Laura Cofino hasn’t always considered the hospital to be her safe place. She has an autoimmune disease that requires her to spend too much time inside sterile, white linoleum walls. So, when she thought about having a child; she knew immediately that if her birth was in one, she would need to have a doula – someone there to support her wishes – by her side.
This became a reality when Cofino was told she needed to have a hospital birth. A friend referred her to local doula and childbirth educator, Debbie Hull.
“I knew a bit of what I was getting into, and I really wanted to have increased support because in the hospital everyone is attentive, but they are attentive when something is happening or an emergency, not necessarily in between or during downtime,” Cofino said.
Hull, who has assisted as a doula in hundreds of births, often has to tell those interested in her services that her role is not that of an obstetrician or a midwife as she is not licensed to deliver a baby or provide direct medical advice. Instead, doulas are certified care providers, and their job is to assist with the physical, emotional and informational support of the mother and her partner and loved ones before, during and after childbirth.
Not all doulas maintain these boundaries, and those that do not, contribute to a slight stigma in the medical world against doulas, Hull said. Careful scrutiny before engaging a doula is warranted, she and other medical professionals said.
According to Hull, in the last few years there have been an increasing number of women opting to have a doula – whether they are having a birth in a hospital, at home or at a birthing center (a freestanding facility not attached to hospital.)
Hull said the rise in doula usage has to do with the internet, having more doulas available and the increased attention to maternal well-being, “There used to be only a handful of doulas in the entire city, I’m talking maybe 10 and now there are dozens and dozens,” Hull said.
However, there are some obstacles in accessing doula care in Texas as it is only covered by private insurance –contingent on the provider – and not by Medicaid, according to the U.S. Department of Health and Human Services.
Dr. Sarah A. Hoopes, an obstetrician and gynecologist at Houston Methodist and St. Joseph’s Medical Center said that the lack of government insurance coverage makes it more difficult for patients like those at St. Joseph’s – a hospital that treats primarily people from lower socioeconomic backgrounds – to hire a doula as they may not have the financial means to pay for this care out of pocket.
The costs of a doula’s service vary per provider, but the average range reported by Major Care – a website connecting users to birth and postpartum providers and information – is anywhere from $800 to $2,000+.
However, Hull said a majority of doulas tend to be closer to the $2,000 range, especially if being a doula is their full-time job – otherwise the lower rates and the number of clients would not allow the doula to continue in the line of work, she said.
Most obstetricians and midwives encourage their patients to have a doula, because when their jobs are done right, they provide help for them and are an additional person in the delivery room with an in-depth knowledge and experience with birth, Hoopes said.
Cofino said thanks to Hull, her entire birthing process, both before, during and after delivery went better than she had expected. She said Hull asked her questions and made sure she felt comfortable about the little things that hadn’t crossed her mind – like choosing whether or not she wanted to wear a gown from the hospital or get an IV.
“There were things that I wouldn’t even consider that she would say were worth considering for my comfort level and ability to get through the rest of my labor,” Cofino said.
Although Cofino’s initial birth plan included trying to avoid any medical intervention, such as getting an epidural; this plan went out the window when Cofino’s OBGYN notified her that she wanted to induce her around the 39-week mark. Hull was constantly in communication with her – in person and over text and phone calls – to weigh Cofino’s options.
“We kind of joke about it now, but I had to have every medical intervention that you could think of, that I didn’t want, but Debbie was there to talk through it all, give me more context and guide me,” Cofino said. “The childbirth I experienced wasn’t necessarily the one I wanted and left me with some medical trauma as a result, but even after it all she was there for me, and we had a discussion about how I was feeling during the postpartum visit, and she did a great job of normalizing the fact that I could be upset and still grateful for my child.”
All Doulas Aren’t Created Equal
Heather Parker did not have to deal with any possible tension between her doula and the obstetrician during her hospital birth – mainly because the doula did not show up until 24 hours into her birth, Parker said.
Parker had wanted Hull as her doula, but she was unavailable at the time of Parker’s due date and the expectant mother engaged another doula. She quickly learned that just because a doula is meant to help, doesn’t mean all will assist their clients to smooth-sailing birthing waters. Parker says she got the exact opposite when it came to the birth itself. Although the doula had helped with labor pain coping mechanisms and other tips in advance of the birth – she did little else.
A warning sign should have been that her doula was difficult to get in contact with which was very different from how Hull operated – making herself available 24/7 via phone call or text message even when she was not Parker’s doula at the time.
Parker had a difficult birth –she had to go into the hospital instead of doing the at-home birth she wanted – when an ultrasound discovered next to no amniotic fluid in her uterus. When the doula showed up after Parker’s partner called for her to come as Parker was entering into active labor; all the doula did was assist with applied pressures and other smaller techniques.
“You lose your voice a little bit in labor because you’re so focused inward on your body and you aren’t really able to communicate,” Parker said. “The problem with that is everyone is rushing around you, coming in and out, asking and doing things and I just thought it would be nice to have another voice in there to advocate for me.”
Although Parker ended the day with a healthy baby boy, the obstetrician who delivered Parker’s baby gave her an episiotomy and ruptured her membranes without her consent, she said.
This is when her doula could’ve stepped in to communicate with Parker what the physician was doing; because although she knew about the episiotomy at the time, she only learned about the rupture of the membranes after going through the whole 33-hour hospital record she requested of her birth.
The second time around, Hull was Parker’s doula making this experience remarkably different compared to her first doula, Parker said.
Hull sat with Parker and her partner and twin sister in the prenatal visits helping her process everything that happened to her during that first pregnancy and helping Parker and her husband make a list of the things that would make this next birth as ideal as possible.
With Hull’s guidance and the early processing preparation work, Parker accomplished what she had wanted all along: a safe home-water birth.
“I wish that every woman could have that experience that I did to be surrounded by the people that you love and trust in your own space and they are there if you need anything, but they are also hands off and they are letting you trust your own body,” Parker said.
Mary Love, a certified nurse midwife and family nurse practitioner and the clinical director of Heart of Houston Birth Center –where about 75 percent of her patients have doulas —
said it is important for mothers to be cautious when selecting a doula.
“Everyone’s a little different, some doulas are more hands-on and connected with their clients and some aren’t or there’s some hesitation going on where it doesn’t seem like the two are flowing together,” Love said. “I tell my clients when I don’t think a certain doula for whatever reason would be a good match for them. I know from other midwives that there are some doulas that will go out of their lane and give medical advice or clinical recommendations and others are known to be notoriously late or are never able to show up.”
A Doula, an About-to-be Mom and Her Partner
Hull says she became a doula “Because I knew that I wanted certain things and I thought I could just say this is how I wanted my birth to go and barring anything medical, it could go that way,” Hull said. “I did not understand that that’s not how the system is set up for mothers; this system is set up where it’s like this is how we do birth and if you want something that is sort of off the beaten path, you have to work to get it.”
There are different certifying bodies for doulas which results in variations in training, said Hull. This is part of the reason she started training doulas, “I do not want to compromise what a physician or another provider is saying, it is never my job to do that,” Hull said. “I would have to work behind some doulas that might have overstepped bounds or behaved inappropriately and all I want to do is ask my clients what questions they have and inform them of what’s going on.”
A doula’s work requires the doula to be in an intimate position watching for the needs of the mother and partners and what is shared between them, Hull said.
“I am really working with two different people with two different experiences, there is a difference between being in labor and being at a labor and both of these people need to be supported and prepared,” Hull said. “Each of them is complementary, but each of them are different so as a doula, you want to be prepared to work with both partners because they are both going to have a baby.”
The mother’s partner is included in conversations between them they have before, during and after the birth.
Partners can be present at the birth helping with breathing exercises or placing pressure points on the mother’s back to reduce pain. They are given the information ahead of time to know what to expect, what to say and how best to support the mother, Hull said.
“What I have heard from my husband and my husband’s friends is that they are grateful for Debbie too, because it is a lot of pressure to put on birthing partners for them to be all the things at once during this process,” Cofino said. “I think it is really helpful – at least it was with my husband – to have someone who was there and knew what was going on and could help be informative and help support your partner but also give you a bit of a reprieve sometimes.”
And if expecting mothers are wanting to explore this option – male doulas do exist. Hull has never had a male back-up doula – one of the doulas she’s training – or known one personally; but there are male doulas that are a part of the Childbirth and Postpartum Professional Association – the doula and childbirth training body that she received her certification through.
When it comes to the mother’s care, Hull has to be adaptable as her duties may vary depending on whether she is at a home, hospital or birthing center.
Hull said when she attends a birth, she tries to keep herself a bit smaller so as to avoid “stepping on the toes” of the obstetrician. She will say something and advise her client if she sees something, but Hull is not there to act as a physician or override the actions or recommendations of a medical professional, she said.
“I know a lot of physicians that are hesitant to work with doulas and some of them I think even get a little tense or maybe let out a bit of an eye roll when they find out their patient is using one,” Hoopes said. “They want to know why they feel like they need one, they want to know if the doula is going to overstep or if they are going to do something that they aren’t recommending or something that isn’t based on evidence.”
Hoopes said that this does not appear to be the feeling toward doulas by a vast majority of physicians. Especially as there is research that having doulas involved in the birth process statistically leads to better outcomes, she said.
The U.S Department of Health and Human Services has reported that labor and delivery when supported by a doula leads to lower C-section rates, lower preterm birth rates and improved the rates of breastfeeding initiation in new mothers.
Doulas also take on the responsibility of communicating with their clients during outcomes that aren’t good. This is especially true for home births or birthing center births where something is going wrong, and a hospital transportation is required.
Slow transports involving the less urgent or more common problems such as some postpartum hemorrhaging from the mother, the baby’s breathing is a little unregular, the baby is not responding well to labor, or the labor is not progressing. The more rapid transports occur if there are serious issues with the baby’s breathing complexly crashing or problems with the mother that require immediate medical attention, Hull said.
“The most common thing I see – especially when a homebirth is transported to a hospital – is at a point there may be a situation where the mother already has to compromise on something that she didn’t want that had to happen,” Hull said. “And that makes it easier for her to throw in the towel in and say, ‘never mind, I’ll just have the c-section,’ or another thing she didn’t want, and I always try to have a little conversation with the mom to see where she is at and what she is thinking and remind her of what she wanted.”
Gaps in Financial Coverage
Without the financial assistance of expanding federally funded insurance to cover doula care in the state of Texas, many Texan mothers cannot afford a doula’s assistance and support, Hoopes said.
Unless an expecting mother has a private health insurance provider that elects to cover doula care – the several thousands of dollars for this care will have to be paid out of pocket.
According to the U.S Department of Health and Human Services, when states choose to include perinatal care in its Medicaid coverage, it increases the access to doula care and other services for populations who would not otherwise have the ability to hire these care providers, the department reported.
There are currently eight states that already provide Medicaid coverage of doula care and six more states are in the process of implementing Medicaid coverage for clients seeking doulas, according to the National Health Law Program, a network of health advocacy attorneys.
Over 60 percent of people of color are covered by Medicaid, meaning that expanding this coverage in Texas would provide a better ability to these populations to be able to afford them.
Increasing access specifically to those who are on Medicaid would increase the chance of better birth outcomes for the populations that already have substantially higher rates of severe maternal morbidity and mortality rates, like mothers of color.
Currently in the Texas Legislature, efforts are being made toward the potential expansion of Medicaid coverage to include doula and other perinatal services under House Bill 465. This bill would introduce a pilot program that among other things, would provide Medicaid coverage of doula services.
The status of the bill is pending, as it was last sent to the Senate’s Health and Human Services Committee for review.
A Lasting Bond
As awareness and knowledge of doulas and their services continue to grow, Cofino said she and other mothers she has known who have used doulas often suggest to expecting mothers in their social circles or those asking for advice to consider doula services.
“Right now, almost all of my best friends are pregnant and one of the first things out of my mouth when I saw each of them after knowing they were pregnant was, ‘Get a doula,’” she said.
Without Hull, Cofino is unsure of what she would’ve done; not only was she right by her and her husband’s side during the birth, but she stayed available to them after – something that is routine for Hull, but that Cofino appreciated.
Within a week after the birth, Hull was back in Cofino’s house, visiting the baby and she and her husband and they chatted about how she was feeling, how the baby was doing and processed the delivery – as it was Cofino’s first time giving birth.
“I tell my families ‘I am your doula forever,’ and then I let them get settled in after our postpartum visit and I tell them goodbye after that and if they need anything, to reach out to me whenever,” she said.
Hull gets birthday cards celebrating four and five-year old birthdays of the babies she helped, phone calls when families are sending their children off to Pre-Kindergarten and repeated requests from mothers’ who are expecting again and ‘can’t do this without her,” she said.
“I am the keeper of these families’ birthing memories, I am likely the only other person besides their partner that they will see again that was a part of their birth,” Hull said. “That’s such a precious and sacred, special thing to be able to be a witness of.”
This article appears in Jan 1 – Dec 31, 2023.
