We have been able to spend a bit of time over the last few days with a doula right here in Nairobi. She is an American who has lived in Kenya for over ten years. The conversation has been both entertaining and enlightening.
It seems the doulas of Nairobi have the impression that the doula movement in the USA is very coordinated and accepted. Imagine her surprise as we discussed the various competing groups not only for the right to call someone a certified doula, but also for the right to decide what a doula is and what she can do. She did not realize there was more than one organization certifying doulas. She did not understand there was opposition to certification of doulas that is as strong as the call for increased education of doulas. She was not aware that not all hospitals have written policies to allow doulas, and there has been talk of hospitals prohibiting doulas (although we did not personally know of any actual cases of this). The internet can give such an inaccurate picture of the realities of life.
We talked about the potential to license and regulate doulas, including the issues surrounding insurance reimbursement for doula services. She was shocked and laughed at the idea the health care system could afford another pair of licensed hands in the delivery room. This was an interesting perspective to American ears. In the United States the couple pays for what they want and who they want whether it was through insurance or out of pocket. But here in Nairobi most maternity care is highly subsidized by the government. If the government can barely afford to hire nurses for the ill, how will they support a system of doulas for the healthy? It made me wonder, how can doulas fit into all health care systems?
We talked a bit about the ways doulas manage to balance family and doula work in the states. She was surprised to learn that the majority of doulas are not making enough money to support their families. She understood her struggles of finding child care and being able to leave at a moment’s notice when on call. For some reason, she assumed American doulas had figured out a solution to this problem. While some had by depending on family or swapping child care with other doulas, we admitted that it was a roadblock to many women who wished to work as doulas. The most startling solution to her was the way some doula groups work together and are hired together, and the mother gets whoever is on call when she is in labor. This went against everything she imagined a doula to be – how can a stranger provide the care?
We also spent time discussing doula groups. She liked the idea of doulas meeting with other birth professionals on a monthly or bimonthly basis for continuing education, although she wasn’t sure she could get the childbirth educators and midwives on board with the plan.
The problem of payment for services was a big issue. Even in Kenya, a doula needs to support the work she does, and it seems the system is less forgiving of a doula who wants to provide sliding scale fees. High costs for fuel and the local customs of gift giving mean her expenses (including nanny care for children when gone) were at least 50% of her fee. Raising her fee to American prices would make her unreachable to most families, and as she practices now she is only able to be hired by those who have the funds to choose private hospitals.
This seems to be a struggle for all doulas. How can doula care be available for those who cannot afford a doula when a doula is only paid by the family? I understand many American doulas volunteer services or provide sliding scale fees. Almost all my personal doula clients were non-paying, but that is because I purposed to be a doula for single women and teens – I went into it expecting to lose money. But not very many women have that option. Perhaps in some systems there is no room for a doula. Instead the nurses and midwives must be trained to provide doula-style care. We talked about the possibility of making doula training part of nursing training. Unfortunately the studies using nurses as the continuous support in labor have not had the same level of outcomes possible when non-nurse doulas are providing the support.
Maybe Kenya’s first step needs to be providing enough midwives and creating a health system where no one is too poor to receive care. Only 44% of Kenya’s mothers give birth with a skilled birth attendant, which really means, only 44% of Kenya’s mothers have access to medical care if they needed it. Kenya’s maternal mortality ratio is 530 per 100,000 births. For comparison, the world average is 260 per 100,000. Kenya has only 11.8 nurses & midwives per 10,000 citizens/residents. When I see these numbers it always makes me feel ill. How can I spend time advocating that American women should all have the luxury of doulas when Kenyan women don’t even have access to care if they want or need it?