The profound inequities in birth and maternal health outcomes between Black and white people in the US state of Florida point to the need for greater support for doula care, Human Rights Watch said in a report released today.
The 62-page report, "Witness, Ally, Advocate, Climate Worker: Doula Care for Justice in Maternal Health in Florida," found that the state provides inadequate financial and programmatic support for doula care, including under state-based Medicaid plans on which almost half of all women who are pregnant or give birth in the state rely. Doulas are non-clinical health workers who provide expert support during birth and provide individualized information about health care options, rights, and resources. Academic and US government research suggests that doula services can help improve the availability, accessibility, and quality of health care services for pregnant people. One multi-country analysis of evidence found continuous labor support by doulas may reduce rates of cesarean delivery and improve Apgar scores (indications of good health in newborns) and women's ratings of the experience.
"Doula care improves the health of pregnant women and other people as well as newborns, and provides much needed support to women and girls and can help address inequities," said Skye Wheeler, a senior women's rights researcher at Human Rights Watch. "But Black and other doulas of color are often fighting for reproductive justice in the face of poor, uncertain, or no compensation."
Human Rights Watch interviewed more than 50 experts, including doulas, clinical maternal health care providers, healthcare administrators, and academics, from the South Florida area. Interviewees indicated that although doula care is increasingly valued by hospitals and other clinical providers, medical systems are not able to support equitable access to their services. Paying out of pocket for doula care costs up to $3,000 over the course of a person's pregnancy, generally making it unaffordable to low-income pregnant women. Doulas who want to work primarily or only with low-income women struggle to make the work sustainable.
"We are there to make sure moms really feel like they are active decision makers," Shantai Latoya Young, a doula, told Human Rights Watch.
This assistance can be particularly important in a medical system that can also be depersonalized, profit-driven, hard to understand, racist, and disrespectful.
Across the US, Black maternal health outcomes are worse than white maternal health outcomes, a major public health and health injustice problem for the country. In Miami-Dade County, according to Florida health data, 13.6 percent of Black women's births result in a low birth weight baby, compared with 6.7 percent for white women, and 18.7 percent of -Black women's births result in a preterm birth (before 37 weeks gestation), compared with 11.7 percent of white women. Low birth weight and preterm birth increase the risk of infant mortality and can have lifelong health consequences.
"Doulas, midwives, and people who are community-based in their birthing professions provide care that's patient-centered, holistic, responsive to the patient, and allows the patient to have autonomy and the support of their loved ones and other things that they need to have a healthy experience," said Dr. Okezi Otovo, a professor at Florida International University, who has a doctoral degree in history and focuses on motherhood and public health. "[Birth should not be] an ordeal to survive or overcome, but rather part of a healthy, joyous, fulfilling life."
In Florida private insurance companies bid to win contracts to administer public health insurance. While most private insurance companies providing pregnancy healthcare coverage for Medicaid in South Florida can pay for doula care, the compensation for doulas is too low and the system is hard for clinics and individual doulas to use. There is also a lack of awareness of the benefit and availability of doula care among pregnant people and doctors, Human Rights watch found.
Knowledge of the benefits of doula care and respect for the vocation are rising, Human Rights Watch found, but in part because the work is both intense and underpaid, too few doulas are able to build sustainable income from the work.
More broadly, Florida's legislature has in recent years undermined the rights of people who are pregnant to reproductive and maternal health by severely curtailing abortion care and rejecting federal government efforts to support more people in accessing health insurance.
Non-discrimination and equality are fundamental parts of the internationally protected right to health, and international law entitles people to maternal, child, and reproductive care. Public health and health care facilities, goods and services should be available, affordable, and offered without discrimination. Services should also be accessible and culturally acceptable.
Reproductive justice advocates, doulas and allies have pressed other US states into legislative action to get doulas adequate compensation through Medicaid, and successfully in California, New Jersey, Oregon, and Washington, as well as Washington, DC. The Florida legislature should require all private insurance companies to cover this benefit, and it should allocate funding for uninsured people to be able to access doula care and for public health campaigning to increase knowledge of the benefits of culturally competent doula care, Human Rights Watch said.
"Doula care is not a panacea, but doulas can be a trusted support to help pregnant people stay healthy," Wheeler said. "Hospitals, insurance companies and government authorities should make sure doulas are accessible to low-income women who want these services and that these care workers are fairly compensated and able to do the work sustainably."
