BOSTON — During her second pregnancy, Lorenza Holt, co-leader of the Massachusetts Doula Coalition, decided to go through childbirth at home with a midwife. When she realized she would have to unnecessarily advocate for her decision at a hospital, her conviction about the choice strengthened.

Soon after, she dedicated her life to working in the doula field and as a childbirth educator.

Doulas are trained, nonclinical professionals that provide education, guidance and support to birthing mothers. This occupation ranges in responsibilities from helping families create birth plans to providing moms with natural pain management through childbirth, and even past childbirth to aid families through the postpartum period.

The role is a distinct difference from midwives, who focus on providing medical care during pregnancy, birth, and the immediate postpartum period.

Holt, who was born in Mexico in 1957, comes from a family of women who had normal, physiological births.

“For all of us, it was part of daily life, and then you come into this country [U.S.] and it’s such a medical event — there’s so much fear, so much restriction, and so much intervention,” she said.

During her first pregnancy, Holt needed a caesarean section. By her second pregnancy, Holt recalled the barriers she faced in getting the birth experience she wanted.

“I wanted to be very intentional about choosing providers and choosing birth setting … to get the birth experience that I wanted. I had to work really hard [for it],” she said.

Eleven weeks before her due date for her second pregnancy, Holt’s doctor informed her during a prenatal appointment that she would need another C-section.

C-sections are effective in saving maternal and infant lives only when they are required, according to a study conducted by the World Health Organization. The same study suggests that the rate of C-section procedures and high mortality risk pregnancies are not linked. Instead, C-sections are now commonly recommended by hospitals and carried out 15% more often than in 1985.

Nevertheless, Holt decided she was going to have a home birth, an experience that allowed the presence of midwives, without any medical restrictions.

While Holt was able to have the experience that she wanted, advocacy for one’s desired childbirth remains restricted for many.

After her homebirth, Holt said she started talking to people in the Hispanic community, who shared with her their traumatic birth experiences.

Birth trauma is distress experienced by a mother during or after childbirth. While trauma can be physical, it is more often emotional and psychological. In fact, a research study showed that up to 45% of new mothers have reported birth trauma.

The risk of a traumatic experience is directly related to how mothers feel in the birthing process. When women are bounded by stress, the birth becomes more difficult.

In 1995, Holt became a doula and worked for the midwives that opened the Cambridge Birth Center under the Cambridge Health Alliance, the first doula program in Massachusetts.

“We created an 80-hour training curriculum that was really beautiful and comprehensive, we made a flyer and gave it to all the patients that the midwives were seeing,” she said.

The center ended up training 20 doulas, capable of providing services in eight languages. Despite the progress in the ’90s, there are still numerous barriers that continue to make doula services inaccessible to growing families in the commonwealth.

Barriers to doula accessibility

Stephanie Crawford, a community doula from Roxbury, said the lack of insurance coverage for doula services pose both a financial and an information obstacle for many families.

She noted that accessibility to information about natural childbirth is especially a challenge in underserved areas in Massachusetts. While the concept of midwives and doulas has been around for centuries, giving birth in a hospital setting has just become the norm.

“We lack a lot of the information that people have had for a long time … you assume that doulas are for people with money, you assume that doulas are not for Black people or people of color,” she said.

While education on natural childbirth is important, Crawford said the next challenge is finding a way to make these services affordable and accessible.

“When I had a doula, I was able to use my flex spending account,” Crawford said, explaining this allowed her to be reimbursed for her doula services. Crawford also noted that she knew her doula at the time, who didn’t require her to pay the full price.

As a doula herself, Crawford said she would suggest families get on a payment plan or even set up doula funds as gifts from family and friends for baby showers.

On top of affordability for families, Christina Gebel, founder of Accompany Doula Care, said the doula workforce often face challenges in their hospital relations.

When Gebel and five other co-founders set out to create an organization designed to integrate doula care into the health care system, they intended to build a sustainable model that would benefit the doula workforce, families who desired access to health care, and enable insurance coverage that would alleviate costs for the service.

She explained the barriers within doula workforce do not pertain to race and ethnicity, but that becoming a doula requires a certain amount of “privilege.” For example, one would need to have a flexible work and personal life balance.

“I think there just needs to be a lot more linguistic diversity among doulas, and my hope is that when we start covering doulas through Medicaid, and providing funding for people to become trained, that will significantly impact the diversity,” Gebel said.

Medicaid coverage for doulas

In 2022, eight states, as well as Washington D.C., implemented Medicaid coverage for doula care. As part of efforts to implement full spectrum pregnancy care, Massachusetts lawmakers are hopeful of enacting Medicaid coverage for doula services before the end of the year.

This progress is heralded in two bills presented by Rep. Lindsay Sabadosa, D-Northampton, and Sen. Liz Miranda, D-Boston. One measure would address Medicaid coverage for doula services, the other on insurance coverage.

“In the legislation this session, we’ve included a piece around workforce development, which we thought was really critical. We heard from the doulas that they wanted something that would help bolster the number of people who are trained… and to make sure that there was continuing education [for doulas],” Sabadosa said.

The Medicaid bill would allow low-income families to access doula services through MassHealth without paying out-of-pocket. It would also provide coverage for pregnant individuals and postpartum individuals for up to 12 months following the end of the pregnancy.

Mothers would be entitled to at least six doula visits across the prenatal and one-year postpartum period.

“That kind of extra care can help address some of the health inequities that we see, so making sure that MassHealth covers it so getting at a segment of the population that is lowest income in the state, and that experience at the highest level of health inequities would really change some pretty abysmal maternal mortality rates in the state,” Sabadosa said.

The Massachusetts Health Policy Commission currently provides funding to birthing hospitals and birth centers through the Birth Equity and Support through the Inclusion of Doula Expertise investment program. MassHealth will also be implementing coverage of perinatal doula services as part of its strategy to address maternal health disparities in 2023.

“My hope is that when we start covering doulas through Medicaid, and providing funding for people to become trained, that will significantly impact the diversity,” Gebel said.

Building hospital relations

While some hospitals in Massachusetts do offer doula programs for pregnant mothers, there is still a lack of consistency in hospitalized settings.

“There’s a large lack of understanding of what a doula is and what they do, and their scope of work,” Gebel said, adding education should extend to all providers such as obstetricians, nurses, and anesthesiologist residents.

“It has to be regular education or part of their initial medical training in their respective schools or professional societies,” Gebel added.

Gebel also noted that receptivity for doulas varies by hospitals.

“That was very apparent during COVID and how different hospitals counted doulas differently towards the maximum number of support people, and that’s really discouraging because it creates a lot of confusion and it’s very upsetting to clients,” she said.

Gebel added that sometimes it also comes down to who’s on staff in the hospital.

“We’ve had doulas in our own organization get treated one way, and then a staff change happens, and all of a sudden, that person’s OK with them coming in or going to the OR or staying in the room during an epidural,” she said.

Sarah Sheehan, a registered nurse currently in the process of becoming a certified doula, reflected her experience working as a labor and delivery nurse, and the perception doulas received from the hospital.

“It was really unfortunate the way I heard the nurse walked over to the nurse’s station and said, ‘Oh boy, here comes the birth plan and the doula,’” Sheehan said.

While this isn’t a generalization to how doulas were treated in all hospitals, she felt that it wasn’t positive.

Sheehan no longer works as a labor and delivery nurse, explaining that after witnessing the treatment pregnant women received, she believes there’s an even stronger need for doulas.

In spite of the need to build a relationship between doulas and hospitals, Gebel said there’s still some signs of “hope.”

Currently, both Gebel and Crawford are a part of Supportive Birth Collaborative at Beth Israel Deaconess Medical Center, an interdisciplinary group working on producing a doula policy for the hospital.

“My hope is that more hospitals will take that proactive stance because otherwise when we start populating the workforce, and more doulas are in hospital, it’s going to be a reactive situation,” Gebel said.

Sydney Ko writes for the Gazette from the Boston University Statehouse Program.]]>