Background to A364B and S3344B
In April 2018, Governor Andrew Cuomo (New York’s Governor) launched the “Taskforce on Maternal Mortality and Disparate Racial Outcomes.” The Task Force consisted of 34 people. Within that group, there were two people from the Black New York doula community. The group met three times between June and December 2018 and made a series of recommendations to the Governor. These included:
- Establish a Statewide Maternal Mortality Review Board in Statute.
- Design and Implement a Comprehensive Training and Education Program for Hospitals on Implicit Racial Bias.
- Establish a Comprehensive Data Warehouse on Perinatal Outcomes to Improve Quality.
- Provide Equitable Reimbursement to Midwives.
- Expand and Enhance Community Health Worker Services in New York State.
- Create a State University of New York (SUNY) Scholarship Program for Midwives to Address Needed Diversity.
- Create Competency-Based Curricula for Providers as well as Medical and Nursing Schools.
- Establish an Educational Loan Forgiveness Program for Providers who are Underrepresented in Medicine (URIM) and who Intend to Practice Women’s Health Care Services.
- Convene Statewide Expert Work Group to Optimize Postpartum Care in NYS.
- Promote Universal Birth Preparedness and Postpartum Continuity of Care.
Governor Cuomo accepted these recommendations and launched a pilot program in March 2019 that would provide Medicaid coverage for doulas. The program was initially intended to be piloted in Erie County and Kings County. However, the number of doulas who registered for it in Kings County was not considered to be high enough for the program to operate, so it continued only with Erie County. Doulas registered in the pilot would be reimbursed for their services through Medicaid, receiving a maximum of $600:
- Up to four prenatal visits ($30 per visit)
- Support during labor and birth ($360)
- Up to four postpartum visits ($30 per visit)
In order to be registered in the program, doulas need to have:
- At least 24 contact hours of education that includes any combination of childbirth education, birth doula training, antepartum doula trainings, and postpartum doula training.
- Attendance at a minimum of one (1) breastfeeding class.
- Attendance at a minimum of two (2) childbirth classes.
- Attendance at a minimum of two (2) births.
- Submission of one (1) position paper/essay surrounding the role of doulas in the birthing process.
- Completion of cultural competency training.
- Completion of a doula proficiency exam.
- Completion of HIPAA/client confidentiality training
There was one open meeting that took place prior to the launch of the Medicaid pilot that several doulas of color and maternal advocacy groups attended. While these attendees tried to discuss the reimbursement amounts with the task force, they were not able to. The fees had been set, as had the requirements for registration and further discussion was not possible. During this meeting, there was no mention of a law that was being proposed on doula certification.
The bills were first referred on January 9th, 2019. The primary sponsors were Assemblywoman Amy Paulin and Senator Jessica Ramos. There were 19 additional co-sponsors. The purpose of the bill is to amend “the public health law to provide the requirements for professional certification for certified doulas.”
The bill outlines the maternal and infant health disparities for people of color and the importance of investing in the prevention of maternal mortality and morbidity. They explain that doula support has been shown to be an effective intervention that has been shown to improve health outcomes, and that “African-American and low-income patients are less likely to have access to doulas (New York State Assembly).” The bill further states that reimbursing doulas through Medicaid programs would improve access to those who cannot afford doula services. So far, so good. The maternal mortality and morbidity rates for people of color are unacceptable. Four times as many African-American people die in childbirth compared with white people. While maternal mortality is improving across much of the world, it increased in the United States between 2000-2015 (Unicef, 2017) and the gap is widening (MacDorman, 2017). New York ranks 30th in the United States for maternal health. The disparities have been called a “maternal health care crisis” by Amnesty International (2011).
When doulas in New York were made aware of the bill that was about to pass, several of them traveled to Albany to try and delay it being passed and to enable further dialogue on its implications. There was a closed-door meeting that none of those who had traveled to Albany were allowed to enter (including those who had been part of the initial taskforce). The lack of representation from people of color and the lack of consultation with a range of doula training organizations, failing to provide a broad perspective, is concerning.
Doula’s in New York met with Assemblymember Amy Paulin, the sponsor of the bill, to voice concerns over regulation of doulas. Assemblymember Paulin insisted that there would be no regulation on the education and training for doulas, and that there would be no scope of practice established as a part of the bill. They were told that the bill would be going ahead but that doulas and doula organizations would have the opportunity to later do chapter amendments.
What does this mean?
Doula support has been shown to be effective in improving outcomes, and we know that people who are marginalized are the least likely to seek out or have access to such care. Individuals within those communities are also the least likely to train as doulas which further disadvantages those who would like a doula who understands their lived experiences because they are part of the same communities. If this bill provides opportunities for people to have doula support where they might not otherwise, why wouldn’t we be fully in support of it?
The problem lies in the language of the bill, the unnecessary restrictions being imposed, and the vagueness of the requirements to work as a doula in New York. Let’s look at each of these and consider how they might impact doulas in New York and the families they seek to serve.
Only a person certified under this section shall be authorized to use the title “certified doula”.
The term “certified doula” has been used since 1997. It is recognized within the industry to mean an individual who has completed requirements and training to work as a doula. Under this bill, any doula in New York who has previously completed a doula training and certification program would no longer be able to use that term unless they meet the requirements of New York State, despite being recognized in every other state. This is regardless of whether they are a part of the Medicaid program or not. Other states (e.g., Oregon and Minnesota) have implemented a registry and we believe that a better term to use would be “State Registered Doula,” “State Certified Doula,” or “State Licensed Doula.” This would eliminate the ambiguity and confusion that the bill would potentially introduce.
“Certified Doula Services” means continuous emotional and physical support provided by a certified doula throughout labor and birth, and intermittently during the prenatal and postpartum periods”.
Emphasis is on the emotional and physical support. There is no mention of the role a doula in providing information and education. The bill specifically states that “nothing in this section authorizes a certified doula to engage in any act within the scope of practice of any other profession under Title 8 of the Education Law or any other law, unless the certified doula would be otherwise authorized to do so by law.” Title 8 refers to the licensing of certain professions and is overseen by the Department of Education. So, according to the bill, a certified doula would not be able to carry out any activities that are recognized in Title 8 as licensed professions. Reading through the definitions of these professions, we can see some problematic areas for doulas. For example (emphasis added):
- Physical Therapist: “The evaluation, treatment or prevention of disability, injury, disease, or other condition of health using physical, chemical, and mechanical means including, but not limited to heat, cold, light, air, water, sound, electricity, massage, mobilization, and therapeutic exercise with or without assistive devices, and the performance and interpretation of tests and measurements to assess pathophysiological, pathomechanical, and developmental deficits of human systems to determine treatment, and assist in diagnosis and prognosis.”
- CBI Comment: How might this impact birth doulas who use heat packs, water immersion, positioning, and devices such as TENs units to relieve pain during labor?
- Nursing: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding, health teaching, health counseling, and provision of supportive and restorative care under the direction of a registered professional nurse or licensed physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner’s regulations.
- CBI Comment: How might this impact birth and postpartum doulas who provide education to their clients? Could this also be applied to childbirth educators and breastfeeding counselors? Teaching about health is a fundamental part of a birth professionals role.
- Social Work: Psychotherapy in the context of licensed clinical social work practice is the use of verbal methods in interpersonal relationships with the intent of assisting a person or persons to modify attitudes and behavior which are intellectually, socially, or emotionally maladaptive.
- CBI Comment: While not offering psychotherapy, doulas do use verbal methods in interpersonal relationships with the intent to assist their clients to modify behaviors. Would this mean that a doula would now be practicing the profession of social worker and therefore carrying out a profession that is licensed?
- Dietetics and Nutrition: Assessing nutrition needs and food patterns; Planning for and directing the provision of food appropriate for physical and nutrition needs; and Providing nutrition counseling.
- CBI Comment: Providing a client with information on their nutrition needs and those of their baby are important roles for all birth and breastfeeding professionals. In addition, postpartum doulas plan and provide food to meet the nutritional needs of their clients.
With the requirement in the bill that doulas do not carry out any profession or task that is outlined in Title 8 we have significant concerns that this opens the door for taking action against doulas who are performing a well-established role, and one that has been practiced for centuries. While Assemblymember Paulin has assured doulas that there is no intention to develop a state scope of practice for doulas, we would be further concerned if New York State added doulas to the list of professions within Title 8 and confine doulas to the role they can carry out. The inclusion in the bill preventing a doula from carrying out a Title 8 act is effectively the regulation of doulas.
Complete an educational program, in accordance with the Commissioner’s regulations.
This would restrict any doula providing services in New York unless they were trained through an educational program as specified by the regulations. The bill does not state what would need to be included in that program or the requirements for completion. It also does not state who will be responsible for determining what kind of education would comply with the bill or how programs would be evaluated. Not all doulas go through a formal education program. Some choose to be mentored in informal ways or apprentice with experienced doulas. Many doulas have been working for 20 years or more without having attended a formal education program but demonstrate excellence in their doula skills. The doors to these different pathways should not be closed.
This requirement has the risk of devaluing doula training programs altogether. Already, we are seeing some training organizations remove the requirement for a doula to attend a birth at all before certifying and simply participate in a weekend workshop and complete an open book exam before being issued with their certification. This does not benefit the families we work with and, in particular, does not benefit people from marginalized communities if a doula can call themselves certified without ever having had to develop skills of reflective practice, develop experience with both clients and communicating with healthcare providers, or build their own cultural competency to understand the issues those clients may face.
Pass an examination satisfactory to the department and in accordance with the Commissioner’s regulations.
Again, it is not explained who would monitor and evaluate this. Written examinations, while effective at testing knowledge, are ineffective in evaluating skills, attitudes, and behaviors. Doula work is competency-based with the development of skills, attitudes, and behaviors being fundamental. Written exams are prohibitive for those who do not speak English as their first language or have learning differences that make sitting an exam extremely challenging. Again, the very people this bill claims to be supporting would be further marginalized through the requirement of an exam.
Be of good moral character as determined by the department.
This addition to the bill is of grave concern. Who determines whether a person’s character is “good” and “moral”? Character assessment is an accepted part of working in many professions such as the law or medicine. This kind of assessment is typically made by those in positions of power and privilege, and exclude people from marginalized groups in the decision-making process. What standards would be used for such an assessment and how could they be objective? How would cultural differences in values affect an assessment like this? Would a sex worker be considered to be of good moral character? What about a person with a history of drug or alcohol abuse who is now sober? Or someone whose child was removed from their care 20 years ago? Or a trans-person? Someone who practices BDSM? An individual who is in a polyamorous relationship? Do traffic violations count? What about someone who is an undocumented immigrant or has an arrest record for minor offenses? The very real experiences of some doulas are precisely what make them the perfect support for a client. For example, a doula who was arrested for possession of drugs 15 years ago may be the ideal doula for a client who is struggling with substance abuse.
This particular line is extremely troubling. Assessing an individual’s character is subjective and culturally defined. Those who work with people in marginalized and vulnerable communities are significantly more likely to fail an assessment of this nature.
Pay a fee of forty dollars to the department for consideration of an application for certification.
The introduction of a fee to apply for certification is a prohibitive requirement for many. The cost would not simply include this fee. For any doula who is not certified by a doula training organization, they would need to pay for training before they can apply to New York State for recognition. Doulas struggling financially, which particularly affects those from marginalized groups, would simply not be able to afford this.
What Are We Doing?
While we support initiatives that aim to reverse the disparities between maternal and infant health outcomes for Black families, we do not believe this bill will achieve this. We need more Black doulas working within the industry. We need programs that support them with grants and scholarships. We need to be encouraging activism and advocacy groups that are already doing great work in supporting marginalized groups. We need agreed standards of training to ensure that doulas who choose certification have the foundation knowledge, skills, attitudes, and behaviors that will ensure the safety of the families they work with and high-quality care. We need to continue recognizing the variety of paths to doula work and acknowledge that doulas from marginalized communities experience barriers that others do not, and we need to support them in taking the path that is right for them. We need to encourage and support doulas who are working with marginalized and vulnerable communities. We need to ensure that we do not impose beliefs and expectations that are culturally defined on people who have less power and privilege than us.
So what is CBI doing to address this bill and provide better support for those in marginalized communities?
First, we are working with the leadership in other training organizations in exploring areas of common ground and identifying where we can collaborate to support doulas in marginalized communities.
Today we are launching our scholarship fund. While we have informally offered this in the past, it is not enough. We need to provide opportunities for doulas within marginalized communities to become trained if that is the pathway they have chosen. As of July 1st, 2019, CBI will offer five full scholarships each month to a birth or breastfeeding professional working within marginalized communities. While not an exhaustive list, this includes working with people of color, indigenous people, refugees, the LGBTQIA+ community, incarcerated individuals, people with disabilities. This will be available for our Birth Doula, Postpartum Doula, Childbirth Educator, and Breastfeeding Counselor courses. Applicants will be required to outline how they are involved in their communities and how the training will benefit those communities, and submit a letter of reference that attests to their work. The scholarships will cover the full cost of training and certification. Birth-breastfeeding professionals globally are welcome to apply. This scholarship program will continue until June 30th, 2020, at which time we will review it.
We have written to Governor Cuomo and expressed our concerns over the bill. You can read our response here. We will continue to lobby politicians to advocate for health services that prioritize the needs of marginalized families.
We are offering our Diversity and Cultural Humility professional development unit free of charge until July 31st, 2019. This self-directed short course will enable doulas from any background to become better versed in cultural competency if this is something that you have not explored before.
What can you do?
Speak to your representatives
If you are in New York, you can contact the Assembly Members and Senator who sponsored this bill. Send them a copy of our response or write your own. They may be unaware of the issues related to this bill and unaware of how it will further disadvantage birthing people of color. A full list can be found below. If you are in another US state, write to your local representatives. Other states could follow the lead of New York and attempt to restrict the work you are doing as well. This is a problem that affects all of us!
Learn more about advocacy
DONA has an excellent, free toolkit on how to carry out advocacy action. You can download the toolkit from this page – scroll to the bottom: https://www.dona.org/the-dona-advantage/advocacy/ explaining how bills are passed and including concrete steps you can take on them.
Support grassroots organizations that are working with marginalized communities
Find grassroots organizations within your own community who are supporting marginalized and vulnerable groups. Support them! Ask them what they need first to ensure the support you are giving them is aligned with their own values and priorities.
Speak to people in your community
Share our response letter or a link to this page on social media. Tell people what is happening in New York and explain why it is problematic.
Develop and build your own skills of cultural humility
Take steps to better understand how to develop skills of cultural humility and the issues that affect diverse groups. There are lots of online resources to support you in this.
For a limited time, we are offering our professional development module on Diversity and Cultural Humility free of charge for anyone who signs up before July 31st, 2019. This is a self-directed short course of XX hours that will provide an introduction to diversity and cultural humility for birth and breastfeeding professionals. Click here to register for the module.
Email addresses of those who sponsored this bill
Governor Cuomo: firstname.lastname@example.org
Assemblywoman Amy Paulin, Sponsor: email@example.com
Senator Jessica Ramos, Sponsor: firstname.lastname@example.org
Assemblyman Richard Gottfried, Co-Sponsor: email@example.com
Assemblywoman Sandy Galef, Co-Sponsor: firstname.lastname@example.org
Assemblywoman Ellen Jaffee, Co-Sponsor: email@example.com
Assemblywoman Linda B. Rosenthal, Co-Sponsor: firstname.lastname@example.org
Assemblywoman Vivian E. Cook, Co-Sponsor: email@example.com
Assemblywoman Rebecca A. Seawright, Co-Sponsor: seawrightR@nyassembly.gov
Assemblywoman Carmen E. Arroyo, Co-Sponsor: firstname.lastname@example.org
Assemblyman Michael Blake, Co-Sponsor: email@example.com
Assemblywoman Inez E. Dickens, Co-Sponsor: firstname.lastname@example.org
Assemblyman Victor Pichardo, Co-Sponsor: email@example.com
Assemblyman Fred Thiele, Co-Sponsor: firstname.lastname@example.org
Assemblyman David McDonough, Co-Sponsor: email@example.com
Assemblywoman Solages, Co-Sponsor: firstname.lastname@example.org
Senator Alessandra Biaggi, Co-Sponsor: email@example.com
Senator Anna Kaplan, Co-Sponsor: firstname.lastname@example.org
Senator James Gaughran, Co-Sponsor: email@example.com
Senator Liz Krueger, Co-Sponsor: firstname.lastname@example.org
Senator Gustavo Rivera, Co-Sponsor: email@example.com