How doulas can help pregnant people of color with depression or anxiety after birth

Patience Riley is a licensed therapist in Georgia who works with people who are pregnant or recently had a baby. Most of her clients have heard of postpartum depression, she said. After all, it’s one of the most common complications of pregnancy.

But some of its symptoms can arise completely unexpected.

“Rage is one symptom that shocks and surprises people,” said Riley, who has specialized training in perinatal (pregnancy and birth-related) mood disorders.

“We usually think of someone (with postpartum depression or anxiety) as being sad or crying all the time,” she said. “Those are symptoms as well, but depression or anxiety can be overwhelming and sometimes that comes out as agitation or rage.”

In Riley’s experience – and in recent studies – mood disorders like depression and anxiety can look different in Black women and other people of color than they do in pop culture. Rage is one symptom that they may not recognize as belonging to postpartum depression because popular understanding of what pregnancy-related mood disorders look like comes from research that’s predominantly been conducted on white women.

“One thing I hear all the time from help-seekers and clients (who experience anger or rage) is that they think they have turned into this awful person, but it’s really just the symptoms (of a mood disorder) that they’re experiencing,” said Riley.

That disconnect between actual symptoms and the popular perception of disorders like postpartum depression contributes to the underdiagnosis and undertreatment of pregnancy-related mood disorders in Black women and other birthing people of color. Studies show people of color are more likely to experience symptoms of postpartum depression and anxiety, and less likely to get treatment than their white counterparts.

While there’s not a one-size-fits-all answer to improving mental health for birthing people of color, one solution has emerged that’s supported by research, been adopted by public and private insurance companies, and championed by birth advocates: doula care.

“As a Black woman, it can feel like it’s taboo to even say you need help,” said Tikvah Wadley, a Chicago-based certified doula who also works as education director at DONA International, the largest doula training organization in the U.S. “But a doula is a friend. It’s having a person to sit and share with you – as another woman of color – about experiencing postpartum depression, that’s beneficial.”

How can doulas help?

Doulas are trained, non-clinical professionals who provide emotional, physical and educational support to a birthing person and their family before, during and after a birth.

Doulas and other community health workers play a role in reducing the risk of pregnancy-related mood disorders, particularly for people of color, and can help connect them with appropriate care if they do show symptoms.

Particularly during the postpartum period – the weeks after a birth – a doula can help ease the stress on a birthing person, said Riley.

“Sleep is the No. 1 protective factor against perinatal mood disorders,” she said. “However, we know it’s very difficult for new parents to get sleep. One of the things that can be really helpful with postpartum doulas is the relief they provide so the birthing parent and their partner are able to get rest and not feel so overwhelmed.”

Having a doula to assist with household chores, changing diapers, holding the baby while the parents rest, or assisting with breastfeeding can make a big difference in a person’s mental well-being, she said.

And because a doula has professional training, she may be better able to recognize the signs of a mood disorder than a relative, and can refer the parent to a physician or mental health provider.

“As a doula trainer, I speak to doulas a lot about how important those postpartum visits are, because you’re an important set of eyes when you go back into that home,” said Wadley. “You’re looking for symptoms, and you need to be able to spot them.”

Wadley said she also teaches doulas to have conversations with their clients before a birth, talking to them about the possibility of developing an issue like postpartum depression and what they want to do about it if it happens.

And if the doula refers a client to a mental health provider, she said, the doula can also go with the client to an appointment to help them feel less afraid or alone.

Doulas for all?

A recent study of Medicaid claims across three states found that women who received doula care were nearly 58% less likely to experience postpartum depression or postpartum anxiety. Research has also shown that women of color who receive doula care experience better birth outcomes than Medicaid recipients in general, including being less likely to have a cesarean delivery and more likely to begin breastfeeding.

But increasing doula care isn’t without roadblocks.

Cost is one of the biggest. Depending on the services provided, number of visits and geographic location, doula care can cost an average of $400 to $2,000 or more. Most insurance does not cover it.

For families that can demonstrate financial need, some community-based doula programs around the country offer free or reduced-cost doula services.

There is change on the horizon. Bolstered by research that recommends doulas as a tool to improve outcomes and reduce healthcare costs, 16 states now have Medicaid programs that cover doula services or are in the process of doing so, according to the National Health Law Programs’ Doula Medicaid Project. A decade ago, there were none.

Private insurance companies are testing the waters, too. After Blue Shield of California launched a pilot program that provided doulas to Black birthing people in communities with high rates of childbirth complications, data showed participants had lower rates of postpartum depression, as well as more full-term births and fewer Cesarean sections, compared to state and national averages.

But even when doula costs are covered, it’s not all smooth sailing. Each state’s Medicaid program reimburses for doula care differently. Minnesota covers six visits plus labor and delivery, up to $770. Oregon reimburses up to $350 for four visits plus labor and delivery. In New Jersey, it’s up to $900. Florida ranges from $400 to $1,000 depending on the plan.

Oregon, the first state to begin covering doula care through its Medicaid program back in 2013, recently announced an increase in reimbursement. But there are coverage gaps. Nearly half the counties in the state have no state-approved doulas, and most doulas were concentrated in the urban areas around Portland, leaving rural communities underserved.

Hospitals and physician’s offices around the country have varying policies on whether patients are allowed doulas, even though the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released a joint statement calling support personnel like doulas “one of the most effective tools to improve labor and delivery outcomes.”

The need for mental health providers of color

In addition to her private practice, Riley works with the Perinatal Mental Health Alliance for People of Color, a program that’s part of Postpartum Support International. The alliance works to bridge gaps in mental health support services for birthing people of color.

Increasing the number of doulas and mental health providers of color can improve access and care for birthing people of color, Riley said.

“In communities of color we see that their health concerns seem to be discredited or not taken as seriously,” she said, “so that’s why it’s even more important to pay attention and to listen when something isn’t going right.”

Research suggests doulas can help reduce the effects of racism and classism in birth care, and that having providers of color can improve health outcomes for patients of color.

“It’s really important for providers of color to openly talk about this, to say hey I’ve gone through this too and I’ve gotten help and treatment,” Riley said. “It helps decrease that stigma – that there are other people who look like me who have gone through this too.”