Could Doulas Help to Reduce Racial Disparities in NJ’s Maternity Care?

Recalling their own experiences, lawmakers get personal, underlining the significant differences in how women of different racial backgrounds can experience childbirth in New Jersey

Credit: Wendy Kenin/flickr
Doula Jen Miriam Altman supports a woman in labor, Oakland, Calif.
The issue was birth, the backdrop was race, and the testimony quickly got personal for Assembly committee members who held a joint meeting Thursday to learn from perinatal providers about racial disparities in New Jersey’s system of maternity care — and the role doulas, in particular, can play in improving outcomes.

Assemblywoman Nancy Munoz, a white woman from Summit who represents wealthy communities in Union County and is a nurse, recalled how all five of her children arrived by vaginal birth, as she had carefully planned.

But Assemblywoman Shanique Speight, a black woman from Newark who works in the Essex County Sherriff’s Office, endured four cesarean sections to deliver her babies, including one in which a lack of anesthesia allowed her to feel the doctors cut into her belly, and after which she suffered significant blood loss.

Assemblywoman Shanique Speight (D-Essex)
“That was not something I should have had to experience,” Speight said, recalling how she never felt she had a choice, or a voice, in the process. “I had healthy pregnancies. I just had big babies — nothing more than that.”

The experience of the two lawmakers (Munoz a Republican, Speight a Democrat) reflects what experts said is a vast difference in how women of different racial backgrounds experience birth in New Jersey, a gulf that results in dramatically worse outcomes for families of color.

Far more black infants born underweight

Statistics show that black infants in New Jersey are nearly 50 percent more likely to be born underweight than white infants and more than three times more likely to die before their first birthday; the disparity is even worse for mothers, with black women facing a maternal mortality rate nearly four times that of white moms.

To better understand these disparities — and determine how to improve on the status quo — the New Jersey Assembly Woman and Children and Human Services committees joined forces Thursday to take testimony from doctors, nurses and policy experts involved in maternity care in New Jersey. The hearing also focused on the critical work of doulas — nonclinical birth coaches who are playing a growing role in perinatal care — and the importance of reducing the use of C-sections and other medical interventions.

Speakers discussed the need for more public conversations concerning perinatal care in general; greater coordination among local programs, county resources and clinical providers; and more funding — including insurance reimbursements — for key services, like doula care, which currently is rarely covered. A bill requiring Medicaid to cover doula services (S-1784), sponsored by Sens. Loretta Weinberg (D-Bergen) and Nia Gill (D-Essex), is scheduled for a hearing today in the Senate Budget and Appropriations Committee, something that several who spoke at Thursday’s hearing supported.

Jill Wodnick, a doula and community educator at Montclair State University, explained that doulas play a role similar to patient navigators, who are paid to help individuals connect with services, but in ways that often are more personal. Like midwives, they are there to assist with the full spectrum of the pre-partum, birthing and post-partum experience, but they do not have the same clinical training.

They can help pregnant women with breathing and stretching exercises, but also ensure they have a bag packed and a ride to the hospital when the time comes; coach them through the birthing process and adjust lights, pillows and other amenities to ease the ordeal; and make sure new mothers identify and report any potentially dangerous symptoms, and get to well-baby checkups as needed.

Doulas also work with fathers

Jill Wodnick
Doulas also work with fathers and other family members, Wodnick said, and they need to represent the cultural and linguistic diversity of families in this state. For this reason, it is particularly important for New Jersey to expand doula services within communities of color, she said. “It may be hard for the birthing mom to talk about where (on her body) she is feeling pain, perhaps,” Wodnick added, and a doula can help tease out this information that clinicians can use to diagnose any complications.

The issue is clearly on the radar of state officials. First Lady Tammy Murphy has launched a series of Family Festivals to help connect residents with services in communities with the highest rates of infant mortality. The first event, in Paterson, drew 300 people and a second gathering was to be held Saturday in Trenton.

Health Commissioner Dr. Shereef Elnahal has made reducing racial disparities in maternal/infant health — and other areas — a priority for his department. This summer, the state announced it would invest $4.7 million to expand intake processes and aid other programs at regional organizations supporting healthy births; of this, $450,000 was devoted specifically to training and funding doula work with at-risk women in Atlantic City, Camden, Newark and Trenton. About 40 doulas have been trained through this program so far, the DOH said.

The benefits of doula care are many and profound, advocates for the practice said. Helene Lynch, director of operations at the Southern New Jersey Perinatal Cooperative, said involving doulas leads to shorter labor, fewer C-sections and other medical interventions, including medications, less stress in general, and better breastfeeding outcomes. “And a more satisfied experience with labor, for sure,” she added.

The word “doula” comes from a Greek term for servant, explained doula and mother of six Ronsha Dickerson — and the goal is to serve the birthing mother and their family. Dickerson has worked with the southern perinatal cooperative to train two dozen community-based doulas to serve women in Atlantic City and Camden.

The hazards of C-sections

“We want ‘doula’ to become a word that is as significant as ‘pacifier’” when discussing birth and children, she said. “And women of color need to see themselves in these spaces.”

For some women, a friend or family member plays this critical role. Assemblywoman Angela McKnight (D-Hudson), realized that she had acted as a doula for her twin sister, 16 years ago. For Assemblywoman Annette Chaparro (also D-Hudson), it was her doctor, Dr. Andrew Rubenstein, who was there to talk about the dangerous “downstream effects” — like cardiac arrest and blood loss — that can accompany C-sections and how hospitals are working to address these issues.

“You were my doula and I didn’t even know it,” Chaparro said, referring to Dr. Rubenstein. “You made me feel so loved. You educated me, you held my hand,” she added. “I never said thank you, but I’ve always thought of you.”

Doula who were newly certified in November, 2018 are expected to help drive down the state's maternal mortality rate.
But much more is needed to be done to ensure that all women have this kind of support, whether from doulas or doctors, those at the hearing agreed. Wodnick urged lawmakers to look at other successful programs, including a California model that has focused on the experiences, positive and negative, of women who have given birth. She said there needs to be more discussion in New Jersey about maternal-infant care so that policies are women-centric and culturally sensitive. Wodnick also suggested the state should tap county colleges to help expand training, scale up local and regional collaborations, and find ways to better engage clinical providers in these initiatives.

Insurance coverage for doula services is also a critical component in expanding the practice, experts told the panel. Debra Pascali-Bonaro, an international childbirth educator and doula trainer — who said she might have been the first to offer doula services in New Jersey, in 1984 — said no insurance carriers currently cover this care, although some self-insured companies are exploring this option. She has been reimbursed on occasion, but only through a complicated, time-consuming appeal process, and never for more than $500, she said.

“This needs to be universal,” Pascali-Bonaro said, noting that by paying for lower-cost doula services, insurance companies can save money on more expensive treatment, like C-sections and other medical interventions. “Respectful care is medicine,” she added. “When women don’t feel respected, honored or get the dignity they deserve, they do not thrive, and birth becomes something else.”

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