Here’s what doulas do, and how they’re fighting for Black maternal health

This bit of advice would transform Love’s experience with pregnancy and change the course of her life. Now, she thinks care from doulas could be one answer to a national crisis, where pregnancy in the United States is riskier than in any other wealthy country in the world, and especially deadly for Black women like her. Love would go on to become a certified doula herself, as well as a key advocate behind a Rhode Island doula bill that passed the state Legislature this year, improving access to doula care. But initially, Love had no way of knowing any of that — she had no idea what a doula was.

Doulas are having something of a moment. This year, Harper’s Bazaar called them “the modern Mary Poppins every parent could benefit from.” Demand for doulas seems to be increasing, and several prominent news organizations have reported in recent years the particular benefits culturally competent doulas offer Black and Indigenous families, who face disproportionate risks in childbirth. Still, many people react to the word “doula” with the same confusion Love experienced all those years ago: What are doulas, and what do they do?

Trained in holistic pregnancy and postpartum care, birth doulas guide pregnant people — cisgender women and those of other gender identities — to getting the medical, emotional, and social care they need. They deliver a range of services, usually in the client’s home — whether that means coaching the client’s birthing partner on how best to offer support, giving stress-relieving massages, or helping to identify health care providers who are aligned with an expectant parent’s individual birthing plan. Doulas don’t take the place of doctors or midwives, and they don’t deliver babies. They do teach clients how to advocate for themselves in the delivery room, and they’re on call to address the innumerable questions and concerns that arise during a pregnancy — questions a typical doctor visit can’t fully address.

In other words, a doula was exactly what Love needed. “I was able to have the physiological birth that I wanted to have, one where I was feeling so supported,” Love says. “I knew that I wanted to give that same experience back to people.”

Love’s positive experience is not unique. Doulas’ methods have been shown to reduce all sorts of physical and psychological trauma in birthing experiences: Doula-guided pregnancies end in significantly shorter labor times, fewer Cesarean sections, increased birth weights and breastfeeding rates, and — not least of all — higher overall happiness for new parents, in part due to the social support that decreases the risk and severity of postpartum depression.

Still, an air of skepticism often fed by stereotypical media portrayals surrounds many forms of holistic medicine, sometimes negatively affecting how people view doulas — if they even consider them at all.

Doulas themselves say there’s no magic to their work. They simply treat pregnant people as individuals and meet their particular needs. “I’m here to make you feel empowered in your experience by making empowered, informed decisions,” says Massachusetts-based doula Adriana Jean Louis. “I’m here to advocate for what your desires are for your pregnancy.” She says that extra time and care are particularly important during the delivery itself: “I’m here to slow down the room.”

This blend of personal advocacy for expectant parents takes on a deeper urgency for Black doulas who serve Black pregnant people. In 2017, the United States was one of only two countries in the world where maternal mortality was increasing rather than decreasing. The country sees about 700 maternal deaths each year — reaching a mortality rate more than double Canada’s. The gap between the US and its peers can be explained in part by the Black maternal health crisis. Black women die from childbirth-related complications at three to four times the rate of white women. American Indian and Native Alaskan women face a similar gap. The disparity for Black women persists — and in some cases, widens — even when controlling for education and other socioeconomic factors. The crisis even reaches states renowned for their health care, like Massachusetts, where Black women die from pregnancy at 2.5 times the rate of other women.

Experts point to various factors that could explain this deadly trend. Researchers have long documented that medical professionals are more likely to dismiss Black patients’ requests, concerns, and pain. The same is true for all women patients, regardless of race, and Black women live at the nexus of these systemic biases. Pregnancy can also be made riskier by stress, and studies show that pervasive racism leads Black people to suffer high rates of chronic and toxic stress, along with the illnesses that follow from it. And social inequality and discrimination expose some pregnant people to a range of environmental and medical risks — poor nutrition associated with living in a community without access to healthy, affordable food, for example — long before their due dates.

Though they cannot make inequities disappear, doulas can guide clients through these risks, arming them with knowledge of how pregnancy and birth affect their bodies and helping to create an environment at home and in the hospital that focuses on clients’ needs.

But doula care can be unaffordable to many of the families who need it most. Costs usually range from $800 to around $2,500 for a birth doula, the pregnancy and fertility website VerywellFamily estimates. Additional services — such as extra visits for higher-risk pregnancies, lactation consulting, and postpartum care — can cost more, and require doulas to maintain additional professional certifications. With few states requiring Medicaid or private insurance to foot the bill, doula care remains a big investment for many working parents, and wholly inaccessible to families already struggling with childbirth expenses.

The price tag almost kept Love from getting doula care. She lost her job early in her pregnancy, and her husband at the time had his work hours cut. The $800 fee for the doula she wanted to hire was suddenly beyond their means. Love regretfully called to explain they wouldn’t be able to afford her services, but a week later the doula called back. Each year, she took on two births for free, “for God,” she said. Love would be one of those two clients.

Gratitude for that gift propelled Love to become a doula herself in 2015. She traveled to upstate New York for training as soon as she could after her daughter was weaned from nursing. And she was determined to give back to Black communities in Rhode Island — a commitment that proved more difficult than she had imagined. “I was having to work with [some Black families] for free,” she says. She found herself caught in a cycle several Black doulas in New England described to the Globe Magazine: juggling multiple jobs and specialties to make ends meet, just so they can serve the very people who inspire them to do their work.

When Love heard in December 2018 that a Rhode Island state representative — a Black lawmaker — was teaming up with reproductive rights advocates to change all of that, getting involved was a no-brainer. She signed up to help, not knowing she was in for a three-year fight to make the state and private insurers step up for Black women’s lives.

Birth and death are closely linked in the life and memory of Rhode Island state Representative Marcia Ranglin-Vassell. As Marcia’s mother went into labor with her in the quiet Jamaican district where they lived, the local woman who assisted with childbirths was busy cooking dinner for her own family and didn’t make it there in time. All alone, Ranglin-Vassell’s mother brought Marcia into the world, unwrapping the umbilical cord that nearly strangled her infant.

Ranglin-Vassell, who’s 61, knows other women who were not as fortunate in their childbirth experiences. Her childhood friend died giving birth to twins in New York City. Her mother’s friend in Jamaica died from childbirth complications. And in 1996, Ranglin-Vassell had her own near-death encounter. Just days after giving birth to twin boys, she began having splitting headaches and returned to Women & Infants Hospital in Providence. She was suffering from a brain aneurysm and preeclampsia. She worried she wouldn’t make it home to raise the twins and her two older children.

The crisis didn’t kill her, but it left her with migraines and high blood pressure. It also left her bewildered. How had bearing children almost cost her — a healthy woman — her life? How had she survived when other women she knew had not? Two decades before she would join the Rhode Island Legislature, she began research that would take the shape of a dream, then a bill, and then a movement, before finally becoming the law.

Ranglin-Vassell read everything she could about pregnancy and Black maternal mortality, a crisis she could see in her own world years before the data confirmed it. She began to come across solutions, too, and one stood out: doula care. She’s unsure when she first encountered the word “doula,” but it brought to mind hopeful stories about Black people and birth. Stories of the women called Ma, Sister, Auntie, or any number of names for those who served their neighbors as guides through the emotional, mental, and physical experience of pregnancy and birth. Such women had been at work in her birthplace of Jamaica and around the world for centuries.

Convinced that doulas were part of the solution, in 2018, two years into her tenure as a state representative, Ranglin-Vassell got to work. She was joined in drafting and fighting for the bill by groups including Planned Parenthood of Southern New England, a reproductive rights organization called Sista Fire led by women of color, members of the Rhode Island Coalition for Reproductive Freedom, and — most importantly — a small and mighty group of doulas.

Advocates spoke at churches, parent group gatherings, activist trainings — anywhere they could build public support. Ranglin-Vassell shared the story of her sons’ birth over and over on social media and in public, even though revisiting that experience still brings her to tears. She recalls polling her fellow legislators one by one, asking whether they knew anything about doulas. Only a handful did, mostly wealthy white men whose wives had hired doulas — a pattern that left Ranglin-Vassell even more convinced of the need for her bill. She met with legislators individually and identified an ally: state Senator Ana Quezada, who agreed to champion the bill. It passed the Senate unanimously that year.

Progress in the House was much harder. The 2019 and 2020 legislative seasons came and went with the doula bill stuck in committee. Ranglin-Vassell recalls offensive comments, including the time a colleague responded to her birth story by asking if something was wrong with Black women’s DNA. Then-Speaker Nicholas Mattiello never called the bill to a vote.

There was other resistance, too, by nurses who worried doulas would displace them in the birthing process, despite their distinct roles, and by private insurers against mandated doula care coverage. But advocates marched on, meeting with opponents until support reached a groundswell in summer 2021 and both chambers passed the bill without a single “nay” vote. On August 11, The Providence Journal photographed advocates looking on proudly as Governor Dan McKee signed the Doula Reimbursement Act into law.

When Ranglin-Vassell speaks of all it took to get to this point, her powerful voice breaks. “I now know that the strength and the fact that I lived was for this fight, so other women don’t have to die, and other women don’t have to be suffering,” she says. Now a grandmother, she cherishes every family milestone. “My fight was for all the women who never got to hold their babies.”

Rhode Island’s journey to passing the doula law is an inspiring case study on the power of grass-roots organizing, and the accomplishment is a beacon of progress amid a national crisis. But with few states embracing similar policies, advocates wonder, What’s next?

Rhode Island joins a handful of states that extend Medicaid coverage to doula services, among them Illinois, Minnesota, New Jersey, and Oregon. Reimbursement rules for private insurers in those states vary. Other states have less aggressive doula legislation or pilot programs granting access to some groups. Federal lawmakers, including Representative Ayanna Pressley, have introduced legislation intended to improve birthing outcomes for Black women specifically, but progress is slow.

Black doulas in Massachusetts describe a skewed landscape where their services are accessed primarily by clients who are either financially comfortable or in crisis — rarely anyone in between. Several hospitals offer programs that provide doulas at no cost to pregnant people who are socially isolated or otherwise particularly at risk — for reasons ranging from sexual assault to criminal justice system involvement. Private practice clients, though, come from almost another world. Black doulas say they serve many Black families, but most of their clients, regardless of race, work in white-collar professions. Though families with more limited budgets sometimes manage to make the investment, doulas say a law like Rhode Island’s would make it easier to reach many more families.

In the Massachusetts Legislature, a 2020 bill proposing Medicaid coverage for doulas failed to make it out of committee. But another bill establishing a committee to lay out racial disparities in maternal care and investigate solutions made it through, and in January, Governor Charlie Baker signed it into law. Massachusetts doula She-Tara Smith is passionate about what she does but recognizes the obstacles she and her colleagues face. “I always say it’s like we’re operating within the system that’s the bigger Goliath,” Smith says. “We can fight all day long to change the system, but it’s not going to happen overnight.”

A mother to three — including a 10-month-old who coos in the background during our phone interview — Smith thinks about that system often as a doula and parent. No matter how joyful the birthing experience, there is “a little bit [of] despair for your Black children living in a world that’s so racially unjust,” she says. “That’s not something necessarily that a doula has any charge over. We talk, we process, and you have another listening ear. … But we can’t take that away.”

That bigger picture is why holistic health interventions are so important, says Brittney Butler, a social epidemiologist at Harvard’s François-Xavier Bagnoud Center for Health and Human Rights. Access to such care must be equitable, she says, to avoid what often happens: pregnant people getting blamed for not tapping into a given health intervention they’re unable to access.

Reimbursements from private insurers will go into effect in Rhode Island starting in July, with coverage up to $1,500. And the state has budgeted Medicaid coverage for doulas, thanks largely to advocates’ work. Shaylene Costa and Quatia Osorio were there every step of the way, making sure the new law would work for doulas and the families they hope to serve. But the work toward equitable outcomes remains unfinished in Rhode Island.

Many doulas have never encountered medical billing systems and have less than a year to get acquainted with software and daunting insurance reporting requirements that other health providers have been struggling to navigate for years — usually with more infrastructure and for much higher pay. These doulas may also need to run interference with resistant insurers. And once the law goes into effect, expectant parents will need to be educated about the new care options.

To doulas in other states considering similar legislation, Costa offers this advice: “Get at the table — when they’re drafting, when they’re editing, when they’re having meetings.” She’s seen the impact her sisterhood has made. Osorio recommends finding ways outside of legislative action to expand access to doula care — pathways that don’t add as much regulation or work for doulas from marginalized communities.

Whatever comes next, Rhode Island advocates see the law as part of a nationwide struggle for Black maternal health. And they’re experiencing the toll that struggle takes. “It is such a space of degradation to have to ask someone and beg someone to see the humanity in the work of Black women. And there is nothing more insulting or infuriating than having to repeatedly speak out about the disparities,” Osorio says. No matter how many times you tell the painful story, she says, “the vileness of that never goes away.”

Even with science on their side and despite a deadly crisis, solutions for reproductive health and Black people’s health rarely make it onto legislative agendas anywhere without a sustained battle — and waves of social change. The 2021 victory in Rhode Island is inextricable from 2020 tragedies, particularly the police killings of Black people that fomented mass protests nationwide. Ranglin-Vassell says heightened attention to the deadly effects of racism helped more people understand the bill’s urgency. After the bill had been sidelined by a previous speaker, she went to current House Speaker Joe Shekarchi and told him that passing legislation on doula care would be a meaningful way for Black women — who turned out to vote and deliver Democratic victories in a crucial election year — to get their due. It was a chance to put weight behind the words “Black lives matter.” Shekarchi supported the bill and called a vote.

Of course, Black doulas know and have always known: Their lives matter. The lives of those they care for matter. These principles guide their work and drive their activism. And as caregivers throughout the cycle of pregnancy and delivery, they are used to seeing long, difficult processes through.

To Felicia Love, that sense of community makes the victory in Rhode Island led by Black women and doulas even more meaningful. “It isn’t the case that outside folks have come in and made these decisions for us,” she says. She’s a parent who could’ve benefited from this law. She knows how profoundly it can help so many Black families. “This bill is truly for the people most impacted by inequality in birth” — and it was drafted and advanced by people who share those experiences.

That, Love believes, is how change is born.

Dasia Moore is the Globe Magazine's staff writer. E-mail her at dasia.moore@globe.com. Follow her on Twitter @daijmoore.