Why this lawmaker wants to make doulas more accessible in Utah.

One bill aims to expand access to doulas by covering the costs for those covered by Medicaid.

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This story is part of The Salt Lake Tribune’s ongoing commitment to identify solutions to Utah’s biggest challenges through the work of the Innovation Lab.

Throughout her pregnancy, Annays Foster tried to prepare for everything. She read books about lactation, she joined an expectant mothers group and set specific goals on what she wanted after the birth of her baby, including waiting a few minutes before clamping the baby’s umbilical cord.

She listened to other mothers. She took notes. But no matter how much information she found, the thought of giving birth still terrified her. That changed when she met her doula, Sindi Virgin, who went into Foster’s home bearing answers, tools and a notebook to write down all of her wishes.

Doulas serve as non-medical support for pregnant women, providing emotional and physical support before, during and after birth.

“The good thing about having a doula is that you talk so much, you connect so much, that she knows all your birth preferences”, Foster said in Spanish. “Because in that moment it gets to the point in which you can’t think, you only want the pain to end.”

Looking back, Foster believes that hiring a doula was the best decision she could have ever made. But that choice wasn’t easy. She was curious about the benefits of having an expert birth guide, but amid all the other costs associated with welcoming a child, a doula was an expense her family could avoid.

“I told my husband ‘I don’t know, we would have to pay, and if all women give birth without a doula, I don’t think it’s necessary,’” she said. “But, no.”

The couple waited until she was 35 weeks pregnant to hire Virgin, when they secured additional financial help from an organization. After experiencing the results, they wish many others could have the same opportunity.

(Courtesy of Annays Foster) Annays Foster holds her baby, Lucca, shortly after birth. Foster hired a doula to help guide her through labor.

Sen. Luz Escamilla, D-Salt Lake City, is sponsoring SB 192, a measure that would expand access to doula services for Medicaid recipients. Medicaid financed about 22% of births in Utah in 2020.

“Having a doula there by their side could make the difference in having a positive birthing experience,” said Ciriac Alvarez Valle, senior policy analyst with Voices for Utah Children. Especially, Alvarez Valle said, for those who feel insecure in the healthcare system or “may not have that knowledge of what questions to ask or know what to expect.”

Advocates like Alvarez Valle also point to research showing doulas can help lower cesarean delivery and postpartum depression odds. One study examining doula care, birth outcomes and costs among Medicaid recipients found that the lowered cesarean rates could also save states’ money.

“When you see the outcomes of those pregnancies,” [with doulas], Escamilla said, “you realize that planning and education truly has a better outcome for those families.”

Improving maternal mental health and wellbeing is an important issue in Utah this year. Gov. Spencer Cox declared February 2023 as “Maternal Mental Health Awareness Month” and several bills aimed at expanding mothers’ health care benefits are under consideration this session. Some of the maternal health measures reflect lawmakers’ efforts to provide options for women, mothers and children as the Legislature clamps down on abortion access.

“Maternal health is the basic place to start talking about kiddos’ health,” Escamilla said. “Because if mom is not healthy, then that kid is probably going to have a very, very negative impact, even through their prenatal experience.”

(Rick Egan | The Salt Lake Tribune) Sen. Luz Escamilla, D-Salt Lake City, is sponsoring SB 192 to support doula care for women covered by Medicaid. The hope is to give more women help before, during and after childbirth. Here, Escamilla discusses another bill in a Senate committee hearing, on Wednesday, Feb. 22, 2023.

Escamilla, a mother of three, believes expanding who can access doulas services is one more way the state can boost outcomes for moms.

“We say we’re a very friendly state towards families,” Escamilla said, “We need to put our money where our mouth is.”

What do doulas do?

Sara Pixton attended her first birth as a doula about five and a half years ago.

“Doulas primarily support their clients throughout pregnancy by getting to know them, getting familiar with their birth preferences, and giving them some skills to stay comfortable during labor and have conversations with their care providers,” Pixton explained. During labor, a doula can help with moving into different positions or act as a kind of interpreter of “hospital lingo.”

Pixton also stays up to date on the latest pregnancy and birth-related research, telling mothers about different evidence-based practices. Her goal is to make sure her “clients feel like they’re making informed decisions.” And doulas like Pixton can be a “megaphone” for a pregnant woman’s voice so that her “preferences are heard.”

(Julie Francom) Sara Pixton is a doula advocating for a bill to cover doula services under Medicaid.

Some doulas can provide postpartum support, helping feed and care for a baby overnight so parents can get enough rest.

“Labor and birth are very intense physical and emotional experiences,” Pixton said. “And sometimes really big feelings come up.” Her job is “holding space for those feelings and validating them.”

“At the end of pregnancy, sometimes you have a lot of hormones, and you just need a good cry,” Pixton will tell her clients. “And I’m here for you if you need to just make a phone call and have a good cry or talk through a difficult decision.”

The barrier of cost

However, the costs, which can run up to nearly $2,000, makes hiring a doula too expensive for many families.

When Pixton was pregnant with her son she learned about doulas and remembered thinking “well, that’s nice for people who have 1,000 extra dollars.” At the time Pixton’s family couldn’t afford the additional cost.

While doulas like Pixton offer a sliding scale, others rely on the job as a vital source of income for their families and have to balance clients who can pay their full fee. Demand for the existing grant programs set up privately by doulas far outstrips the financial help currently available, Pixton said.

“I think it’s something that ought to be available to anyone who desires it,” Pixton said.

She believes providing doula services to Medicaid recipients would help. So far, there’s been bipartisan support for SB 192 and it’s already passed the Senate. As of press time, it still had not been considered in the House.

The importance of doulas is clear to mothers who went through difficult births or simply needed a little extra support.

“[Having a doula] empowers you,” Foster said. “But there are a lot of people who can’t do it because of financial reasons.”

Had Virgin, her doula, not been in the room, she said, the hospital staff would have convinced Foster to take an epidural at the beginning of her labor and to take a pharmaceutical that would accelerate contractions —all contrary to what she wanted; the most natural birthing process possible.

Yes, Virgin set up a relaxing ambiance in Foster’s hospital room, lit candles, diffused essential oils and took pictures. But, her job as a doula went beyond that. She translated everything that went on during Foster’s labor, helped her move through tension and make informed decisions that best aligned with her beliefs.

“She was my brain in that moment,” Foster said.

Today, the good memories of the birth of Lucca, now a toddler, overpower those of the physical pain. “What comes after the baby’s birth,” she said, “that’s the serious business.”