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Doulas are getting paid by people who can afford it. But people who can’t afford it don’t get doulas. We want to make sure that group can get a doula, because their babies are dying, being born too small – and we know that doulas can help. To not support them in getting a doula is unconscionable. Women who are on Medicaid who want a doula should have one. And we should find a way to pay for it.”

–Shafia Monroe, founder of the International Center for Traditional Childbearing (ICTC) in Portland, OR

“The mission of ICTC is to increase the number of Black midwives, doulas, and healers to empower families, in order to reduce infant and maternal mortality.

–From the ICTC Mission Statement

Shafia Monroe is a midwife, community leader and the force behind Oregon’s House Bill 3311. HB3311 was the first legislative step toward reimbursing doulas through Medicaid and highlighted questions of class, access, and health disparities in Oregon. Over 99% of American births take place in hospitals where, despite the aura of safety, US maternal mortality doubled since 1987. “African-American women are nearly four times more likely to die of pregnancy-related complications than white women,” according to Amnesty International and infant mortality in African American communities is twice that of non-Hispanic whites. Shafia Monroe and her allies responded to the crisis with research and community organizing at the state level, and Oregon is taking steps to increase health equity.

The Oregon Health Authority (OHA) issued a report showing disparities in Apgar score, birth weight, cesarean birth, infant mortality and postpartum depression for Pacific Islanders, African Americans and Native Americans. OHA examined existing community-based doula programs – the Farmworker Doula Program, the Connect One Project and The Haven’s Doula Program – which demonstrate the benefit of what ICTC terms “full-circle care”; prenatal, birth and postpartum support. In these programs, doula-supported women were more likely to use prenatal care, had babies with healthier birth weights and breastfed more easily. In its conclusion, OHA wrote, “the Committee recommends doulas as an overall strategy to improve health equity in Oregon’s birth outcomes.”

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(ICTC Sistah Care students display signs they made for actions supporting HB3311 at the state capitol in Salem.)

For doulas outside wealthy areas, paying the bills can be more daydream than reality, a fact that spurred Shafia into political action. For years, she trained doulas in African American communities, where babies have the “highest death rate in the nation,” but discovered they couldn’t support themselves. “Every time we turn around,” she said, “they have [day] jobs! They’re not doing the work! We found out that the clients they see are so low income they can’t afford to pay them. And they can’t afford to do it for free.”

Despite the promise of HB3311, questions of access remain. For now, there’s talk of limiting reimbursement to time spent at births, negating the benefits of prenatal and postpartum support outlined by OHA’s report. Also, the initial figure is paltry. A thoughtful article on Science & Sensibility outlines the importance of carefully considering socio-economic implications of compensation: “One…consequence may be that the resulting system will continue to perpetuate a model of economic marginality and potential exploitation for the doulas who serve a low income population of childbearing people.”

“I can count the doulas of color in Oregon,” Shafia told me. “It’s extremely low. So this is another way for women who tend to be underpaid anyway, just sort of based on who they are, this is a way for us to get more doulas, whether they’re Puerto Rican, Hispanic, or Asian. It’s just a way to help other people to consider this as a profession, because otherwise it’s not attractive.”


Labor Day, 2013

According to Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists,“Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”

Reducing US Maternal Mortality as a Human Right, American Public Health Association

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(Washington DC, Rally to Improve Birth, 2013)

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(Washington DC, Rally to Improve Birth, 2013)

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(Detroit, MI, Rally to Improve Birth, 2013)

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(Los Angeles, CA, Rally to Improve Birth, 2013)

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(Northwest Indiana, Rally to Improve Birth, 2013)

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 (Orlando, FL, Rally to Improve Birth, 2013)

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(Philadelphia, PA, Rally to Improve Birth, 2013)


Fun facts: In 2011, the American College of Obstetricians and Gynecologists found two thirds of its practice bulletins lacked basis in “high-quality, consistent scientific evidence.” US patients lack inexpensive options to support physiological birth, such as a nitrous oxide and nation-wide hospital midwifery care, while costly technology, sometimes with questionable benefits, is the norm. For years, American consumers were uncharacteristically passive, paying more than any other country for maternity care that ranks about 40th in the world for maternal mortality.

But change is in the air thanks to a powerful tool that’s jumpstarting innovation – an educated public with purchasing power and a voice. I’ll offer two examples of progress: for-profit insurers actually beat Medicaid to the doula-reimbursement game in 2009 and this fall my So-Cal doula listserv was buzzing with reports of real live walking epidurals at Cedars-Sinai, a prominent LA hospital.

Since CPT codes were established for birth and postpartum doulas, families can file for reimbursement from their insurer after paying their doula. Tammy Ryan, third-party reimbursement coordinator for DONA International, cautiously estimates that about one-third of submitted claims receive some type of reimbursement.

Successful reimbursement depends on consumers’ persistence. According to an experienced LA doula: “The person who answers the phone [in the claims department] has one job … to say, ‘NO, we don’t reimburse for that!” But, “I’ve had several clients reimbursed for 50-70% after being told that the insurance company did NOT reimburse…the ones who are persistent are the ones who get reimbursed!”

If you’re curious about the process, here’s what you need (templates of required documents here):

– Insurer’s claim form or the 1500 Universal Claim Form.

– A superbill from your doula. Ask for itemization and cost breakdown of visits, birth and phone/email support.

– A letter from your doula detailing her services, credentials and training.

– A letter from your doctor or midwife describing medical necessity, health benefits and/or lower costs associated with having a doula.

– Your letter, explaining why you want/need a doula (optional, but really helpful.)

Tips for successful claims:

❤ Straight-up calling your insurance company before birth to ask for preauthorization for a doula. This streamlines reimbursement, which is nice because doing paperwork while caring for a newborn could easily be an advanced interrogation technique.

❤ Asking your doctor or midwife to write a “Letter of Medical Necessity.”

❤ Making sure your doula has a National Provider Identifier (NPI) number. It takes 20 minutes to apply for one.

❤It’s probably best, though not absolutely necessary, to hire a certified doula.

❤ NLP the claims person: “How much will I be reimbursed for my doula?” vs. “Do you reimburse for doula services?”

❤ Keep copies of all your claim materials in a folder IRL or on your desktop, and be ready to resubmit them at least four times.

Sounds fun right? Well, anyway, that is how it’s done.

Ok, onto the exciting news. During my doula career (est. 2009), there have been occasional birth-improvement-type rallies at Cedars-Sinai in LA – people standing on a corner, holding a sign and being part of a collective voice. The hospital is responding with encouraging attentiveness. Among other things, they’ve premiered a fellowship program in obstetric anesthesiology – hence the giddy reports of walking epidurals.

Imagine: Being able to walk and maneuver your body. Being able to use the toilet, no catheter necessary. With an epidural.

Let’s do birth activism together and organize for Cedars anesthesiologist Dr. Mark Zakowski to travel the country providing trainings!

(Seriously, contact me if you’re interested in trying to do something like that.)


 “It keeps startling me that at the beginning of this 21st century, at a time when we can . . . explore the depths of the seas and build an international space station, we have not been able to make childbirth safe for all women around the world. … This is one of the greatest social causes of our time.” 

–Thoraya Obaid, executive director of the UN Population Fund, quoted in Amnesty International’s “Deadly Delivery” report

During pregnancy and birth in America, combined oppressions affect who has a safe birth and who doesn’t – racism, poverty, unequal access to resources, profit before people, poor nutrition, rape culture, female subjugation, high incarceration, exposure to environmental damage, violence against women, a decade-plus of war, disenfranchisement – does this list have an end? Addressing these issues in the context of pregnancy and birth requires us to address them outside the hospital as well. We birth community witches have a favorite kum-ba-ya: “Peaceful birth for a peaceful earth.”

In patriarchy, the war has been on the mommies, not among them. Disagreements about foreskins and breastfeeding and “natural” vs. “unnatural” diffuse when we get real about health inequity and the glacial pace of mortality- and injury-reducing innovation in American maternity care. But to be honest, I’m hopeful about the future of American birth. Consumers of maternity care are finding a voice to demand the advances they deserve because healthier births cost less. A quote attributed to Marsden Wagner says, “Birth will not change until the women take to the streets.” In the current global climate of financial distress and turbulent social movements, our care providers, governments and hospitals are actually listening to us very closely. What will we ask of them?


Further reading:

Mother-Friendly Hospital Initiative

Baby-Friendly Hospital Initiative

Why Trayvon Martin Has Everything To Do With Black Women’s Birth Outcomes

Scientific Evidence Underlying The American College of Obstetricians and Gynecologists Practice Bulletins

Pushed by Jennifer Block

Born in the USA by Marsden Wagner

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Full spectrum doula, evidence-based medicine, zero-waste life, animals, astrology, foraging, music, kitchens, states of consciousness, the rise of the goddess and clothes.

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