Real Support for the Support Person: I Did the Math on the NY Doula Pilot Program

Photo by Jessica Felicio on Unsplash

It’s been stirring in my mind for quite a while now — Every time I see another fundraiser for midwifery school, or hear of another person taking a break to get a job to support themselves or their families for a while, or hear a birth worker tell me about the shocking discrimination they experienced at the hand of a care provider, nurse, midwife or another birth worker, or even think about some of the things I’ve encountered myself as a doula in my community…

“What do you know about the experience of the Black birth worker?”

When this question was asked in a small room of mostly white birth workers in my city, the room fell quiet. And then — I can’t remember if someone literally asked, “Is it different for Black birth workers?” Or not — or maybe in other words — but I know the bit of conversation that followed made it clear that this question just hadn’t really occurred to many people before. 

But yes, it’s different.

And now, I have this awful feeling that I’m a broken record, but if I am… it’s not because I’m broken it’s because the broken things I’m talking about still haven’t healed. And the NY Doula Medicaid ordeal is a prime example of that truth.

Because once I looked into it, it became incredibly clear to me that this initiative is more about lip service to a buzzing topic than actually delivering consistent and quality support to the folks it’s claiming to — and will, beyond that, do a disservice to the folks who support them.

According to the New York State Doula Pilot Program webpage, doulas will be reimbursed $30 per prenatal visit, $300 per birth attended, and $30 per postpartum visit. Why?

“Fees are approximately 43% of NY OB/GYN professional fees and 50% of midwife fees.”*

Alright. So let’s go ahead and think about this.

The average rent for a one-bedroom in New York City is $3,100. The average spent on utilities in the U.S. generally (couldn’t find it for NY specifically) is $211. Average on food is $317. Transportation, $211. Entertainment, $106. Clothing, $106. Insurance and other misc costs, $106 (which is ridiculously low). Let’s pretend this doula has no debt. Let’s say they’re just trying to set aside $100 a month for emergency savings.

Total: $4257 a month for one doula, living alone with no child or partner, (and certainly not also pursuing midwifery school or certification).

The NY Doula Pilot Program page estimates 7 visits and one labor and delivery visit per doula client, a total of $510 per doula client (also note that 2-3 prenatal visits, labor support, and one postpartum visit are standard for most doulas).

So, doing the math, it would take 9 clients a month (9 births, and 63 prenatal visits) for that doula to stay financially afloat (if the reimbursement comes through quickly enough to pay those bills). Let’s just act like this is reasonable for now and move forward…


“But Cheyenne, the NY Doula Pilot Program isn’t only for Black birth workers, so why are you conflating the two?”

It will not only impact Black birth workers but it will largely impact Black birth workers since many do have and will continue to have clients on Medicaid.


“But Cheyenne, the Medicaid Reimbursement doesn’t need to be their only source of income, they can work a part-time job or take clients who can pay better, too.”

Alright let’s say they have a part-time job — 20 hours a week, $12/hr (min wage in NY is $10.40/hr).

Now they’re making $960, so they only need to fill a $3,297 gap. They’d need to attend to 7 clients (7 births and 49 visits) in the remaining 20 hours a week to make that work.**

Not only that, they’d need to specifically have a part-time job with a boss who’s willing to be flexible with them when they get called to a birth during their shift hours — who won’t just fire them — and because inevitably they’re going to have some overlap between working hours and labors — it’s incredibly unlikely they’d even make the full $960 a month.

Now let’s say they take one client a month who can pay $1200 (about the average cost of a doula). They’d need to make $3,057 more.

That’s 6 more clients. Which is a total of 7 clients (7 births and 49 visits). And let’s take a moment to consider that 7 due dates in one month… a few of those babies are coming at the same time. So no way is that doula going to be able to be present for all of those visits and all of those births. So really… they’d need more…

AND, let’s acknowledge the cost of time we’re talking about here. Because you know this doula is going to have to take time to process all the paperwork for all of these clients, and pay for postage or whatever to submit them, and wait for reimbursement to be processed and allotted to them.

“But Cheyenne, maybe they can fundraise the difference.”

Black and POC birth workers are already fundraising to the ends of the earth to support our work. We ask for funds straight up, we offer little rewards, we turn to fun slogan t-shirts — we’ve been doing this.

In fact, we’re already working multiple jobs, too — trying to juggle clients who are able to pay more and those who are not able to pay as much, too — living with roommates to reduce costs, applying for scholarships, dipping into savings, living without certain things, leaning on friends and family, etc.

And all the while that we do these things, we experience discrimination just like our clients do — day to day in normal life, and in the birth world, too — whether because unconscious or conscious bias based on the color of our skin or because of distaste for / misunderstandings of our roles as support people or all of the above.

And by our peers we are asked to explain (“Can you teach me about…”), solve (“Tell me what I need to do…”) and not to talk about (“Why does race have to be brought into everything?”) the inequities that we face.

As we look into the eyes of the parents that we work with, telling them, “I am here to support you,” many of us are being forced into corners that leave us feeling unsupported ourselves. And then we look around as see that we’re not alone in this. And we talk about it. And we wonder (among other things), “When will something be done to support us?”

And then a headline about a Doula Program pops up. And we open the page. And what do we see…

It is more than a little frustrating. It is literally adding insult to injury to create a system to support a group of people that cannot support the support persons themselves.


“But Cheyenne, if you’re okay with taking on free births in general, why aren’t you grateful for some support from this program for NY doulas?”

Payment from a program like this and payment directly from a client — that’s a horse of a different color.

The families we’re working with on Medicaid aren’t handling budgets of millions of dollars, moving money around on spreadsheets with teams of accountants, looking at income flow from multiple avenues and then telling us, “This is what I have left to set aside for your services.”

Is a response like mine actually ungrateful, or holding a capable authority to a reasonable standard?


But Cheyenne, at least they’re trying something, right? Can you really expect it to be perfect out the gate?”

Birth work is a job. Birth workers are doing a job. A job with expenses we must pay to perform it properly. A job that takes a physical toll on our bodies, and an emotional toll on our beings. A job that sometimes requires that we remain as a continuous support person for 10, 12, 16, 24+ hours.

Yes, it’s a beautiful job that we feel called to and incredibly honored to do… and it’s so impactful that many of us are WILLING to make sacrifices to do it — but that does not mean we shouldn’t expect to be able to sustain our own lives through it.

And I’m not saying that I don’t think folks should participate in this pilot program, or that it shouldn’t exist at all. I hope that many people do participate and find ways to make it work for them, and advocate for improvements that would make it better.

But I have a very real concern that there’s no intent to improve it — that in fact, people somewhere are patting themselves on the back for what they’ve created — a system that perpetuates the “Strong Black Woman” trope by making “Strong Black Birth Workers” who must make due with the little allotted to us on top of the regular set of stressors we continue to have.

Nothing would make me happier than to be proven wrong on that.

Because to be honest, I’m not interested in the “Strong Black Birth Worker” blue ribbon for myself or anyone else. I want safety, support, joy and empowerment. As we stand in the gap for those who are bringing new life into the world, I want birth workers to be able to have full lives of our own.


*This doesn’t justify the payment of the doula, it just means that OB/GYNs and midwives are also being underpaid and done a disservice when they’re reimbursed by Medicaid, too.

**None of this began to address taxes.

---

Fighting for Reproductive Justice Within My Faith: Make Christians Act like Jesus Again

Photo by Love Your Neighbour on Unsplash

In the intersections of my identity I am both someone who fights for reproductive justice and someone who believes in God and in Jesus Christ. A Christian. It’s easy to say, and yet heavy in my mouth and heavy on my fingertips as I type it out. Why? Because my faith has been used as a tool of oppression for generations, and still today (within reproductive justice and beyond).

People have used scripture outside of context, and a perversion of the concept of holiness to shame and dehumanize people, and to limit their choices and free will, and to improperly elevate and offer power and money and status to other people.

When speaker Kira Shepherd from the Racial Justice Program (and more) at Columbia Law began to speak about “White Christian Supremacy” at Decolonize Birth Conference this weekend, I had a visceral reaction. A skin crawl. A sinking in my gut, in part because I already knew… 

Christianity as a Weapon

I knew that during slavery, people who called themselves Christian declared themselves superior over others to justify enslaving them, humiliating them, beating them, scarring them, separating them from their children and families, and killing them.

I knew that during integration, people who called themselves Christian resisted having Black students join their White children in school by building their own schools, schools explicitly created to maintain segregation, schools created through the houses of God, to reject other people created and loved by God.

I know now that today, people who call themselves Christian (and Catholic) are also doctors and staff in hospitals that turn pregnant people away from appropriate care, often without explanation, because of policies that are based in religious belief, for example, ones that confuse the lines between appropriate medical treatment and abortion.

Specifically, Kira Shepherd spoke about a pregnant woman who had gone to the hospital twice during early pregnancy with intense pain and bleeding, and was sent home twice with only aspirin, and nearly died, because doctors felt the treatment that would solve her medical issue could endanger the unborn baby (essentially saying that the woman’s life was less significant than her unborn child’s life).

Is it not nonsensical, that people who base their beliefs on Jesus who healed even on the days it was unlawful to do so on, would deny medical care to those explicitly seeking it from them?


My Personal Wrestling with God

Grappling with tensions and realities like these have led to me to an incredibly difficult place of introspection and questioning. It’s not unlike my teenage years when I asked myself, “Is this my faith? Or is it simply my parents’ faith?” In this season of my life, watching all that has been done in the name of Christianity that has shaken me to my core, I have asked myself, “Am I ashamed of the Gospel?”

As a teenager, I read, and I researched, and I prayed, and day by day, in my mind and my spirit I knew that God was real, I knew that Jesus was my savior, I knew that His hand was on my life and that He had created me to use the skills He gave me to show His love and grace and mercy (and sometimes also anger) to those around me — those who knew Him, and those who weren’t so sure, and those who didn’t believe what I believe.

In this season, I have read, and researched, and prayed, and day by day, in my mind and my sprit I know that I am not ashamed of the Gospel, but I am deeply ashamed of the oppressive things that people have stood crookedly on the Gospel to do. It still confuses and frustrates me how it’s even possible. And to be entirely honest, I often feel like I exist on a desert island within my own faith, watching the main ship heave off without me, partially relieved because I know I don’t even belong on it, but mostly very sad.


What the Bible Actually Says

The whole point of striving for holiness as a Christian is to strive to be like The Holy One, Jesus Christ, the fulfillment of God’s law. Our

lives are not about measuring up to laws and standards or forcing those things on others (neither am I saying that all laws are meant to be thrown to the wayside). But for those of us who believe in Him, we need to examine Jesus — What did He do when He lived and breathed and walked on this ground? Who was He? — And start measuring ourselves up to that.

Look at Jesus. Jesus, who was not ashamed to speak with the woman at the well (though that was scandalous for His time), who had had many husbands. Jesus, who was not ashamed to step in to protect the adulterous woman who would have been stoned (and to put the ones holding the stones in their place, also). Jesus, who was not ashamed to challenge the rich young man who thought he could achieve his way into heaven (Jesus said, Give 👏🏽It 👏🏽 All 👏🏽Away 👏🏽Son 👏🏽 and the Rich Young Man said 👋🏽🚶🏽🚶🏽🚶🏽). Jesus, who was not ashamed to have his cloak touched by the desperate and “unclean” woman who had been bleeding for years and no one had been able to heal her until Him (and not only that but He comforted her and admired her faith and called her daughter). Jesus, who turned over the tables in the temple when people were selling things — why? Because the temple wasn’t supposed to be a marketplace. It was, and still is supposed to be a house of prayer for all the nations…

Jesus, who was not ashamed, as He hung on the cross, to offer salvation even to the criminal at His side. A criminal who said, “My suffering is justified… still, Jesus remember me…”

How have we forgotten? How do I watch so many “holy” people act so ashamed to interact with so many people who Jesus literally showed us that He reached for and turned towards?


So What Next

Those of us who believe in the God of the Holy Bible (as opposed to the commercialized, capitalist, red, WHITE, and blue God we encounter so often in the US), and who believe in Jesus Christ, His son, and the Holy Spirit, who intercedes for us — we have layers of serious work to do.

We not only have to do the work that God actually calls us to in the first place — the work He specifically and uniquely knit into us as He made us in our mothers’ wombs. But we also have to undermine the oppressive forces that have so successfully rewritten the general understanding of our faith — and in effect have actually co-opted Christianity — what it means to follow and be like Jesus — and in truth, removed being like Jesus from the picture entirely.

Let’s be honest. In this age, the temple is truly more marketplace than house of prayer for all the nations. Which should make our response pretty easy. Let’s turn the tables over.

Let’s be like Him, by being in relationship with people, all the people. And when things feel grey and unclear and scary — instead of running away from each other, let’s pray and wrestle together as brothers and sisters for something better. For something life-giving.

I know some of y’all will have questions that I don’t have answers for. I really don’t. I just have one day at a time, thoughts and desires and prayers and actions that I will look for fruit from in this life, and I will bring to God at the end of my time to say, “Remember me?”

---

Reparations, Redistribution and Other Hopes I Have for My Local Birth Community

Photo by Geovanny Velasquez on Unsplash

The following thoughts come from what I've seen so far, in my two years of engaging in birth work in Richmond, what I've heard my elders share in Richmond and in other communities I've had a chance to visit and hear about, and just what I find myself dreaming. There's room for reparations, redistribution, honoring each other, and supporting folks more fully in this work we're doing. I'd really like to sit at a table that continues having these conversations.

I want to see reparations.
What are reparations? Pretty simply, reparations are amends that are made for wrongs that have been done. 

Wrongs have been done and are still being done to folks in the birth world, even here in Richmond. Sometimes these wrongs are traumatic and life-altering, even resulting in death. Other times they are subtle, not even recognized as traumatic at all. But anytime someone is not asked consent before being checked vaginally or having their water broken or being given pitocin, anytime a request to avoid an intervention is denied without medical necessity, anytime someone is not given access to a translator and not communicated with or communicated with with an attitude because their first language isn't English (translation is supposed to be provided by law in hospitals), anytime a racially insensitive or outright offensive comment is made, whether the speaker recognizes it or not — these are wrongs that are not uncommon in our community.*

These wrongs are the reason I'm a birth worker. Sometimes they're prevented by my presence, and other times the edge is simply taken off as I step in to protect space for my clients to think clearly about the decisions they want to make, and offer comfort that otherwise might not be there at all.

I empathize with the reality that care providers face of rising insurance costs of their own and the real potential career destruction that comes with liability, but this current climate in which they often reign with seemingly unchecked power, and with every defense up against ever admitting any wrongdoing — imposing and protecting themselves at the potential expense of their patients — it’s unhealthy on every side. As professionals, doctors need safe spaces to recognize where they’ve fallen short and grow. The whole system needs a space to do that. Where are the policies falling short? Where are they setting folks up for poor experiences?

Meanwhile, as patients, parents need to have their experiences affirmed and recognized, to be apologized to when they’re wronged, and moving forward the parents served after them deserve care that gets better — not just remains cloaked in ignorance, repeating errors of the past.

What could this practically look like? At the very least, our hospital systems investing in practices and policies that support better comprehensive and individualized care for all expecting parents.

Take a moment and consider this. Imagine you go to the doctor. You're sitting on the examining table. The nurse left a while ago, the doctor's coming in soon. The doctor comes in, sits on the edge of the table and sticks his gloved finger up your nose. How does this situation strike you? Uncomfortable? Inappropriate? Jarring? 

I've seen a doctor come into a room with a sleeping laboring person and proceed to begin a vaginal check without prompting. I've seen a doctor clamp an umbilical cord, after the mother said she wanted delayed cord clamping, laughing and saying, "This isn't my first birth," then cutting the infant's cord, yes, against parental wishes.

I understand that hospitals are not full of malicious people cackling in closed door meetings. But something has been lost in this setting. Some recognition of how these roles of patient and care provider should really be regarded. And someone within those walls needs to recognize and begin repairing.

I also wonder who’s at the table for these conversations about making healthcare better? Folks like the families my colleagues and I work with? Many of whom would be owed reparations should that explicitly exist? I find that doubtful, unfortunately.

Maybe that'd be a place to start. With listening to the people being served.


I want to see redistribution.
What makes redistribution different than reparations? In my mind, redistribution isn’t necessarily connecting the ones who’ve explicitly done the wrongdoing to the ones who’ve been wronged, but more broadly ones with privilege or access to ones with less privilege or access.

This concept is particularly significant in the birth world, from my perspective, because not all birth workers enter into this work with the dream/vision/intention of creating a typical for-profit business model. Some of us enter into this work as a sort of mission, to work with folks who look like us, have experiences like we’ve had, and we know we are uniquely equipped to serve.

The doula who enters into work the former way and the doula who enters into this work the latter way often seem at odds — not just in the Richmond community but others. But we can work together. I’m not going to attempt to sugar coat it. I don’t think it’d be easy. But I think it’s a conversation we need to really keep having.

I have a very specific vision for this. It’s actually kind of simple and extremely doable.
 

There are a lot of doulas in Richmond who offer their services from $0-$1000+ whether as individuals or as a part of businesses and collectives. For the sake of this hypothetical situation let’s just say there are 5 birth doulas who take on an average of 2 clients a month for a year for $1000. They build into their business a plan to donate $50 per client to anorganization that provides free doula support. They also ask their clients at their postpartum follow-up session if they’d be willing to make a donation to someone in Richmond having a doula who can’t afford it.

What would happen?

5 doulas, 2 births a month, 12 months
= 120 births

$50 from each $1000 fee
= $6000

25% of families (30) give $100 in addition
= $3000

That’s $9000 from 5 birth doulas and the families they worked with. We have more than 5 birth doulas in Richmond, and possibly more than 25% of families who'd be willing to give toward the gift of doula support for others. We also have postpartum doulas. And birth educators. And photographers. And placenta encapsulation specialists. (We have abortion doulas as well, but I've left that out of this list because personally I don't think someone should have to pay for this support, the depth of the struggle to just safely access the service when it's sought out is deep enough.)

The economy of our birth and reproductive community has the capacity to sustain work that reaches further. We just haven’t gotten on the same page about it… yet.


I want birth workers to know each other and honor each other’s expertise and callings.
I understand that not everyone feels like they have the capacity to — or feels like they should have to — stretch themselves to meet folks from very different parts of this community. And I’m not saying we should all have to go to the same monthly potluck or cookout. But we should all know that the others exist and honor and respect the spaces that we occupy.

What does honoring each other’s expertise and callings look like?

It's about context and thought. It can mean challenging your friend and fellow birth worker to teach that class, to add that package, to share those skills they have. It can mean suggesting that someone else sit down or slow down, not try to be a jack of all trades, or center themselves in an area, because perhaps it's inappropriate, or it's undermining another part of the community. It can mean going to someone who’s been doing some kind of work for a long time and saying, “I have an interest in this too, do you think our community has need for more of it? Or that I can reach another segment?” And then being open to hearing, "No," and their reasoning. They might be right. They might not be. But it'd be better to make your decision with their perspective.

The point is, honoring each other requires that we step outside of ourselves and our own interests a little to really recognize and value others. What if we overcommunicated? I wish we would overcommunicate just a little more. Would other problems come out of that? Probably. It’d be refreshing though to deal with those problems for a change. I’d be intrigued by the challenge.


I want our families to be supported in body, mind, and spirit from conception (or prevention thereof) to birthing outcome.  
Does this strike you as too good to be true? As I write it, I can’t deny there’s a part of me that wonders how I could even dream it. But I don’t just dream it, I’m working with folks toward it.

Because people are going through all of these things. Whether we do nothing or we do something. People around us are struggling with infertility, they’re struggling with miscarriage, they're struggling with preventing pregnancy, they’re struggling with unexpected pregnancies, with their decisions on abortion, with healthily carrying their babies, and with having the births they want and they can safely have — where, with whom, in the way that fits them and their family.

Any of us who are working within this birth community — I believe we’re all on the same page with that last paragraph. We all care very deeply about these people and want the best for them, and are already willing to work for it. Let’s work deeper, wider, and wiser.


*Though I feel like it shouldn't be necessary to add, I want to say that I've seen hospital providers, from nurses to OBs to midwives, show the best of hospital care also. The system we're struggling in often does these folks a disservice as well. I believe if they felt better supported, we'd all reap the benefits of that, too.

Have something you'd like to talk with me more about? Hit me up.

---