Each year, more and more birthing people solicit the services of doulas. Evidently, the scope of the doula practice is becoming increasingly clear.
Research indicates that doulas contribute to positive maternal and infant health outcomes. While this is especially notable in the context of the United States’ worsening reproductive health crisis, we must take steps to understand the historical and cultural significance of doulas and midwives—and acknowledge where we currently fall short in honoring it. Birthwork is an ancestral practice rooted in Black tradition, and yet, today, most of the United States’ doulas are not Black. 61.9% of doulas in the U.S are white while only 10.1% identify as Black. What’s worse, doula services are commonly associated with affluent, white birthing people. The increasing knowledge of the benefits of racially-concordant care and our current reproductive health crisis—which primarily impacts Black birth givers—underscore the necessity of investigation.
A doula is a non-clinical care provider trained to assist people at a major point of life transition. When people use the term today, they are most likely referring to birthing and postpartum doulas. These doulas provide emotional, physical, and informational support to birthing people through pregnancy, birth, and the postpartum period. Like the nature of their roles, the settings in which they practice are various. Some doulas choose to work in hospitals and clinics, while others support clients in their homes or in birth centers. They are an invaluable resource during this major transitional period, especially for our most vulnerable populations.
Unfortunately, the members of our most vulnerable populations are not represented, and part of this is because of their systematic removal. While the history of birth work starts long before chattel slavery in the United States, the first recorded instances of birth work in the United States center the Black Grand Midwives of the American South. Among them was nurse-midwife Maude Callen. Hospitals were often inaccessible to enslaved birthing people, and at many times, trained doctors refused to serve them. In the absence of adequate care and support under the system, midwives, who were trusted members of the African American community, took on the role of supporting the births of enslaved people. They held prominent roles in their communities as a result, and often served as leaders. Maude Callen facilitated home births, set up a clinic outside of her home in one of South Carolina’s poorest counties, and treated ill, impaired, and pregnant people.
While enslavers who looked to maintain their labor force often benefited from the services of birth workers, birth workers centered the health and well-being of their community members before anything else. Black midwives continued to support people in having safe, empowered births long after Emancipation in remote parts of the south. They gained their knowledge from their ancestors, and they passed their knowledge on to their descendants.
Unfortunately, with the rise of the field of obstetrics and gynecology came the dismissal and criminalization of Black birth workers. Physicians of the white medical establishment often competed with, and excluded midwives and other birth workers from their practice. New standards of credentialing and accreditation, along with unfavorable working conditions, pushed many Black birth workers out of the workforce altogether. Black birth workers ultimately paved the way. They bridged the gap between the healthcare system and African American communities, and yet, the emergent system disregarded their care in favor of a more clinical, impersonal approach.
Today, Black people face a slew of other issues that either keep them away from the field of birth work, or push them out of the field entirely. Structural and institutional shortcomings, such as the experience of racism and discrimination within the medical system, excessive caseloads and administrative burden and low compensation make it difficult for the United States to maintain and support its Black birth workers, despite the increasing acknowledgement of their value.
It appears that the United States wishes to call birth workers back in. The maternal mortality rate in the United States has steadily increased over the past few decades. According to the CDC, about 700 birthing people in the United States die each year as a result of pregnancy-related complications. Law makers and advocates are citing doula care as an invaluable resource in improving the United States’ maternal health outcomes. While their analyses and the accompanied statistics are promising, they unfortunately ignore the elephant in the room. The maternal mortality rate disproportionately impacts Black birthing people, and the field of birth work is predominately white. We must work to undo the effects of the systemic racism that pushed Black birth workers, (who heightened the visibility of the practice), out of the field if we are to bridge gaps and improve the outcomes of those our current practices impact most.
The ancestral wisdom and lived experiences Black birth workers bring to their practice has positive implications for the care of Black birthing people, who are among the most neglected under our current medical establishment. Black birth professionals emphasize patient-centered care specifically, which means that they acknowledge the unique manifestation of health issues across all spheres. Recent research studies point to the importance of racially-concordant care for minoritized populations.
In addition to studies on racially-concordant care, findings on the distinct manifestations of condition symptoms for Black birthing people aid in making the case for restoring diversity in the field of birthwork. A new study found that Black birthing people report experiencing less obvious depression symptoms. Researchers found that Black women are more likely to report self-criticism, self-blame, trouble sleeping, irritability, and reduced ability to experience pleasure than the more widely recognized symptoms, like feelings of sadness or hopelessness. What this means is that postpartum depression may also manifest differently for Black birthing people—a reality that other Black birthing people are likely to note during postpartum care.
While the field of birth work is lauded as the optimal solution in the national fight to support the survival and health of our birthing people, it is not a field that is unmarked by the legacies of systemic racism. We must continue to grapple with unsettling realities so that we’re not replicating the delivery of care that happens in the hospital.
The restoration of diversity in birth work is only the start of a longitudinal effort. We must think beyond present conditions and embrace the African diasporic belief that the past, present, and future are interconnected. We must honor the core values that govern the birthing practices of our doulas and midwives—the idea that we can curate safe spaces for birthing people, and that ancestral knowledge about nutrition and the reproductive experience should be widely accessible.
