Stevie Merino didn’t always know what a doula was, but going into her pregnancy, she knew the importance of having an advocate by her side.

Merino, who grew up in Long Beach on Medi-Cal insurance, had experienced firsthand the difficulties in accessing adequate health care that come with poverty—but with a background in activism and an anthropology degree, along with being married, Merino thought things would be different by the time she was pregnant, she said.

“There were all these correlating things I thought would protect me from the experiences I had read and heard about as a woman of color birthing in the United States,” Merino said.

But when it came to finding an advocate to help her through her birthing process, she was shocked by the scarcity of culturally relevant doulas available, she said.

Throughout her birth experience, Merino became the target of numerous microaggressions.

“I ended up having to kick a nurse out while I was pushing my baby out because she was being rude,” Merino said. “I really had to self-advocate in such an intimate and vulnerable time in my life.”

And Merino was far from alone in her experience.

Black people in particular face the largest health disparities and experienced maternal mortality rates three or four times higher than all other racial and ethnic groups in California from 2011 to 2019, according to the California Department of Public Health.

While many factors can contribute to the stark variability in risk of death, some are particularly prevalent, according to the U.S. Centers for Disease Control and Prevention, including access to care, quality of care, structural racism and implicit biases.

Based on what she went through, Merino became determined to be a small part of a bigger solution. A few months after she gave birth, Merino was on her way to Oakland for a doula-of-color training, with her 3-month-old in tow.

And a couple of years after that, Merino gathered with other birth workers to create a Birthworkers of Color Collective, an initiative that, while rooted in Long Beach, has trained about 200 people across the country and even internationally, and is currently in its 10th cohort.

Still, for people of color, access to doulas remains limited due to a lack of awareness, a lack of cultural competency and a lack of affordability, even as they can help both to prevent bad outcomes and to ease what’s often an understandable distrust in the health care system.

“Hospitals and medical professionals need to do real community work to improve their relationships and their legacies in certain communities,” Merino said. “That’s criminal that someone can be more at risk because of racism.”

“I can’t tell you how many clients I’ve supported where they’ve been asked the most outlandish, disrespectful things, where in comparison, my White clients, they get so much more leeway, are treated with so much more respect,” she added. “I’ve been to so many births and so many hospital visits and doctor visits, the distinction is not left up to the imagination.”

Need for culturally relevant care

Even as Black people may disproportionately benefit from doulas, studies have shown that the doula community is predominantly White, and primarily serves White middle-class women.

It’s a problem that helped push Toi Nichols to found the Long Beach nonprofit M.O.R.E. Mothers, which provides resources and supplies to people who are pregnant or have children. Part of achieving that mission is ensuring people of color are aware of the service and support that a doula can provide, especially in an experience as vulnerable and overwhelming as childbirth, Nichols said.

“You don’t feel so much like a number,” she said. “We try not to make it a thing of the statistics and just harping on the negative aspects that women of color face when they go into the hospital,” Nichols said. “We try to make sure, ‘OK, we know what this is, but let’s work on tools. Let’s have that close support system of a doula or midwife that you feel comfortable with.’”

Educating mothers about doulas is personal to Nichols; when she gave birth to her first child in 2018, she experienced a traumatic nerve injury—an injury that was preventable, she said.

“I didn’t know how to advocate for myself,” she said. “I’m a strong believer that the support that a doula brings really changes outcomes for women of color and their maternal experience in hospitals.”

Nichols used a doula during her second pregnancy.

“We are the ones dying greater than our counterparts, we want someone who can understand what that means and can tap into … that fear that’s brought on because of the facts of the matter,” she said. “Personally, I wanted someone of color, someone that understands the history, can understand my cultural needs and wants and desires.”

For people with language limitations, a doula can be particularly crucial, said Lidia Medrano, a doula and childbirth educator who has worked in the community since around 2007.

“My mom had seven children. She didn’t speak English. She had to sign things she didn’t know she was signing,” said Medrano, who also offers services in Spanish.

Medical professionals should be receiving more training regarding cultural sensitivity, said Medrano.

“I would love for everybody to step back and see the person and family for them and not categorize them. Everybody has different needs,” she said. “We want everybody to have a birth experience that they feel good about.”

While more community awareness surrounding doulas is certainly needed, medical professionals also need to become more aware of the role doulas can play, Medrano said.

“Sometimes doctors (think) we’re just trying to take away clients, but hopefully in the future, (with) more education, more services, more clarity for doctors, it will change their perspective of how we can walk hand-in-hand to support their clients,” Medrano said.

Challenges with accessibility

Still, awareness only goes so far.

Apart from limited doulas of color available and a lack of awareness, cost is one of the largest barriers preventing marginalized groups from accessing doula services, Merino said.

Medical insurance typically doesn’t cover home births or birthing services, so while interest has increased since the pandemic, people’s accessibility and resources haven’t changed.

Some clients have been able to successfully advocate for themselves with their insurance, but not everyone has the same tools to self-advocate, Merino said.

Recently, a few programs have opened up to help fill in the gaps.

In 2021, for example, the Birthworkers of Color Collective became a nonprofit, and with the help of grants, the organization can now provide fully funded doula services to those in need, Merino said.

But offering affordable services can still be a challenge. While doulas such as Merino and Medrano provide sliding scale services when possible, it is not always sustainable, and birth workers deserve a living wage, Merino said.

“While many of us come into this work because we’re passionate, and we want to be a part of eradicating and minimizing birth disparities, it’s my full-time job, how I pay my rent, upkeep the lifestyle my 7-year-old loves,” Merino said. “It’s not just this hobby.”

Other programs, though, are also available.

Within Long Beach, Black residents can connect to the Health Department’s Black Infant Health program. Organizations such as The Victoria Project and the LA County Department of Public Health’s African American Infant and Maternal Mortality initiative also work to provide free services.

And in January, ​the state Department of Health Care Services plans to add doula services to the list​​​​​​​​ of preventive services covered under the Medi-Cal program—demonstrating an increase in awareness and recognition of importance, Merino said.

Another way forward

With doula services becoming more accessible, success stories like that of Malinda McWilliams may become more common.

McWilliams, 36, is from the Los Angeles area but was living in Virginia without any family nearby throughout her pregnancy and birth experience. She used a doula to help provide that much-needed sense of community.

Her doula washed clothes, coordinated a maternity photoshoot, helped her mentally prepare for her birth through journaling prompts and even facilitated a birthing ceremony for McWilliams to reclaim her birth experience, she said.

Since losing her mother in 2017, McWilliams had always tried to avoid hospitals, and she had planned on a home birth, until complications arose during labor and she ended up in the hospital, she said.

“You hear a lot about women of color who go into hospital and not coming out,” McWilliams said. “We don’t feel protected … A lot of times Black women—we are viewed as having really high pain tolerance. If we’re really in pain, it’s kind of like it’s ignored, so just having somebody that’ll be there and advocating for you, it makes all the difference.”

Having a doula and midwife by her side helped to reassure her that she was supported, she said.

“You have this village you have for a lifetime. Because of that experience, we’re family now. It all came together like anything that’s meant to be,” McWilliams said.

For Merino, experiences like McWilliams’ should be the rule, rather than the exception—though she recognizes that doulas should not be the only way to achieve better birth outcomes.

“A lot of health disparities are really rooted in systems, and systems need to change,” Merino said. “There’s so much institutional racism, sexism, there’s so many resource allocation issues and so many other things that need to be addressed that were highlighted during this pandemic.”

Although doulas play a role in tackling health inequities, they are only a piece of the solution, Merino said.

While everyone who wants a doula deserves to have access, it is also a shaky space, where doulas are being propped up as the answer to maternal health, Merino said.

“We’re not supposed to do this on our own,” Merino said.

“We truly need community in order to have an optimal experience,” Merino said. “Can we do it alone? Sure, many of us have been. There’s this ‘Supermom’ trope, but we lose a lot from it … hopefully having doulas and having support can truly shift that narrative.”