The “Informed Community” that Doulas Offer Can’t Be Overvalued, Especially for Black Lives

Justice Kreider of Harrisonburg, Virginia, rests with newborn Everly Rain Kreider on June 13. (Photo courtesy: Justice Kreider)

Giving birth can be stressful and scary, with the outcome, ideally, being joyous.

Unfortunately, as the articles on maternal and infant health in this inaugural issue of The Science Writer indicate, the experience of pregnancy is too often marred by racial and cultural disparity that leads to tragic outcomes. For Black and Indigenous women, who suffer from worse outcomes than white women, access to culturally focused health services and information can make all the difference.

In countries like the US, doulas in particular have been an underutilized, undervalued maternal health partner. That needs to change.

Doula-assisted mothers, research has shown, were twice as likely to be spared a birth complication, either for themselves or their baby, compared to mothers who didn’t use a doula. These mothers were four times less likely to have a baby with low birth weight and more likely to initiate breastfeeding.

While doulas aren’t qualified to deliver babies, they do offer trained support throughout pregnancy and after, and they are more likely to be a person of color than OB-GYNs or midwives—important because cultural connection may be a factor in terms of outcomes.

I believe it’s time to give this great benefit that doulas offer a shorthand: “informed community.”

Information alone doesn’t improve prenatal nutrition, birth preparedness, post-birth mental health and breastfeeding. After all, the internet contains practical information on all these things. Having someone with you who has helped others and who has sensitivity to your cultural traditions and preferences—a guide to literally commune with—helps convert indecision to action, empowering a pregnant woman. While the relationship starts as a partnership, it’s really broader than that because of the emphasis on team-focused care that includes all of the doula’s connections. Doulas can use their knowledge and network to serve as powerful advocates.

Justice Kreider of Harrisonburg, Virginia, shared with me a story that illustrates this power. Kreider lost her second child, Selah, after the baby had to be delivered early via emergency cesarean birth. Selah had Costello Syndrome, a genetic disorder that delays mental and physical development. The baby died after nine days in the neonatal intensive care unit. So when Kreider got pregnant again five months later, her OB-GYN told her she would have to deliver once more by cesarean—a surgery that comes with its own risks, especially the second time around.

But Kreider read online that it was indeed possible to have a safe birth vaginally. As a precaution, the American College of Obstetricians and Gynecologists recommends that the delivery occur in a hospital.

Then she found out about Birth Sisters of Charlottesville.

“To my delight they also catered to Black women and that made me feel even more comfortable,” she said.

Though she and her doula, Charlsie Stratton, never met in person because of COVID-19, Stratton provided consultation via Zoom that supplemented Kreider’s clinical visits and, perhaps more crucially, utilized Stratton’s contacts in the medical community.

“Charlsie was very kind and listened to my concerns and she believed in my ability to have a VBAC [vaginal birth after cesarean],” Kreider said in an email. “What I am really thankful for is her willingness to call and get me transferred to the [hospital’s] midwives because I was very uncomfortable with the doctors there. I was told it was too late to transfer since I was 32 weeks but she sought out calling the people she knew to get me in. She told me that it’s worth it for my comfort. And it was such the right choice.”

Everly Rain Kreider was born June 13, vaginally and without complications, and her mom reported that they were happy and healthy a month later.

I believe examples like these of informed community in action—on par with medical resources or the “social determinants of health,” such as living in a safe house or neighborhood—may even outweigh, to some extent, the uneven distribution of wealth in the United States, which leads the industrialized world with the infamous distinction of the worst maternal health outcomes.

We know money and resources aren’t everything. Hispanic (or Latinx) women in the United States, though historically possessing less wealth, tend to have similar or better birth and overall health outcomes than white women. And Hispanic people generally live longer lives. Researchers have puzzled over this for years, calling the relatively better health “the Hispanic paradox.”

One resolution to this paradox could be that Hispanic culture emphasizes informed community in pregnancy. Matriarchs are known for passing down their knowledge, and extended family are often in the home providing support, both during birth and well after.

“Everyone recognizes a better prognosis for the pregnancy, and even for the neonate, when those close to the new mother are supportive,” says Dr. Pedro A. Poma in his classic article “Pregnancy in Hispanic Women,” published in the Journal of the National Medical Association.

A handful of U.S. states have wisely begun investing in doulas, because they are both evidence-based and affordable. Still, no one would expect doulas to carry all of the burden. Women need a village of people to help them, especially if they are going through pregnancy alone or are experiencing domestic abuse. This includes the doctors and nurses involved in their care, who work in a sometimes inflexible system that has historically earned the distrust of Black Americans. For Black women to be truly heard when they have a complaint that might be related to a chronic condition, or a preference related to giving birth that might reduce trauma, it will take a cultural shift. A system that centers agency and choice for Black women and others in childbirth, without losing the very real gains in obstetric care that have made it safer to give birth, is very much achievable.

To that end, health care needs more Black OB-GYNs and midwives. There are some problems at which it’s advisable to throw money. Investing in the training and hire of Black medical professionals is not only an equity issue but one that can save lives.