Emily Oster

19 min Read Emily Oster

Emily Oster

Doulas for All

How Senator Samra Brouk is changing birth in New York

Emily Oster

19 min Read

Here at ParentData, I write about data and evidence, with the hope that sometimes these conversations will lead to change. I’ve written a number of times — both here and in my books — about the data on doulas, and how strong the evidence is to support their value. That evidence is so strong that, I think, it should be a policy focus.

Actually making that policy, though, is hard. Which is why I’m glad we have people like today’s guest, New York State Senator Samra Brouk, to do the on-the-ground work. Senator Brouk spearheaded an effort in New York to get doula services covered by Medicaid (which they now are, as of January 2024!). We talk today about our mutual love of data, why doulas are important for maternal health, especially for Black women, and how to convince your older colleagues that these issues matter.  

Senator Brouk is a kindred spirit. This conversation was incredibly fun for me, and I hope you enjoy it.

To spark your interest, here are three highlights from the conversation:

Why did you choose to have a doula for your birth?

Senator Samra Brouk:

For me it was really important to have someone who I knew could really stick up for me with my medical team and who could quite honestly give me hard truths that I might need to understand. Because my goal at the end of the day was to walk out of the hospital healthy with a healthy baby.

And for so many Black women like me, instead of worrying about the colors in the nursery and what kind of crib and what kind of cute nursing tops we want to buy, we are faced with the fact that in New York State, no matter how much money, how much education you have, it doesn’t matter. We are still five times more likely to die in childbirth. 

So I think a lot of people understand maternal mortality is bad in the U.S. It is worse for Black and brown women, and so here I am, a legislator working on these policies in my day job, tremendously fearful every night when I’m thinking about how I’m going to go through the process.

How do you stay motivated in your policy work? 

Emily Oster:

Author CommentI’m an economist. Everything is constrained optimization: every dollar that you spend on one thing is a dollar you’re not spending on something else. So figuring out what are the interventions that are going to work the best is part of that challenge. When you step back and you think — we’re talking about people dying in childbirth, we’re talking about something which we should be willing to spend all of the money on — why don’t we do all of the things? And that is not the political reality, but I can imagine that piece of it must frustrate you sometimes also.

Senator Brouk:

It frustrates me all the time. 

And so I can say this, as I still consider myself somewhat of an outsider, right? Because I spent more time doing other things in my career than I have in this part of my public career. So I still think like that too, and I remember being faced with those questions. And to be very frank, a lot of those questions came up in last year’s budget in New York where I nearly changed my middle name to “doula.” Because every room I was in, I mean I won’t say I was yelling, but I was speaking very sternly and assertively and sharing my data points and making sure that people understood how important these policies were and how important this funding was. And one of the things I’ll say is that I think that it is easier to ignore this topic when you don’t have a new mom, Black woman legislator in the room fighting for it.

You couldn’t tell me it wasn’t worth it, you couldn’t tell me that it doesn’t work, because I had experienced what some of these interventions can do to promote healthier outcomes for me and my daughter. So I mean, none of it comes easy, definitely, and it’s always a tradeoff when it comes to policy and obviously budget decisions. But I think we have to always consider: where have we historically ignored and where have we historically not funded and thought about the outcomes for certain people? Because we have a lot to make up for, and I think about that a lot. I have 10, 20 years to make up for when it comes to maternal mortality and especially when it comes to Black maternal mortality.

What does your legislation do and how did you pass it? 

Oster:

I think one of the things that’s most striking for me is doulas are often not covered by insurance, and they are definitely often not covered by public insurance, which is the insurance that many people who most need a doula have. So doulas are not typically covered by Medicaid. 

There is a cost-effective argument for doulas to be covered by Medicaid, which is that if you reduce the C-section [rate], if you reduce the time in the hospital, that time is very expensive. And so actually, in principle, you might well break better than even — you might make money by paying for everybody to have a doula. It’s free money. Free money is so rare. 

So tell me about your legislation.

Senator Brouk:

So, it’s actually a whole package of legislation, because of course you can’t do everything in one bill. But basically, a couple of years ago, we started with a work group that would essentially have the Department of Health really study how much should a doula reimbursement be. And the reason we started there is because in New York State, about 46% of births are covered by Medicaid. So we thought, what better way to really jump-start this than have the Department of Health really figure out how much this reimbursement would look like through Medicaid? And then what happens a lot of times in states is once Medicaid has a rate, commercial insurers will follow that rate. Maybe make it a little bit higher, but that becomes the base level where usually nothing will be lower than that.

So we started with that work group. We held a hearing on doula care and what it would look like to be statewide. And as part of that advocacy grew, it really became a priority item for the state senate, probably because I was educating everyone on what doulas were. But then also the governor took notice as well — took notice and really created it as a priority of her own.

And so starting this year, January 1st, 2024, we finally have statewide Medicaid reimbursement for doulas. And that, we hope, is going to make a huge difference, obviously, for birthing people.

Full transcript

This transcript was automatically generated and may contain small errors.

Oster:

This is ParentData, I’m Emily Oster. 

When my daughter was born, when I was in labor I had two people in the room most of the time, my husband and my doula Melina and if I had had to pick one it would not have been close. At some point my husband, who I want to be clear is a wonderful person, left to eat a bagel because it was covered in onions and he needed a break and was hungry. Melina did not take a break, she didn’t go eat a smelly bagel. She sat in the shower with me and sprayed my back with warm water, she had me move into different positions, she encouraged me to push in different ways. And she was there when the baby came out after two and a half hours of pushing, which I definitely would not have been able to do without her support. She was there before the birth to help us get prepared and she came afterwards, she was one of the first people when we got home to come and tell me that in fact yes, the baby was swallowing and I could stop freaking out quite so much. 

I had a doula because the evidence said that it was a good idea and this is a place where both my own experience anecdotally and the data really lines up. There’s a tremendous amount of randomized trial evidence of other information that tells us that doulas can improve birth outcomes, they can improve birth outcomes especially for vulnerable groups. I have tried shouting many times from the rooftops, “Hey. Everyone should have a doula, it’s cost-effective. It would improve people’s lives. Hey. People. Doulas.” 

But one of the things about being a writer is that you just write this and you hope people read it, you hope people do something about it. My guest today is one of those people who is actually doing things about this.

News clip

State Senator Samra Brouk, who represents Rochester and the legislature. has been an advocate for doula services. Brouk and others have repeatedly pointed to the lifesaving benefits of having these certified healthcare advocates during and after pregnancy.

Oster:

Senator Samra Brouk is a state senator in New York State and one of the bills that she has pushed forward is a bill that will cover doula care for women in New York State on Medicaid. As of January 1st 2024 Medicaid will cover doulas for births in New York State. It becomes one of 13 states where that’s true, the hope is that there will be more. Samra and I today talk about the importance of doulas, about her own experience as a black woman working with a doula and why she felt that was so important. And then we talk about how she convinced the other senators not all of whom are themselves users of doulas to actually pass and fund this legislation. She’s a delight to talk to and we get serious and we also get funny and we talk about our personal stories, and it is refreshing to speak to someone who’s doing the work out there. I hope you enjoy this conversation. After the break, Senator Samra Brouk. 

Senator Samra Brouk, I am so thrilled that you’re joining me. Thank you so much for being here.

Senator Brouk:

I’m so glad to be here with you.

Oster:

So senator, I’d love to ask you to just introduce yourself.

Senator Brouk:

Absolutely. So I’m Senator Samra Brouk, I proudly represent the 55th Senate District in New York State. So that is the Rochester area in western New York for anyone who might be familiar and some of the surrounding suburbs. So that’s my as you’d say day job. But I’d say probably my even more important job that I hold dear is also being a mother to a near two-year-old little girl who definitely keeps me even busier than being a state legislator. And I also have the honor of chairing the mental health committee in the state senate and as I’ve dubbed myself the resident doula advocate and champion in New York State.

Oster:

I’m really excited to talk about doulas because as we’ve talked before and this is something I think we both really believe in, care about, think it’s crazy everyone is not obsessed with. So it’s always fun to get to talk to someone else who loves the same thing that you love. Before we get into the specific issue of doulas, I want to step back a little bit to maternal health challenges. I mean this is something we’ve both thought a lot about, talked about in different venues and black maternal health is a particular issue. If we look out at the data, maternal health in the US is very poor relative to the world globally. Maternal health for black women in the US is appallingly bad comparable to places where the healthcare infrastructure is substantially worse. And so I’m curious, coming from your policy angle… I’m not even sure how to ask, how are we going to fix that maybe is the first way I would ask it?

Senator Brouk:

I think about that question all the time, and I also think it’s so important to share that certainly I’m privileged really to be in a position today where I can make policy decisions and write laws and fight for budget resources every year. But this has been a problem for so long, and I just want to share a quick story because every time I’ve told people this they’ve been just as shocked as I was. But I remember… So I worked in many nonprofits before I ran for office and I remember being at this event that was supposedly around supporting moms and maternal health, and I just happened to be there. I think I was a nonprofit employee, so I think a corporate sponsor had put it on or something like that. So we were attending and I remember seeing this graph that had maternal mortality and up until that point, I think I was probably in my early mid-20s. It’s not something I had thought about maternal mortality it just wasn’t in my vernacular.

And I remember seeing this graph and it had the US at the very top for maternal mortality, which is a bad thing. Right? That we have such a high rate of maternal mortality and I kid you not, I believed so deeply and wholeheartedly in our healthcare system here in the US that I assumed this woman had the graph wrong. I assumed she had accidentally inverted it and I said, that has to be impossible and so I remember from that first shock that I had at this point that was over 10 years ago. To now being in a position where I’m digging deeper into it, not just on a national level but in a state level and then in a local level as well and just realizing that this is something that’s not getting better. And so I may be biased, I came into office because I’m trying to change so many of these things. So I do believe that through policy decisions, we can write the ship on these things and we have seen very modest improvements based on policies that we make.

And so when you ask the question, right? How do we change this? We’ll get into more detailed reasons or ways to do it. But I think at the very 30,000-foot view, there are policy decisions that we can make that can make it easier for birthing people and their partners to go through this process to have access to quality care. Right? We can do things like that and then on the other hand we can do is, we can actually fund things that are working. And so we have been able to identify positive trends when it comes to maternal health and maternal health outcomes and in many ways it’s incumbent on us every budget cycle and we’re in a budget cycle now. Every budget cycle to continue to fund things that are working and to increase funding for things that could have an even greater and more positive effect.

Oster:

And this is where for me we can see some of the on the ground value of data because that is how we figure out what’s working and if we think about a budgeting cycle. Which is I’m an economist, everything is constrained optimization, every dollar that you spend on one thing is a dollar you’re not spending on something else. So figuring out what are the interventions that are going to work the best is part of that challenge. I actually think it’s a very frustrating part of that challenge because when you step back and you think we’re talking about people dying in childbirth, we’re talking about something which we should be willing to spend all of the money on. What are you saying? That we have to find that the small number of things that work, why don’t we do all of the things? And that is not the political reality but I can imagine that piece of it must frustrate you sometimes also.

Senator Brouk:

It frustrates me all the time and I think one of the things is, I’m three years in… I guess this is my fourth legislative session that I’m starting. So this has not been the bulk of my career, so my brain still works very logically the way everyone else’s does before you get into public office.

Oster:

They haven’t sucked you in yet to some kind of disaster?

Senator Brouk:

Not yet, and people are waiting for it. They’re waiting to say, “Okay. Oh, Albany’s going to get to you.” And I said, “Oh, Albany is not going to get to me.” And so I can say this as I still consider myself somewhat of an outsider, right? Because I spent more time doing other things in my career than I have in this part of my public career. So I still think like that too and I remember being faced with those questions, and to be very frank a lot of those questions came up in last year’s budget in New York where I nearly changed my middle name to doula. Because every room I was in, I mean I won’t say I was yelling. But I was speaking very sternly and assertively and sharing my data points and making sure that people understood how important these policies were and how important this funding was and one of the things I’ll say is that I think that it is easier to ignore this topic when you don’t have a black mother. Like new mom, black woman legislator in the room fighting for it.

You couldn’t tell me it wasn’t worth it, you couldn’t tell me that it doesn’t work because I had experienced what some of these interventions can do to promote healthier outcomes for me and my daughter. So I mean none of it comes easy, definitely and it’s always a trade-off when it comes to policy and obviously budget decisions. But I think we have to always consider where have we historically ignored and where have we historically not funded and thought about the outcomes for certain people? Because we have a lot to make up for and I think about that a lot. I have 10, 20 years to make up for when it comes to maternal mortality and especially when it comes to black maternal mortality.

Oster:

Yeah. And I think, I mean maybe the slightly positive frame on that is the fact that we haven’t spent any time thinking about this, investing in it. It means that there are things we can do that maybe there’s a little low-hanging fruit or lowish. So let’s talk about doulas because I think it is an example of some effectively low-hanging fruit if we could just get it done. So let’s just start by can you give me the rundown on what a doula is? Explain it to me like I am a 67-year-old male legislator from upstate.

Senator Brouk:

I have a lot of experience with just that.

Oster:

So that’s a good audience for you?

Senator Brouk:

Even my family gatherings. “Oh, Samra I heard you on the radio again. What is this doula you’re talking about?” So first, the basic definition of a doula is these are non-clinical and I want to be clear that people understand that, because this was actually a question that I got just at a grocery store actually a couple of months ago. A constituent came up and asked me and said, “You’re not going to use an OB anymore or you’re not going to use a midwife?” And I said, “Doulas are non-clinical.” So they are in addition to your regular medical team just so that we’re all clear. So they’re non-clinical providers that offer physical, emotional and informational support both to the birthing person and the partner and this support can occur before, during and after childbirth. And so a quick example is, for example for myself I’ve hired a doula I think I was probably sometime in my second or third trimester.

We did a lot of birth education and met and talked about birthing plans and all of that, and then she was there continuously during my birthing process and then afterwards she was one of the first people to check in on me and make sure we were doing okay postpartum.

Oster:

So there are many ways we could talk about doulas, so one is what this is like and one is what the data says. So I want to start with what is it like? I mean, you had a doula. You want to tell me about your experience?

Senator Brouk:

Yeah.

Oster:

So there are many ways we could talk about doulas, so one is what this is like and one is what the data says. So I want to start with what is it like? I mean, you had a doula. You want to tell me about your experience?

Senator Brouk:

Yeah, let’s do it. It’s literally my favorite thing to talk about birth stories, doula stories. So the best way I could describe it and specifically for me what I was looking for is… And I interviewed several people to see who would be a good fit, right? Because anyone who knows me knows that’s very on par with who I am, is I want to make sure I have the best. Right? For this little child I’m bringing into the world. And so I interviewed several people and I really thought about it as, listen I know I am a very strong-willed person. I know what I want when it comes to this birth plan but I also knew enough about quite honestly maternal mortality and what I might encounter as a black woman in that hospital that I knew I needed someone who would stand up for me and that was really important to me. I have a very, very supportive partner but this is also potentially traumatizing for him to have his partner in all this pain and going through this process.

So for me it was really important to have someone who I knew could really stick up for me with my medical team and who could quite honestly give me hard truths that I might need to understand. Because my goal at the end of the day was to walk out of the hospital healthy with a healthy baby, that was my goal. And for so many black women like me, instead of worrying about the colors in the nursery and what kind of crib and what kind of cute nursing tops we want to buy. We are faced with the fact that in New York State, we no matter how much money, how much education you have it doesn’t matter. We are still five times more likely to die in childbirth, so I think a lot of people understand maternal mortality is bad in the US. It is worse for black and brown women, and so here I am a legislator working on these policies and my day job tremendously fearful every night when I’m thinking about how I’m going to go through the process.

So really having someone that I could build rapport and trust with was really crucial for me. So before I went into the hospital what that support looked like is I remember… I still have piles and piles of paper, not paperwork but reading material that my doula gave me. Lactation support, an Apgar score, what’s that? Which I know you probably covered in a million other ways. Things that most people have no idea what these are and we actually did a four-hour private lesson. Four hours where we were on Zoom because it was still kind of COVID times and my husband and I sat on the couch and we sat with our doula and she educated us about all these things that we should be expecting, things that we should plan for. The understanding that a birth plan is just that, it’s a plan, it’s a wish, you never know what’s going to happen. And so that was really needed for me, I remember one day I was feeling very panicky and I was starting to get very nervous and I felt like something was going on with the baby.

And for many of us we don’t have an on-call doctor or nurse at all times, it’s really hard in our current healthcare system. And so who did I text at 11:00 at night? My doula and who answered me at 11:00 at night? My doula. And she quickly assessed kind of how I was feeling and that was the point where I trusted her to tell me, “You should really call the nurse hotline at your OB’s office.” Or, “Why don’t you try this? Here’s some breathing exercise, have some water, tell me about what happened today, what might be happening?” And so having that support and then going into the birthing process was really helpful. Because I was essentially bringing this second person who I had such a close relationship with and who had experience at the hospital with these nurses, with these doctors. And so it was an incredible support, and I know we’ll get to the data and I’m itching to get there. Because I love sharing the data with people because this all sounds nice, right? It’s all anecdotal and I didn’t have a perfect birthing experience.

But my doula helped me get through it so that I didn’t feel so bad about the fact that it didn’t go the way I had planned. But also that all feeds into the data that actually shows overall that they improve maternal outcomes.

Oster:

After the break, more ParentData.

Oster:

Let’s get to the data and then I want to come back to how what you were saying about the personal experience kind of feeds into the data. Because I think part of what’s so interesting about this data is how much data we have on efficacy. But actually how little in some ways we have about mechanisms, which isn’t really important for policy but is an interesting question to think about. What is it about that relationship that you had that delivers these outcomes? So let’s put a pin in that piece and come back to it after we talk about the data. So you want to give me your data and… Give me your data.

Senator Brouk:

Listen.

Oster:

I can see, this is mostly audio and so people are not going to be able to see that you’re basically in the camera and I feel like if I talk first we’re going to be in trouble. So please come out of your camera and do the data.

Senator Brouk:

Well listen, now I’m a little nervous. Right? This would be like you coming on and writing a bill in front of me where I’m going to sit here and give data.

Oster:

We’re trying to talk to some of these senators and be like, why are you so loud?

Senator Brouk:

So I mean, here’s what I’ll say and then you go because the truth is you are the data person. But the overall because what we were looking at is things like reducing C-section rate, so cesarean sections. Right? They reduce those, the length of labor they can reduce that. And so here’s an interesting one for New York that I’ll share from my perspective, is in New York State we do have a maternal mortality review board and they do review outcomes. And one of the things that we found is that discrimination actually has been identified as a large contributor to some of the pregnancy-related deaths. So in 46% of all pregnancy-related deaths discrimination was identified as a probable or definitive circumstance surrounding the death. So when you look at something like that, we also know that doulas can really interrupt that discrimination. And so when I talked about being a black woman in this process I had to think about things like my pain is not seeing the same as a non-black woman.

I also had to think about things like my black husband if he were to get assertive on my behalf through implicit bias that may be perceived differently than someone else’s partner. And so when I look at some of the things that doulas do, that was one of the things that this woman was able to do is interrupt and really show up and to intervene where those potential points of contention could have been created. So those are overall things that we see and specifically when you look at New York data, it’s really alarming. That that’s nearly 50% of all deaths they cited discrimination. So when we talk about the fact that overall deaths 78% of them were preventable in New York State. You start to see why we say, “Okay. Adding a doula to this birthing and care team really could make a difference.” And I’ll shoot it back to you because now I want to hear the rest of your data.

Oster:

Yeah. So the data piece of this I find so interesting and compelling is okay, so when we think about data like this I think people have this in mind. Like I’m going to compare people who have a doula and people who don’t and see differences in birth outcomes and that approach would be terrible. Because of course it is still the case that richer people are more likely to have doulas and their birth outcomes are better for other reasons. What’s amazing about these data though is that we have large-scale randomized studies in which we can see that women who are randomized to having a doula have better birth outcomes, less use of cesarean sections, less use of epidurals, typically higher Apgar scores. There’s a bunch of other things that point in that direction and some of that evidence is just from women who are assigned doulas at the hospital.

You show up, you’ve never had any of this back-end support that you’re describing. It’s just come to the hospital and they’re like, “Here’s this extra person.” And still that has a positive impact. The other piece of it, the data that I love is that there’s this randomized trial in which what they do in the treatment group is they ask people to find a friend. So they actually ask them like pick a female friend and we’ll give them some basic doula training, like some basic training in what to do and they see that improves outcomes. So taking a friend, giving them a little bit of training and how to be supportive, how to be whatever these ways are that that turns out to have higher Apgar scores trending towards a lower C-section rate. So there’s a bunch of things on this which make you think many ways to look at it. There are positive benefits and then people are happy and I guess that’s the piece we talk about these data.

We’re always like, “And then it costs less which we’re going to get into because it does cost less.” But when you call people later, they’re happier with the experience and that really matters. I mean, all these things matter but that’s like we don’t want to forget that that also matters.

Senator Brouk:

Yeah, and I’m so glad you brought that up because you’re right. I think so often and of course as a legislator I understand the dollars and cents of it all and so being able to tell a hospital or even an insurance company, “Hey, here’s a plug for the rate I think they should be getting is 1930.” $1,930 per birth is what I think it should be. It’s a little bit lower with the Medicaid rate in New York State, but it’s something. But either way, either of those numbers is less than paying for an entire cesarean or is less than an extra day in the hospital. Right? Because doulas can also lower the decrease the length of labor. But aside from all of that, you’re absolutely right. It’s also about the joy and this is actually something that has come up a lot in the doula community in New York State and we have a lot of what we call community doulas and community doulas are really those who are really rooted in their own communities.

Right? So they’re not necessarily someone like you mentioned if you’re very wealthy you could fly out a doula from California or wherever you are and no, but these people are actually rooted in the community. They’re more reflective of the language and culture and race and ethnicities that are in that community and we talk a lot. So it’s a lot of black and brown women, and we talk a lot about how the joy has been stolen from childbirth and even in the way we talk about it, we talk about black maternal death, we talk about black maternal mortality. Even the talking about that, the ripple effects are it creates this kind of secondary trauma to women who have not experienced the trauma like myself who can imagine it so clearly because of how much it’s talked about. So I love that you talked about the actual joy and how you feel when you leave that hospital or that birthing center with your child, because what we also know is what’s the number one most common pregnancy complication at least in New York State.

It’s maternal mental health conditions and that’s more than postpartum depression, there are a plethora. I didn’t know you could get OCD on set, high anxiety postpartum and so all of these things are working together. Right? Because we’re not siloed human beings that we can compartmentalize, “Okay, this was the physical part of birth, now that’s over I’m going to go home and be a different person.” That’s not how it works and I share that about my story that it did not go according to plan. I was in the hospital for four days, I did not expect to be there for four days and yet I felt more positive actually about my experience. Because I had a doula that at least I understood what was happening along the way and if we want to talk about this decrease in cesarean rates, I saw it in action. Because I was a blink away from getting an emergency C-section, and my doula is the one who intervened and allowed me to have the birth that I wanted to have with my child.

So again, that just leaving and I think you said this. Right? At the end of these trials and we did the same thing with our doula pilot here in Erie County in New York where we asked these questions, and one of the major pieces of data was satisfaction. A higher satisfaction with the birthing process when you had a doula.

Oster:

I think it is worth noting that in the great swath of human history this is a thing people had, right?

Senator Brouk:

Yeah.

Oster:

Maybe we didn’t call it doulas, though actually doula is a very old Greek word. But people would have babies surrounded by other women who had done this before and so that idea of a support person doesn’t seem crazy. And then of course, after you have the baby there was a support person and we’ve sort of moved into a world that’s much more single nuclear family based, much less community based and I think some of that gets lost there.

Senator Brouk:

Yeah, like where’s our village?

Oster:

[inaudible 00:28:38] who’s got this newfangled doula idea? It’s like well, cave people came up with it and so we’re just sort of continuing the trend from the cave when we used to use this.

Senator Brouk:

Literally. Everyone’s talking now, like you just said there was this village and a lot of millennial parents and we’re all like, “Where’s our village?”

Oster:

Where’s the village? Where’d it go?

Senator Brouk:

What happened to it? Can I get it back? But this is probably another podcast worth of gripes here about how we’ve really changed how childbirth is supposed to be for so long. Like you said, you had your supports, you had your people, it wasn’t this super medical experience. Now it is, right? And what I hope that we can do both kind of on the level of society and of course until we get there in our collective consciousness I’ll keep passing bills to force us into that shift. But I hope we learn to take what worked, right? Obviously there are many things that are helping birthing people and their children live longer and have better outcomes and there’s science and there’s so many great things out there. But we can’t forget some of the very basic kind of it’s almost like a human connection if you think about it, right? The data you had about just having a friend. We can’t forget some of the very, very simple things that worked and as we put them into a modern society… Now, I’m getting on my soapbox for real.

As we put them into a modern society we have to fund them the way we fund every other part of the birthing world.

Oster:

Okay. So let’s talk about this funding piece because I think one thing I will say, and I want you to tell us about your legislation. I think one of the things that’s most striking for me is doulas are often not covered by insurance, and they are definitely often not covered by public insurance which is the insurance that many people who most need a doula have. So doulas are not typically covered by Medicaid. There is a cost-effective argument for doulas to be covered by Medicaid, which is that if you reduce the C-section, if you reduce the time in the hospital, that time is very expensive. And so actually in principle you might well break better than even, you might make money by paying for everybody to have a doula which I think it’s free money. Free money is so rare. The money tree is so rarely giving out its free money and so tell me about your legislation.

Senator Brouk:

Yes. So it’s actually a whole package of legislation because of course you can’t do everything in one bill. But basically what we started was a couple of years ago, we started with a work group that would essentially have the Department of Health and really study how much should a doula reimbursement be and the reason we started there is because in New York State about 46% of births are covered by Medicaid. And so we thought what better way to really jumpstart this than have the Department of Health really figure out how much this reimbursement would look like through Medicaid. And then what happens a lot of times in states is once Medicaid has a rate commercial insurers will follow that rate, maybe make it a little bit higher. But that kind of becomes the base level where usually nothing will be lower than that.

So we started with that work group. We held a hearing on doula care and what it would look like in New York State to be statewide. And as part of that advocacy grew, it really became a priority item for the state senate probably because I was educating everyone on what doulas were. But then also the governor took notice as well, took notice and really created it as a priority of her own Governor Hochul. And so starting this year January 1st 2024, we finally have statewide Medicaid reimbursement for doulas. Before that we had two pilot programs that were just simply not funded nearly where they should have been, which made it hard to recruit doulas. But we had somewhat success in Erie County as I mentioned earlier with that pilot program and really based our statewide Medicaid reimbursement on that. And so right now in New York State and we are actively working to get more doulas online to do this. But right now, if you are a Medicaid recipient in New York State you can have Medicaid cover the cost of your doula.

And that we hope is going to make a huge difference obviously for birthing people. But the next big thing we have to do is to have commercial insurers cover this as well. I’m really happy to share that several insurance companies have reached out. They don’t reach out to me on a lot of things, but they know for when it comes to maternal health I can’t tell you how many people have reached out to me, have wanted to talk about this process. Because they want to do what’s right as well and also it can’t be ignored as you pointed out, it is also a cost saving measure which is fine. For a profit seeking entity that’s fine. If we’re going to save moms and babies I’ll stand with you, right? We will get this done, and so the hope is that I might not need to legislate to get commercial insurers. But we have the legislation there just in case and then I’ll just add because I said it’s not just one and done, now we have to really build this field of doulas and so we now have legislation around a doula workforce fund.

Because what we found it’s oftentimes just a single woman maybe who is a doula who simply does not have the administrative backing. Right? To be able to fill out Medicaid claims to make sure she’s getting paid so she can support her family and so on. And so we have a workforce fund that would really go to a lot of the community-based organizations who house doulas and help them with a lot of the administrative work to really make sure that folks can stay in these roles and then the second piece is we have legislation around doula friendly designated areas. So for example, there’s a lot of hospitals that are starting to learn how to be more, “Doula friendly.” And so we really want to make sure that we can study that at a state level and put forward recommendations so in the future hospitals can actually be designated as a doula friendly place.

Oster:

I think that’s awesome, and I hope that other states do it. I mean I think this is a model, right? The hope is that it’s not just New York but that other places figure this out as a model. Maybe the fed… I mean, yeah, that would be my hope.

Senator Brouk:

I mean, federal government if you’re listening you too can do this.

Oster:

You too can do this, although the states control Medicaid so it’s little…

Senator Brouk:

So essentially the states have to ask for waivers to use Medicaid for these different things. If the federal government says hey, you should all do this then probably more states would do it and definitely they’ve been supportive. I’ll actually say VP Harris tweeted back when it was Twitter, tweeted about our bill and I almost lost my whole mind because I was just so honored. I couldn’t believe she knew what we were doing about doulas in New York. But I’ve gotten to talk to her about some of the doula work, and she’s incredibly, incredibly supportive and a few states have done this as well. We became the 13th state to do it and I’m really hoping others… I mean, here’s the playbook just go online and copy our bills. It’s okay, and they can do it there as well.

Oster:

It’s so exciting. Okay. I’m going to end by asking you a personal question. You can say no.

Senator Brouk:

Oh, gosh.

Oster:

What is the most joyful moment of your birth story?

Senator Brouk:

Oh wow, that is capital P personal. The most joyful moment of my birth story. Oh, actually that’s quite simply. So as I said, I had a difficult birth and when she was finally out she didn’t cry right away and when I first heard her cry that was 100% the… I tear up thinking about it, but that is 100% the best most joyful moment of my whole life.

Oster:

Yes, there’s nothing better than that. I will tell you, here’s an example of what I’m like. I’ll tell you, I don’t think I would describe this as the most joyful moment but this is a moment that involved my doula with my second child. So I was pushing and because of the position of this I could see… My water had broken right at the end, and so I could see that it was green which is a sign of meconium and in the middle I’m pushing the baby’s head is coming out. And I was like, “Is the water clear?” And my doula was just like, “Just [inaudible 00:37:43] push. Stop thinking about this.” It was just like, “Come on, get focused on your job. Other people are worried about the science that’s not your job right now.”

Senator Brouk:

The occupational hazard.

Oster:

Totally. Just like excuse me, I need a little more data here so I can decide what I want to be doing about the situation. I just want to know how hard I should be working. Is this more of a push hard or are we is it like we have time to try it out?

Senator Brouk:

You’re being efficient with your energy is what I heard.

Oster:

Exactly, I’m just trying to save it. But my doula, she was just like, “Just keep going, keep going.”

Senator Brouk:

It’s like how they say doctors are the worst patients, right? You know way too much.

Oster:

Totally. Yes, I’m not a doctor but I play one on TV and I’m definitely the worst patient. This was such a treat. Thank you for all your work and this topic it’s one of the ones I like the best because it feels solutions oriented. I feel like when we talk about a lot of these issues it’s easy to feel defeated and to look at those graphs of maternal mortality or whatever the outcomes and be, how are we going to make progress? This is like, “Hey, I got something for you. It’s not all the progress but it’s something that would help.” And so it must feel good to get to be a person who actually does make some of that happen.

Senator Brouk:

100%. I’m so glad you said that because all of this is doable, and I think a lot about how we got ourselves into this predicament with the maternal mortality crisis and in many ways it is a human made predicament. These are not naturally occurring factors that are leading to mortality. Therefore, we absolutely can change it and we’re doing a good job in New York and there’s more to do and I really hope that other states get inspired to continue this work as well.

Oster:

Thank you so much, Senator Brouk.

Senator Brouk:

Thank you.

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OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

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Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

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📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76.

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