Community doulas work toward birth equity

When Wakina Robertson birthed her twins in Buncombe County 30 years ago, it was a harder experience than it should have been. The babies arrived nine weeks early.

“I wasn’t listened to,” she tells Xpress. “Did I want to have my babies early? … If I could have pushed a little longer to carry them a little longer…”

She trails off, then notes her babies “stayed in the hospital a long time.”

Robertson, who is Black, didn’t feel that her medical team listened to her concerns when she had her twins. And 19 months  later, she didn’t feel as if she could advocate for herself when a doctor proposed she get her tubes tied at age 24. “After I had my last baby, the birth control was pushed on me to get sterile,” she recalls.

Robertson continues, “I’ve always said I would’ve had more children, but I was stopped. I was young; I listened to what they told me. I did not have a voice.”

Her personal experiences, as well as attending a public talk by Dr. Arthur James, an obstetrician at Ohio State University committed to decreasing infant mortality in Black communities, inspired Robertson to train as a certified birth doula and postpartum doula.

Through Sistas Caring 4 Sistas, a group of doulas committed to serving families of color in Buncombe County, Robertson has assisted with delivering 92 babies. “To me, helping our moms be able to have a voice, that’s deep in me,” she says. “That’s a passion for me.”

Racial disparities in Buncombe County’s birth outcomes, especially infant mortality, are stark: The death rate for Black infants from 2013-17 was nearly four times that for white infants, according to the 2019 State of the County Health Report. (Infant mortality is most often caused by babies born prematurely or with a low birth weight.)

In 2018, Buncombe County Health & Human Services released a community health assessment that identified improving birth outcomes and lowering infant mortality as top priorities. Local organizations like Sistas Caring 4 Sistas are furthering birth equity — the term defined by the American Academy of Family Physicians as “the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequalities in a sustained effort.”

They’re committed to this work, even as the COVID-19 pandemic has at times made it more difficult.

Unequal chances

Disparities in birth outcomes seen nationwide are echoed locally, including preterm births, which the federal Centers for Disease Control and Prevention identifies as those occurring before 37 weeks of pregnancy. In 2020, the most recent year for which data is available, the CDC reported a nationwide preterm birth rate of 10.09% — a slight decrease from the 10.23% preterm birth rate nationwide in 2019.

But the preterm birth rate nationwide among non-Hispanic Black mothers didn’t change significantly from 2019 to 2020: The CDC reported a drop of only .03 percentage points, from 14.39% to 14.36%. That percentage reflected the highest preterm birth rate of any racial group in the country.

Similar disparities in preterm births existed in Buncombe County, according to data collected between 2013 and 2017 and published in the Buncombe County Community Health Improvement Plan in 2019. Research found the overall preterm birth rate in the county was 9.9%, but that among Black mothers was 13.8%.

Black infants in Buncombe County also had a greater chance of low birth weights compared with their white counterparts. While the county’s overall rate for low birth weight was 8.3%, among Black infants it was 15%.

‘Sitting at the table’

Cindy McMillan co-founded Sistas Caring 4 Sistas with Robertson and Nikita Smart in 2016, and the group began providing doula services for the Asheville-based Mountain Area Health Education Center. Sistas Caring 4 Sistas has since assisted over 250 families with births.

McMillan has seen maternal health outcomes for families of color increasingly prioritized and credits MAHEC for considering doulas as “an integral part of the health care team,” which enables them to advocate for their patients. “Sitting at the table with all of our partners that we have, the synergy is really good,” she adds.

The three certified doulas with Sistas Caring 4 Sistas also have a mentorship program that is helping to train eight additional doulas. Robertson says a lot of interest in that training has come from women who were assisted during childbirth by a doula themselves.

COVID challenges

The Sistas Caring 4 Sistas program has encountered some obstacles through the COVID-19 pandemic’s disruption of health care.

“When COVID first began, [doulas] weren’t allowed in the birthing space in the hospital,” explains McMillan. “That was a bit of a challenge that we overcame by providing iPads on the floor of the hospital, so our clients could interact with us via FaceTime through the tablet.”

Doulas were eventually allowed to return to hospital rooms in July 2020. Since then, all health care professionals have worn gloves and masks — typically N95 masks for the most protection — while assisting with a birth.

That extra gear has taken some adjustment. “They couldn’t see our smiles, and we couldn’t see their smiles,” McMillan. “We had to learn how to read your eyes and understand your needs through another form of communication.”

But doulas and birthing families have adapted, she says, noting that these measures provide “more protection for everybody involved.” Still, she acknowledges, the experience can feel less personal than everyone may want.

Prior to COVID, birthing families were allowed to have multiple support individuals, such as a partner, parent or other children, in the room. Now, “you’re only allowed one support person outside of your doula,” McMillan says.

So, Sistas Caring 4 Sistas has continued to rely on FaceTime for connecting friends and family to support birthing moms  in the delivery room. “We try to make it as family-centered as possible under the conditions that they won’t be able to have everyone there that is really excited for them giving birth,” she says.

‘Systems were failing’

Robertson and McMillan both say they believe birth equity in Buncombe County is headed in the right direction, emphasizing the strong partnerships they have with health care providers.

“We’re here — they know we’re here,” says Robertson of the Black community. “I believe that [community doulas] will be sustainable, as long as everybody continues to collaborate together, to listen to the community and allow things to be community-led.”

But work must go beyond positive changes to health care to eliminate racial disparities. Ameena Batada, professor of health and wellness at UNC Asheville, agrees that other social determinants of health — like social and physical environments, and access to health services — are key to addressing birth inequality.

“Even though the doula programs are integral to the positive change that we’re seeing all over the country and in Western North Carolina, we definitely need to reevaluate our health care system and our social determinants of health,” says Batada, who teaches about maternal and child health. “The systems were failing people of color beforehand.”