Approximately 700 women are dying from pregnancy-related complications in the U.S. each year. Black women are three times as likely to die from pregnancy-related health issues as white women; in New York City, they're 12 times more likely to die from pregnancy complications. But studies have found that mothers who work with doulas are two times less likely to have birth complications and four times less likely to have a baby with low birth weight.
Some states (and even presidential candidates like Kamala Harris and Elizabeth Warren) have worked to find legislative solutions to the factors that contribute to poor maternal health, such as institutional bias against black mothers and poor access to health care. Yet in New York state, which has made headlines for its ambitious task force aiming to combat maternal mortality, doulas are concerned a new law will be a major setback for those who are currently making progress on this front.
Bill A364 (and its state senate counterpart S3344) seeks to establish ground rules for certifying doulas, a multi-step process that includes either completing a training course sanctioned by the state health commissioner or providing proof of equivalent training that meets the commissioner's standards, passing an examination, and paying a certification fee of $40. Per the bill, which was passed by the state assembly and senate on Tuesday evening but has not yet been signed into law, "only those certified [through the aforementioned means] may provide doula services."
This might seem like a straightforward effort to make doula practices safer and more consistent. But to the doulas the law would affect, it's an unwanted intrusion on their work and on the rights of their patients.
"This further marginalizes women who do this work," says Latham Thomas, a doula, Well+Good Council member, and founder of Mama Glow, a maternity lifestyle brand that offers support to those giving birth as well as education to doulas. She argues that because doulas are not clinicians, they should not be subject to licensure or certification from the state. "The work that we’re doing is non-clinical support; it’s standing alongside women who are making decisions for themselves," she says. "The idea that people from the state are going to control something that women have been handling on their own doesn’t feel right. The state should not have anything to say about how a woman [gives birth] and who she chooses to have in that room with her."
"The state should not have anything to say about how a woman [gives birth]." —Latham Thomas, doula and founder of Mama Glow
While the specifics of the law are vague, Thomas says that the state certification requirement is an extra burden for birth workers, who are generally already trained and certified through a program like hers or through the many others offered in New York. Doulas may have to pay for further training (sanctioned by the state) if their existing training doesn't meet the state's standards—which have yet to be defined.
Chanel Porchia-Albert, the founder and executive director of Ancient Song Doula Services, is equally concerned. (Her organization released a statement on Wednesday evening in opposition to the bill, saying, "While these bills were created with the intention of expanding doula care and access to marginalized communities, the proposed legislation contradicts these efforts.") For example, the bill stipulates that certified doulas must be of good moral character. "What defines that?" she says. "Who defines that?" As for the requirement that doulas must take an exam through the state—she says it's unclear as to what will be on that exam. "Doulas already go through an examination process when they go through services and training with Ancient Song," she says.
Determining who is a "valid" certifying body could also have negative implications for doulas of color, Porchia-Albert says. "As it stands, white middle class doula organizations have been the center and focal point of a lot of implementation, [while] black doula organizations and organizations of color have been less seen as being reputable organizations," she says.
All of these potential hurdles could make it harder for doulas to serve their own communities, both Porchia-Albert and Thomas say, particularly low-income communities of color. "It creates an environment where people have to comply. If they don't comply, then they're renegades on the outside of the system," Thomas says. It could also create deserts of doula access in low-income communities if the doulas who serve them aren't able to get re-certified through the state. "This could take away the autonomy of the consumer from being able to choose who their advocate is in their birthing experience," Porchia-Albert adds.
Other doula organizations have expressed deep reservations about the bill. DONA International, a doula training and certification organization based in Chicago, sent a letter to New York Governor Andrew Cuomo on Wednesday urging him not to sign the bill. "We are concerned about the possibility that this could lay the groundwork for the criminalization of doulas who are not certified through the state. We have seen the criminalization of midwives, due to similar legislation, limit the access of women to qualified midwives," the letter states, according to a copy of it shared on Twitter. (DONA International did not respond to requests for comment by press time.)
Porchia-Albert says that what's most frustrating is that she and other doulas had been in conversation New York legislators about its pilot program expanding Medicaid funds to cover the costs of doulas services for individuals in certain parts of New York—including co-writing a report shared with legislators on the efficacy of doulas at improving maternal health. "We were told that the intention behind [the bill] would be regulating those who would be accepting Medicaid reimbursement," she says. But this bill's language does not make that distinction, which means that it could be applied to all doulas, regardless of whether they wish to take the Medicaid reimbursement or not, she says.
Assemblywoman Amy Paulin, who sponsored the bill in the state assembly, did not reply to requests for comment. Senator Jessica Ramos, who sponsored the state senate version of this bill, declined to comment for this story.
Ultimately, Thomas sees the passing of this bill as a reproductive rights issue. "While I’m sure [the lawmakers] are well-meaning and want to address maternal mortality head-on, what the state is concerned with is control. This is something we see along the entire reproductive continuum," she says. "We have to see this as a larger problem, just as we see with abortion and breastfeeding and birth and mensuration and sex education."
Both Thomas and Porchia-Albert emphasize that there is still time to stop this bill, since it has yet to be signed into law by Governor Cuomo. "My hope is that we can get the bill amended and if not, then killed and revisited," says Porchia-Albert. She says that Ancient Song will be putting out information in the coming days on how people who want to fight the bill can participate and create a new solution. In the meantime, she suggests people reach out to their representatives "and let them know you're in opposition of this, and that they should seek out community experts" for guidance in this space.
"This is an opportunity for unification amongst all doulas, white and black," says Porchia-Albert. She hopes that legislators will listen to the feedback from community doulas like herself this time and be willing to work directly with people on the ground rather than sticking with the bill's more top-down approach. "We want to push for a more equitable language and bill."
For more on doulas, read about Latham Thomas and her vision for community-driven advocacy. And here's why fertility should mean more than just a person's ability to have kids.
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