By Nada Hassanein, Stateline.org
“Don’t give me narcotics.”
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Emmalee Hortin, a doula, recalled one of her clients delivering that message to hospital staff. Doctors were operating on the woman to clear tissue after a miscarriage.
But despite her patient’s pleas, clinicians still administered fentanyl via IV to manage pain, Hortin said. Her client had substance use disorder and had been working toward recovery.
“She was really, really upset,” Hortin said. “She actually was really worried about returning to use, and so was her husband.”
Hortin is a doula trained in supporting pregnant and postpartum moms with substance use disorder — a role in increasing demand amid the nation’s concurrent crises of maternal mortality and addiction.
In recent years, more states, including Colorado and Utah, have passed laws to include Medicaid coverage for doula care. Some clinics are incorporating peer recovery doulas and other providers are offering training to bolster the workforce.
Many doulas who specialize in helping moms with substance use disorder are recovering from addiction themselves, or have helped loved ones with addiction. Hortin, a mother of three and stepmom to three others, is nine years into her recovery. Drawing on her own experience of isolation and addiction, she’s able to relate to struggling moms. She works at One Health, a Montana community health center that trains doulas from across the state in peer recovery.
In the case of the woman who asked not to be given fentanyl, Hortin recalled, hospital staff asked for her help to “defuse” her client’s emotions. “I was like, ‘Well, my job is not to defuse emotions, if you weren’t listening to my patient,’” she said. “When a patient in recovery, or that is working towards recovery, asks specifically for no fentanyl — that’s one of her triggers — you need to respect that.
“We had to do a lot of breakdown work and debriefing through the emotions,” Hortin said. “She felt like she couldn’t trust the hospital.”
Mental health conditions and substance use are leading underlying causes of maternal death, according to the federal Centers for Disease Control and Prevention.
Those conditions can arise, or worsen, during pregnancy. Without treatment, it can be an especially vulnerable time for people with addiction and those who are trying to get sober, said recovery doula Britt Westmoreland, program coordinator for the University of Colorado’s recovery coach doula program.
Founder of Eggbaby Doula Services Aleece Weaver, right, demonstrates the work she does with pregnant clients. Weaver does pro bono doula care with clients in recovery at Utah perinatal recovery clinic SUPeRAD. Peer recovery doulas help moms with addiction, and state Medicaid plans have been expanding to cover doula care. (Anna Shmynets/Anna Shmynets/TNS)
Peer recovery doulas can advocate for patients in labor settings as well as support them when they face stressors or crave illicit substances during pregnancy or postpartum. Being in recovery themselves also helps foster trust and more open communication.
“It’s a lot easier for us to build rapport with people because there’s not a power differential or that systemic mistrust,” said Westmoreland, who is in long-term recovery and, like Hortin, knows the stigma and difficulties firsthand.
Stigma and bias
Stigma and bias around substance use disorder, mental health conditions and pregnancy can cause shame that prevents moms from reaching out for help or opening up about their struggle, doulas and doctors say. Those issues are exacerbated for Black and Indigenous women, who are disproportionately drug tested in hospitals during labor and disproportionately likely to be investigated by child welfare agencies, research has shown.
Native women can feel they’re treated differently in hospitals, said Julianne Denny, who is Cree, Ojibway and Mikmaq. Denny refers to her role as an Indigenous “birth worker,” as she supports women through cultural practices as well as through doula care. She trained at One Health and earned an addiction studies degree at Stone Child College.
It’s her job “to remind [moms] of their humanity and that they can gain control over their addictions and they can keep their babies,” she said. “That’s the endgame — is that their baby is safe and they’re safe, and we want our moms to grow with our babies, and our babies to grow with our moms.
“A big part of our work is working through the tough parts with moms to get them through to a successful pregnancy where they’re proud of themselves and they feel empowered.”
Hortin helps recovering moms up to three years postpartum. Working with clinicians, she helps create a personalized care plan for each family.
Emmalee Hortin works with a client this month. (Emmalee Hortin/Emmalee Hortin/TNS)
“No matter what these parents are struggling or facing, that’s not all they are,” said Hortin. “When we keep people held to our stigma and our bias, why would they want to change when no one’s willing to trust that they can?”
Policies to expand coverage
One day last week, 34 pregnant and postpartum patients with substance use disorder were on the schedule at the University of Utah’s Substance Use & Pregnancy—Recovery, Addiction, and Dependence (SUPeRAD) Clinic, where Dr. Marcela Smid is the medical director.
This week, more than 50 patients are on the schedule in a three-day period. Smid said her clinic gets patients from rural areas in Wyoming, Idaho and eastern Nevada.
States are slowly expanding coverage for doulas. Utah passed a law last year to start the process toward Medicaid coverage of doula care. Federal officials approved Utah’s plan, effective April 1, to allow certified doulas to be reimbursed via Medicaid.
“Now that we will be able to be paid through Medicaid, a lot of doulas will be able to feel this work is sustainable for them,” said Aleece Weaver, founder of the Utah Doula Access Project. She currently does doula work pro bono with Smid’s clinic.
Smid said the majority of the clinic’s patients are on Medicaid, which is the largest payer for behavioral health care nationwide. Most of her patients can’t afford to pay for doula care out of pocket, and because the state policy hasn’t gone into effect yet, doulas care for her patients pro bono.
Lanita Hoskinson, a peer recovery doula at One Health in Montana, holds a newborn. (Lanita Hoskinson/Lanita Hoskinson/TNS)
Colorado also recently expanded its Medicaid coverage to include doulas, and Montana passed a law last year establishing doula licensures, a first step toward coverage.
Beyond coverage, access is also an issue — especially in rural communities where health care providers, including mental and maternal health clinicians, are scarce. Smid travels monthly to Wyoming, where most residents don’t have easy access to maternal-fetal medicine specialists, she said.
States included goals of expanding behavioral and maternal health care access in their bids for federal dollars under the new five-year Rural Health Transformation Program.
For example, in its application, Montana said it would use the money to train a variety of health care providers and community-based professionals, including peer support specialists, in maternal health and crisis intervention.
Mental health conditions contributed to about 70% of Montana’s maternal deaths between 2020 and 2022 — with substance use contributing to more than 40% of those women’s deaths.
“It’s really just providing support to people that are already feeling hopeless. It’s about giving them the tiniest bit of hope and walking through it,” said One Health recovery doula Lanita Hoskinson. “All these families, they need somebody, especially in these frontier rural areas — they have nobody.”
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.
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