Show Black doulas the money! The No. 1 problem facing them is pay inequity.

The CEO of the National Black Doulas Association details some of the challenges that Black doulas are up against. 

Black Maternal Health Week, which closes today, began this year with news of a Black family in Texas losing custody of their newborn after following the advice of their midwife about the infant’s jaundice care. 

This ordeal is a “perfect example” of the sort of barriers Black doulas and midwives face while trying to conduct care, Tracie Collins, founder and CEO of the National Black Doulas Association (NBDA), said in a recent interview with theGrio. Collins said while doulas are a key part of combating the troubling Black maternal mortality rate, they face a slew of challenges on the job. A major one is pay inequity.

Collins said insurance companies and doctors’ lack of understanding of the role of Black (and brown) doulas perpetuates pay inequity, the No. 1 problem facing Black doulas. The average cost of hiring a doula is around $1,500, but Collins said white doulas can make between $20,000 and $50,000 more a year than a Black doula. 

“This is why we are working so diligently and quietly until things are solidified with insurance companies to add doulas into their benefits,” she said. 

The pay gap is also a reason that Collins started NBDA, which has business development embedded in its training curriculum and extends the training further through mentorship. “I wanted to teach Black and brown doulas the business aspect,” she said. Not just how to support families. You also have to understand it as a business.” 

Beyond business savvy, the general perception of Black and brown doulas contributes to this ongoing pay inequity. Collins recalled a recent interview she did during which the interviewer erroneously stated that Black and brown doulas offered their services for free. 

“That is why white doulas continue to surpass Black and brown doulas when it comes to pay equity. We are referenced as ‘the community workers’ versus actual birthing professionals,” she said. “There are a lot of doulas who have advanced degrees. You know, there are a lot of doulas who get in there and work with the community but they should not be devalued from a pay standpoint due to the color of their skin. The work is all the same.” 

Meanwhile, there are those other challenges that doulas face. From insurance companies not covering their care to being barred from the delivery room to seemingly being undermined at every turn, they are up against huge obstacles. Collins noted that these conditions exist because physicians and hospitals both lack a cultural understanding of Black and brown families and what doulas and midwives do. “Every birthing person needs a doula,” she said.

By providing necessary emotional, informational — and even physical — support throughout pregnancy, doulas prepare clients for the birth itself. Midwives provide crucial hands-on medical support for the birthing person and baby. You can often find individuals who are certified to offer both types of services. Both, Collins said, should be considered members of a team. 

The evidence of doulas’ success was once mostly anecdotal, but increasingly studies point to their benefits. A National Library of Medicine study, for instance, confirmed that “doula-assisted mothers were four times less likely to have a low birth weight (LBW) baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding.”

According to Collins, doulas increase birthing satisfaction by at least 20%. They also decrease the need for cesarean sections by 20% and decrease the rate of medical intervention by 30%. 

Collins said she hopes perceptions will soon shift in mainstream medicine. Particularly, “cultural competency for hospitals, for doctors and physicians,” she said. “Then a level of accountability with insurance companies, so if [physicians and hospitals] don’t adhere to the set policy when it comes to accountability, there is some repercussion in their dollar, in their pay. And that they have to go through a system of being held accountable.”

Though a lot of what Collins describes are things that require a cultural shift in how doulas and midwives are viewed, there are solutions birthing people can utilize now.

When it comes to affordability and getting Black doulas paid for their vital work, Collins said pregnant people can push back against physicians unwilling to sign off on doulas or midwives and ask for the rejection in writing. “Once you start to create a paper trail, then you know, they tend to straighten up because their major concern in hospitals, and doctors, they’re gonna always operate from liability first,” she said. 

The family in Texas bumped up against this dynamic. Physicians weighing in have noted that the pediatrician — who suggested the family seek medical intervention for the infant and who subsequently reported the husband and wife to Child Protective Services (CPS) when they chose not to after consulting with their midwife — could have potentially been liable if the baby’s condition worsened. 

Collins also said parents-to-be should be wary of any practitioner who doesn’t respect their wishes or challenges how they choose to parent their child. “Those are some key things to pay attention to,” she said.

Further, she stressed that planning a pregnancy healthcare strategy should require at least the amount of research that goes into planning a vacation. This includes thoroughly vetting care providers, reading reviews, getting a sense of the cultural understanding of potential care providers as well as learning their philosophy on doulas, midwives and other desired care approaches. If they’re not in line with your values, Collins recommends seeking out someone else. 

“Just because your insurance company is accepted, they’re in network, does not mean you have to go with this person,” she said. “Really explore your options. Understand your rights. Communicate with a patient’s rights advocate.”  

In terms of ensuring that doulas are paid, Collins pointed out that pregnant people can get creative. “If they don’t have the resources, people can put it on their birth registry,” she said. “Say, ‘Pay for my Doula. I don’t need all of these toys and other things for my child’.”  

Many doula groups around the country make gifting doula services convenient by offering gift certificates. 

Another piece of advice that Collins offered is that pregnant people seek out a certified doula or midwife — it’s a bonus if they’re NBDA-certified because their curriculum specifically trains in Black and brown traditions. Collins recommends also asking doulas and midwives how many births they’ve handled and how many they handle per month. 

It’s also vital to know what’s at stake. According to Centers for Disease Control and Prevention, Black birthing people are 2.9 times more likely than white birthing people during childbirth or from childbirth-related causes. Black doulas and midwives can help navigate the process, provide close-up monitoring and act as a liaison or proxy.

However, they alone cannot solve the systemic racism that can — as the Texas incident might suggest — vilify Black parents and even themselves. “That’s the reason why doulas are not the solution,” Collins said. “They are just a part of the solution.”  

Kay Wicker is a lifestyle writer for theGrio covering health, wellness, travel, beauty, fashion, and the myriad ways Black people live and enjoy their lives. She has previously created content for magazines, newspapers, and digital brands. 

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