriers for birth workers of color to join the industry.

Low reimbursement rates make it difficult for doulas of color to make a living. One of the lowest amounts reimbursed is in Nevada, where a doula is paid only $150 per delivery by Medicaid–compared to $900 in Rhode Island. Because of that, very few doulas enrolled to be Medicaid providers in that state. In February, Nevada raised the total reimbursement amount to pregnancy to $450 per client, but advocates are still lobbying for an increase to $1500, to be on par with rates in Rhode Island and Washington DC, which reimburse doulas $1,500 and $1,950 per client for the full scope of care, respectively.

Legislation for doula reimbursements opens the possibilities for birth workers to earn fair wages and make a full-time living from their work. Despite the challenges in earning a full-time living wage as a doula, both Thomas and Lawson have noticed growing interest in the profession. They attribute it to the increasing availability of doula education programs as well as research on maternal and infant mortality.

The job can be physically and emotionally consuming. Many doulas do other work, such as lactation consultation or yoga instruction, to financially support themselves, as their monthly doula earnings are based on how many clients they take and how much they charge per birth.

Parents are also increasingly aware of the benefits of having a doula. They are concerned, more than ever, about maternal care rights and inequities that increase their likelihood of unsafe births, especially after the overturning of Roe v. Wade last year highlighted gaps in reproductive rights.

Pregnant people of color continue to look for options to keep themselves and their babies safe. “There’s a lot of interest in doulas these days in general. There’s been a lot in the press about maternal mortality. People are scared. We’ve asked people, ‘Why do you want a doula?’ And they say, ‘I don’t want to die,’” says Thomas. “It’s a real, visceral, deep-seated need.”

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Yesica Balderrama is a Mexican journalist and writer. Her work has appeared on WNYC’s The Brian Lehrer Show, Latino USA, NPR, iPondr, Prism Reports, Guernica, and others.

Mariela Murdocco, a bilingual multimedia journalist and photographer, has been nominated for five Emmy Awards. Born in Uruguay and based in New York City, she began her two careers simultaneously in 2002. She has worked as a reporter, TV producer, anchor, photographer and videographer for Consumer Reports, Telemundo, News 12, The New York Daily News, Banda Oriental, The Jersey Journal, and The Associated Press. She was a TV correspondent for Canal 7 in Uruguay and has contributed to The Guardian, The Huffington Post, Hola TV and Fox News. In 2012, she was elected national Spanish at-large officer for the National Association of Hispanic Journalists.

Lygia Navarro is an award-winning disabled journalist working in narrative audio and print. She has reported from across Latin America, as well as on Latine stories in the United States and Europe. Lygia has reported for The American Prospect, Business Insider, Marketplace, The World, Latino USA, the Virginia Quarterly Review, the Christian Science Monitor, The Associated Press, and Afar, among other outlets. She has also worked as a podcast producer, and her work has been supported by many grants and fellowships, including most recently the Journalism & Women Symposium.