Kali King could sense something was wrong during her last pregnancy. She had gone into labor, but when she went into the hospital on a Sunday, her cervix wasn’t dilating. She wanted to see her OB-GYN the next day, but one of the doctors there was insistent she could wait until Thursday for a check-up.
“She dismissed me,” said King, who lives with her family in Northern Virginia. “But I kept telling her something didn’t feel right.” She followed her gut and went to see her regular doctor the very next day. At the appointment, King learned almost all the amniotic fluid around her baby had disappeared.
Her doctor sent her back to the hospital for an induction, and her son, Noah, was born hours later. But for King, it was only the most recent experience of feeling ignored during her pregnancy. Noah was her sixth baby, and she told her husband he was going to be her last. The experience also spurred her to make another big decision — becoming a certified doula to support other mothers through their pregnancies.
“I just didn’t want that to happen to anyone else,” she said. “As a Black woman, when we go into these spaces, we’re always dismissed. There’s always a sense of, ‘You don’t know what you’re talking about, you don’t know your own body.’”
Amid what some public health experts have described as a crisis in maternal mortality, Virginia is leaning on providers like King to reverse a concerning trend. Earlier this year, the General Assembly expanded Medicaid to cover the services of doulas, who provide advice and support to families during pregnancy. The decision makes Virginia one of just a handful of states to implement the policy, which officials hope to have in place by spring of 2022.
Doulas are frequently seen as a frontline defense in the fight to improve outcomes for people who are pregnant. Over the last 25 years, rates of maternal mortality have risen across the U.S., even as medical science continues to advance. In Virginia, rates rose from roughly 7.5 per 100,000 live births in 1982 to 16 per 100,000 in 2018, according to data from the state Department of Health and the March of Dimes. The risk is notably and disproportionately higher for Black individuals, who are more than twice as likely to die from pregnancy-related causes as someone who is White.
For Black mothers, the troubling statistics are all too real. During her final pregnancy, King learned a high school friend and her cousin-in-law had both died during or shortly after childbirth. Dae Adamson, another doula based in Roanoke, miscarried early into her own first pregnancy after multiple doctors refused to give her an ultrasound — even when she told them something felt wrong.
“Black women get pregnant and a lot of times their first thought is, ‘Am I going to make it out of the hospital?’” Adamson said. “‘Is my baby going to make it out of the hospital?’” She was also driven to become a doula after her own experience during pregnancy, and the knowledge that expecting Black mothers in Southwest Virginia often have few options when it comes to finding a provider who looks like them.
Support is just one of the services doulas can offer. Nichole Wardlaw, a certified nurse-midwife who practices in the Hampton Roads region, said people don’t always know what to expect during pregnancy or what their options are when they’re giving birth. Typical check-ups with providers are often short, but doulas can provide additional education and advocate for their clients to make sure they’re the ones calling the shots.
“Informed consent is giving you the facts — the risks and the benefits — and letting you make your own decisions,” King said. Doulas are also there for support during the childbirth process, whether it’s through massage or breathing exercises or guidance. Adamson can still remember one of her clients who was going through a particularly difficult labor. Doctors were ready to try a vacuum extraction, but Adamson first directed her client’s husband to sit behind her back and support her as she pushed.
“That second or third push, the baby popped right on out,” Adamson said. “And I remember, the provider looked at me and said, ‘I never would have thought of that.’ But that’s what they hired me for, to bring this baby into the world in the most natural way possible.”
That support and advocacy appears to improve birth outcomes, according to some research. One study reported that doula services can lead to more positive self-reported experiences during childbirth and reduce the likelihood of C-sections or instrumental births, including vacuum extractions. Another study found mothers were four times less likely to give birth to a low-weight baby and two times less likely to experience birth complications.
Even without certification, there’s a long history of close friends and relatives providing emotional support throughout pregnancy and labor. Many doulas, including King, said they’ve provided their services informally for decades. But the push for regulation in Virginia is to make sure there’s a baseline standard of care. There’s no requirement for doulas to become certified or to accept Medicaid, but those that do must complete at least 60 hours of training under a curriculum with more than half a dozen core concepts — from lactation support to newborn parenting education.
“To say you’re a state-certified doula and be in the database, we all need to understand what that actually means,” said Emily Yeatts, a member of the Virginia Department of Health’s doula regulations team and supervisor of the agency’s reproductive health unit.
That’s because policymakers specifically expanded Medicaid with the goal of reducing mortality and narrowing long-observed racial disparities. Research from Virginia’s Maternal Mortality Review Team recently found that close to 70% of people who died from a pregnancy-related cause had at least one chronic condition. Nearly 50% of them also relied on government-provided insurance.
But trained “full-spectrum” doulas, as they’re often referred to, can provide care before and after childbirth. The state’s Medicaid program will reimburse up to eight visits starting from conception to six months after delivery, in addition to attendance at the labor.
During that time, doulas can provide a range of services, including screening for conditions like postpartum depression and coordinating follow-up medical care. In some cases, they might be there just to offer support or help take care of the baby if parents are feeling overwhelmed.
“I’ve seen lots of clients who just didn’t have the support they needed,” said Wardlaw, who worked at a federally qualified health center for low-income patients before she started her own midwifery practice. “We had everything from single moms to indigent care, and one of the worst things to ever see is a client who comes to the hospital by themself and leaves by themself.”
Given how crucial that support can be, some local health districts have established their own program to link residents with free services. Richmond-Henrico, for example, launched a program in April and has already connected 150 people with doulas.
The initiative is currently funded through local grants that are distributed to two community-based doula organizations when they take on new clients. But Amy Popovich, nurse manager for the health department, is hoping Medicaid expansion might make the program redundant.
Without financial assistance, the cost for a doula can range from $800 to $1,500. According to King, many end up providing the services for free to clients in need. With Medicaid expansion, though, the hope is for more patients to be referred to doulas early on as a critical part of their care team — and for doulas to get reimbursed regardless of a client’s financial status.
“Hopefully it takes us out of the picture,” Popovich said. “It does allow more access and freedom to have the individual person use Medicaid, but also for doulas themselves to have direct access to more funds.”