As a mother-to-be, Phelicia Cadet had one wish: a healthy pregnancy and birth.
Yet as an African American woman, Cadet and her baby were at disproportionately higher risk for complications during both of those events. When she gave birth to a healthy baby boy, Kashden, at the Brigham last spring, Cadet was relieved and overjoyed to experience exactly what she wished for — something she says she could not imagine achieving without the support of her doula.
“She was the other person who had my voice,” Cadet, 28, said of her doula, a person trained to provide physical and emotional support to pregnant patients and their loved ones before, during and after childbirth.
Although not medical professionals, doulas offer education, companionship, advocacy and guidance around prenatal care, labor and delivery, breastfeeding, infant care and more. Doulas also often serve as liaisons between a patient and their medical team, helping families communicate their goals and understand information about birth interventions, pain management and other aspects of their care.
“She was like a second family member for me,” Cadet said. “I could trust her, and I knew everything would be OK because I was in the hands of somebody who understood me, could guide me through this and would make sure I had a safe pregnancy and birth.”
Studies have shown that doula support is linked to improved outcomes for mothers and babies, including lower rates of unplanned cesarean sections (C-sections), but access to doula services is not equitable. Doulas are usually not covered by health insurance, and paying out of pocket can be expensive. A birth doula, for instance, can cost several thousand dollars — putting it out of reach for many of the patients who might benefit most.
Early in her pregnancy, Cadet was excited to learn from her Brigham obstetrician, Nicole Smith, MD, MPH, of the Division of Maternal-Fetal Medicine, that she was eligible to participate in a program that would pair her with a doula for free.
One of 19 pilots supported by Mass General Brigham’s (MGB) United Against Racism strategy, the program, called Birth Partners, seeks to address racial inequities in birth outcomes by improving access to doula care. Across MGB, Black patients are twice as likely to have an unplanned C-section compared to white patients. Additionally, Black, Latinx and Indigenous patients leave the hospital exclusively breastfeeding after giving birth less than half as frequently as white patients.
Currently in its second year, the Birth Partners pilot has funding to provide doulas to Black and Indigenous patients — populations deemed to be at the highest risk for complications — who are planning for a vaginal birth at the Brigham, Massachusetts General Hospital (MGH), Newton-Wellesley Hospital or Salem Hospital.
The program uses a monthly lottery system to match a select number of interested patients with doulas, and the team monitors participants’ C-section and breastfeeding rates, as well as patient experience metrics.
Although research has yet to pinpoint precisely how or why doulas affect birth outcomes, the benefits of their involvement in pregnancy, birth and postpartum periods are clear and measurable, Smith explained.
“There’s a lot of data that supports the utility of doula support and their efficacy in decreasing the risk of cesarean birth,” Smith said. “Doulas provide emotional and physical support, and they can become a communication bridge to help everyone understand the goals of the family.”
‘Like I Was Her Sister’
After learning she was eligible, Cadet eagerly enrolled in Birth Partners and was connected with longtime doula Ieshia Lee of Birthing Gently, one of two Boston-based doula agencies that partners with the program.
Lee served as Cadet’s doula for most of her pregnancy, as well as during her delivery and following the birth of her son. They continue to remain in touch, with Lee checking in to see how she and Kashden, now 9 months, are doing.
“Sometimes your role gets to be bigger than a doula,” Lee said. “I wanted Phelicia to feel like I was her sister. I supported her with everything she was going through as a mother, pregnant woman and a human being.”
Without participating in the Birth Partners program, Cadet says she would not have been able to afford doula care. As a result of her experience, though, she feels strongly now that doulas should be covered for any patient who wants to work with one.
“Giving birth is not easy,” Cadet said. “Every woman in this world deserves to get this type of treatment and support.”
Ultimately, Birth Partners’ leaders hope that the program serves as a model for increasing access to doulas more broadly for all pregnant patients — something that may soon come to fruition.
MassHealth, the state’s public health plan, is exploring an expansion of benefits to potentially cover doula services for its members. If approved, the hope is that private insurers will follow suit, explained Allison Bryant, MD, MPH, senior medical director for Health Equity at MGB and an OB-GYN at MGH.
“It would be great for everyone to have access to a doula at no cost,” Bryant said. “The nature of our grant funding shaped the scope of our pilot so that we’re starting with groups who are at highest risk, but this is a fantastic intervention from which many patients could benefit.”
Smith agreed, adding that she hopes doulas become a routine presence in labor and delivery units everywhere.
“In many hospitals, there can be tension among providers when a doula is there, but I think our nursing staff and physicians are really quick to welcome innovation and consider novel approaches to advance birth equity,” she said. “Their embrace of this program has been a classic demonstration of why we provide great care at Brigham. It’s wonderful to work as part of a team who prioritizes patient- and family-centric care.”
Building a More Diverse Doula Workforce
A key component of Birth Partners is pairing patients with doulas who share their racial or cultural background.
“Doulas provide a bridge beyond language — in terms of the language that clinical teams use versus how patients and families speak to one another — and some of that can be sharing a lived experience,” said Allison Bryant, MD, MPH, senior medical director for Health Equity at MGB and an OB-GYN at MGH.
To grow and sustain the availability of diverse doulas, Birth Partners also funds a scholarship program to train aspiring doulas in partnership with Birthing Gently, a Boston-based doula agency that provides DONA International-approved doula training workshops.
In its first year, the program provided scholarships to 20 people, and has received funding to award scholarships to another 20 individuals to further create opportunities for aspiring doulas of diverse backgrounds, including race, ethnicity, language, sexuality and/or gender identity.
Among those who have been awarded the scholarship is Taylor Goyette-Frechette, LCSW, MSW, senior consultant for Education and Learning in the MGB Office of Diversity, Equity and Inclusion. As someone whose role consists of developing and implementing racial equity education for MGB’s workforce under the United Against Racism strategy, Goyette-Frechette says she jumped at the opportunity to apply.
After completing the training last fall, she was paired with her first patient shortly afterward. The patient had requested a doula of color, and Goyette-Frechette, who is Black, says she was humbled to be by her side throughout her pregnancy and birth.
“For me, it is so personal — being a Black woman, knowing the data, hearing stories like Serena Williams’,” said Goyette-Frechette, referring to the tennis star’s recent essay in Elle magazine detailing her life-threatening delivery and having her health concerns dismissed by her care team. “I feel that I can connect, support and find deep solidarity and community with other Black birthing people. Everything from our differences to the uncanny nuances of our similarities — having that understanding when a patient describes an experience they’ve had allows me to pick up on the subtleties of what they’re saying. These details are essential for healthy transitions through the prenatal, birth and postpartum periods.”
Formerly a project coordinator at Southern Jamaica Plain Health Center and domestic violence advocate for the Brigham’s Passageway Program, Goyette-Frechette says she considers doula work a natural extension of her career path.
“I see myself as a clinical social worker who develops trauma-informed, racial justice trainings for a health care system, where I now also have an opportunity to support people giving birth who have experienced the medical system as a place of harm, historically,” she said. “It just feels so right. It feels like where I need to be.”
To learn more about how to apply for the Birth Partners doula training scholarship, contact firstname.lastname@example.org.