In St. Louis, doulas push for better reproductive health care — especially for Black patients

ST. LOUIS – For Carmen Southall-Wamhoff, it’s impossible to talk about access to reproductive health care without talking about what it means for maternal mortality, and the deep, systemic inequities that exist within it.

Southall-Wamhoff has been a doula, a labor assistant that provides physical and emotional support, for 21 years. She is also a licensed practical nurse, a childbirth educator, a certified lactation counselor and a car seat safety tech. So much attention is given to birth itself, she said, with few resources or supports available for the prenatal and postpartum challenges that are critical to maternal health outcomes.

This is especially true for Black women in Missouri, who are four times more likely to die in childbirth than others in the state, Southall-Wamhoff said, pointing to findings from the state’s Missouri’s Pregnancy-Associated Mortality Review (PAMR) board published last year. Black women living in Missouri are also more likely to experience severe maternal morbidity, a term used to describe acute conditions that either cause death or create short or long-term health complications, the report found (a rate of 220 per 10,000 live births compared to 89 per 10,000 live births among white women).

READ MORE: Missouri’s last abortion clinic finds itself in center of Roe fallout

Southall-Wamhoff and others involved in the STL Doula Project, an organization created to better support for marginalized communities before and after pregnancy, have been focused on this issue for years. Doulas provide “continuous physical, emotional and informational support to their client before, during and shortly after childbirth,” according to DONA International, a doula certification organization based in Chicago. That can look different — emotional support or advocacy with medical professionals during labor, assistance with breastfeeding, support in navigating postpartum challenges, or communicating with hospitals before, during or after birth — depending on a person and their needs.

Efforts like this are a part of the conversation in many communities in the wake of the Supreme Court decision to overturn Roe V. Wade. In June, the St. Louis Board of Aldermen, led by Alderwoman Annie Rice, put forth a bill creating the Reproductive Equity Fund.The plan included using federal funds to bring more access to reproductive care . The bill, passed and later signed by the city’s Mayor, Tishaura Jones, allocates $500,000 of ARPA funds to support organizations that provide direct services to support reproductive care which includes access to doula care and lactation support. According to the bill the St. Louis Department of Health will establish a process for how the money will be allocated.


St. Louis Mayor Tishaura Jones stands with Jamaa founder and CEO Okunsola M. Amadou. Jones presented a a proclamation to Jamaa Birth Village in honor of Black Maternal Health Week back in April. Photo by Church Productions

“Black women have heard the call,” said Southall-Wamhoff, who is on the board of the STL Doula Project. “They understand the assignment and they are answering the call.”

Elizabeth Lewis, a March of Dimes’ director of maternal and infant health, said an emphasis on doula care needs to be a part of the fabric of finding solutions.
“If we’re seeing that [doulas are] improving outcomes, then we have to make that sustainable and attainable for all people,” she said.

Part of the work for March of Dimes, established in 1938 by President Franklin D. Roosevelt, is birth equity and eliminating bias in birth, Lewis said.

There is some slow movement in other states, such as New Jersey, where doula care is being incorporated in the care for child birthing, Lewis said. New Jersey is one of six states where people can be reimbursed for doula services through Medicaid. But what is important is that the work includes the organizations on the ground who have been pursuing the same mission for years. In Missouri, that includes Uzazi Village in Kansas City and Jamaa Birth Village in Ferguson.

Okunsola M. Amadou founded Jamaa Village, a maternal health organization in St. Louis, in 2015, which she says was rooted in her own traumatic birthing experience. “Both me and my oldest son almost lost our lives during childbirth,” she said.

During her second pregnancy, she said she was forced to have another cesarean section, which made her “ passionate about discovering what were other alternatives or options so that people didn’t have to go through.”

Since then while the organization’s advocacy has grown, so has their outreach.

“When we started there were only five Black practicing doulas in the region, and now we’ve trained over 200,” Amadou said.

Training for doulas can look different depending on the organization. Training to become a certified doula at Jamaa Birth Village consists of 60 hours of training in a hybrid community environment, which includes virtual prerequisites, live virtual learning modules and in-person hands-on learning & practice sessions.

Amadou said while some hospitals that welcome doulas and implement policies that encourage clients to have them, most hospitals treat them as visitors.

“Generally, doulas will be called by the client to attend their birth, and the doula will mainly interact with the client, and give additional support to the client based on what’s needed or directed to them by their doctor and nurse team,” she said.

Amadou said there is a misconception that doulas are expensive. Jamaa has free and sliding scale payment plans, and many other doula organizations work to make sure the option is within reach for those who need it, she added.

“We need more trained and certified full-time doulas who are skilled in providing culturally congruent care to Black and Indigenous pregnant people of color,” she said.

For this reason the birth village is also expanding its work; the organization is currently preparing to build what Amadou calls Missouri’s first Black birth center.

The space will also double as a learning hub where doulas across the country can come to study and train to be doula.


Jamaa Birth Village plans to open a new birth center it says will be a hub where people can come from all over the country to train to be a doula. Photo by Jamaa Birth Center

“We have an architectural team that’s already submitted the plans to the city of Ferguson for approval so we should be building next year,” Amadou told the NewsHour.

That work has also spread across the United States and in other parts of the world. “We’ve done projects in Colorado and in Virginia, and we were just recently contacted to do a project at the state level in Ohio,” she said. “We right now are collaborating with the doula project in Elmina and Dutch Komenda, Ghana.”

Funding barriers and challenges

A doula’s work covers not only when a person is pregnant but also the postpartum period. It is a time health professionals say is crucial but the healthcare system does not often care for people long after they give birth. In the state of Missouri, postpartum care under medicare only lasts up to 60 days after birth.

However there have been efforts to change that. Part of the American Rescue Plan Act allows states to submit a plan to expand Medicaid coverage for postpartum patients up to a year after birth. The option became available to states starting April 1 of this year and will remain available for five years.

A bill this year from Missouri Sen. Jill Schupp, D-St. Louis County, sought to authorize Missouri’s implementation of the extension, but it was blocked in Missouri’s Republican-controlled Senate and did not pass.

Hakima Tafunzi Payne, CEO of Uzazi Village in Kansas City, said postpartum care is not an area where access should be cut. “Problems can occur postpartum, so it’s wrong just to abandon folks after they have their babies when that’s when they actually need support more,” she told the NewsHour.

Uzazi Village was founded in 2012 to provide community-based maternity care to decrease maternal and infant health inequities. In addition to supporting birth, their doulas make six to seven prenatal and postpartum visits to a patient.

It is a resource Payne said should be more accessible “ as one important part of the solution of Black maternal mortality and health and mortality.” she said.

WATCH MORE: Vice President Harris delivers remarks on efforts to improve maternal health

Southall-Wamhoff said closing the equity gaps in maternal healthcare will meanunderstanding that the barriers birthing people of color face exist before and after pregnancy, she said, emphasizing the need for postpartum care.

“When you think of postpartum, we call it ‘the fourth trimester,’ so it could be up to a whole year before one feels like … she’s back to herself,” she said.

Nikki Miller, a mother of three and now a doula herself, said it took two years after her first child was born to feel like herself.

“It took me a long time to accept the fact that my body had changed, and that was something that I was going to need … to accept,” she said.

Miller worked her entire pregnancy. “She said she did not experience any health issues while pregnant, but she had to have an episiotomy, a significant surgical incision, during delivery.”

After birth,Miller not only had to adjust to life as a new parent but also subsequently seek hands-on psychotherapy to address mental health issues that developed as a result of a difficult labor. Though the therapy helped, she said, it was also very “uncomfortable.”

“It was very, very, very hard for me to just kind of get over what had happened mentally and then basically be able to take care of my son at the time and be available for him emotionally, those were like the hardest things to get over,” she said.

Sixty days after birth is not enough of an extension for new parents to recover, Miller said.

“It takes a year for everything to settle your organs and things to kind of settle down,” she said. “All the chemicals that our bodies and brains possess, you know, no one goes back to normal in two months.”

Falling off the healthcare cliff

CDC data from 2020 shows that disparities in pregnancy outcomes are not unique to the Midwest — the national maternal mortality rate for non-Hispanic Black women is 2.9 times the rate for non-Hispanic White women.

Dr. Ebony Carter is an obstetrician who treats high-risk patients with one or multiple complications that can arise during pregnancy and delivery.

“My heart, where I really like to serve, is patients who are low income, they’re predominantly women of color,” she said. “Most of them live in zip codes where the pregnancy outcomes are terrible, rivaling the outcomes in the developing world.”

While the months when a person is pregnant are crucial, Carter said so too are the periods before and after pregnancy.

“The irony in that is that pregnancy outcomes are in large part determined before you get pregnant, it’s all of the accumulated things that you bring into the pregnancy with you,” she said.

“Usually you go from this intensive prenatal care, you’re being seen every single week to then you deliver and you don’t see anybody for at least six weeks.”

READ MORE: How this Medicaid extension throws postpartum parents a lifeline

But the issue, according to Carter, has a lot to do with people’s access to healthcare — period.

“I think one of the things that’s happening and in Missouri that’s unfortunate is that there’s no safety net. That by the time people come to us, they’re already extremely sick, have lots of co-morbidities that are complicating pregnancy, and in the seven months that I care for them, we wrap those things up in a nice boat, right? We have access to insurance coverage. We get all of those things really, really well controlled. And then you have the baby and what happens? People fall off of this health care cliff about 60 days after they deliver if they have Medicaid and no longer have insurance,” she said.

Though much of the data is disheartening, Carter says there have been small glimmers of hope in Missouri, such as voters approving Medicaid expansion back in 2020 which went into effect last October. However, inequities continue.

“Let’s also not pretend that insurance is the end all, be all, it’s helpful, it’s necessary to have access to care but the other reason that we’re seeing that the disparities that we see, particularly for women of color, particularly for black women, is because of past and present injustices,” she said.

It is an unfortunate reality she said we have to face.

“The fact of the matter is, I live in the city of St. Louis and we did redlining and racism really, really well in my city, and it’s no accident that there are certain places where people have everything that they need and there are certain places that they do not,” she said.

For Lora Gulley, director of community mobilization and advocacy at Generate Health in St. Louis, the way to start is recognizing “ racism and by racism we’re talking about policies and practices, the experiences that Black women and working people have trying to get their daily needs met,” she said.

Her organization works to advance racial equity in everything from pregnancy outcomes to overall community health. It is work she says is complex, deep rooted and systemic.

“If we’re talking about improving birth outcomes, we’re looking at some of the most ingrained disparities in our region and they rest in maternal and child health,” Gulley said.