In New York City, Black women are eight to twelve times more likely to die from pregnancy than their white counterparts, and nearly three times as likely to develop a life-threatening complication during delivery. The racial disparity, which also exists on a national level, prompted Mayor Bill de Blasio's administration to announce a slate of reforms in 2018 that largely focused on increased hospital care at the city's public hospitals, better reporting, and public education.
Now, mayoral candidate Eric Adams is proposing a city program that would offer doulas to all first-time mothers. Often described as birthing coaches, doulas help women throughout pregnancy, birth, and after they give birth. New York City has seen scattered programs over the years but no comprehensive large-scale effort to date. Last year, a maternal home visits program launched by First Lady Chirlane McCray was canceled due to a lack of funding.
Since the race began, Adams has aggressively campaigned on the issue. A known health evangelist, he has frequently linked a child's experience in the womb to later life outcomes. Other candidates, including Andrew Yang, have also floated the idea. The use of doulas has been endorsed by many leading health experts, including the Centers for Disease Control and Prevention and the World Health Organization.
The list of potential benefits are significant. According to a 2019 New York City Department of Health report, "Doula care has been associated with lower rates of Cesarean birth, preterm birth, low birthweight, and postpartum depression, as well as with increased rates of breastfeeding, and greater patient satisfaction with maternity care."
Lynn Freedman, an expert on maternal health at Columbia University, said, "I think there’s little dispute that it can be a good thing." But as with any policy, she cautioned, "The devil is in the details."
In a recent interview, Adams walked Gothamist through his plan and for the first time provided precise numbers as well as a rollout strategy.
Aside from providing nutritional, physical, and emotional support, Adams said that he believes doulas can break down institutional healthcare barriers, especially for low-income people of color.
He said, "If you have a doula that's culturally sensitive, that is knowledgeable about the different cultural norms, and can get inside the household and could have those home visits with the mothers, they can start identifying with them on a level that they understand."
What is Adams's plan?
Adams said he intends to start his doula initiative through a pilot program that would pay for 55 doulas spread evenly across the city's 11 public hospitals, also known as the Health + Hospitals (H+H) system. Those 55 doulas would cover around 2,000 births, according to Adams.
Eventually, the full H+H program would increase to 150 doulas covering about 6,000 births.
For context, roughly 120,000 babies are born in New York City in a typical year.
Who qualifies for the plan?
Adams said he plans to offer free doula services to neighborhoods where residents face high risk factors: those with low access to quality healthcare and nutrition, high levels of chronic diseases, low-income mothers whose first language is not English, and communities with high cesarean rates. A 2016 study found that Black women in New York City had the highest rate of cesarean births of all racial and ethnic groups.
So would the program only be offered for poor or at-risk women?
No. According to the campaign, as the H+H program grows, it will be offered to all women who want to opt-in, but those who can pay out-of-pocket or use insurance will be required to do so.
How much would it cost? And how could it be funded?
Adams's campaign estimated that the pilot program would cost about $5 million a year. The full program, with 150 doulas, would cost about $10 million annually. The campaign said that the cost of the full program is cheaper per birth because the pilot includes start-up costs.
Funding would come out of the city's budget, but Adams said he is eyeing Medicaid for partial reimbursement. According to a recent Washington Post story, only three states—Minnesota, New Jersey and Oregon—have subsidized doula services through Medicaid. According to the paper, research has suggested that the use of doulas might lead to overall healthcare cost savings through fewer c-sections and pre-term births.
In 2018, New York launched a Medicaid pilot program to cover doula services in Buffalo and Brooklyn. But the pilot's low reimbursement rates resulted in a lack of doula participation, forcing the state to suspend the pilot.
There are also outside funding sources. Freedman, of Columbia, cited the pharmaceutical company Merck, which doles out grants to cities through its initiative Merck for Mothers, which seeks to reduce maternal mortality across the world.
But irrespective of other funding, Adams said he is committed to having the city fully pay for the program. His campaign added that as women who can pay for the services out-of-pocket or through insurance sign on to use the city's doulas, the hope is that the program could be self-financed.
How many doulas are there in NYC?
There is no official count of doulas in New York City because the profession lacks a uniform certification system. However, the Department of Health in 2019 noted that the Metropolitan Doula Group, the largest doula network in the city, estimated that there are 200 to 300 birth and/or postpartum doulas working in New York City.
Would the program entail training for new doulas? How much do private doulas typically charge?
Yes. Adams said that he envisions increasing the number of working doulas through training programs. He noted the short duration of the training, which typically takes between two to three days.
A city survey found that birth doulas charge on average $1,550 per client, with a range between $225 to $5,000 covering between two to 12 home visits. Private insurance companies do not typically reimburse for doulas but some may cover some of the costs.
Expense has been one of the reasons doula use has traditionally been skewed toward white upper-class women. But there has been a growing movement to bring low-cost doulas to communities of color. In Brooklyn, Ancient Song Doula Services focuses on reproductive justice. A 2018 New York Times story reported that a majority of its clients were women of color and that more than half of the doulas themselves were low-income.
Adams estimated that under his program, doulas working for the city could earn $60,000 a year. "That's a good middle-class job," he said.
Have other cities launched a similar program?
A number of cities, including New York and Baltimore, have implemented doula training programs. But as mentioned above, the broader push to integrate doulas into the healthcare system has been through states which have mandated the coverage of doula services through Medicaid.
New York City would likely be the first city to finance its own doula program.
What do doulas think of the plan?
Jesse Pournaras, a New York City doula and women's healthcare advocate, said she was glad to hear mayoral candidates talking about doulas although she had questions about how the city could afford such a program during a fiscal crisis. "We need to be paid a living wage and the city has some serious budget limitations right now," she said.
She also noted that the industry is divided about doulas being employed by hospitals. For example, would such doulas feel under pressure to curtail their advocacy based on hospital rules? And would they be restricted to working scheduled shifts that compromise the continuity of care for clients?
When it came to expanding training, Pournaras suggested having the city enlist doulas to conduct community-based training for anyone who wants to be a doula so as to enable new expectant mothers to enlist the support of their own friends and family.
In general, she said the pandemic had raised the role and importance of doulas. Last spring, as hospitals closed off maternity wards to visitors for fear of spreading coronavirus, she successfully petitioned the state to force hospitals to allow doulas to accompany pregnant women.
She said the resulting executive order from Governor Andrew Cuomo amounted to the state recognizing doulas as essential workers.
"We’ve hit this moment where I think programs like this are finally ready to get off the ground," she added.
This story is part of The Big Idea, a series explaining bold and interesting ideas pitched by candidates in the mayor's race. Listen to WNYC's All Things Considered for an interview with the reporter about the plan and more news from the campaign trail.
