One thing that was inadequately addressed in both my childbirth education and doula training was supporting women who have cesareans. The reason may be that the focus is so heavily placed on treating birth as a normal, natural process, that the reality that a third of all women give birth surgically somehow gets lost.
For this reason, I decided to attend the International Cesarean Awareness Networks (ICAN) 2016 annual conference in Birmingham, AL. I packed up my kids and a friend to help out, drove the 11 hours south, checked into a campground and left my family each morning to attend the conference in the city.
The first speaker I heard was Hermine Hayes-Klein, a lawyer, lecturer and action researcher. Her lecture was entitled, “Claiming the Right to Respectful Support in Childbirth.” She was uncompromising in her support of a woman’s right to plan a vaginal birth after cesarean (VBAC), asserting a woman’s human and legal right to make this choice:
- Decisions in which women were forced to have RCS were erroneous.
- When informed consent exists, the Dr. is not responsible if the woman refuses.
- Finances, not liability, is the driving force (lots of research to support).
- Having sacred rights respected is a human right:
- Right to spiritual freedom
- Right to cultural integrity
- Legal right to birth at a location and with provider of choice falls under right to privacy. When midwives sanctioned, this right violated.
In the historical portion of her lecture, she described how the Witch Hammer, a 14th century guidebook used during the Inquisition, was used to annihilate midwives. She quoted the text as saying, “No one does more harm to the Catholic faith than midwives,” who were blamed for a baby shortage since they had knowledge of contraception. I cried while listening to how a group I so closely align myself with were systematically persecuted, but I’m glad to now have this knowledge.
Regarding birth plans, Ms. Hayes-Klein said, “Women like birth plans, but providers don’t.” She gave the following advice:
- Use specific language: “My birth plan is that I will make all the decisions about my care on the basis of info, advice and support from my providers.”
- Women like birth plans, providers do not.
- Ask provider: “Is there any circumstance in which you would override my wishes or act without my consent?”
For women who believe that their rights have been violated during pregnancy and/or birth, she advised women to “Tell your provider what went wrong.” She said that providers need to hear about how their patients experience their care.
The hardest part about teaching classes has been finding appropriate, inclusive, affordable locations. I did a series of mini-classes last summer at the Muskegon Area Career Tech Center, but was unable to charge the participants. I did a vaginal birth after cesarean (VBAC) class at On the Path Yoga studio in Spring Lake, but they are a busy studio with lots of other things going on. That’s why I was delighted to receive permission to hold classes at The Center, a welcoming location conveniently located in the four corners in North Muskegon. Earlier this month, I learned that they were moving and going through other internal organizational changes. I immediately thought of the lovely Red Lotus art gallery, located in downtown Muskegon in the basement of the Century Club building and was pleased to find out how accommodating they are to a small business like mine. An artist myself (I sell buttons at the gallery), I’m looking forward to teaching surrounded by unique families and beautiful art!
While attending the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in January of this year, I had the pleasure of hearing Joanne Bailey, PhD, CNM, speak on “Hydrotherapy and Waterbirth: Evidence, Outcomes and Challenges.”
According to Dr. Bailey, the first documented waterbirth occurred in France in 1803. It wasn’t until the 1970’s and 1980’s that waterbirth started to become more popular in Europe and Russia. In 1983, Michel Odent described 100 stories of waterbirth, mostly positive. In 1989, Barbara Harper, who had studied waterbirth in Russia, held the first waterbirth conference in the U.S. She later went on to found Waterbirth International.
Despite such a long, successful history, there are only three options for a woman who wishes to have a waterbirth in West Michigan today. The first is to deliver at home. Women choosing a homebirth may rent or purchase a pool that can be set-up in her home and in which she may labor and/or give birth in. The second option is to choose to give birth in a free-standing birth center, of which there are currently two in West Michigan. At Midwifery Matters, in Greenville, each of the birthing rooms has a large corner tub. The Simply Born Birth House, in Grand Rapids, has deep tubs to labor and birth comfortably in. The third option is for rebels. If a provider is knowledgeable about how to safely manage a delivery underwater, the woman may refuse to get out of a hospital tub and deliver underwater.
Why is waterbirth so difficult to access within a hospital? Rebecca Dekker of Evidence Based Birth asked herself that same question while delving into the research and case studies that led to the 2014 joint ACOG (American Congress of Obstetricians and Gynecologists) and AAP (American Academy of Pediatrics) statement against waterbirth. Her conclusion was that they based their decision on limited, isolated cases and not on the larger body of evidence suggesting that waterbirth is safe.
While all West Michigan hospitals have policies against waterbirth, this is not the case everywhere. In fact, Dr. Bailey tells the story of how the first waterbirths occurred at University of Michigan Health System in 1996 as the result of a consumer-driven effort. Currently, 16.4% of the births there occur underwater.
How about you? Did you have a waterbirth and if so, how did you achieve it? Please share your story!
One of the highlights of the American College of Nurse Midwives (ACNM) Michigan Affiliate conference this past January was the presentation on Nitrous Oxide. The presenters, Michele Amstutz, RN, c-EFM and Laura Bozeman, MSN, RNC, CNL, c-EFM, from St. Joseph Mercy, enthusiastically described how they overcame obstacles through persistence, teamwork and education to bring laughing gas to their hospital.
From an historical perspective, the presenters explained that nitrous oxide was available for pain relief in labor in the United States up until the 1980’s, when epidurals grew in popularity. In recent years, the number of US hospitals offering nitrous oxide for women in labor has increased. Currently, two West MI hospitals, Spectrum Health Zeeland and Gerber Memorial offer it. Mercy Health Hackley responded to me on Twitter in January that they don’t have a start date yet, but their goal is to have it available within the next year.
When considering pain relief in labor, many women are concerned about the impact on the fetus. Fortunately, nitrous oxide is metabolized in the maternal lungs and clears rapidly, so only 80% of 1% of what the mom inhales reaches the baby. Studies have shown that there are no adverse effects on fetuses, including effects on fetal heart rate or apgar scores.
When it comes to maternal outcomes, nitrous also has advantages over other forms of pain relief. It does not require moms to receive intravenous fluids, have the fetus be continuously monitored, or restrict mobility, as with an epidural. The units can even be used with women who are in the tub! Unlike narcotics, it is non-addictive, which may be of concern to moms in recovery.
Something that I hadn’t considered was the many ways nitrous oxide could be used during labor and even postpartum. Because it is anxiolytic, or a medication that reduces anxiety, it can be used during medical procedures that may make a woman tense, like starting an IV, a foley bulb placement, or a vaginal exam. Although it cannot be used in conjunction with an epidural, it may be used during the insertion of one. Furthermore, many providers prefer it to local anesthesia for repairing tears after delivery because there is less distortion of tissues.
Nitrous oxide isn’t for everyone. Some women prefer a completely unmedicated experience. A small percentage of those who use it will experience side effects, most commonly dizziness and nausea. There are a few contraindications, including vitamin B12 deficiency. Finally, if a woman wants complete pain relief, she will probably not be satisfied with nitrous alone.
What about you? Have you used nitrous oxide for pain management during labor? I would love to hear about your experiences!
One of the things I loved about working for Public Health – Muskegon County was the opportunities for continuing education. Now that I’m self-employed, a smaller budget forces me to be more judicious while I also must work around being on-call. Nevertheless, 2016 is already turning out to be a great year for learning.
In January, I had the pleasure of attending the Michigan Affiliate of the American College of Nurse Midwives (ACNM) conference on physiologic birth in Kalamazoo. In April, I took a road trip with my kids and a friend to Alabama for the International Cesarean Awareness Network (ICAN) conference. Both of these provided chances to network and connect with people making a difference for birthing women in my state and across the country. Webinars are convenient, but nothing compares to getting to hang out in-person with inspiring individuals.
I would like to share some of what I learned from each of these trainings, to plant seeds of inspiration in expectant women and birth professionals everywhere. To do this, I’ll be sharing a series of blogs, highlighting the “pearls of wisdom” I learned from so many experts in the field of childbirth.
One of the speakers at the ACNM conference was Lisa Kane Low, PhD, CNM, FACNM, FAAN, who spoke on “Promoting Physiologic Birth to Reduce Primary Cesareans.” She introduced me to birthtools.org, an ACNM website that contains 3 quality improvement (QI) bundles for reducing primary cesareans: intermittent auscultation as a standard for low-risk women, comfort & coping and promoting spontaneous labor progress.
For those of you who aren’t familiar, Rebecca Dekker of Evidence Based Birth has a great article on what intermittent auscultation is, why it should be the standard of care for low-risk women and how to get it. Basically, intermittent auscultation is checking the baby’s heartbeat every so often through a fetal stethoscope, as opposed to through an electronic fetal monitor.
Listening to Dr. Kane Low speak, I couldn’t help but wonder about the mandatory “strip” in triage. For those who are unfamiliar, most hospitals put women who arrive in labor in an area called triage in which they are monitored to check on the baby’s health and the progress of labor. After a designated time period of being attached to an electronic fetal monitor, if the baby is responding well, the mother is either admitted or discharged home based upon how much she has progressed.
I have my own story to tell about triage. With my first baby, I had been laboring for about 22 ½ hours at home when I arrived in the hospital via the longest cab ride of my life. When I get to the maternity floor, they take their time, asking questions, entering information in the computer, pretty much ignoring the fact that I’m in labor. Finally, they assign me to triage. For the first time in my labor, I was confined to a bed, told to lie on my back, and had monitors strapped to me. Eventually, a nurse checked me and announced that I was completely effaced and dilated to an 8. Finally, they believed me that I was in labor! I couldn’t wait to get out of that room, off the bed, and get those uncomfortable monitors off of me!
So, I asked the presenter what evidence there is for this triage protocol. Her answer? “Data does not support the 20 min. strip in triage.” What?!? She went on to say that the only reason this remains standard practice is due to tradition.
Look, I understand that many women present to the hospital thinking that they are in labor, only to be sent home. However, for women like myself, arriving in active labor and being subjected to this practice that has no evidence to uphold a tradition? There is hope for change, though. The Alternative Birth Center at Providence Hospital in Southfield, MI, has ditched the 20 min. triage strips with great outcomes – way to go Providence!
As a doula, two of the most important people in my life are my sitter and my back-up doula! Through the Lakeshore Doula Network, I have been fortunate to have had several area doulas willing to support my clients in the rare event that back-up is needed.
One time, I had two clients due the same week. Beth Singleton was my back-up doula. When they both went into labor at the same time, she was there for me. I cannot tell you what a relief it was to know my client was in good hands!
Beth and I have met to talk about working together since then. After making lists of our strengths and weaknesses, we identified ways that we are similar as well as ways we can mentor and support each other as we continue to develop our businesses. We recently signed a formal agreement outlining our commitment to provide back-up for each other.
Let me introduce to you, Beth Singelton, Birth Doula!
Hello! My name is Beth Singleton. I have lived in Muskegon my entire life and graduated from Reeths Puffer High School in 2000. I am the proud mother of 4 awesome kids and have been married to my husband for almost 14 years. I have given birth in both a hospital setting and at home. In 2014 while pregnant with my 4th child, I completed my DONA training and am currently working towards my certification. Aside from my life as a wife, mother, and birth doula, I have spent many years working as a floral designer and I LOVE writing poetry (I have self published two poetry collections so far!). Free time with my family is best spent in nature, preferably by the river or in the woods, with my camera in hand. I am also a huge fan of watching the sun rise.
I have always had a passion for pregnancy and birth and am very grateful to the women in my life that have allowed me to be present during the birth of their children. What I’ve witnessed while watching other women labor and experienced during my own is that having support is vital to a positive birth experience yet, it is something so many women do not have. Giving birth is one of the most challenging and life changing experiences a woman can go through and how she experiences it can have a lasting effect on how she feels about herself, her baby, and the bonding experience. I know the importance of achieving the desired labor and birth and it is my hope to provide women with the information and support needed to do this. There is no crystal ball that can predict how labor will go. That is why I think it is so important for a woman to have support.
During pregnancy, I believe it is pertinent for women to educate themselves and build a good support team. It is also the perfect time for a woman to learn about self care and begin implementing this into her daily life if not already doing so. As your doula, I will be there for you during your pregnancy to answer questions, provide moral support, go over the importance of self care, help you with a birth plan if you’d like one and go over what you ideally think you will need from me. When you are in labor, it is my goal to be there for you and do all that I can to make sure you feel in control and empowered, providing you with the support you need to be a better advocate for yourself. Whether it is simply my presence that is needed, encouraging words, a shoulder to cry on, or hands on support like massage, I will be there for you. In the instance that complications do arise, I will remain with you and support you through those challenges as well. I believe all women have an inherent sense within them that guides them instinctively through labor and childbirth. My hope is that in all I do, I am able to hold that space for you, allowing you as an individual to experience labor and birth in whatever way you so desire. After birth I will visit with you, talk about the birth, talk about how you are feeling, and I can provide some help with breastfeeding if you need it.
I view birth as something sacred and a laboring woman as someone to be respected and held in the highest regard. There is a transformation that takes place whether a woman is having her first baby or her fifteenth and I consider my being allowed to bear witness and provide support during that transformation an honor. I also believe that a doula’s support is meant to complement and enhance the care that is already being provided by those who are giving clinical support and by loved ones who are also present to help. In birth (as in most of life), there are no do-overs. That is why I feel it is imperative that a woman who will be giving birth is surrounded by people who understand and are sensitive to the significance of the moment.
Recently, The Guardian broke the story of five pregnant women who were denied emergency care at Mercy Health Partners because religious directives at the Michigan hospital system ruled over best medical practice.
The report that the article refers to is actually a claim that I wrote from my experiences as an employee of Public Health – Muskegon County. I decided to come forward and share my name and story because the harm and suffering these poor women went through was wholly unnecessary and something must be done to ensure people are aware that is a growing crisis that needs to be stopped.
Mercy Health Hackley Campus is more than a hospital to me – it’s a home away from home. My first experience there was emerging from my mother’s womb over 40 years ago. Since then, I’ve attended meetings there, participated in and organized trainings, and completed case abstractions as the Fetal Infant Mortality Review Coordinator (FIMR).
In 2009, when I suffered complications from an incomplete miscarriage, Dr. David cared for me, performed surgery with sensitivity to my emotional needs and helped me have a healing experience.
As a doula, I’ve provided support for more deliveries occurring at Mercy Health Hackley than any other location. I have been impressed by the adherence to certain obstetric practices, such as immediate skin-to-skin and delayed cord clamping, which have been challenging to implement elsewhere.
In 2007, Hackley Hospital merged with Mercy, leaving Muskegon with a sole Catholic healthcare institution under Trinity Health. Despite many positive experiences with the dedicated staff there, a grave reality slowly started to sink in as many of them shared with me the struggles of healthcare that is dictated from afar by a group of Bishops, none of whom are doctors or will ever become pregnant, and prescribed religious directives.
The Tamesha Means lawsuit against the US Conference of Catholic Bishops and the EMTALA complaint outline substandard care to patients. What’s also at stake is how the Ethical and Religious Directives impact thousands of Trinity health employees and their families every day. Mercy Health is the largest employer in Muskegon County, with more than 3,500 employees. None of these employees, their spouses or their dependents up to the age of 26 have insurance coverage for birth control to prevent pregnancy under the insurance coverage that Mercy Health provides.
I stand in solidarity with the staff of Mercy Health in outrage of their and their patients’ denial of the basic human right of complete access to comprehensive reproductive healthcare services.
If you live in the State of Michigan and are being denied birth control coverage by your employer or know someone who was denied services at a religious-affiliated hospital, you can learn more information about your legal rights by contacting the ACLU of Michigan at (313) 578-6823.
As a birth advocate, supporting the rights of women who plan a vaginal birth after cesarean (VBAC) will likely keep me busy for the duration of my career. My heart goes out to women who have to navigate their healthcare options for childbirth after a cesarean one facility, practice and provider at a time. At the end of their inquiries, many find that their options are limited by their individual histories, provider decisions, hospital policies, insurance reimbursement and even politics.
Since October, I’ve been working through the West Michigan Better Birth Network, the local chapter of the non-profit, Birth Network National, to address the official VBAC ban at Spectrum Health Gerber Memorial. We have collected stories of women who have had VBACs there in order to stress to administrators that, despite being counseled that the main hospital campus, Spectrum Health Butterworth in Grand Rapids, is the safest place to labor and deliver, they have legitimate reasons for choosing a community hospital setting. [Link to a sample letter from Rebekah Thompson of New Life Doula Services. Link to my own letter from the perspective of a Substance Abuse Prevention Specialist.]
I was recently attending an event at Amanda Holbert’s yoga studio, Renew Mama. While discussing the work of the WMBBN, Amanda brought up the “ban” on CNMs attending VBACs in West Michigan hospitals. Amanda inspired me to look into this restriction further. Why could CNMs attend VBACs in some hospitals, like Borgess in Kalamazoo, but not at Spectrum Health Butterworth (the only hospital in West Michigan that both allows VBACs and has CNMs who deliver there)?
I called Spectrum Health to ask about their policy on CNMs attending VBAC deliveries and was referred to Charmaine Kyle, Clinical Nurse Specialist in Women and Infant Services. Right away, she informed me that the hospital does not have an explicit policy banning CNMs from attending VBAC deliveries. I checked in with Jen Kamel of VBACfacts, an advocate for greater access to VBACs nationwide, who suspected internal politics to be the culprit.
Before hearing back from Charmaine with a definitive answer, I attended the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in Kalamazoo. There, I met midwives from across the state, most of whom are supported in attending VBACs at the hospitals where they work. Meeting these midwives made me even more determined to find out what is causing the restriction and advocate for overcoming it – West Michigan women deserve all possible options!
This past Wednesday, I received a reply: “a midwife is available through the residency clinic and would be able to establish care with a patient antepartum. When it comes time for delivery the midwife would partner with an obstetrician and co-manage the care during labor. The only problem right now is we don’t have enough midwives to provide 24/7 coverage. Our hospitalist (core faculty) obstetricians would manage the care during the night and on weekends.” In other words, a woman could see a midwife for prenatal care, but could only have one in attendance at her birth if she happens to deliver during normal business hours.
After speaking with a CNM in private practice who delivers at Spectrum Health Butterworth, I learned they are in a similar situation. The hospital’s laborist (salaried staff Ob/Gyn) will not cover them in the event a cesarean becomes necessary, so an obstetrician from their practice has to both be available and willing to stay at the hospital until the mom delivers without being paid to do so. Since they cannot guarantee that this requirement will be met, the midwives who practice at the hospital cannot advertise their ability to take on pregnant women planning VBACs.
Several changes could move West Michigan toward increased access to CNM-attended VBAC births in hospitals. First, Spectrum Health Butterworth could hire more midwives so that those working in their residency clinic could be paid to cover births occurring 24-hours a day. Secondly, the hospital could further find creative solutions to overcome the liability fears of the laborist which lead to the unwillingness to cover the midwives working in private practice. Thirdly, other hospitals that allow VBACs could hire midwives. Finally, smaller community hospitals who already have midwives delivering there could remove their VBAC bans.
Are CNMs able to attend VBACs in hospitals in your area? What worked to increase access in your community? Do you wish you had this option? I want to hear from you!
I’d like to honor women who make childbirth choices that make them vulnerable to judgment in their social circles, like planning a repeat cesarean or a home birth. While no one is obligated to defend any of their family’s personal healthcare decisions, I’d like to open the conversation about the complexity and diversity of individual situations that create the context for such an important decision as how to give birth to one’s child.
1.) Support: While it may be easy for an outsider to say, “Screw your family member or provider,” most people rely on support within their relationships long after the birth of their children. For some women, it may be worth it to avoid conflict around their birth decisions knowing that they will not have to heal wounds in the future. Relationships are complicated and based on a history that predates this event.
2.) Timing: Babies arrive on their own schedule, paving the way for the unpredictability of parenthood. Unfortunately, modern life is not always so flexible and accommodating. Wanting to schedule the birth of a child around the availability of the one person you cannot imagine not having by your side at the moment of birth or in the weeks to follow is rational.
3.) Tradition: Some choices are normalized in a family. Other times, we seek to not fall into the footsteps of our foremothers. Carrying on or rebelling against a historical family pattern are both common and natural reactions.
4.) Economics: What a family can afford is often the driving factor behind their reproductive decisions. When the top choice is not feasible, compromises are inevitable.
5.) Experiences: Our individual experiences with birth are unique. Negative past memories, whether personally or vicariously lived, sometimes impact us more than facts.
6.) Values: What each parent holds dear will influence their decisions around birth. Filtering our options through our values helps us move from knee-jerk to more conscious decision-making.
From the outside, someone’s choices may seem completely irrational or even self destructive, but under the surface lays the foundation for their actions. For example, many people will judge someone who chooses to stay in an abusive relationship without trusting them to best know how to stay safe in the face of adversity. Imposing strong opinions or even facts that dispute another’s choices does not honor our diversity. Instead, we can strive for confidence in our own decisions while respecting the choices of others.
Have you every felt frustrated by the choices or judgement of others? What helped you reach a greater understanding?
These are my predictions for childbirth in 2016. What do you think? Please include your thoughts and your own predictions in the comments!
5.) WHO changes their position on episiotomies
“Perhaps it is time to move beyond the question ‘What are the appropriate indications for episiotomy?’ to the more fundamental question ‘Is there an appropriate indication for episiotomy?’
In 1996, the World Health Organization published “Care in Normal Birth: A Practical Guide,” recommending an episiotomy rate of 10%. Since that time, episiotomy rates in most countries have declined. The practice of selective episiotomies has continued despite the fact that there has never been a randomized controlled trial showing that they have any benefit whatsoever.
This has become a point of contention between some birthing women and their providers. In fact, in 2015, an obstetrician in the United States surrendered his license after being caught on video performing a forced episiotomy on a patient.
In 2014, a study was undertaken in Brazil called, Comparison of Never Performing an Episiotomy to Performing it in a Selective Manner, or EPISIO. Although the study is complete, the results are not yet published. The researchers collected data on newborn, as well as maternal outcomes. If this research shows that, even in cases of macrosomia and fetal distress, episiotomy holds no benefit, the World Health Organization may take a stand that even 10% is too high, with global implications.
4.) ARRIVE study results increase elective inductions
Dekker’s lecture introduced me to the A Randomized Trial of Induction Versus Expectant Management (ARRIVE) study, in which women would be randomly assigned to either induction at 39 weeks or expectant management. Although some of the sites are still recruiting subjects, the data should be in by the summer of 2016 and results may become public by the year’s end.
Other than furthering the schism between the medical and natural childbirth camps, news that elective induction at 39 weeks prevents adverse outcomes could place a strain on hospitals. As Dekker pointed out, if hospital maternity wards are full with women being induced, will there be enough room left for women who arrive already in labor?
3.) US cesarean rates continue to decline
The cesarean rate for birth in the United States hit an all-time high in 2009, but has declined for most racial and ethnic groups since. This has not been an accident, but due to a concerted effort by consumers, researchers, hospitals and providers.
For example in 2014, the American Congress of Obstetricians and Gynecologists (ACOG) changed the definition of active labor from 4 to 6 cm, cause more women who present in early, or latent labor, to be sent home.
The coming year may also see changes in hospital policies on Vaginal Birth After Cesarean (VBAC), which holds the potential to further decrease the cesarean rate. Many women choose to have their VBAC at home, not because that is their first choice, but because no other options are available. A study published in the Dec. 2015 issue of Birth showed that, although Home Births After Cesarean (HBAC) have high success rates, when a uterine rupture does occur, perinatal death is more likely. As local work on perinatal regionalization, a system of designating where infants are born or are transferred based on the amount of care that they need at birth, continues, more community hospitals may reverse their VBAC bans. This will make VBACs more accessible and safer for women who prefer a hospital birth closer to home.
2.) Out-of-hospital birth rates continue to rise
While out-of-hospital births represent a small percentage of all birth in the United States, they have been on the rise since 2004. When it comes to home births in one West Michigan county, Kent, home births have increased 116% in the last 8 years!
According to the American Association of Birth Centers, the number of freestanding birth centers in the United States also continues to rise, from 170 in 2004 to 248 in 2013. There are currently two freestanding birth centers in West Michigan, Cedar Tree Birthing Suite in Grand Rapids and Midwifery Matters in Greenville. As more birth centers continue to open, the number of women choosing this option will also grow.
1.) More states will pass laws providing insurance reimbursement for doulas
All the research points to the potential healthcare savings if doulas become more widely available, due to the lower rates of cesareans, pitocin induction, medical pain relief and more. At the present, only two states, Minnesota and Oregon, require Medicaid to cover the cost of a birth doula.
All that could change now if three national organizations, Choices in Childbirth, the National Partnership for Women and Families and Childbirth Connection, have anything to do with it! Key Recommendation in an executive summary released in early 2016, include having congress mandate Medicaid coverage for doulas and state legislatures mandating private insurance coverage for doulas. If policy makers take their advice, 2016 may turn out to be “The Year of the Doula”!
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