ST. PETERSBURG — Courtney West stepped into the house and ran with her arms wide open to greet Samara Jackson.
Moments later, Jackson’s 8-year-old son, Orion, strolled down the hall, past the family wedding portraits and toward the pair who were laughing and hugging like lifelong friends.
“How are you baby boy?” West asked Orion as she turned and wrapped her arms around him, too. “Well, I can’t call you baby boy anymore, can I?”
Orion is a big brother now. Two weeks earlier, Peace Jackson — just over 6 pounds the last time his mother checked — was born at home.
“When’s the last time you ate?” West asked Jackson during her visit that Friday afternoon. Then she checked on how mother and baby were sleeping.
The day before, West had assisted with another delivery. She’s booked until June, she said. When she makes plans, they come with the disclaimer, “unless I’m at a birth.”
West sees doulas as the “mothers of mothers.” In her own practice, she serves as caretaker, chef, masseuse and often times advocate for families in hospitals and doctor’s offices. She assists with home births and hospital deliveries, offering additional comfort and expertise for families. The vast majority of the mothers she cares for are women of color.
Pregnant with her second child in the midst of the pandemic and the intensity of last summer’s Black Lives Matter protests, Jackson, 30, shied away from the hospital where Orion was born. They had induced her, and she felt forced into using formula instead of breastfeeding.
This time, she sought the care of a Black midwife and a Black doula. This time, she wanted more support.
A persistent disparity
Zulgeil Ruiz Ginés, who heads the only Hispanic-owned midwife practice in Hillsborough County, is booked until August. She receives a handful of calls every week from women of color who are scared, determined to avoid traditional health systems that have discriminated against them.
But with limited capacity, “I’m turning people away,” said Ginés, whose own childbirth was rife with mistreatment.
“It’s no way to come into the world with trauma,” she said.
Black women once dominated the field of midwifery in southern states. Their enslaved forbears had passed down West African childbirth techniques through generations.
From the 1930s to the 1960s, the Florida Department of Health recruited midwives for women who had no access to medical care due to poverty and segregation, according to Sharon Hamilton, former president of the Midwives Association of Florida. Back then, Black people were often not allowed in hospitals.
Since then, the number of Black maternal health care providers has dwindled.
And the rates of maternal mortality and preterm births have increased in the U.S., even as medicine and technology have advanced, according to an analysis by the Kaiser Family Foundation, which noted trends since the 1980s.
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Black women face death rates related to pregnancy that are over three times those for white women. For American Indian and Alaska Native women, pregnancy-related death rates are more than twice as high as white counterparts. The rate for Hispanic women was similar to white women, the Kaiser analysis found.
The outlook is somewhat brighter in Florida, which has seen a significant drop in the rate of maternal mortality over the last 10 years, particularly among Black and Hispanic women, said Dr. William Sappenfield, a University of South Florida professor and the director of the Florida Perinatal Quality Collaborative.
Still, disparities persist, Sappenfield said.
For so long, researchers studied race as a physiological cause for the disparities, said Jessica Brumley, director of the division of midwifery in USF Health’s department of obstetrics & gynecology. But “it’s really racism and the social and systematic effects of that over generations that are affecting health outcomes.”
Patients who are cared for by a provider who looks like them have better outcomes, said Brumley, and if you’re Black or brown, you’re less likely to have a provider who looks like you.
Noticing differences in care
Throughout her pregnancy, Delaine Williams mastered the art of dropping hints in conversations with nurses and doctors.
She’d mention her college degree and say her husband’s name in passing. She’d bring up the clients she worked with as a group insurance consultant. She’d let them know about her journey with in vitro fertilization.
“I felt like I needed to wear that privilege on my sleeve in order to be treated with kindness,” Williams said.
Still, it didn’t protect her.
After the birth of her daughter, an awful headache took hold, a side effect of her C-section. Williams could hardly walk, her vision blurred, she could barely hold her baby, she said. She returned to the hospital and, after hours of begging for medication, the pain management team refused, saying her pain wasn’t as severe as she let on.
“Everyone was working really hard to convince me that what I was experiencing was not what I was experiencing,” said Williams, a Tampa native and Florida A&M University graduate. “I had a lot of trouble advocating for myself.”
With the pandemic raging, her husband couldn’t stand by her side at the hospital. And as a Black woman, not having a partner with you “changes the way you’re perceived,” said Williams, 35. At the hospital, attendants assumed she was on welfare.
After her mother called demanding to speak with the administrator on duty, the head of the emergency team came to her room. Deeply apologetic, the doctor explained his wife had experienced the same issue and offered medication to ease the pain.
Since then, Williams has steered clear of the hospital and used a doula for postpartum care.
Black emergency room patients were 40 percent less likely to receive pain medication than white patients, and Hispanic patients were 25 percent less likely, according to a study published in 2019 by a researcher at George Washington University School of Medicine & Health Sciences.
Dismissing Black and Hispanic women’s pain is one of many ways implicit bias affects their quality of care, experts say.
West, the doula, says she cares for many second-time moms afraid of hospitals after their first experiences: women stitched up wrong after surgery, or consistently talked down to. She’s heard from Black and brown fathers who said they were removed from the delivery room for asking why their partners were being mistreated. A mother of 10 who said she sought her help after bad experiences during every pregnancy, finally hoping to have a good birth.
The traditional medical structure traumatized West, much as it does her clients.
When her blood pressure increased throughout her pregnancy, doctors threw medication at her, she said. And when her baby was delivered, no one checked on her. “I could be bleeding out right now,” she recalled thinking. “Where’s the care?”
Then came severe postpartum depression and sleep deprivation. Again, “they threw me on some meds and that was it,” said West. During that period, West was offered a copper intrauterine device for birth control and an allergic reaction left her sterilized.
In response, nurses made remarks suggesting she didn’t need to have more children anyway.
“I trusted them,” West said. “How dare you take something so precious from me?”
When Ciara Tucker of St. Petersburg started having chest pain, she went to a community health clinic. After four visits, a multitude of tests and repeated radiation, doctors took a urine specimen. Tucker, 38, was pregnant. A complication with her twins was causing her heart problems.
At 17 weeks, she lost one of the babies due to causes she says were unrelated to the radiation. Still, Tucker describes her care at the clinic as “total chaos” and is angry her babies were put at risk.
Another St. Petersburg resident, registered nurse Briana Hickman, was aware of the disparities facing mothers of color when she got pregnant with her son. So she recruited West as her doula for additional support.
“Being a nurse kind of works in your favor,” said Hickman, 27, who noticed the gaps in care firsthand as a Black patient. Having West as her advocate allowed Hickman to ask doctors more questions and push back when she felt pressured into taking certain medications.
A week before Ni’Chelle Lawson gave birth, harsh contractions forced her to check into the hospital. With no rooms available when she arrived, Lawson, 27, said she sat in the lobby with West as nurses walked by “almost like they were smirking and making fun of what I’m going through.”
In the Black community, “we’re pushed to get an epidural, to get a C-section. We’re pushed to feel like there is no other option than the option that is given by the doctor,” Lawson said. But throughout the pregnancy, West helped her speak up when she didn’t want to go with what the doctor was pushing on her, she said.
“I had more of a voice than I thought that I had.”
A systems problem: ‘The numbers don’t lie.’
As doctors become more aware of the discrimination and communication barriers permeating maternal health care, some hospital systems are looking to bridge the gap by incorporating midwives and doulas into their operations.
“There are certainly differences in philosophy” between the practice of obstetrics gynecology and midwifery, said Brumley, the USF professor. While obstetrics and gynecology specialists are experts in the management of medical complications and surgery, midwives are experts on the physiology of pregnancy and birth. They complement one another, she said.
Hospital midwives traditionally treat high-risk patients who may have multiple conditions, she said. The personalized care families may find with licensed midwives who work outside hospitals is difficult to recreate in a facility because of the sheer volume of patients.
Licensed midwives don’t see high-risk patients. So, to ease the concerns of women who are high-risk but do not feel safe in hospitals, some hospitals offer team-based care that includes nurse midwives.
In Hillsborough County, ReachUp Inc., an organization working toward equality in health care, has been incorporating the use of doulas to chip away at maternal health disparities for the past two decades.
“We need to listen to women,” said Estrellita “Lo” Berry, ReachUp’s president and CEO, “and really, truly be able to have dialogues about implicit bias.”
As the disparities persist, advocates are pushing for structural change and — in some cases — starting to make them on the grassroots level.
“The numbers don’t lie,” said Yamel Belen, owner of One Love Doula Services, which serves women across the region. “Every provider should be very well-versed in diversity and inclusion.”
Belen’s practice offers free planning sessions to families of color in hopes of combatting the disparities. While she doesn’t have the funding to offer all of her services at no cost, a single session can help families feel empowered, Belen said.
It “gives us an opportunity to educate you,” she said.
Back inside Samara Jackson’s kitchen, West, the doula, gazed at baby Peace in her arms. “He’s the most precious thing,” she said. “I’m so proud of you.”
Jackson said she was going to miss her.
“You don’t have to miss us,” West said. “We’re here. We’re not going anywhere.”
“I want to be at all the birthdays.”
The Foundation for a Healthy St. Petersburg provides partial funding for Times stories on equity. It does not select story topics and is not involved in the reporting or editing.