A doula provides support and advice to a new mother. Photo: Kenneth Dickerman/The New York Times/Redux

On the December day I found out I was carrying a baby, the only thing I could think about was my own mortality. Weeks before I got the news, I’d read a blockbuster report by NPR on black maternal death. In New York state, black women die in childbirth at three to four times the rate of white women; that’s also the national average. In New York City, where I live, black women are 12 times more likely than white women to die in childbirth, according to a report by ProPublica.

So many black women die in childbirth that it drags America’s maternal mortality rate high above other wealthy industrial nations. “Black expectant and new mothers in the U.S. die at about the same rate as women in countries such as Mexico and Uzbekistan,” the report said, referring to data from the World Health Organization. Studies have shown that neither income nor educational background matter. In a country where how much money you have defines the care you get, being middle-class is no insurance policy for a safe childbirth. “College-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school,” NPR reported. Even America’s most famous tennis player, Serena Williams, had an avoidable near-death experience when she gave birth.

I didn’t talk about my fear of dying with anyone, not even my partner. It was as if I thought talking about it would make it more real, harden the probabilities. In our early conversations, my husband Evan (then boyfriend) and I talked a lot about money. We wondered how we would afford day care, which is prohibitively expensive in our city. I joked with him about how many organs we’d each have to sell in order to purchase a two-bedroom apartment in our neighborhood, where the average price for one is $2.65 million. But I knew that I could not leave my life in the hands of doctors alone, however well-intentioned, and that meant there was one more expense we needed to run: a doula. More specifically, a doula of color.

Doulas are birth workers who help women prepare for birth, aid in the birthing process, and provide support once the baby is born. Their specific responsibilities can look different for every expectant mother: They are a combination of a strategist, advocate, confidant, outside opinion, and aide. Hiring someone to fill all of those roles simultaneously is not cheap, but I knew it was worth it.

According to the American Pregnancy Association, doulas help to decrease the overall Cesarean rate by half, the length of labor by a quarter, and requests for an epidural by 60 percent, so they are an amazing tool for black expectant mothers who face high mortality and morbidity rates. ProPublica reports that black women are almost 50 percent more likely than their white counterparts to deliver prematurely, and those premature births put infants at risk. Nationally, black infants, ProPublica says, are twice as likely to die before they turn 1, regardless of a mother’s income and education.

We ended up shelling out a whopping $2,400 (normal for an experienced doula in New York City) for our doula duo, Elizabeth Perez and Yael Borensztein, whose company Root and Spark was my first choice. The duo were attentive and internalized my concerns about being a black woman giving birth in New York City. And having worked at well over 100 births combined, I trusted they knew their way around a hospital.

But low-income mothers in New York don’t have access to this kind of support, and the state is trying to change that. On March 1, New York launched a pilot program that expands doula services and birth coaches to women on Medicaid in Erie County, in upstate New York. The pilot program was originally supposed to include Kings County (affectionately known as Brooklyn), but was postponed after not enough doulas signed up, according to a spokesperson from the governor’s office.

The state’s original press release for the program said it was “part of the Governor’s multipronged initiative to target maternal mortality and reduce racial disparities in health outcomes,” but the pilot failed to launch on time in Brooklyn, where 34 percent of the population is black, as opposed to Erie County, where the black population is less than half of that. Caitlin Girouard, press secretary for Governor Cuomo, said in a statement that they would continue to work with local groups in order make sure “as many doulas as possible are made aware of the program”. The Kings County part of the pilot is now considered “phase two” of the program, and will launch as soon as enough sign up.

Doulas are generally perceived in popular culture as extraneous, a tool for the bourgeois. But doulas serving communities of color are anything but. Perez and Borensztein gave me open-ended advice throughout pregnancy (I can’t tell you how many texts I sent my doulas about my acid reflux); therapeutic services (the emotions associated with pregnancy are tough!); and creating a birth plan (I felt strongly about waiting at least a minute to cut my baby’s umbilical cord). Doulas help mothers through the birthing process itself, which can take days, making sure unneeded medical interventions don’t take place, and being around after it’s done for breastfeeding support, emotional support, and any of the other myriad questions new moms have during the postpartum period. One doula, Tia Dowling-Ketant, told me she has stopped doctors from breaking a woman’s water without consent, an intervention that is sometimes unneeded. For low-income mothers, a doula can help find free or low-cost resources.

My labor came on quickly — my contractions started at about two minutes apart and consistently lasted up to 45 seconds. I knew it was time to go to the hospital, but when we called my doctor, she suggested that since I could speak through some of my contractions I should continue to labor at home. It was Borensztein, a certified nurse, who stepped in and stood up for me when I didn’t have the wherewithal to do it for myself. (We went to the hospital a few minutes later and I was almost fully dilated.) When more than ten hours into my labor I had developed preeclampsia, a life-threatening pregnancy complication, I asked my doctor questions and my doula reported back to us, in layman’s terms, what was going on and what it meant for my labor. After I gave birth, Borensztein, who had been with me for 15 hours, swapped with her partner, Elizabeth Perez, my other doula. It was Perez who helped me with my immediate postnatal care, never leaving my side in those first couple of hours, and speaking with nurses who were in and out.

My doulas were my translators and my caretakers when I was confused, bleary-eyed, and exhausted during my 15-hour labor. If I didn’t have a doula, I’m positive my foray into breastfeeding would have lasted two days, not six months (and counting). When my child couldn’t latch onto my left breast 48 hours postpartum, I got in touch with a lactation consultant. Unfortunately she charged $325 for a 30-minute Skype session. So I called my doula, who talked me through what to do to fix it, and my baby was able to latch again within a few hours.

Doula Tia Dowling-Ketant with some of the women and babies she’s worked with. Photo: Courtesy of Tia Dowling-Ketant

On its face, New York’s program seems like an excellent idea. Get doulas, who are proven to lower C-section rates and medical interventions, to help women who need it most. But the devil is in the details, and in Medicaid, the most important detail is the reimbursement rate. The reimbursement fee set for doulas in the pilot program is $600, according to an administration official for the governor’s office, and will include four prenatal visits at $30 each, plus labor and delivery at $360, and then four postpartum visits each at $30. The official says that comes out to $23 an hour, $7 above the state’s minimum wage. Doulas, who are unlicensed, the official says, are expected to make 54 percent of the total Medicaid fee that would be paid to doctors, who are licensed.

New York’s reimbursement rates are in line with precedent. Minnesota’s program, which started in 2014, offers parents on Medicaid up to six doula visits, plus assistance at the birth — all told a doula is entitled to about $400 per client, a paltry amount when you think about how much money it takes a person to live comfortably in a state where the median annual income is about $65,000. Oregon’s rate is $350 for only four home visits and assistance during the birth, according to its website. But in New York City, where the average rent for a two-bedroom apartment in Brooklyn is $3,200, some doulas argue that it’s nearly impossible to take part in the program and pay their bills.

On a gray and bitter-cold day in February, just two weeks before the state’s implementation of New York’s pilot program, a group of black doulas, local organizers, parents with babies, and community members gathered to protest the reimbursement rate the state of New York plans to give doulas for their work. As a dramatic backdrop for the protest, SUNY Downstate Medical Center in Brooklyn is a hospital infamous for its high black maternal death and morbidity rate. According to ProPublica, at SUNY Downstate, where 90 percent of the women who give birth are black, 62 percent of women who hemorrhage while giving birth experience serious complications. The state average is 34 percent.

“It’s not in my best interest,” said Ali Anderson, a doula and one of the organizers of the protest, led by a group called Black Youth Project 100 (BYP100) and a community-based doula services and training organization called Ancient Song. The groups are demanding that the city reimburse doulas $1,500 for their services. As Anderson explained, the reimbursement costs weren’t enough to cover the cost of child care, commuting, and the job itself. “A doula is with a client for days at time and $500 [the proposed rate when I talked to her] doesn’t offset my cost of living,” she said. Kiki Valentine, a doula and breastfeeding activist agrees — the structure of Medicare reimbursement makes it a dubious proposition. “This cap absolutely deters more experienced doulas,” she said.

Dowling-Ketant, who is black, told me it’s important for her to do community-based work but is upset by what the state thinks her services are worth. “I feel like it’s an insult,” she said. Dowling-Ketant, who has private clients as well as low-income clients known in the industry as “community clients,” says she didn’t expect to make big bucks through the Medicaid program, which is why she has a private client base, but thought she’d at least be entitled to $60 per visit. “I treat all of my clients the same. If I spend an hour and half with my private client, I do the same for my community client,” she said. But the truth is that community clients sometimes need more attention than those who can afford to pay higher rates. “I’m helping someone find resources,” Dowling-Ketant said about her community clients. “It’s about helping someone find access to a food pantry, to mental health care, to housing. You need to cover a lot of stuff.”

Another disincentive for doulas interested in the program is the red tape and disorganization they say surrounds the program. “I want to serve Medicaid clients,” said Anderson, but for starters, she doesn’t even know how to bill for Medicaid, a laborious process. Assemblywoman Michaelle Solages, one of the bill’s sponsor’s, agrees. Doulas, she said, “have to put in for the services and hope that insurances and Medicaid gives them money back.” Fighting to get reimbursed, the assemblywoman said, is “unsustainable.” The governor’s office, for its part, says it has held a number of webinars and meetings over the past few months to help guide prospective doulas through the onboarding process.

While the governor’s doula Medicaid reimbursement program is new, Brooklyn has had its own version since 2010. By My Side, an initiative that provides doula services to low-income New Yorkers, will continue to operate in certain areas of the borough. The governor’s program will eventually provide services in areas of the city that do not already have an existing program.

Doulas, like doctors, get better with experience, and the rate of pay for doulas reflects that. Industry standards for are commensurate with experience: If you have been at more than 100 births, you are considered a tier 6 doula and pay is generally $2,300 and up. But low-income women aren’t afforded that same choice. The government-sponsored program will, fears Dowling-Ketant, attract less-experienced doulas who will do the work for lower pay. Ultimately, Dowling-Ketant says of the pilot program, “you’re trying to do something but not really.”

But, it’s just the beginning for New York, says Laura Vladimirova, director of programming for the Women’s Center at Marks JCH of Bensonhurst, who sat, briefly, on the steering committee for New York’s upcoming doula Medicaid pilot program. “When you’re dealing with institutions, it’s always going to be a slow process, it’s never going to be stellar,” she said. While Vladimirova, who I spoke to by phone, is hopeful for the future of this program, she isn’t shy about its current limitations and says the pay falls short. Assemblywoman Solages agrees. “We’re trying to figure out how to fund doulas,” Solages told me over the phone. “This pilot program is to flesh out the issues and we hope to expand it.”

New York has begun the long and uncomfortable process of facing institutional inequalities around how black babies are brought into this world. It’s just the beginning, and a lot needs to be done in order to make this effort work in earnest. And it’s important. Black life hangs in the balance.