By Elizabeth Thompson
When Kira Kimble goes to the hospital to assist a client giving birth, she is charged with everything from keeping her pregnant client informed about the choices they have — whether they want to get an epidural, have a natural birth — to making sure her clients are simply being addressed by their names.
Kimble said her clients report microaggressions as common for pregnant people of color throughout their nine months. This makes something as small as being addressed by your name a big deal.
“A lot of times if the names are too complicated, or have too many vowels, or accent marks, there’s not even an attempt to pronounce their name,” Kimble said. “And so we really make sure that we are protecting them from those microaggressions.”
Kimble is the owner and a certified doula at Charlotte-based Mine-R-T Doula Company (pronounced like “minority”). Her team of doulas of color offers services specifically tailored for all kinds of clients, such as plus-size birth, or vaginal birth after a cesarean section, Kimble said.
American Indian, Alaska Native and Black mothers are two to three times as likely to die from pregnancy-related causes as white pregnant people, according to the Centers for Disease Control and Prevention.
“If you have the money, you have the ethnic background, you get one form of treatment,” Kimble said. “If you don’t have the money and you have a different ethnic background, you get a substandard of care, and it shouldn’t be that way.”
Doulas have been found to reduce the incidence of births via cesarean section, the rate of birth complications and medical interventions during the birthing process, and one study showed that doula services also increase breastfeeding rates.
Low-income pregnant people and people of color stand to benefit the most from doula services, but it can be difficult for them to access them. Doulas across North Carolina offer a variety of services at a variety of costs, from pro bono to thousands of dollars.
What do doulas do?
Doulas are typically nonmedical, trained professionals who provide “physical, emotional and informational support” to pregnant people before, during and after birth, according to Doulas of North America (DONA) International, a doula certifying agency.
For Kimble, that means assisting clients with choosing a provider who they feel comfortable with, having talks about exercise and nutrition while clients are pregnant and making sure her clients get the birth that they want and they will be satisfied with.
Kimble also works to make sure that her clients are aware of all their choices for treatment.
Sometimes doctors may put a Black pregnant person on a high blood pressure medication based on statistics about Black pregnant people, regardless of whether that particular patient has high blood pressure, she said.
Regardless of education and socioeconomic status, Black pregnant people have worse pregnancy outcomes than their white counterparts. A Black pregnant person with a college education still has a pregnancy-related mortality ratio five times higher than white pregnant people, according to the CDC.
The University of North Carolina at Chapel Hill recently launched a program to increase the number of Black doulas in the state to address maternal mortality rates that disproportionately affect Black women, North Carolina Health News reported.
“We really make sure that they are asking questions and making sure that they are understanding that,” Kimble said. “Because if it’s your first child, you don’t know that not everybody goes through this. And so we make sure that they are knowing what questions to ask.”
Postpartum, she keeps a watchful eye on her clients — and she knows how to spot things that could have been missed.
“Especially during this time, when they’re short on beds, they’re short-staffed and are really turning people out really quickly, we are spotting mistakes,” Kimble said. “We are alerting our clients that ‘Hey, what you’re experiencing isn’t normal. You need to go to the emergency room or you need to call your provider.’”
Sybil Pye, a postpartum doula at Durham-based Emerald Doulas, says it sometimes surprises people that her first priority is the health and wellness of the birthing parent.
“A lot of people think that we’re glorified nannies,” Pye said. “I make this very clear when I meet with clients to sort of delineate the difference between doulas and babysitters, doulas and nannies, doulas and housekeepers.”
Pye used to be a nurse, and while her medical knowledge can be useful, doulas are non-medical professionals.
That doesn’t mean that her work isn’t intertwined with her clients’ health. Pye has been able to identify red flags in clients exhibiting signs of postpartum depression. Those red flags can manifest in many different ways, she said from sleeping too much to not sleeping at all, having no interest in their baby, or not letting anyone near their baby — “anything that is extreme.”
The COVID-19 pandemic certainly didn’t help, Pye said.
COVID and doula services
Going into a hospital can already be daunting, especially for people of color, Kimble said. The COVID-19 pandemic only increased fear.
“There’s already knowledge of increased numbers and increased likelihood of dying during childbirth or having serious complications during pregnancy and following pregnancy,” Kimble said. “When you throw COVID on top of it, it made that [fear] even higher.”
At the height of COVID-19 restrictions, many hospitals only allowed pregnant people to bring in one person to the delivery room, which meant many patients had to choose between their partner and their doula.
Some doulas FaceTimed into delivery, Pye said. Other birthing people who were depending on a doula to make them feel safe and protected in the delivery room looked for other hospitals where they could bring their doula, Kimble said.
Many people in the Research Triangle area don’t have family to be with them during their pregnancy, since there are many young professionals and university students who recently moved here, Pye said.
“A lot of people are not from here,” Pye said. “They don’t have family. And so they much prefer having one safe, trained professional person as opposed to grandma, grandpa, auntie and uncle coming on planes, trains and automobiles.”
That’s where a doula can come in and offer the guidance and support people need during and after pregnancy.
Affording a doula
As beneficial as doula services can be, they can also be expensive. In order to afford doulas services, some clients have to get creative, Kimble said.
“I’ve heard of people selling their car,” Kimble said. “People sell stuff, they would GoFundMe their baby registry instead of gifts … They find a way and that’s what mothers do.”
Other pregnant people fund their doula services with gift certificates, Pye said, or they ask grandparents or other relatives to fund their doula support. Some doulas also volunteer their time to clients.
There has been a growing investment in doula services, as some states such as Oregon and Minnesota changed their Medicaid regulations to include doulas. In North Carolina, doula services are not covered by Medicaid, but some legislators filed a bill that would explore doula coverage and doula Medicaid, but it went nowhere once it was introduced. The legislature did, however, include a one-year Medicaid extension for new mothers in the state budget.
Including doula services in Medicaid could be helpful for lower-income pregnant people who might not be able to afford it, said health policy analyst Alexis Robles-Fradet at the National Health Law Program.
The National Health Law Program aims to improve health outcomes for pregnant people on Medicaid by expanding access to doula care in its Doula Medicaid Project.
Attaching doula care to insurance could be a double-edged sword, Kimble said.
“Sometimes insurance will tell you which doulas you can use,” Kimble said. “It defines what a doula can and can’t do because if they’re the ones paying, they get to set the parameters. It also ties our hands because when the patient is paying for us, they get to determine what they need, what they don’t need and what their care is going to look like.”
Including doula services in Medicaid shouldn’t be exclusionary to one kind of certification or type of doula, Robles-Fradet said. Doulas’ voices should be included in crafting any kind of legislation, she said.
“Just making sure that in every process, especially when you’re building a bill, trying to pass it in the legislature, that doulas are engaged in your process,” Robles-Fradet said. “They give feedback otherwise it’s probably going to be difficult to implement.”