Last month a bill quietly passed through the New York State Legislature that puts birth workers, commonly known as doulas, on a path to becoming professionalized in the eyes of the state. The bill says that doulas can now be certified in the state of New York by taking courses at (as of yet, unspecified) organizations chosen by the Health Department, an entity that has “had an existing relationship with doulas,” said Amy Paulin, the bill’s sponsor. Paulin, who represents the 88th district, says professionalizing is always a good thing: If the state lends legitimacy to doulas by allowing them to get certified, then hospital staff will feel more comfortable with their presence, and it will hopefully position doulas to make more money. The governor has not yet signed the bill.
Doulas are birth coaches, hired to help people through the pregnancy, birth, and postpartum process. A big part of a doula’s job is to encourage clients to advocate for themselves so that they have the best birth and postpartum outcomes. But no doulas were involved in the crafting of this bill, and for many of them, the legislation feels like a punch in the gut. “We are autonomous,” said Samantha Huggins, co-founder of Carriage House Birth, one of the handful of organizations in New York that provides certification for doulas. “We are not beholden to the medical-industrial complex and that’s why this bill is very triggering for us,” she said. Among her concerns, Huggins listed the prospect of working with insurance companies, hospitals, and the state as drawbacks. If this bill is signed by the governor, Huggins said, “it will make it different to earn our clients trust and function the way we currently do,” because doulas will no longer be operating completely outside of the government.
For doula-certification organizations, it’s a possible hit to business. “This is harmful to New York families,” said Huggins, “and to New York small business,” she said, adding that a doula who’d signed up for Carriage House’s certification course has pulled out, citing the bill’s passage. Carriage House, like all other doula-certification programs, runs the risk of not being approved by the Health Department.
Many leading doulas are also finding the bill’s language confusing and are concerned about its reach, something that might impact birth workers’ ability to be effective support systems for their clients. “If your mother came in and wanted to squeeze your hips and encouraged you to ask questions then that they would be semi-outside of the parameters of the new law, because they’d be providing emotional support and seek evidence-based care,” said Huggins, criticizing the law’s vagueness. “They would be acting as a doula.” When I posed the question to Assemblywoman Paulin, she assured me that “all the legislation does is allow doulas to have an added credential,” and that people would not be denied entry into a hospital without the credential.
But the assemblywoman also said that this is possibly just the first phase of professionalization. Paulin sees it as a stepping stone to another bill that will require doulas to have a license. The rationale, she said, is that mandatory state licensure could pave the way to guaranteeing that doulas would be able to get Medicaid reimbursement from the federal government for their work with low-income women. “The next step would be to do a law after this,” she said, “that says doulas are entitled to Medicaid reimbursement and can get a federal match,” so that, she said, “they can make more of a living wage.” The new pilot reimbursement program, she conceded, is inadequate. “Maybe they would be licensed at one point, which would have credentialing in a different way,” she said, with “additional requisites to fulfill.”
Expanding Medicaid to include a reimbursement for doulas is part of a larger push to address the staggeringly high rate of black maternal mortality: In Kings County, the black maternal mortality rate is 12 times what the rate is for white women. It’s a fact that Chanel Porchia-Albert is acutely aware of as founder of Ancient Song Doula Services, an organization focused on providing services to women of color and low-income women, and that also provides certifications for doulas. Porchia-Albert said she finds the bill as it currently stands to hurt community doulas rather than help. “You have to be clear about language, especially when you use black maternal mortality as a reference,” she said. “Did you speak with anyone?” she said, referencing the bill’s sponsors. “The answer was no. ‘We spoke with the Department of Health.’ That’s not community,” she continued. “That’s not a reflection of people who are disproportionately affected.”
In March, Governor Cuomo’s office launched a pilot program in conjunction with the Health Department to expand Medicaid to include a reimbursement for doulas, a way to give low-income women access to doulas. The pilot program was supposed to launch in Brooklyn, where 34 percent of the population is black, and in Erie County, where the black population is less than half of that. But the pilot program only launched in Erie County. Caitlin Girouard, press secretary for the governor, told me: “We are continuing to provide Medicaid training and outreach to the doulas of Kings County.”
Porchia-Albert also takes issue with other aspects of language found in the bill. Tucked in the bill is a line that determines a doula will be provided a New York certification based in part on “good moral character as determined by the department,” which Porchia-Albert said could deter or even prevent formerly incarcerated women from becoming doulas. “This is trying to disenfranchise the people who are trying to do the work people need the most,” she said, adding that another requirement, a $40 application fee, can also be a deterrent for women seeking to do community-doula work. “The intention of this bill is good,” said Kiki Valentine, a breastfeeding advocate and doula, “but the execution was not.” Valentine echoed Porschia-Albert’s concerns around “good moral character,” and the lack of attention paid to black and brown doulas in the process of crafting this bill.
When I asked Paulin why she didn’t work with doulas on the legislation, she said “it would be the more common thing for constituent groups to reach out to legislators,” adding that “it goes both ways.” But the sponsor has vowed to bring doulas into the fold to come up with some amendments to the bill before it goes to the governor’s desk and met with doulas in a town-hall meeting last week. Another of the bill’s co-sponsors who was present at the town hall, Michaelle Solages, told me that she is “very close to the doula community” and plans to “advocate so we can make a legislative fix in the future,” Solages said. “I always want to be there in helping them.” She reiterated this point to the doula community during the town hall, and said she had only been made aware of the controversy surrounding the bill right before it went to a vote.
Paulin cited the professionalization of midwifery through licensure in New York State as a model for doulas, but the state’s support of midwives is anemic at best. In the beginning of 2019, Mount Sinai, a hospital in New York City, closed its birthing center. According to a report released by Every Mother Counts, “nearly half of NYC hospitals with maternity units have no midwives attending births (18 of 39) as well as more than one-third of hospitals in NYS (46 of 125),” and attended only 10.1 percent of all births in the state in 2015. The report also addressed how little midwives are reimbursed from health-insurance companies as compared to physicians; they are reimbursed 85 percent of what a doctor would receive “for the provision of identical services.”
“It feels like the state is in our vaginas,” said Valentine in our initial conversation. Solages, for her part, says, “We have to make sure that the professionals are trained professionals that are not going to harm women.” But Huggins offers a reminder of the sobering statistics of New York. “People who are in power have not done right by New York families and that’s why we exist,” said Huggins. “Why do people even hire doulas? Because they want support and we been through the path many times. We’re the trail guides. If we’re not autonomous, it won’t be the same.”