Social Change and Birth Economics

They say that where there is a will, there is a way. Where there is demand, there is someone ready to meet that demand. This is the most well-known and understood theory of economics in our modern day and yet it doesn’t always hold water.

If you fall ill and need medical care, you don’t usually get to choose what hospital you go to or what treatments you receive. In healthcare, theories of supply and demand get warped by legal, physical, and/or cognitive incapacities to make choices regarding what services to receive and when and how to receive them. Supply and demand does not govern healthcare like other systems because of the buyers’ lack of choice in what services are offered, how and when they are provided, or even whether they are provided at all. For example, in much of the United States, not providing medical care when it is needed can cost a provider their license even if the patient insists they would prefer not to receive treatment (for lack of ability to pay, desire not to indebt family members, a wish to terminate their life, or any other reason).

For much of the world, pregnancy and birth are the most significantly risky financial experiences of a lifetime. A healthy pregnancy and birth alone carries a serious economic burden in prenatal, birth, and postpartum care – and if you forgo preventative prenatal care, you may find yourself at an increased risk of greater financial burden in the long run. People with health insurance may not have to carry this major economic burden, but if you are under- or uninsured, you may carry a greater brunt of the cost despite arguably needing even greater levels of care.1

Furthermore, in the United States, nearly half (45%) of pregnancies are unintended, according to Finer & Zolna (2011)2. Planned pregnancies more likely involve financial planning for the pregnancy; unplanned pregnancies, on the other hand, often carry a more significant financial burden on the parent(s) precisely because it is unplanned. In a country where birth control access is geographically determined, where access to abortion is under fire, and where people face significant stigma for their reproductive decisions3, it is not at all controversial to claim that pregnancy-related healthcare is often a necessity of an unplanned physical circumstance. While not necessarily traumatic, healthcare and its associated financial costs are frequently coerced upon people in our country with a differential impact upon women, communities of color, people with disabilities, and trans, undocumented, and impoverished people.

As doulas, we are not medical professionals. People generally do not come to us in crisis. Our services (and our fees) are generally not coerced upon our clients. The doula-client contract is a consensual process where one agrees to pay the other for services rendered.

Nonetheless, we must question our place within larger realities of the economic system of healthcare and access to family planning.

While doulas are not medical professionals, the services that we provide carry significant medical benefits to our clients. Provision of birth support by non-familial and non-medical personnel is associated with reduced risk of birth complications, thus fostering a happier and usually less expensive birth experience.

I want to make it plain and clear before furthering my argument: doulas and new parents all deserve economic security for themselves and their families.

There are three arguments I see regularly within doula communities, that 1) every birthing person deserves a doula, 2) doulas should be paid what they’re worth, and 3) a birthing person will find a way to pay for a doula if they really want one. The first two arguments work in direct conflict with each other. The third argument is not based on any data that I know of but on the personal experiences of doulas who charge a living wage – and who therefore may have a self-selected pool of data on which to base their claim. This argument also ignores that most doulas expect a down-payment before a birth and the birth itself is often the least economically predictable part of the reproductive process and carries the greatest potential financial burden – with no warning.

Each doula needs to determine for themselves how they plan to work for the benefit of their client and of themselves. Doulas need to eat and most doulas are driven to this work from an empathy and passion for birth. Many are driven to this work out of a passion for social justice, but the fight for social justice is made tough if you can’t pay the bills. What can we do?

We must not ignore the economic circumstances in which we work. We must not silently accept those economic circumstances. Our work creates economic benefits for hospitals, insurance companies, and patients; when we work with disadvantaged communities, our work directly addresses health disparities couched in violent reproductive histories.
We must not depoliticize our work. We are working and living within a larger cultural trend – a trend couched within an expansive self-proclaimed feminist community – where feminism is marketed and capitalized upon. There are many ways to be a feminist. One way, these days, to be feminist is to be “an independent woman” (read: wealthy); this capitalist version of feminism ignores the lived realities of low-income people. We need to be real – yes, we all desire and deserve economic self-sufficiency and such economic self-sufficiency is important to women (given histories and current realities of financial abuse at the hands of men), but this watered-down version of feminism ignores that one person’s wealth is another’s poverty. Someone must suffer for your security unless we build systems of mutual economic support and interdependence.

Access to health care is internationally recognized by the United Nations and World Health Organization as a human right. Furthermore, maternal and child health are priorities of the WHO and of the United States’ Healthy People 2020. If we wish to raise the significance of our work, if we hope to be of service to birthing people who desire our support, and if we expect a living wage, then we must advocate for ourselves within this human rights framework. We support, honor, and protect the health and human rights of birthing people. Our services create emotional and financial benefit for individuals and health and financial systems.

We must advocate for our work to be supported in due kind without significant burden upon those receiving our care. In advocating for ourselves and our clients, we create common economic security. We must call for insurance companies, medicare, and medicaid to cover our services using our pay scales. We must come together in the fight for labor rights and protections; we deserve health insurance, family leave, and retirement as in any other profession. We must unionize with other freelancers in recognition of our common economic rights and needs. We must call for the supports provided to other helping professions; our economic security will free us to make the change we hope to see in the world.

1This disparity may widen if we see the repeal of the Affordable Care Act. Those of us who care for or work with impoverished people must have a voice in this debate.
2Finer, L & Zolna, M. Unintended pregnancy in the United States. Incidence and disparities, 2006. New England Journal of Medicine, 84(5): 478-485. doi: 10.1016/j.contraception.2011.07.013.
3If we care about birth, by the way, we should be involved in social movements to protect and expand reproductive health care and family planning access for all people. While related, this argument is outside the scope of my current argument.


Rory O’Brien

MSW, MPH, DTI certifying doula

Rory is a doula dedicated to supporting LGBTQ families establish themselves and grow. In addition to providing doula support to LGBTQ people, Rory is a public health professional and social worker with training specifically in sex education and violence prevention. Find Rory on Facebook or at his website.

(photo credit: Erin Falacho Photography)

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