Khadija Fox screamed in pain when the doctor forcefully pulled her baby out in a Stockton hospital birthing room years ago.
The attending nurse yelled at her to stop screaming, so she did.
As a young Black woman in her early twenties with little knowledge of the birthing process, she remembered feeling as if she were being treated like a child.
“You almost forget you’re a grown woman. You’re at the mercy of everyone around you,” Fox recalled of that memory. “I thought this was normal.”
Fox says the birth of her child wouldn’t have been such a traumatic experience if she had been encouraged to listen to her body.
Fast forward about a decade. Today Fox, 37, is a certified doula – a woman whose services include personal, emotional and physical support throughout a client’s pregnancy.
Unfortunately, Fox says negative experiences with the medical system aren’t uncommon for Black women across the board.
Because of recent changes in state law, however, it’s now easier for pregnant Black women to get help they need from certified doulas like Fox.
It started in the beginning of last year when Medi-Cal benefits were extended to doula work. Then, Assembly Bill 904, authored by Southern California Assemblywoman Lisa Calderon, D-Whittier, was passed in fall 2023.
The new law is the first in the nation to expand access to doulas within private insurance networks. It states the cultural, institutional, environmental and social needs of Black, Indigenous and marginalized women are not being met.
The new law lists those factors as the reasons why the United States has the highest rate of maternal mortality among higher-income countries. That equates to roughly 1,200 pregnancy-related deaths annually, three out of every five of which are preventable.
The new law could also be helpful in the San Joaquin Valley, which has some of the highest rates of infant mortality for Black and Latino babies in the state, according to the California Department of Public Health.
For example, San Joaquin County had the highest rates of Black infant mortality in 2023, with a rate of 12.4 deaths per 1,000 live births. In the same study, Fresno was found to have the highest rates of infant mortality among Latinos at 5.9 deaths per 1,000 live births.
Black women have the highest maternal mortality rate in the U.S. at 69.9 deaths per 100,000 live births in 2021. That’s almost three times the rate for white women, according to the Centers for Disease Control and Prevention.
Additionally, AB 904 created a new section of California insurance law that will require providers within the state to address the high rates of maternal and infant mortality through the creation of mental health programs and doula coverage by Jan. 1, 2025.
The value of doulas
There are several types of doulas dedicated to educating and supporting people on their pregnancy journeys. Some doulas even specialize in caring for people who have undergone abortions and those struggling with fertility.
Doulas enrolled as Medi-Cal providers have to complete CPR and HIPPA training.
Training to be a doula consists of a 16-hour training program on the topics of lactation support, childbirth education, foundations on anatomy of pregnancy and childbirth, non-medical comfort measures, prenatal support, labor support techniques and developing community resources.
Fox became a doula in 2018 and provided free services for many years to practice before starting her own business. She has worked with about 25 women and their families throughout her career.
After the Medi-Cal benefit was announced, she said multiple healthcare networks reached out to her and she became a provider for health plans like Health Net and Health Plan of San Joaquin.
She now owns and operates The Divine Birth Academy in Stockton to help people become certified doulas, Medi-Cal providers and more.
Doulas hope for higher wages
Fox said she, like many doulas, do the work because they love it, not for the money.
Since it’s too expensive for clients to be charged by the hour, Fox offers a flat rate to people paying out of pocket. But due to the round-the-clock nature of doula work, the $1,500 she charges isn’t enough to pay her bills.
Doulas schedule regular appointments, but are also on call and work during deliveries which can sometimes take 24 hours or more.
Fortunately, Fox also works at Public Health Advocates, an organization dedicated to changing laws to create a healthier community in San Joaquin County.
She works as an associate policy manager, building the framework for doulas to be trained and certified as lactation consultants for the region.
Because Medi-Cal benefits have been available for over a year, Fox hopes private insurance companies pay doulas more now because AB 904 was passed.
“I would assume that (the rollout) would be very similar to (Medi-Cal’s) because it is kind of like setting a foundation for what it looks like. I hope that they pay more,” she said.
Doulas who enroll as Medi-Cal providers are eligible for compensation up to $1,154 for perinatal visits and the attending the delivery. As a member of the doulas’ Medi-Cal benefit stakeholder committee, Fox said there is an ongoing discussion to raise the compensation to $1,300 by next year.
“A very big challenge for pretty much every doula that’s Medi-Cal certified, is actually getting paid,” Fox said. “When it comes to the claims portion, we don’t really have a whole lot of support.”
In the Black doula community, Fox has noticed so many others struggling to get set up with Medi-Cal. She said they eventually end up giving out free services while waiting for a response to their claims.
“I know so many doulas right now that won’t even sign up for Medi-Cal, because they think it’s kind of a waste of time. Or, they rather just work harder to get people to pay out of pocket instead of waiting, waiting, waiting, waiting and just hoping that you get anything,” she said.
In the Stockton/Modesto area, full service doula care can cost as high as $2,500 and $3,350 without insurance.
More protection for mothers
Because Black patients in America have a history of being ignored and dismissed by their healthcare providers, Black women have to make sure they’re more educated about their health issues and learn how to advocate for themselves.
Fox said Black women in particular need extra advocacy in birthing spaces, because of biases that lead to a general lack of cultural awareness.
She recalled a time when one of her clients passed out in the hospital bed during their first time giving birth. Her client’s husband got scared at the sight of his wife unconscious and began calling for a doctor.
Unfortunately, instead of reassuring the man, the nurse reacted offensively and brought in another nurse for backup.
Fox calmed the man down by intervening and explaining to the nurses that his outburst was perfectly natural, considering how statistically dangerous childbirth and hospitals are for Black women.
For example, Sharon Washington-Barnes, a 31-year-old Black woman from Manteca, was encouraged to have her fallopian tubes surgically removed by two different obstetricians.
She and her husband have been trying to conceive their first child for the last three years. The doctors proposed the surgeries because of blockages in her tubes that have been the main issue during her fertility process.
Washington-Barnes was not shocked by the fact that her doctors wanted to render her infertile because she was facing issues getting pregnant.
Three aunts and her grandmother had been pressured to get premature hysterectomies. Because of their experiences, Washington-Barnes refused surgery both times.
She finally found an obstetrician gynecologist in Oakland, who validated her choice to get a third doctor’s opinion. Her new provider is making plans to use less invasive procedures. She is now looking for affordable, local doulas to help her on this journey.
The importance of connection
Washington-Barnes said the Valley needs more Black doulas not only for their work, but also for their cultural significance. Doulas that look like her and understand the hurdles she faces as an African-American woman make her feel safer.
“When you walk in and you see things that don’t connect to you at all, and then the people don’t look like you, what does that tell you? You shouldn’t be here,” she said.
“And then when the first recommendation is the removal of your reproductive organs, that really tells me that I shouldn’t be here, and then that my child shouldn’t be here. It just continues the unfortunate cycle.”
A doula is another form of protection from the medical establishment’s history of mistreatment of Black women, Washington-Barnes said.
“It’s sad that you even have to be looking at it in the way of another form of protection versus just like another medical expert, sadly, but that’s really what it is for Black women. It’s another form of protection. It’s another layer, somebody that may get in the way before things really take a turn.”
Access to services
There are public services aimed to support Black women during pregnancy in the Valley, but Fox and others say they’re too few and far between.
The Black Infant Health Program within the San Joaquin Public Health Department is dedicated to addressing these issues. However, the program only has seven staff members, said Interim Coordinator Angela Egbuchulam.
BIH works case by case with mothers who come in, and even connect them with Fox when they are looking for more support in the form of a doula. Egbuchulam would like to see more doulas in the area so more women can be helped in a timely manner, as opposed to being placed on the waiting list.
Dr. Pooja Mittal, the chief health equity officer and advocate of the Doula Pilot Program for Health Net echoed Egbuchulam’s concerns.
“I believe that two of the largest hurdles in the space are the lack of a centralized directory for locating doulas and the challenges doulas face in terms of how many clients they’re available to take on at a time,” Mittal wrote in an email.
“Because doulas provide individualized physical and emotional care for each client, it leaves them with limited availability.”
You can learn more about the doula services available to you by asking your health insurance provider about their coverage policy.
Vivienne Aguilar is the health equity reporter for the Central Valley Journalism Collaborative in collaboration with the California Health Care Foundation (CHCF).