Isabel Gonzalez-Smith is angry—a silent, simmering, heart-pounding kind of anger.

She’s standing in the lobby of a hospital with a woman who’s just 24 weeks pregnant but experiencing intense contractions, a sign of dangerously early labor. Babies born at this point have around a 50 percent chance of survival, and the mother is scared. It’s her second visit to the hospital today.

This time, a man sits behind the reception desk and asks the mother a series of increasingly private questions. They reverberate through the crowded space, echoing off the walls and into the ears of strangers. Isabel tenses, but remains quiet as he jots down her responses.

What’s your date of birth?

What’s your insurance policy?

How many pregnancies have you had?

The answer to this one is high. The man looks up from his notepad suddenly, raising his eyebrows.

What? he asks, incredulous.  

“I was like, what the hell is going on? It was just a complete disregard for her privacy,” Isabel says, her eyes flashing at the memory. “He took us to the labor and delivery floor. But I was so shocked that right when you walk in, that’s how she was treated the moment she walked in the door.”

It should be noted that this pregnant woman—who did not end up going into premature labor that day—is African-American. Isabel is Latina, and although she’s seen this kind of behavior before, it never fails to rouse a deep, smoldering frustration inside of her. She remembers glancing over at the pregnant mother, expecting protest, insult, embarrassment. Instead, the mother remained unfazed.

“Perhaps that’s the saddest thing,” Isabel says. “And I didn’t say anything to her because I didn’t want to make her upset—she was already upset about the situation. But inside, I was just screaming.”

Isabel is a librarian at the University of Illinois-Chicago and doula on the side, trained to assist and support women during their pregnancies. Her job is to remain steadfast and calm—a voice of reason in the often-hectic throes of pregnancy and childbirth—and for the most part, she’s become good at playing nice. But she’s sick of seeing women like this mother slip through the cracks.

Isabel works with and was a founding member of a group called the Chicago Birth Workers of Color (ChiBiWoCo). It’s one of several Chicago-based organizations fighting to increase access to healthcare and combat discrimination via affordable doula services.

Formed in February 2016, the group calls for rallying marginalized communities through birthing services and reproductive empowerment. “We envision communities that are able to thrive, self-determine, and live autonomously, free from judgment, ridicule, and criminalization as it relates to their choices of parenting and birth,” their Facebook page reads.

For Isabel and the other members of Chicago Birth Workers of Color, birth work offers more than just a friendly face during pregnancy and childbirth—although they certainly place a high value in the community-building, emotional aspects of their services. They repeat a mantra: birth justice is social justice.

“There are people who, from the get-go, have less access, less opportunity and less value put on their lives and their wellbeing,” Isabel says. “If you recognize that, then you see that it’s more than going back to the way it was. It’s an equalizer. It’s straight-up social justice work.”

Birth wasn’t always like this—the hospitals and waiting rooms and the cold impartiality of bureaucratic healthcare. Throughout much of history, the birth of a child has been a collective event, a time for women in the community to gather and prepare for a new life to be brought into the world. From Ancient Greece to medieval Europe and beyond, a baby was born in the confines of the home, either with the assistance of a midwife, town doctor or a group of women.

This part sometimes makes people twitch, because it feels so archaic. But what about modern medicine? We cringe just thinking of the women who died in childbirth before the advent of hospitals, the full-throttle pain of laboring and fading away while their families watched helplessly.

It’s undeniable that hospitals have, on a whole, improved birth outcomes drastically. In certain U.S. metropolitan areas, nearly one-third of babies born in 1900 died before reaching their first birthdays. Mothers died in droves, falling victim to hemorrhaging and eclampsia and puerperal fever from dirty hands.

But in just 10 years—from 1938 to 1948, as hospital births went up from 55 percent to 90 percent—maternal mortality rates decreased by 71 percent. Today, the average American woman can feel reasonably assured about her own safety and the safety of her baby. Infant mortality rates are at around 5.9 deaths per 1,000 live births. The maternal mortality rate is at 28 deaths per 100,000 births, a number that is higher than it’s been in recent years but still a vast improvement in comparison to the beginning of the 20th century.

Yet the numbers start to seem less confident when broken down by demographic.

Here’s a laundry list of statistics: According to the Centers for Disease Control and Prevention (CDC), non-Hispanic black babies have an infant mortality rate that’s nearly two times higher than average at 11.1 deaths per 1,000 live births. Hispanic infant mortality rates hover around the average U.S. rate, but the figure is growing and has increased 11 percent since 2005.

A low birth weight sets a child up for a slurry of health and behavioral problems down the road, including higher high school dropout rates, decreased wages and accelerated aging.

Perhaps most shockingly, black women die in childbirth at a rate of around three to four times higher than their white counterparts.

The problem is pervasive in Chicago, seeping into different neighborhoods in different ways. Chicago has an average low birth weight rate of 10.1 percent citywide. In Hispanic and black communities on the South and West Sides, that number soars to nearly 20 percent. A low birth weight sets a child up for a slurry of health and behavioral problems down the road, including higher high school dropout rates, decreased wages and accelerated aging. And although there’s little data on infant mortality rates in the city, the state of Illinois has a black infant mortality rate of nearly 12 per 1,000 births, placing it in lockstep with problem-stricken countries like Libya and Venezuela.   

All this is happening in the shadow of Chicago’s state-of-the-art medical centers, where families in need could theoretically receive some of the best care in the country. Resolving the disparity isn’t about finding the right hospital or developing new medical techniques—it’s a matter of getting those families access to the innovations we already have.

Whether because of financial reasons, educational gaps or even just the underlying racism pulsing throughout the healthcare system, black and brown communities continue to face vastly unequal birthing options and outcomes. And its tangible ramifications are harming women and babies throughout the city and the country.

This is where doula services and other forms of birth work come into the picture.

The concept of doula work has not yet made its way into mainstream American pregnancy culture. DONA International, the world’s first doula-certifying organization, launched only in 1992. Since then, it has trained 12,000 doulas worldwide, roughly 500 of whom currently operate in the U.S.

Unlike a midwife, a doula has no formal medical training—in most cases, just a weekend-long class, some required reading and a series of births she must attend before obtaining official certification. She does not even wear scrubs. Instead, she offers a three-pronged service of physical, emotional and educational support over the course of several prenatal appointments, the birth itself and a postpartum visit or two.

“Instead of being like, ‘If you can’t afford me, you don’t deserve me,’ you can be like, ‘I’m going to be a businesswoman and try to do the most that I can for myself.’”

This covers a lot of territory, ranging from breathing exercises to breastfeeding techniques to murmurs of encouragement during the most punishing throes of labor.

But doula work is not just a matter of maternal comfort. A 2016 study from the medical journal “Birth” found that women who received doula care had around a 22 percent lower rate of preterm birth, along with decreased likelihood of C-sections and higher newborn Apgar scores, which determine the healthiness of a baby at birth. Researchers estimate that trained doulas could save Medicaid and private insurers almost $1,000 a birth.

And yet, if you’ve heard of doula work at all, it’s likely been in the context of upper-middle-class culture. It’s a word that conjures images of candlelit home births, of flashy alternative medicine, of placentas packed into pills and tucked into a designer purse. These are the doulas for the affluent and white, people who can afford to think about birth in terms of experience rather than necessity. Isabel playfully calls them “chi-chi doulas.”  

The cost of private doula services ranges anywhere from $800 to $1,200—sometimes as high as $3,500 or more, depending on where you live. These numbers aren’t wholly unreasonable. Doula work spans the course of several months, from pregnancy to childbirth to postpartum visits. And during the last few months of a pregnancy, doulas are on call 24 hours a day, waiting for their clients to go into labor. For a family in the West Loop making an average of $98,000 a year, $1,200 might not even be a significant burden. For a family in Garfield Park making around $15,000 a year, accessibility dwindles.

Doulas of color maintain a tenuous balance between their need to make money and their desire to serve underprivileged communities. Many of the doulas at ChiBiWoCo offer a “sliding scale” method of payment, which allows families some flexibility in deciding what they can pay. Isabel hasn’t been officially certified yet, so her prices already start fairly low compared to the average private doula rates in Chicago, yet she still is willing to negotiate with families.

Right now she’s teaching a birthing class at a reduced rate for her “sister’s best friend’s sister,” who was excited to find out that Isabel offered doula services but couldn’t afford her price point.

“Instead of being like, ‘If you can’t afford me, you don’t deserve me,’ you can be like, ‘I’m going to be a businesswoman and try to do the most that I can for myself,’” Isabel says. “But I’m also going to balance that out with volunteer doula-ing for a family that really, really needs it and doesn’t have the means to pay me what I would expect a family that does have that money to be able to.”

Even then, having the money to pay for a doula may only be half the battle. For women who live in food deserts or crime-ridden areas of the city, survival takes precedence over pregnancy stretches, or which essential oils will make them the most relaxed during childbirth. They may not even know what a doula is, or how they could go about finding one.

“There really is a big access issue to not simply having a doula, per se, but to education around birth and just reproductive justice generally,” says Shanika Helaku, another founding member of ChiBiWoCo. “So just having access to quality healthcare that is respectful to people’s individual cultures and their individual needs and, really, their identities.”

Shanika has been a certified doula since 2016. Isabel describes her as “poetic”—she speaks with an artful passion, referring to her two-year-old son and unborn child as “starseeds.” She wears long, dangling glass earrings and makes all-natural soaps and other body products on the side, offering them to her clients as part of an herbalist birthing package.

“That helps people feel empowered to have a birth the way they want it—whether they want to use interventions or not.”

As a doula, her work focuses on people of color and queer communities, teaching birth classes about how they can advocate for themselves in a hospital setting—how to avoid stories like Isabel and the mother she took to the hospital.

“They can kind of come in prepped to know what their rights are, to have education about some basic offerings that they have at the hospital,” Shanika says. “So that they don’t have to get their information from someone who might have a coercive tactic around sharing [that information].”

Shanika teaches her clients to know what kind of paperwork they’ll be presented, the drugs they’ll be offered and the questions she’ll be asked. She’s not concerned about whether or not the women accept the hospital’s offerings—though she prefers the idea of a medication-free birth, she feels the decision should ultimately be left to the mother. Being informed can help women feel as though they are in control of the way their birth goes.

“That helps people feel empowered to have a birth the way they want it—whether they want to use interventions or not,” Shanika says. “But they feel empowered to have the choice.”

Both Shanika and Isabel are also passionate about the benefits of breastfeeding, which can sustain a baby exclusively for up to six months and supplement their diet for a year or more. Poor women and women of color are less likely to breastfeed their children than their whiter, wealthier counterparts—even though they stand to benefit from the most from the free source of food. Recently, ChiBiWoCo traveled to the Freedom Square encampment site to hand out a zine they made on the topic, which offered general lactation information alongside breastfeeding tips and tricks.

“Statistically, the people who need to be breastfeeding, or could benefit from breastfeeding, don’t even have support in doing something like this,” Shanika says. “We created that zine to provide some education and support, and also to get our name out so that people know you can always come to us for whatever it is that we need.”

(From left to right) Jeanine Valrie Logan, Isabel Gonzalez-Smith, Shanika Helaku, Jacoba Cruz-Rodríguez, Telika Howard (Photo courtesy of Shanika Helaku)

ChiBiWoCo isn’t the only organization mobilizing the birth justice movement in Chicago. Amy Catania, a doula based out of Humboldt Park, bristles at the idea of doulas being an exclusive, a for-profit industry catering to the wealthy, white and holistically inclined.

“It definitely represents a significant segment of who’s doing doula work,” she says. “But it’s not actually the majority of what’s happening in Chicago.”

Amy is the executive director of Chicago Volunteer Doulas, an organization aligned with the birth justice movement that offers free doula services to low-income women in the Chicagoland area. She and the rest of the board of directors lead around 60 volunteers, who provide doula services to around 125 families a year.

They don’t have an office, and they operate on a budget of around $70,000 a year. That’s up from $45,000 last year, thanks to the inclusion of yearly in-kind donations.

“We’re tiny, I have to say,” she says, laughing. “We come across as being bigger and flashier than we are.”

“I ask them if there’s anything they would like, or if they have any expectations and that kind of thing. But for the most part, they don’t have expectations, which is also really cool.”

Jane Bradley, a senior studying health sciences at DePaul, volunteers as a doula at CVD on the weekends. Like the rest of CVD’s on-call volunteers, she signs up for 12-hour shifts—either 7 a.m. to 7 p.m. or vice versa—and dutifully waits to see if she’ll get a call from a midwife. Around one out of every four shifts, she’ll get called in to one of seven hospitals around Chicago.

“The first thing I really do with people, if it’s appropriate, is explain who I am and what I’m there to do,” Jane says. “I ask them if there’s anything they would like, or if they have any expectations and that kind of thing. But for the most part, they don’t have expectations, which is also really cool.”

Amy, who is a mother of three, has roots in Chicago—she was born and raised in the city’s Near South Side in a family of seven girls. Growing up, she says she was always encouraged to speak up for herself and what she believed in. Her career in social justice began when she was just 9 years old, marching and fundraising for handgun control. Later, she worked in anti-domestic violence and sexual violence organizations. This work has affected her life across all spectrums, particularly in regards to her doula work. CVD, for instance, runs a four-hour intercultural communication workshops that focuses on birth in connection to power and privilege. Participation is mandatory.

“Not everybody approaches being a doula as a movement,” she says. “Some people think of it as an industry, which is a relatively recent development. For me, I couldn’t have thought of it any other way.”

Other programs simply incorporate doula services into their broader work in Chicago communities.

Kirbi Range is the director of Project Hope, a program operating out of the Marillac Social Center in East Garfield Park, which specializes in assisting teen mothers. Alongside prenatal and parenting classes, the young women in the program receive doula service from their seventh month of pregnancy onward.

“I think with children and families going through so much these days, they need to have quality services and resources to help them kind of just navigate through daily things,” Kirbi says. “And challenges that they might be going through, whether it’s getting food on the table, or paying for their bills, or finding housing, or learning how to be a mother at a young age. If we don’t have these things for them, it just kind of sets them up for failure.”

“This child could fall into the gaps, so it’s like a village mentality—a community mentality.”

Kirbi’s background is in child development with a specialty in infancy, and she’s worked for several nonprofits over the course of her career. She stresses the importance of the “birth-to-5 demographic,” which researchers say fundamentally affects human cognition, behavior and learning outcomes. Making sure that these children receive health care and quality parental care from this age onwards is key to setting them up for a viable future.

“We want to ensure that we’re starting as early as possible to make sure that they’re getting everything they need to succeed in life,” she says.

Because of the need for early life care, birth justice means that doulas are invested not just in birth, but in the overall development of the child. Their work doesn’t stop once the baby is out of the womb—birth is only the beginning.

“Doulas sometimes are for life,” Shanika says. “We kind of keep track with parents and babies even after birth, because we are invested in the family. We are invested in the longevity of this new life.”

If one doula can’t make it to a new mom’s house, no problem—another can volunteer to pop by and check in on her, see how the breastfeeding process is going. If a new mom is feeling lonely and scared, a doula can come bring her a home-cooked meal or find someone to mind the baby for a while.

“This child could fall into the gaps, so it’s like a village mentality—a community mentality,” Shanika says. “As many people that can wrap our arms around them as possible—let’s do that. And that’s one of the beautiful things I’ve found about doulas, period.”

Last week, Isabel gave birth to her second baby. Shanika will follow soon after in May. For a while, they will retreat from birth work and into their own private spaces with their babies—take some time to revel in the joy of having created new life.

But soon, the desire to resume their efforts will begin, the fluttering anxiousness of knowing there is still work to be done. It calls them to action. Isabel says the call runs in her blood.

“It makes me feel like everything that I do, there’s a reason and purpose for it,” Isabel says. “If something were to happen to me and I’m no longer around for my son, then other people can tell my kid what I stood for. And he can keep doing that, too.”

Header image courtesy of Nick Anderson. 

Correction: An earlier version of this article did not list the full last names of Jacoba Cruz-Rodríguez and Jeanine Valrie Logan.

An earlier version also stated that Chicago Volunteer Doulas’ budget had increased as a result of a donation button, which was incorrect. The budget increased as a result of in-kind donations.