Celis works as a community-based outreach doula at Open Arms Perinatal Services, a nonprofit that provides services to low-income people giving birth in King, Snohomish and Pierce counties. As parents navigate pregnancy, childbirth and life with a newborn, they may enlist the help of a doula, whose services range from helping parents understand the labor process to offering emotional support. Open Arms offers its services at no charge, meaning clients can save hundreds to thousands of dollars. The cost of doula services can run from $500 to $3,500, according to the New York Times.
The difficulties of bringing a child into the world go beyond labor. Dila Perera, executive director of Open Arms, said the nonprofit also refers people to resources that can help them through hardships such as mental health issues, struggles to pay bills and domestic violence.
“The families we work with are facing incredibly steep odds,” including poverty, housing insecurity and a lack of social support, Perera said. “We really have to fill that gap for them and navigate the system.”
Margarita Celis carries a box of diapers as she makes a house call on May 23, 2022 to one of her clients, who gave birth five months ago. Celis is a community-based outreach doula at Open Arms Perinatal Services and often works with immigrant parents to provide support and care before, during and after birth. (Genna Martin/Crosscut)
Nearly 90% of those served by Open Arms are people of color, including refugees and immigrants. Open Arms works to pair expecting parents with doulas who have an identity in common with the family. For example, Celis is originally from Peru and works with Latinx clients who value sharing a cultural connection with her.
“Even though some of them don’t speak Spanish,” she said. “But their mother speaks Spanish. And their tías or their uncles. So for them it’s part of their culture.”
Celis and others at Open Arms work with communities often excluded in the doula world, which has been a historically white industry in its clientele and workforce. The support of a doula could be especially critical for women of color in Washington, many of whom in 2020 were more likely than white women to deliver their babies early or at a low birth weight. The push to make doulas accessible has even extended to the federal government. In April, the U.S. Department of Health and Human Services pledged $4.5 million to hire, train, certify and pay doulas in places where mothers and babies face poor health outcomes.
“The fact that maternal deaths disproportionately happen to Black women is a national crisis,” said Carole Johnson of the U.S. Health Resources and Services Administration in a statement on April 1.
Helping families of color
Doulas offer support during labor, but their impact on families doesn’t end at the hospital.
“Doulas are known for helping to improve birth outcomes because they often just help someone navigate that birthing process,” Perera said.
In 2020, Indigenous women in Washington were more likely than any other race to give birth early, while Black women were more likely to deliver babies at a low birth weight, according to the Washington state Department of Health. Families working with Open Arms have been less likely to deliver underweight babies, have labor interventions and give birth prematurely, according to Perera.
The organization’s birth doula services program includes an intake process in which the nonprofit asks clients if they have preferred identities (religious or cultural, for example) that they hope to have in common with their doula. Participants get three prenatal visits to talk about expectations and comfort measures; support during labor, like massages and emotional care; and three postnatal visits to help families adjust to life with a baby.
Open Arms also runs a community-based outreach program for people who identify as Black, Indigenous, Latinx and Somali. Through this program, families can stay connected with a doula until their child turns 2.
People within 200% of the federal poverty level can access the services of the organization, which means a family of four making $53,000 or less would be eligible, according to federal guidelines for 2021.
Doula Margarita Celis goes over a questionnaire in Spanish with one of her clients, Victoria Ramirez, who gave birth five months ago. During postnatal visits, which will continue until the baby is 2 years old, she will talk with parents about the baby’s growth and development and check in on the family’s needs. (Genna Martin/Crosscut)
Sharing the same race
Another element of a doula’s job involves being an advocate for their clients, an especially crucial role when the people they work with could be subjected to medical racism.
In hospitals, people of color may experience different treatment than white patients, said Vonda Prioleau, who manages contract doulas for the birth services program at Open Arms. In practice, this could mean providers neglecting to explain medical procedures or failing to give patients a say in their care. As a result, a doula can serve as the middle person, asking doctors to describe a recommended procedure and why it would be necessary for the birthing person.
Having a doula in their corner might buffer some of the structural barriers people of color face in medical settings. For example, Black women are more likely to die of causes related to childbirth than white women, a phenomenon experts attribute to inadequate health care and chronic conditions that go untreated.
Celis, who works with Latinx families through Open Arms, said most of her clients want to deliver vaginally rather than through a cesarean intervention. Cesarean section procedures can be vital to the health of a baby, but also pose their own risks, including blood clots, infection and death, according to a 2019 story in the Atlantic exploring the prevalence of C-sections. Celis remembered an instance when a doctor wanted to perform the procedure on one of her clients whose labor was progressing slowly.
“She was getting there, little by little,” Celis said. “But the doctor, I think she didn’t want to wait.”
The doctor gave a one-hour time limit. If the patient was not ready for birth by the end of that hour, the physician would push for a cesarean section. The client was ultimately able to deliver her baby vaginally, but the pressure did not sit well with Celis.
“That was not right,” she said. “They’re supposed to wait if they have to wait.”
Beyond having a facilitator to communicate with health care providers, a parent partnered with a doula from a shared community may have an easier time getting culturally-specific needs met.
A Somali doula, for example, may be able to identify culturally relevant, nutritious food for a client, Perera of Open Arms said, while a Latinx doula might encourage a client to ask for an interpreter during labor.
More doulas of color in Washington?
The doula experience varies not only based on the person seeking care, but also on the type of doula providing it.
The topic of affording and accessing training came up during a University of Washington study published in February about addressing systemic racism in doula services, according to Paula Kett, one of the authors. Kett, a research scientist at the University of Washington’s Center for Health Workforce Studies, specializes in perinatal health and public health systems.
She also noted the type of training looked different depending on whether the organization was community-based or more mainstream, the latter referring to those that consider doulas a part of the broader health care system. Of the two, Kett said community-based groups were more likely to cover topics like how to support clients when they experience racism in their medical care.
The study looked at how organizations have worked to recruit, employ and train doulas and sought their thoughts on systemic changes necessary to confront health inequities and make doulas more accessible. Another takeaway, according to Kett, was the desire for community-based organizations to have a greater voice in policy and decision-making relevant to doulas.
Earlier this year, the state Legislature passed House Bill 1881, which gives birth doulas the opportunity to apply for certification through the Department of Health. A certification process means doulas can get Medicaid reimbursement, broadening their ability to work with people on the program, the South Seattle Emerald reported in April.
Several doulas testified in favor of HB 1881 on Jan. 27.
“Like many Black doulas, I was called into this profession through my lived experiences of being harmed and traumatized by medical providers,” said Jazmin Williams, a full spectrum doula and lactation and feeding specialist, during her testimony. Williams, an organizer with Surge Reproductive Justice, described her own birthing experience of being told there were no beds or nurses available for her. “As I was leaving, the doctor pointed to a white woman and said when I look like her, then I can come back."
This experience, she told Crosscut via email, led her to birth work and opening her own birthing practice, BLKBRY.
The ongoing attention to doula services at the state and federal levels may speak to a broader shift in how we think about the birthing experience, including — and especially — for women of color.
“In the birthing process, doulas are at the head,” Perera said. “They’re at the birthing person’s head, whereas other providers are at the feet…. The doula is focused on what the birthing person needs.”
This story has been updated to add more context about Jazmin Williams’s profession and testimony before the Legislature.