Crystal Johnson chose to have her youngest child, Olivia, at home. Johnson lost a baby between the births of her fourth and fifth children, and she says her doctor at UVA kept telling her not to worry about her high blood pressure during the pregnancy. When she was at a doctor’s visit while pregnant with her fifth child, Elias, the doctor asked lots of questions, trying to figure out why she had lost the baby, whom she named Sadie. The staff kept asking Johnson if she was sure it had been her husband’s child. As Johnson and her husband, Roger Richardson, left the room, Johnson heard the doctor say, “It probably wasn’t his baby.”
Because her pregnancy with Elias was considered high risk and she had to get an ultrasound every other week, Johnson asked if her insurance would cover them. The doctor said she was certain Medicaid would cover the tests—Johnson says the doctor assumed that because she was black, and had multiple children, she was on Medicaid.
But Olivia’s birth was a completely different experience for Johnson. Rachel Zaslow and Debbie Wong served as her midwives, and Johnson called them at 3am last December 17 to let them know she was in labor. Olivia, her sixth child, came into the world at 7:21am. The midwives cleaned everything up while the rest of the kids got ready for school.
“I feel like women—especially black women in the community—have poor birth experiences over and over again,” says Johnson, who now serves as the doula coordinator for Sisters Keeper Collective, an organization of about 45 African-American and Latina doulas who serve as advocates for women of color before, during and after the birthing process. “And they don’t know what they have to do to get a better experience.”
Zaslow runs Mother Health International, a nonprofit that is dedicated to improving neonatal mortality rates in areas of the world where they are the highest. The organization has a birth center in Uganda where it trains midwives (health professionals who can deliver babies at birthing centers, homes or hospitals), and they have done work in countries such as Senegal and Haiti. Zaslow spends up to six months of the year outside of the U.S. working with the group.
Zaslow, who moved to Charlottesville from New York a couple of years ago with her family, says high neonatal mortality rates and high mortality rates for mothers during childbirth aren’t exclusive to other countries. She points to New York City, where black women are 10 times more likely to die in childbirth than white women. According to the Midwives Alliance of North America, more than 16 percent of African-American babies born in 2013 were born preterm (less than 37 weeks), compared with 10 percent of white babies. MANA says that African-American women are four times more likely to die from pregnancy-related complications than white women.
The Greater Charlottesville Improving Pregnancy Outcomes Workgroup, run by the Thomas Jefferson Health District, works to reduce adverse pregnancy outcomes in Albemarle, Fluvanna, Greene, Louisa and Nelson counties. The group, which includes a variety of stakeholders in the health care field, meets monthly.
In 2014, 2,638 babies were born in the Thomas Jefferson Health District: 2,003 white, 360 black and 275 other races. The department of health calculates five-year rolling averages for infant mortality, and says the total number of infant deaths is small each year (Charlottesville, for example, experienced no black infant deaths in 2013 and 2014). Nevertheless, a disparity among the races is evident, Zaslow says. The infant death rate in Charlottesville (per 1,000 births) from 2009-2013 was 12.7 for black babies and 4.8 for white babies. In Albemarle, it was 5.9 for black babies and 3.0 for white babies.
There are many layers to the root cause of this disparity, Zaslow says, but a key component is that this difference exists across class lines. An African-American woman who eats healthy and sees the best doctors still has a much higher chance of dying in childbirth than a white woman, which points to racism and oppression as the underlying causes, she says.
When Zaslow asked local members of the African-American community about their birth experiences, she heard the same phrases over and over again: “We don’t get treated fairly in Charlottesville. We don’t get taken seriously.”
“Especially when you’re pregnant, it’s a very vulnerable time and if your doctor says your baby is going to die unless you do this, there’s a lot of room for medical power,” Zaslow says. “And in the medical profession, if you don’t think your patient is going to understand what you say, it’s easier to just give a blanket statement…instead of explaining ‘here are the benefits and here are the risks’ and now you have a choice.”
In an attempt to make the process less traumatic, a Sisters Keeper doula will meet with the parents a couple of times before the birth to discuss what to expect, talk about what choices the couple has and help train the mom to ask her health care team questions to better understand her options—and know she is allowed to say no.
“Trauma is intergenerational,” Zaslow says. “If a mom has a negative birth experience and feels shame or hurt or not listened to, that impacts how she mothers; it impacts her ability to bond with her baby; it impacts her ability to make medical choices for the baby. That leads to all kind of ripple effects, in the child and the community’s life.”
Family ties
When Zaslow, who is a trained midwife as well as doula, started talking with other doulas and midwives in Charlottesville, she noticed a trend: Everyone was white. The people she talked to expressed frustration with wanting to help women of color, but didn’t know how to reach them.
“I started looking at these issues of trust that are apparent within the health care system itself,” Zaslow says. “For women to have trusted community-based birth partners who look like them, who can understand their experiences firsthand and who believe them and trust them [is key].”
Sisters Keeper Collective, which falls under the umbrella organization of Mother Health International, held its first training of 15 African-American and Latina doulas in April 2015, after Zaslow got the word out and visited different community spaces. But they quickly discovered one of the barriers to reaching their intended community was the word “doula,” which was unfamiliar to most people of color. They decided to call themselves birth sisters, to evoke the idea of a family member. Doulas not only provide information to families but act as emotional support, including helping to coordinate child care for siblings while the mother goes into labor, guiding her through breathing and visualization exercises during the birth and making sure she has the right resources after the baby is born, such as breastfeeding information.
Another barrier was the cost of the service, not just for clients but for the birth sisters themselves, who had to be on call and take time off work or find child care for their own kids when mothers went into labor. A five-year $500,000 grant, the organization’s largest, has come from the Charlottesville Area Community Foundation. The money pays the birth sisters a stipend for each birth they attend, and the doula services are free for African-American women who are Medicaid eligible. Other community foundation grants cover all women of color, and the collective also allows women to pay on a sliding scale.
Elizabeth Moore trained as a doula when she was 22. She’d always loved the sacredness of birth and supporting women through the process. When the Charlottesville native moved back to town in 2013, she started gathering a list of doulas who might be interested in offering their services pro bono to members of the refugee community (Moore works with the International Rescue Committee’s New Roots gardening program). Moore coordinated the volunteer doulas, informally called the Charlottesville Volunteer Doula Network. A couple of years ago she and Zaslow began talking about ways to combine forces. When Moore receives a referral from area organizations such as Jefferson Area CHIP, IRC and UVA, she’ll either send them to Sisters Keeper or connect a mother-to-be with a doula within her network; sometimes a doula from each group is assigned so they can both be on call.
Moore says they help with about 10 births a year, and that many of the refugee moms are having their first babies, which means heightened anxiety. A lot of the time a doula will do a pre-birth hospital tour for the women, so they can see the rooms and ask questions about paperwork for birth certificates, for instance. Often, because the family is new to the country and doesn’t have a support system and the father must care for other children, the doula role becomes even more important.
“Every birth is so, so special,” Moore says. “I remember the last one I was at was with one of the Sisters Keeper doulas, so we were both there and the father was with the kids. Afterward, he was very emotional and said, ‘Because you two were here, [it was like] her mother and sister and aunt and everyone was here to support her.’”
Latoria White was part of the initial birth sister training for the Sisters Keeper Collective two years ago. She had informally served as a doula during the birth of her niece and nephew, and realized how important that advocate role was as she helped her sister voice her decision to deliver vaginally even though she’d had an emergency cesarean section with her first baby.
“Recently I had asked my mom about her experience birthing me. My father was an absent father and she said she was in the birthing room alone,” says White. “So that was kind of full circle for me, now wanting to be there because no one should have to go through that experience alone.”
One of the biggest obstacles for White, who has a master’s in psychology and worked as a rural services adult outreach advocate at Sexual Assault Resource Agency and was a casework counselor at Shelter for Help in Emergency, has been helping families from historically marginalized populations learn more about their rights. She wants to help women take charge and make choices for themselves.
“I want moms to feel comfortable asking questions and let them know this is a reciprocal relationship,” White says. “I want them to know I’m learning from them as much as they’re learning from me. Each birthing experience I learn something about women, birth work and also something about myself.”
White loves the relationships and rapport she builds with the families she assists (she’s been a part of seven to eight births total), and she recently helped guide Mustafa and Salma Subhan, who are from Afghanistan, in navigating the American birthing process. In Afghanistan, fathers are not allowed in the rooms when a baby is born, and Mustafa says being present for the birth of his daughter, Kawsar, was such a special moment. He says he is grateful for the outstanding health care services he and his family received at UVA, as well as the care and respect from hospital staff for his wife and daughter.
And Latoria is “more than a doula,” Mustafa says. She not only helped the couple with advice before the birth and with birthing techniques, but she stayed with Salma at the hospital while Mustafa cared for their other children. She has also met with the family several times since the birth.
“Latoria is now a very close friend,” Mustafa says. “I respect her very much and am thankful for what she did for my family.”
Lasting impression
“Do you want to see a photo of him?” Doreen Bonnet asks. She holds up her phone and scrolls through a couple of photos of a newborn baby—her first as a doula-in-training.
Bonnet is sitting in the living room of Eunice Waituika’s home, where she’s been visiting with the family and softly rocking 2-month-old Haniel. Haniel, which means “God’s grace,” is a good baby who hardly ever cries, according to his mother.
Bonnet, who works as a business analyst for a company that makes clay tennis courts, never thought she’d be doing this kind of work (each doula is partnered with another doula/midwife for three births before she can do one on her own), and she says her first birth experience was amazing. She met with Waituika (who immigrated from Kenya with her husband and young daughter in 2016) three times before the birth, for which birth sister/midwife Wong was also present. In these sessions they got to know one another, and Waituika talked about how nervous she was to give birth in an unfamiliar country. And Waituika’s first birth had not been a great experience—she was alone in a Kenyan hospital.
Waituika called her birth sisters at about 9am on May 19, and Haniel was born at 9:01 that evening. During labor, Waituika and Bonnet walked up and down the hospital hallway together, talking about Waituika’s home country and how she met her husband.
“That’s something beautiful, to witness the transition of a mother,” Bonnet says. “To see her that morning and see what a mother goes through, that transition that happens to give birth is amazing. I had to fight tears the whole time…people say it’s a miracle and it really is.”
Waituika says she couldn’t have done it without her birth sisters, because her husband had to leave for Air Force training two weeks before she gave birth.
“I just kept saying thank you to them because I don’t know that I would have made it without them. They really helped me—I was almost giving up,” Waituika says. “They were breathing with me and it made it easy. I wouldn’t feel as much alone in this when we would breathe in together. They carried the pain that I had. It was really nice.”
Future outcomes
Diane Sampson, a prenatal education coordinator with UVA’s Women’s Health Services and member of the Improving Pregnancy Outcomes group, refers patients who come to her clinics to the collective if she thinks they can benefit from their services.
“I think all women need to be emotionally supported in labor, but particularly with hospitals, labor and delivery can be a really scary place,” she says, “even if you feel empowered and connected. It’s really nice to have someone there who loves birth, who understands what women are going through and who acts like a sister or an aunt or grandmother through it. And I think there’s a particular need for women of color.”
“My vision for Sisters Keeper Collective is that when a black person in Charlottesville gets pregnant, the first thing they think and know is that they have a birth sister.” Rachel Zaslow
Sampson says nurses and physicians love working with doulas, because it strengthens the whole health care team for a patient. UVA added a midwifery primary care center in October 2015.
“Both models—the home visiting that CHIP does and the work the doulas do supporting families—both of these models have good evidence that they work and lead to healthier births and better relationships, better parenting in the long run,” says Jefferson Area CHIP Executive Director Jon Nafziger.
White says she hopes the collective continues to train as many doulas and that it attracts midwives who are part of marginalized communities. And Moore says although doulas have become more common in the last 10 years, there’s still work to be done, with “a huge desire to make that accessible to everyone, not just the wealthier middle class.”
On a larger scale, Zaslow says she hopes that a sense of trust and feeling safe within the African-American community will emerge over time and that needed resources, such as black moms meet-ups and pregnancy support groups, will help African-American women throughout their entire journeys as mothers.
“My vision for Sisters Keeper Collective is that when a black person in Charlottesville gets pregnant, the first thing they think and know is that they have a birth sister,” Zaslow says.