According to the Centers for Disease Control and Prevention, the maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births. That’s a steady rise from 2018 and 2019, which had rates of 17.4 and 20.1, respectively. This follows nearly three decades of significant increases.
In Delaware, strides have been made to reduce maternal mortality rates. But following national trends, those strides are not reflected in the Black population.
In 2019, Black women made up 28% of live births in Delaware, but they represent 78% of pregnancy-related deaths over the 2017-2021 period.
“The problem is that we know that this is an issue and there’s not enough people talking about it,” said State Rep. Melissa Minor-Brown, who has been actively working to bring attention to this issue and implement solutions.
In 2022, she was the prime sponsor for two bills that work to increase access to doulas – like Jade Johnson – who is a practicing doula in Delaware and surrounding states.
“So, a doula is a professionally trained labor coach or birth support person who provides mental, physical, educational, and emotional support for pregnant women throughout labor, birth and postpartum,” Johnson explained.
Since starting her doula training in 2017, Johnson says she’s noticed an increase in demand for doula services. She attended 17 births last year, up from seven the year before.
Doulas are not a new phenomenon, but nationwide there’s been an increased focus on their ability to improve birth outcomes. Unlike midwives or doctors, doulas do not deliver babies or perform any type of medical intervention. Their space in the birthing process is one of support for the mother and family.
Upon examining the root causes of the high rates of maternal mortality, and what Minor-Brown refers to as “near misses” in the U.S., it becomes clear that advocacy is a well-grounded solution.
There is widespread coverage of birthing people, specifically Black birthing people, having their voices silenced. Tennis champion Serena Williams experienced complications following her c-section and nearly died when her concerns were dismissed.
Shané Darby, the founder of Black Mothers In Power and a Wilmington City Council member, says doulas help remind their clients that they know their bodies best.
“Doulas, when they’re present, are able to empower their clients, the people that they’re working with. The birthing people. To have them ask questions, speak up for themselves, understand their body. Being able to articulate that and communicate that to healthcare professionals. And a doula is there to also give support when they feel like their birthing person isn’t being listened to. Giving them the resources that they need to be heard when they’re dealing with their doctors or the healthcare system,” said Darby.
Cultural competency also plays a large role in a doula’s ability to connect with their client. Being able to employ a doula from a similar background, whether that be racial, geological, or socioeconomic, has several benefits. For the doula, they have a leg-up in understanding some of the baseline needs of their client. And for the client, there is an increased level of comfort.
Noting that it is currently a white woman-led profession, Black Mothers In Power is taking a multifaceted approach to increasing diversity in doula work. This means allowing clients to find Black birth workers more easily.
“On our website, we have the first directory of Black birth workers. So that could be community health workers, midwives, doulas, OBGYNs. We’re currently building up our database more. That directory is currently on our website,” Darby explained. “So people who are looking for a doula, or need a doula, they can go look at the directory and contact people individually. Or they can fill out a form and their information will go out to all of the doulas who are currently on that platform.”
It also means increasing the number of Black doulas in the state overall, which Black Mothers In Power is doing through their Community-Based Doula Training Program. Based in New Castle County, BMIP recruits, trains, and helps to certify ten doulas each year.
While their program isn’t specifically for New Castle County residents, having doulas live and work within their close community is an advantage.
Similar doula training is occurring statewide. In Kent County, the Do Care Doula Foundation trains doulas through their Central Delaware Community Doula Program. And in Sussex County, the Parent Information Center runs the PIC Community Doula Program.
But an increase in doulas in the First State means nothing without access.
Minor-Brown’s doula-focused bills were introduced with the data-driven understanding that increasing access to doulas in communities would lead to fewer negative birth outcomes.
House Bill 343, signed into law in July 2022, required that the Division of Medicaid and Medical Assistance present a plan to the General Assembly by November 2022 for coverage of doula services by Medicaid providers.
“I received DMMA’s report on November 2nd, 2022. And I now have a bill that is drafted because it seems very feasible for us to cover doulas under Medicaid,” said Minor-Brown. “So I have a bill that is drafted and it will be circulated in the next week or so that mandates that DMMA provides reimbursement for doulas.”
Both Minor-Brown and Darby agree that financial ability should not be a barrier to receiving a full spectrum of maternal care.
Black Mothers In Power is deploying doulas in low-income communities through their Community-Based Doula Service Program. The pilot program, funded through the Wilmington Housing Authority, provides free doula services to pregnant individuals living in WHA housing.
Understanding that the maternal health crisis and the racial disparity gap within the crisis were exacerbated by certain groups not receiving optimal care, the First State is focusing on not leaving anyone behind.
Another one of Minor-Brown’s bills, House Bill 345, provides access to doula and midwifery services for pregnant women and up to six-week postpartum women in custody in Level IV or V prison facilities.
“Imagine being incarcerated. You’re already in a higher level of stress. And you don’t even know if you’re going to be able to hold your baby, you don’t know where your baby goes afterwards,” Minor-Brown emphasized. “Just that stress level that women have being incarcerated… we need to make sure that they have someone that they can talk to. Someone who can help them reduce that stress. Someone that can be there for them emotionally and physically.”
Increased prenatal stress is directly associated with adverse pregnancy outcomes. This includes low birth weight and preterm birth, both of which put infants at an increased risk of death. Long-term stress can also lead to high blood pressure, which during pregnancy brings an increased risk of life-threatening conditions such as preeclampsia and gestational diabetes.
In addition to doulas reducing stress through emotional support, they also reduce stress through educating birthing people on the risks of pregnancy, working to avoid complications through preventative measures in a manner tailored to the background and needs of the birthing person. For incarcerated women, having a doula who understands their stress from firsthand experience could be life-changing.
This is something the state is tapping into, according to State Rep. Minor-Brown.
“We have another organization that is actually coming in that is interested in providing doula training to women who are incarcerated and eligible to receive that training. So that they can really have those tools under their belt for when they are released from prison and they may encounter a woman who is incarcerated, or was recently incarcerated, and they may be able to relate to that woman which is so important,” she said.
According to the Maternal Mortality Review Committee, from 2017-2019, more than 80% of pregnancy-related deaths were preventable. Some of the leading underlying causes of death include mental health conditions, excessive bleeding, infection, blood clots, and hypertensive disorders.
In addition to working with the client's mental health and overall reducing stress, the educational work of doulas includes providing more options for birthing people. This includes reminding them that cesarean sections, the use of which are on the rise globally, may not be the best choice for everyone.
C-sections are surgery, and increase the risk of infection and other post-op complications.
Johnson makes it clear that c-sections are sometimes the safest option, but notes that they are often pushed onto birthing people. A key component of her work is making sure that her clients are empowered, understand their options, and feel safe in saying ‘no.’
“There’s a time and a place for everything. A lot of people think doulas are anti-C-section, or anti-induction, or anti-whatever. We are pro-informed consent and informed decisions. So there’s gonna be a time and a space for a c-section. There’s gonna be a time and a space for everything,” Johnson explained.
In a medical system where Black birthing people are made to feel powerless, doulas help to increase options, reduce fear, and bring autonomy back to birth.
For those interested in getting a doula, Minor-Brown points them to the Healthy Mothers and Infant Consortium for resources. And Darby notes that until Medicaid coverage is implemented, the Black Mothers In Power Relief Fund can help put money toward any birthing person looking to boost their birthing team.
