‘A Second Level of Power’ for Black Birthing Families

Deneen and Will Bradfield knew they wanted to hire a doula for the birth of their second child.

They wanted a natural birth process with no anesthesia or epidural, a procedure in which a numbing medication is injected into the spinal fluid to relieve pressure and pain.

“Having more control, more comfortability during that process is definitely a reason why we chose to have that support,” Deneen said. “You have someone there who is able to advocate for you, someone who already knows your birth plan…it gives you a second level of power, because with people thinking that we’re so strong, they can say ‘I’ve been with this lady for nine months, and she’s really in pain.’”

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Deneen, who was 38 at the time, knew she was at a higher risk of complications due to her age. Her pregnancy coincided with the COVID-19 pandemic, adding another layer of uncertainty.

The Bradfields connected with doula Kelle Pressley as soon as they made their pregnancy announcement. Throughout the process, the couple strengthened their bond with each other and learned breathing techniques, stretching and massages, and even how drinking certain teas would thin Deneen’s cervix.

Will added that Pressley’s help empowered him to be more involved and supportive before, during and after their son Cash’s birth in 2020.

“It was during the pandemic, so we weren’t allowed any additional people in the delivery room,” he said. “With it just being me and her, [Pressley] also helped to prepare me in order to be of assistance to her and with helping with the birth. It was a plus because it helps put together a team. I’m going into it with full knowledge.”

Working with Pressley, the Ruperts strengthened their bond and were better able to recognize potential problems. Following delivery, Deneen experienced post-preeclampsia, in which her blood pressure was dangerously high postpartum. She didn’t experience headaches, chest pains or blurring vision.

“I literally just did not feel good in my body, and I knew something was wrong,” Deneen said. “When I told my husband, he said, ‘let’s make an appointment.’”

Deneen’s blood pressure was so high – 207 systolic/110 diastolic – it caused monitors at home and the hospital to report error messages. Preeclampsia can result in strokes or heart attacks, which is often fatal for Black women postpartum. Deneen spent six days in a hospital.

Kira Kimble looks out for birth moms and their babies.

Kimble is the founder and CEO of Charlotte-based Mine-R-T Doula Company, a team of 10 birth professionals serving clients in a seven-county region. Doulas are not medical professionals, but they attend births and advocate for clients. In her work, Kimble has seen the difficulties facing Black birthing people, doulas and midwives that contribute to maternal and infant mortality gaps.

One is a lack of trust between people of color, especially Black women, who are nearly four times more likely to die of pregnancy- and birth-related complications, and medical institutions. According to the Centers for Disease Control and Prevention, 80% of those fatalities are preventable.

“A lot of times, those disparities occur because the patients didn’t feel like they could just disclose their concerns, or they didn’t feel like their concerns are being addressed,” Kimble said. “They felt like they were being rushed through appointments and felt like they were more of a bother. “Our job is to really keep them in the driver’s seat, so their voice is recognized, and their voice has value.”

Birth workers advocate for clients in addition to providing culturally competent care to mothers, birthing people, and their infants through physical, emotional, and educational support before, during, and after labor and delivery.

Black doulas and midwives can help mitigate the impacts of racism embedded within the healthcare system, including addressing causes of pregnancy-related deaths.

In 2020, nearly 10% of all U.S. doulas were Black, according to Zippia, an online recruitment company. Black doulas earn an average salary of nearly $48,000, nearly $9,000 less than their white counterparts, who make up 60% of all doulas. White people account for 90% of all midwives.

Although women make up 94% of the doula workforce, their average salary of $51,750 is 3% less than that of men ($53,000).

Doulas are trained to understand complications that can come with pregnancy and provide clients with information about the symptoms of preeclampsia, encourage them to talk with their health care provider about their blood pressure, and ask questions about tests such as gestational diabetes.

North Carolina does not mandate licensing for doulas, and many seek it through independent organizations.

The history of Black birth workers in the U.S. can be traced to enslaved African women who provided care as midwives using traditional customs and practices in their communities as well as their enslavers. After emancipation, Black midwives were still in demand and present for half of all births into the early 20th century. With the modernization of healthcare and growing racism and misogyny, fewer midwives attended births, which corresponded with increases in maternal mortality, especially for Black mothers.

That lack of cultural competency, as well as a shortage of Black medical professionals, lead to gaps in treatment and outcomes, said Keisha Bentley-Edwards Ph.D., associate professor at Duke University of Medicine.

“The idea of a hard reset, not just at the in the med school setting, but throughout people’s career – professional development, getting better understanding of how racial disparities persist – is important,” she said. “When you see the biggest or the greatest racial disparities are untreatable diseases and conditions, the areas where there is a standard and effective care that can be provided, that’s where you find the biggest disparities between Black and white people. So that, to me, rings the alarm there are pieces of the puzzle that are missing.”

Hospitals are businesses, Kimble contends, and birthing is a cash cow. There’s also an incentive to avoid medical malpractice lawsuits, which protects profits.

“Same with the providers. They want to keep their jobs,” she said. “Their obligation and their loyalty is to their employer. That's why having an independent doula is so beneficial.

“C-sections are major surgery. “They cost a lot more than being in a room and not intervening and letting a woman have a baby by herself. “There's also the litigation factor where the hospitals don’t want to lose money because of being sued because they made a mistake. In order to prevent those things, they’re quicker to intervene and have a c-section where they can control things.”

Independent doulas “don't have to worry about pleasing the hospital,” Kimble adds.

A 2021 report by the National Perinatal Task Force found that the United States, despite spending more on health care than any country, underperforms when it comes to maternal and infant health at 57th for infant mortality and 48th for maternal deaths. In the NPTF’s Black Mamas Matter Toolkit, Black maternal and infant mortality are addressed as human rights issues.

In “Medical Apartheid: The Dark History of Medical Experimentation on African Americans from Colonial Times to the Present,” Harriet A. Washington documents how medical colleges, circus sideshows, museums, slave owners and medical researchers all participated in objectification and dehumanization of Black people – often for financial gain.

Washington cites cases of enslaved and free Black people, whether dead or alive, being experimented on without their consent; fortified with entries from medical journals and newspapers explaining how the Negro race was incapable of sufficient intellect to make logical and important decisions about their own bodies.

Kimble points that those ideas and beliefs have not dissipated over time, connecting Black maternal and infant mortality as a feminist issue, raising concerns about body autonomy and health.

“Women have the right to say no in the birth room, the boardroom, and the bedroom,” she said. “And under white supremacy, they don’t like to hear women saying no. They don’t always believe them as being capable of making decisions. For Black women, it’s even more so.”

Income and education level exacerbate the likelihood of experiencing bias from medical professionals, and negative health outcomes.

“If you are maybe low-income, maybe you have a lower education level; Sometimes we don't think that you have the wisdom to know what's best for you. There is always this kind of overreaching voice of ‘we know what’s better, or what’s best for you, so we're going to make the decisions for you.’”

Kimble takes a critical eye to hospitals announcing the addition of in-house doulas, especially Black ones. She contends that independent doulas provide better outcomes, such as less perineal tearing and fewer interventions.

“Black maternal health is a hot-button issue, and so hospitals are trying to figure out ‘how can we jump on that?” she said. “How can we have doulas under our umbrella so that we can be competitive with other hospitals?’ When you mix doulas in with hospital staff, you lose that independence, and now the doulas are reporting to the hospitals and having the same issues that the hospital staff has, where they’re worried about ‘am I going to get a negative review from this hospital?’”

A 2023 review in The Cureus Journal of Medical Science showed doula support is beneficial beyond the scope of hospitals:

“[T]he benefits of doula support may be generalized beyond full-time hospital-based doulas… Compared to mothers who received standard care, the women with a lay doula had decreased labor times, increased Apgar scores at one and five minutes, and a downward trend with cesareans.”

Kimble also identified another reality: people often don’t pay attention to an issue until it’s too late.

“What's happening in maternity care happens with Black policing,” she said. “The things that you see policing do with Black men is what maternity care does to Black women, and a lot of times it’s ignored until you see something that happens in a spotlight,” she said. “Black doulas, Black birth workers are screaming about the mistreatment of black women in the medical setting that nobody’s listening to us.”