David Brauer

If you’ve never heard of a doula, don’t worry. Experienced birth attendants
have been around since the beginning of humanity, but the term — Greek for
“trusted servant” — dates back only to 1992, when a Seattle childbirth
educator decided the position needed better branding.

Today, fathers are allowed in the delivery room and midwives sometimes
elbow out doctors. Doulas fill a remaining gap: They serve as an
experienced peer focused solely on the mother’s physical, emotional and
psychological needs. Doctors or midwives must split their time worrying about the
baby’s delivery; nurses typically shuttle among several births. Dads, of
course, are riveted on their partners, but we’re so deeply involved we can’t
be always be counted on for levelheaded decision making — and besides, even
we earnest Lamaze graduates have little experience in knowing what to do when dilation comes.

While doulas aren’t medical professionals, their effectiveness has been documented by medical institutions. Allina Health Systems, a Minneapolis-based HMO
and hospital network, did a 1996 “meta-analysis” of six clinical trials. The
results showed a 50 percent reduction in Cesareans among mothers who used
doulas, a 25 percent decrease in the length of labor and a 30 percent drop
in the use of pain medication. When Allina did its own trial, the results were even more striking: Mothers assigned to doulas had 64 percent fewer Cesareans,
38 percent fewer epidurals and a 27 percent reduction in labor duration.

Even studies that showed no reduction in C-sections — such as one done by California-based HMO Kaiser Permanente — found that the use of doulas provided emotional benefits to mothers. Women accompanied by doulas are significantly more likely to cope well with labor, rate the birth experience as good and say that enduring labor improved their feeling of self-worth.

“If a doula were a drug, it would be unethical not to use it,” says Dr. John
H. Kennell, a pediatrician at Cleveland’s Case Western Reserve and a father
of the modern doula movement.

Yet despite its successes, the “doula movement” remains largely
word-of-mouth — which is how Sarah and I found out about it. A few years ago, I hosted a radio show. As the lone liberal on a conservative AM talk
station, I’d use nonpolitical topics as a way to create space between caller insults. While Sarah was pregnant, my conversation naturally gravitated to the joys and fears of impending fatherhood.

Midway through the pregnancy, Doug, one of my regular callers, phoned after a show. His wife, Maureen, was a doula and wanted to offer her services. The cost was $300 for a couple of pre-delivery meetings, attendance at the birth and postpartum follow-up. (I later found out that doulas typically charge between $200 and $600, depending on region and extent of consultation.) I was suspicious, but Doug had proven himself to be one of my more thoughtful intellectual combatants, so I figured it couldn’t hurt to meet Maureen. If it got weird, at least I’d have a good anecdote for a slow morning.

A suburban matron soon turned up on our doorstep, looking as proper and
beatific as a door-knocking Jehovah’s Witness. In truth, Maureen was
an evangelical Christian — a not-uncommon trait among doulas. The
profession sports a liberal-conservative coalition rivaling WTO protesters:
The God Squad is equally matched by the New Agers; both share a belief that birth is a natural and spiritual thing.

Since Sarah and I are confirmed secular humanists, my first reaction was,
“Uh-oh.” It would’ve been the same had an earth mother flounced in. But
Maureen quickly won our trust. She focused on what we wanted out of the
birth and asked us to be blunt about what we didn’t want.

“Well, I said, “we don’t want to be evangelized.”

“Fine,” she responded, “I won’t.” And she didn’t.

Instead, she earned her description as a “servant” by passing on a ton of
information about labor and delivery and running through various scenarios — including the use of drugs during delivery. Some doulas, I’m sure, can let a subtle anti-drug bias creep in, but Sarah and I never felt that from Maureen.

Over the course of our pre-delivery sessions, we built up trust in Maureen, leading us to ask the sorts of questions we might not have been comfortable throwing out in a group class. It became easier to talk about fears — including mine. I could
admit my absolute lack of confidence, talking through each of my panic
scenarios like a paranoid to a shrink.

Some couples worry that Dad will be upstaged by the doula on delivery day — a reasonable fear. I tell prospective Dads that a few hundred bucks is a small price to
pay for Knucklehead Insurance. Allowing fathers in the delivery room is
a wonderful and well-intentioned gesture, but most of us are rookies
as labor coaches, and it’s ridiculous to have a rookie in charge of anything, much less his gravid wife’s comfort.

“It’s almost unreasonable the pressure we put on fathers,” says Kennell. “I
work with med students who have been training for a year, and when they go
into hospital divisions for the first time, it’s very common for them to
feel faint. [Doulas] are a great psychological benefit to mothers, but also
to fathers.”

When Sarah went into labor, we found ourselves in a situation Maureen had
warned us might occur: She was tied up at another, very difficult birth. She would
have to send her backup.

Soon after we made it to the hospital, Allison, a severe Australian,
arrived. The three of us had no bond outside of the fact that we all knew Maureen. The first hour didn’t go well for me. Fortunately, it went well for Sarah. Allison locked on to Sarah like a lamprey to a rock. She was so competent and assured that I became nothing more than a marveling spectator. Sure, I’d learned about the
birthing ball, breathing exercises and the soothing effects of the seated
shower, but who knew when the time was right for each? Allison did.

While I wasn’t interested in wresting command of the pain-relief detail, I also
wasn’t doing the most that I could do. I vividly remember standing behind Sarah,
watching Allison work, and realizing that I’d drifted out of my wife’s sight
because of some imaginary inadequacy I felt in comparison to the doula, rather
than concentrating on what the hell was happening with my wife.

But no one was telling me to be passive. I gathered my wits and decided to
assert myself ever so gently. I moved back in front of Sarah, essentially
sharing space with Allison. I started to ask Sarah my own questions when my
instinct moved me, cracked a pallid joke or two and basically resumed being
myself. This was met with no resistance; Allison was fierce but not a control freak.

With us, at least. There was one charged moment. A nurse had left Sarah
hooked to a baby heart monitor. After several minutes, Sarah whimpered, “My
belly’s cold.” I probably would have waited until the nurse returned,
assuming that such discomfort was the price of vital information.

Allison snorted. “I’m going to get someone,” she said, and stomped out of
the birthing room.

Soon an apologetic nurse appeared; she explained that she’d been busy and
had forgotten to unhook the monitor.

Some medical professionals resent having to deal with another party in the
delivery room, though our OB and nurses apparently did not. Even the nurse who made the error sought us out after the birth to tell us how neat it was to work
with the doula. I’m sure it’s a relief for professionals working with us
amateurs to have a seasoned intermediary to go through. Doulas themselves
insist that they defer to the clinicians.

“Doulas say that their place is at the patient’s head, not in the
physician’s way,” explains Bonnie Blake, vice president of operations for
two Allina hospitals.

That’s how it was during the late stages of Ian’s birth. Sarah experienced
excruciating back labor, but she didn’t ask for an epidural. Allison stood
behind her head, offering steady suggestions: how to turn, how to
breathe — simple suggestions that I would have been grasping to recall, had
a doula not been there. I sat next to Sarah, held her hands, gazed into her
eyes and offered reassurance. Meanwhile, the OB and the nurses worked
undisturbed. After six and a half hours of labor, Sarah delivered our
perfect baby son.

Our doula did not prove herself to be some sort of human ibuprofen, able to
miraculously mask the pain. “Childbirth didn’t feel like people said it
would feel — it hurt a lot more,” Sarah recalls. “But fear makes pain
worse. Maybe my pain wasn’t any less, but I wasn’t afraid. I would have been terrified if Allison hadn’t been there to tell me this was normal.”

Now that we’ve become doula acolytes, I’d like to know why health plans are
so timid about promoting them. Forget, for a moment, about the emotional
advantages. Even in the bloodless financial world of the modern HMO, doulas
make sense. Each bypassed epidural saves about $150; a forgone C-section
saves around $3,900. If one woman in 10 avoids a Cesarean, the money saved
could pay for doulas for all. This, folks, is health maintenance.

Yet even Allina, which documented the benefits of doulas in its own studies, offers a mere $150 toward the expense of hiring a doula, and this incentive is available at only two of its 15 hospitals.

Allina, says Blake, wants to slowly increase the use of doulas, gradually making
sure the benefits shown in the 1996 study hold. Still, it’s no accident that its hospitals with doula programs also lack nurses’ unions. Two Allina officials told me that the nurses’ union fears that the doula program is a backdoor attempt to reduce the number of nurses on duty.

Blake insists Allina isn’t looking to replace nurses with doulas. She predicts that resistance will drop as more nurses work with patient-provided doulas — and don’t lose their positions because of it. Physicians don’t see doulas as a direct
threat to their profession, but some still need to see the advantages of
doulas for themselves.

Union nurses aren’t the only one who distrust Big Medicine. Doulas are thought of as cool and sort of alternative when patients seek them out, as we did, but Blake suggests that mothers might find it more difficult to bond with a labor coach if institutions are the promoters. “We prefer to be a less paternal
organization,” she says.

I don’t know. It is possible that health-care costs might rise in covering the heart attacks people would experience when offered cheap, innovative, human support — but I say let’s take that risk.

Two months ago, Sarah discovered she was pregnant again. Our baby is due in
June. Of course, we’re going the doula route again, reimbursement or not.
This time, Maureen promises us she’ll be there.

“It burns the heck out of me that I can’t get decent coverage here, but I get great coverage if I go to Arizona,” says the retired business owner.

Grigsby pays hundreds more out of her fixed income because the alternative was worse: dying among strangers. “I wanted to be near my family,” she says. “I’d seen people down there in Arizona, living in nursing homes, all alone. That wasn’t going to be me. So I said to heck with it — I’m coming back here, and if I go broke, I go broke.”

Luckily, she says, she is still doing OK financially. “[But] if I was somebody in real need, I wouldn’t dare come back here, even if it meant not living close to my family,” she says.

Like Grigsby, Charles and Margaret Van Guilder will keep living in Minnesota — but they may get divorced to do so. Margaret suffers from advanced Parkinson’s disease, and Charles says Medicare reimbursements are so small that they pay $595 a month more than they would in south Florida, where even taxi rides to the doctor get covered. Divorcing Margaret would allow Charles to shelter assets that will otherwise be drained until she qualifies for indigent care. They say this is their only choice, because they refuse to move out of state.

“We want to live where we want to live,” Charles Van Guilder says. “Why should we move to a [high-reimbursement] state when the money should be equitably distributed in the first place?”

Minnesota residents are not suffering from bad health care; treatment costs are among the lowest in the country. But they are victims, a new suit claims, to geographic discrimination by the federal government. Millions of Americans are affected by Medicare’s varying subsidies to local HMOs, but Minnesota is the first state to do something about it.

Residents of places as diverse as Honolulu, Albuquerque, Salt Lake City and Rochester, N.Y., as well as most rural towns, are paying hundreds more for far less coverage than those throughout the urbanized Sun Belt and in many big Eastern cities, according to a study by the Dartmouth Atlas of Health Care.

“This is a nationwide rural health-care issue,” says Peter Wyckoff, executive director of the Minnesota Senior Federation, Metropolitan (Minneapolis-St. Paul) region, a consumer rights group. “[But] Minnesota is one of the few states where nearly everyone has gotten the shaft.”

A federal lawsuit filed here last month alleges that reimbursements in the 39-million-person program are so geographically irrational that they are unconstitutional. The suit claims that individuals such as Grigsby are denied the Fifth Amendment right to equal protection under the law.

“It’s as if you could double your Social Security check by moving from Minnesota to Miami. Nobody would think that was fair,” says Megan McAndrew Cooper, editor of the Dartmouth Atlas of Health Care, which tracks local coverage differences. “Everyone pays into Medicare at the same rate, but some people are getting twice as much out of it.”

Seventy-two-year-old Mary Sarno would probably agree. Sarno, who lives in Florida, wants to be near her daughter but in court filings says she simply can’t afford to move to Minnesota, where her daughter lives. Sarno and her husband claim that they can’t afford to pay the $800-a-month increase in drug costs. The suit claims unfair Medicare subsidies not only violate Sarno’s equal-protection rights, but her constitutional “right to travel.”
(This argument was used recently to overturn state welfare laws that gave smaller payments to newcomers.) Courts have decreed that the government cannot create barriers to people moving freely between states.

Although Sarno is effectively a stand-in for millions of Americans allegedly hurt by Medicare rules, she won’t talk about her situation to maintain her privacy, according to her attorney.

And the defendants aren’t saying much either. Although formally, the defendant in this case is Health and Human Services (HHS) Secretary Donna Shalala, supporters of the suit say their true gripe is with Congress. Dr. Robert Berenson of HHS issued a short statement after the suit was filed, shifting blame to legislators. “The law typically sets the methodology Medicare uses,” Berenson wrote. “We consistently work within those laws and with Congress to ensure that Medicare beneficiaries can receive quality care in all regions of the country.”

The reimbursement saga seems to be a textbook case of unintended consequences becoming politically ossified. In 1965, Congress created Medicare to ensure coverage for all Americans over 65 and the disabled. The program did this on a “fee-for-service” basis — paying more when
seniors use more services.

But in the ’80s came managed care, which promised rigorous cost-containment so patients could get “more efficient” coverage for less. Subsequently, seniors flocked to these managed care programs, enticed by small co-payments and prescription drug coverage not covered by traditional Medicare.

Congress paid each HMO based on the average cost to treat patients in each U.S. county. Areas like Minnesota and upstate New York, which adopted aggressive managed care early and bled costs out of their systems, got smaller reimbursement checks. Paradoxically, other places that didn’t clamp down on total medical spending were rewarded. These included areas with hospital building booms, such as south Florida and parts of Arizona, or areas that couldn’t politically close down hospitals with excess beds, such as New York.

“It wasn’t obvious what was going on,” says Cooper of the Dartmouth Atlas of Health Care. “But a hospital buys an MRI and doctors use it; an area’s total costs go up. You build a hospital, and doctors tend to fill those beds.”

In the low-cost areas, Medicare reimbursements to HMOs were often too small to cover the basics. As a result, HMOs simply left those areas because they couldn’t offer a plan better than Medicare’s traditional fee-for-service plan. In Minnesota, for example, Grigsby has just two HMOs to choose from. The Minnesota Department of Health reports that at peak enrollment 12 years
ago, 160,000 state seniors were in Medicare HMOs. Now, just 38,000 remain.

Patients who leave HMOs have little choice but to go back to traditional Medicare, with its larger co-payments and no prescription drug coverage.

Although there has been some legislative reform, drafted to fix the price discrepancies, critics say it doesn’t go far enough. That’s why they say the suit was filed — to achieve in court what they couldn’t through normal legislative channels. “Politics simply hasn’t worked,” says Wyckoff of the Minnesota Senior Federation, a consumers group.

So an orchestrated effort — by two groups normally at odds with each other, the Minnesota Senior Federation and local HMOs — was launched to find plaintiffs, organize support and communicate the issues to the public.

“Here’s how [the plans] got our attention,” Wyckoff says. “They told us 50,000 seniors would lose their [HMO] coverage in the metro area by the end of 1999 because we weren’t doing anything.”

Managed care helped fund the suit; the Minnesota Senior Federation, a consumer group, would find the disgruntled senior. And that’s how Sarno became the face of this problem.

Supporters of the suit claim that Minnesotans and similar locales have little to lose; a successful suit would simply help them. Local HMOs would get more business; seniors such as Grigsby and Van Guilder would get more choice (and presumably better coverage); and local hospitals would get more traffic if seniors have more Medicare dollars to spend.

But it’s not clear what kind of ramifications a successful suit would have for parts of the country now benefiting from higher reimbursements.

One possibility is that Congress would be pressured into balancing the disparities: High-reimbursement places such as South Florida and Arizona would get less, while Minnesota and Northern California would receive more. But Wyckoff warns that this “solution” could backfire and end up just penalizing seniors in other parts of the country.

At the very least, this lawsuit has raised awareness of the discrepancies in senior health care. If the pressure mounts, then maybe, advocates say, Congress will draft a more equal system — so you couldn’t know what city you were in just by looking at your health coverage plan.