Melinda Johnson had a rough time with her second pregnancy. She became bed-ridden and on an IV, suffering from preeclampsia-like symptoms and persistent vomiting.
Through a connection with the Doulas for CT Coalition, she hired a doula, Kaylani, to help her.
“Kaylani was able to walk me through homeopathic remedies for my nausea. She was able to walk my husband through practices that he could assist with in holding me and other massages to relieve some of the pain that I felt in my sciatic,” Johnson told legislators during a public hearing on Monday.
When she went into labor at 1 a.m, she said, her doula was the steady presence who could keep an eye on the environment while Johnson was concentrating on the actual birth.
“My doula is a person at that moment who is not swept away in the emotions of the birthing process, who was fully familiar with the fast pace and the sequencing that usually comes with giving birth, and she’s a second pair of eyes to things that we couldn’t keep track of for just being swept away in the moment,” said Johnson.
Multiple women of color, many of whom were doulas, testified at a Public Health Committee meeting on Monday in support of a bill, S.B. 986, that would create a statewide process for doula certification. Supporters of the bill said that having doulas — who offer support and advice for a woman and their families through pregnancy, birth and post-birth — can decrease the likelihood of c-sections and improve communication between women of color and their doctors and nurses.
“In my collective we work to ensure that our clients know how to advocate for themselves and for their unborn child. We work with them on birth plans, discuss home life, mental health, birth positions, nutrition, preeclampsia, gestational diabetes … common drugs used for induction, exercise, other children who may be in the household, sleeping habits, breastfeeding, and more. We meet with clients weekly up to 6 weeks postpartum to ensure that both mom and baby are thriving,” Tyranzia Lindsay-Edwards, a doula from Ansonia, wrote in her testimony.
Cynthia Hayes, who has been a doula for 19 years, told legislators that she went through a 14-month training with the doula collective Earth’s Natural Touch, which lists itself as the “largest Black Owned training organization of Doulas in Connecticut.” She said that she hoped the bill, which requires doulas to complete a training program or combination of training programs in order to be certified, would create a uniform set of qualifications for doulas, while also allowing people who have been working as doulas for a long time to continue.
Johnson, who is the director of community engagement and advocacy for the YWCA Hartford Region, said that having doulas certified by the state would be necessary so that they could be reimbursed by Medicaid. Private insurance generally does not cover doula services, leaving people to pay out of pocket.
“What we have access to”
Certifying doulas is one of several steps that the state is suggesting to address both the lack of healthcare services for new mothers and their babies in the rural parts of the state and high rates of maternal mortality for women of color. State officials are proposing solutions that go beyond the traditional healthcare system: birthing centers, doulas and home visits for new mothers.
According to data from the CDC, maternal mortality among Black women nationwide increased from 37.3 women per 100,000 in 2018 to 55.3 women per 100,000 in 2020. Comparatively, maternal mortality among white women increased from 14.9 women per 100,000 to 19.1 women in 100,000 over the same period.
Tracy Caldwell, a certified doula trained through Earth’s Natural Touch, said she saw disparities in how white women and women of color were treated while she was working in the Maternal Fetal Medicine department of a hospital in Hartford.
“I witnessed a Black woman – who asked for an ultrasound because she thought something was wrong with her baby – get escorted out due to personal biases, her size, and race, instead of her getting the information that she had the right to know, politely asked for, and said she wasn’t leaving without. She was humiliated and sent home without knowing what was really happening with her baby,” Caldwell wrote in her testimony.
State Rep. Robyn Porter, D-New Haven, referenced a study that Blue Cross/Blue Shield conducted in Florida showing that having doulas who also had knowledge of the community they were working in improved health outcomes for mothers of color.
Porter said she did not believe that Black women had high rates of maternal mortality because of genetic factors — instead, she said, it was a question of who was providing the care and what access the women had to that care.
“I think some of it is implicit bias, and then I think some of it is very explicit bias. It just depends on who you’re dealing with and how people have been trained,” said Porter. “I don’t think it’s necessarily that we are predisposed. I think it’s what we have access to in order to be healthy.”
A different place to give birth
Another key provision of the bill considered on Monday that could be beneficial for women of color in particular, Juthani said, was the option to give birth in a birthing center rather than a hospital.
“In our state and in our nation we have a maternal health crisis where Black birthing people are suffering the consequences more than any other birthing population,” Juthani told the committee.
But the birthing centers wouldn’t just be an advantage for women of color — they would also provide a potential solution for women who live in areas of the state where services for maternal health are few and far between.
Two hospitals in more rural regions of the state have recently expressed intent to shut down labor and delivery services — Sharon Hospital in Litchfield County and Hartford Healthcare’s Windham Hospital in the Northeast corner.
But the Connecticut Hospital Association said that there needed to be regulations developed for the birthing centers before a new category of licensing was created. They also expressed concern with what they saw as an “unfunded mandate” on hospitals to contract with the birthing centers. The association quoted statistics from the federal Center for Medicare and Medicaid services which found that 16-20 percent of women in birthing centers had to be moved to a hospital because of additional risks in their pregnancies.
“It should be incumbent on birthing centers to follow protocols and clinical guidelines, established by DPH, to ensure safe care and transfers; arrange for and provide for medically appropriate, staffed transfers (following federal and state EMS protocols); as well as to provide data that allows quality and safety to be measured in real time,” the Hospital Association wrote in testimony.
State Sen. Saud Anwar, D-South Windsor, said he was concerned that birthing centers could exacerbate the already existing shortage of physicians.
“If I was an OBGYN and we started to see a lot of the healthy births happening outside of the hospital systems, that would have a selection bias and more complicated cases would come to the hospital setting,” said Anwar. “And that would automatically from the malpractice insurance companies they would say ‘oh if you are an OBGYN, we are going to jack up your health insurance even more’ and that would actually be one more reason for them to leave our state.”
He also said he was concerned that the birthing centers would wait until the last minute to send patients with complications to the hospital.
Juthani said that hospitals would ideally partner with birthing centers, and perhaps even own them. She said it was critical for the hospitals to have partnerships with the centers in the event that a pregnancy becomes dangerous and the mother needed to be given higher-level care than a birthing center could provide.
“Although the pregnancy may have been a low risk pregnancy, if something untoward were to happen over the course of the delivery process, there needs to be an arrangement with a hospital to assure the safety of that mother and child,” said Juthani.
Bringing the baby home
Beyond labor and delivery, the state is also considering a statewide program that would support children during their first year of life.
Commissioner of the Office of Early Childhood Beth Bye told the legislature that the Office of Early Childhood is piloting a program in Bridgeport in which every baby born in Bridgeport Hospital will receive one to three home visits from a nurse, with follow-up visits from a Community Health Worker. The pilot will begin in May.
Bye said that Family Connects, the program that the state is using, found that participants in the first year of the program had fewer child welfare referrals and less postpartum depression, and greater connections with the community. New Jersey and Oregon are also in the process of implementing the program.
“We know that the brain and executive function are set in the first five years of life,” said Bye. “And we do know you don’t need any kind of degree to bring that baby home, but a little guidance can go a long way… it’s helping the parent feel confident and get off on a good foot.”
Bye told the legislature about a study she remembered learning about in graduate school showing that having a developmental psychologist educate parents about the capabilities of a newborn had an impact on how the child was doing in third grade.
“If just that did it, imagine one to three visits plus a link to community services,” said Bye.
Bye said the program will be funded through preschool development grant funds, a grant from the CDC and COVID relief funds. Bye said that in the future, they were working on using medicaid funding to sustain the program.
Deirdre Gifford, executive director of the Office of Health Strategy, said that the challenge was to convince commercial insurers to cover the program going forward, which comprises about 60 percent of the births.
“It’s in their economic interest, because we know it ends up saving money,” said Gifford.
Both Republican and Democratic legislators praised the program and the long-term benefits that it could have.
“This is one program that we believe that could really have a generational, lasting impact,” said Bye.