Just five years ago, when family health advocate Stephanie Fields would ask a woman receiving services at the city’s Black Infant Health program if they had a doula, more often than not, they would reply by asking what a doula is.

Nowadays, the situation is quite different—and most reply by saying, ‘“Yes, I want one,’” Fields said.

Awareness around the benefits of doulas, particularly for women of color who face numerous health disparities compared to their White counterparts, has risen significantly in recent years, although for many, accessibility remains an issue.

However, this month, Medi-Cal took a step toward improving access and expanded its coverage to include doula services, encompassing all pregnancy and postpartum outcomes, such as abortion and miscarriage.

“We have to start somewhere, where this becomes a regular part of medical care, a regular part of prenatal and pregnancy care, because women deserve it, and they need it,” said Fields, who who first joined the Black Infant Health program as a client and has since worked with the organization for about 25 years.

Fields has been pregnant seven times, although five did not survive, she said.

“I did have someone there, my mom, but just imagine having additional support from someone who could have explained to me the different procedures that I needed to go through,” Fields said. “It takes the fear and the stigma out of those things, so that you can go through with confidence and just know that you’re gonna be OK.”

‘Humanity versus racism’

Black women, specifically, 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. Black infants die at three times the rate as White babies, before reaching the age of 1.

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

Health disparities, particularly among Black Americans, can be linked to generational stressors that trace back to American slavery, and the trauma not just of slavery itself, but of the residual effects of racism, said Gwendolyn Manning, Black Infant Health program coordinator.

“Our priority with Black Infant Health is to expose that reality . .  and then try to implement or infuse their life with tools to help them to reduce stress,” said Manning.

Through group sessions focused on community, connection and empowerment, and other support sessions such as life planning and case management, connecting participants to doula care is a cornerstone at the Black Infant Health Program, which serves pregnant or postpartum Black women at least 16 years old who live in Long Beach or a surrounding area.

“I think about doulas in terms of humanity versus racism,” said Manning, who noted that she was born with the help of a midwife. “History just continues to repeat itself in regard to some of the social dynamics around a woman having to advocate for herself. … We’ve seen this in real time with this program. I’ve seen it in my family.”

Doulas have been proven to improve both maternal and infant health outcomes, said Angie Dixon-Hamlett, a social worker and Black Infant Health program’s team supervisor as well as  doula-in-training.

“You want to see someone who looks like you, so that you can feel comfortable at a time when you’re very vulnerable, and you’re scared,” Dixon-Hamlett said. “The time is now to start bringing back what we probably should have never let go, you know, is having people around us that are going to support us throughout our pregnancy, as well as in postpartum.”

Doulas can play an important role in helping people feel seen and heard in medical care, and with doulas now at the forefront of conversation, there is an opportunity for even more progress, Dixon-Hamlett said.

“It’s that real opportunity to further empower Black women who have been so invisible in so many ways,” Dixon-Hamlett said. “Now they’re going to be really seen and heard.”

Increased accessibility, but an imperfect system

Although Medi-Cal coverage promises to improve accessibility for marginalized communities, a complicated process and low reimbursement rates could remain a barrier.

“Because it’s still in the infancy stages, we have yet to see how fast things will be in terms of reimbursement and the application and medical providers getting on board,” said doula and executive director of Birthworkers of Color Collective Stevie Merino. “But we’re remaining optimistic.”

For doulas who apply to be a provider, approval could take up to 180 days, and then they must also connect with specific insurance companies, Merino said.

For doulas interested in providing services to those with Medi-Cal, being a part of an established organization rather than operating independently will be beneficial when it comes to the administrative side of the process, Merino said.

“This process might be a heavy lift for people who are doing this on their own,” Merino said.

Merino estimates that the Medi-Cal reimbursement rate for doulas will be around $1,200, broken down by specific services, which is quite low, particularly considering the cost of living in LA County, she said.

The average rate in the area typically starts at $1,500, depending on experience, training and skills, with some doulas charging upward of $3,000, Merino said.

“I know that a lot of people were advocating during this process to make it as accessible and easy as possible, but the reimbursement rate definitely should be increased,” Merino said. “I hope and I know that we will be a part of really advocating for that, as this continues to roll out.”

At Birthworkers of Color, many doulas including Merino offer sliding scale services, and services at the city’s Black Infant Health program are also free.

“So many people that I know, especially doulas of color, have been providing these services for free or lower than what the Medi-Cal rate is, so hopefully this will help to offset the work that they were already doing in a more sustainable way,” Merino said.

For doulas who work with particular providers or insurance companies, there will likely be a consistent stream of clients, due to the need for doulas, Merino said.

“We do want there to be an overwhelming interest,” Merino said. “This is a career, and you can make this a career—there can be financial sustainability and security.”

A Long Beach Health Department staff member watches an educational video as part of doula training for the agency’s Black Infant Health Program Wednesday, Jan. 18, 2023. Photo by Brandon Richardson.

A growing interest in doula services

Medi-Cal coverage could play an important role in changing the perception of doulas, Merino said.

As celebrities have shared their experiences using doulas, contributing to doulas’ popularity, it has also created a misconception that doulas are a luxury for the most privileged, Merino said.

“Now people are seeing that no, doulas aren’t a luxury, they’re actually a necessity, and they’re something that anyone who wants one should be able to access, because we all deserve support, right?” Merino said. “I think that that’s really beautiful.”

Insurance providers are estimating that there will not be enough doulas to meet the rising interest, and Merino hopes that Birthworkers of Color, which has a doula training program, will see an increase in people interested in becoming doulas, she said.

But as for how many doulas end up signing to be Medi-Cal providers, it remains to be seen if low reimbursement rates and the complicated process will be a deterrent, Merino said.

“I think there’s still a lot more advocacy to be done, and we have to see what this process is like,” Merino said. “But community doulas and organizations are definitely monitoring and are going to continue to advocate as needed.”

A need for more support

Uplifting culturally competent doulas and organizations through forming partnerships and providing funding is a necessary step toward reducing the health disparities that exist within Long Beach, Merino said.

For an upcoming Birthworkers of Color doula training in March, over 100 people reached out for financial assistance or scholarship opportunities, Merino said.

“We offer as many as we can, but we also often take a financial loss from that,” she said. “I think the next step in this medical benefit, but just in general, is funding culturally relevant doula trainings that are coming from community organizations—that is going to be so important for this work and for this benefit to be sustainable.”

The Black Infant Health Program, which is a statewide program and has had a location in Long Beach since its 1989 inception, received a multi-million dollar funding increase in July 2022—a promising step toward combating the health inequities across the state. Of that increase in funding, the Long Beach program received $816,800.

“As engaging and uplifting and wonderful as doulas are, they can’t do it all,” Dixon-Hamlett said. “We can’t do it all, we need a systemic reinvention to really address all of these inequities.”

The Long Beach center has used its portion of the funds to increase its capacity and services, Manning said.

Although the additional funding went into effect for a year, program staff will be looking for ways to standardize that funding, said Manning.

“Our whole community, not just the Black community, but our whole entire city, state, nation—we cannot say we’re well until all parts of our society are well,” said Dixon-Hamlett. “This is one of the things that I think Black Infant Health does and doulas do, is it helps to remind people that there are things that we can do, there are preventable aspects of labor and delivery and postpartum and prenatal that we really can intervene on.”

Angela Dixon-Hamlett, program supervisor of the Long Beach Health Department’s Black Infant Health Program, demonstrates the proper method of swaddling a baby using a doll at the agency’s office Wednesday, Jan. 18, 2023. Photo by Brandon Richardson.

Next steps

For those who may be interested in utilizing doula services through Medi-Cal, they should start self-advocating and discuss options with a medical provider, Merino said.

Currently, a referral from a care provider is needed, although it is not limited to OB-GYNs, Merino said.

“There’s a long list of providers who are able to essentially sign off on this,” Merino said.

Some medical providers don’t even know that this medical reimbursement exists yet, and some are very “anti-doula,” Merino said.

“I think that was one of the reasons why community doulas really advocated to make sure that the list of providers was very broad, so that no one person or one individual would be able to stop someone from receiving the doula care that they deserve and that they want,” Merino said.

But in the meantime, many of the doulas at Birthworkers of Color Collective have already signed up or are in the process of becoming Medi-Cal providers, and are eager for next steps, Merino said.

Many clients, as well as numerous medical providers and insurance companies have also already reached out to the collective regarding the new coverage.

“I’m sure there will be hiccups and bumps in the road,” Merino said. “But hopefully, there’ll be a lot of good that will come from this.”