Shannon Kopelva, who is a citizen of the Ft. McDermitt Paiute-Shosone, Hualapai, and Hopi Nations from Moenkopi, Arizona, has always sought out medical providers of color. When she learned she was pregnant with her first child, she reached out to Hummingbird Indigenous Family Services, which provides expecting mothers with childbirth education, advocacy during labor and delivery, and postpartum care. Kopelva liked that Hummingbird doulas meet with their clients weekly during their pregnancies (as opposed to prenatal doctor visits which are typically monthly up to 28 weeks), and she also wanted to bring her child into the world with a sense of his Indigenous identity.
In late April, Kopelva was 38 weeks pregnant when her Hummingbird doula, T’leeuh Antone (they/them, a citizen of the Akimel O’odham Nation of Arizona), pulled up to her house in downtown Seattle for their weekly visit. Antone brought muslin wraps and a brown baby doll to practice swaddling. Also in their car trunk was a cradleboard, or a traditional protective baby carrier and sleeper, and materials to make medicine bundles of cedar herbs for the birth.
Seated around Kopelva’s kitchen table, Antone went over the birth plan Kopelva and her husband, Andy, could expect at the scheduled Cesarean section at a nearby hospital for her breech baby the following week. She was still hoping the baby would flip so she could deliver naturally; Antone taught her some positions that could help move breech babies in utero.
Kopelva’s birth plan included filling the operating room with Hopi music, traditional storytelling, and medicinal massage oils. “That’s what I need to capture: the smell of rain in Tucson,” she said, as busy hands wrapped herbs into small bundles to bring to the hospital.
“When the setting isn’t home, we’re trying every sensory way to bring culture into the space,” Antone explained. “A lot of this work is things that I would do for my family.” When their mother gave birth to their younger brother two decades ago, a nine-year-old Antone stayed by their mother’s bedside through the birth. “It’s all things that we intuitively did in our culture. So it feels very natural and loving to be able to be a support [in] reclaiming birth practices, parenting practices, and community.”
From Kopelva’s perspective, she likes that she doesn’t have to explain herself to Antone, and that they both share a “reverence for the desert.” “It’s really important and really great that it can be someone who understands where you come from and understands the customs,” she said. “Bringing back our traditions is something that is much needed in order to be healthy and full individuals.”
Indigenous doulas aren’t just healing—they can be life-saving for Native women who are falling through the cracks of the U.S. health care system. Women in the U.S. suffer the highest rate of maternal deaths—defined as death during pregnancy or up to a year afterward—among the world’s high-income countries. In 2021, the average maternal mortality rate of all high-income countries was 17 deaths per 100,000 live births, but in the U.S., that number was 31. While, globally, maternal mortality rates continue to improve, the U.S. is headed in the opposite direction: From 1999 to 2019, maternal mortality rates in this country have doubled. Rates have spiked dramatically in the past five consecutive years, according to federal Centers for Disease Control data.
Black and Indigenous communities bear the brunt of those maternal deaths: Native American and Alaska Native women in the United States are three times more likely to die during childbirth than white women. It’s even worse in Washington state, which is home to 29 federally recognized tribes. A report published in early 2023 by the Washington State health department shows Native mothers die eight and a half times more often than white mothers during pregnancy or within a year after, which is more than any other race. And perhaps most surprising: that risk is equally shared among Indigenous women, regardless of income, education, or geographical location. For white Americans, the richer and more educated you are, the less likely you are to die in childbirth, research shows. But, the CDC notes, the same isn’t true for Native women.
“Often what we’re told as Native women is: we’re unhealthy. We’re too addicted, too fat, too chronically ill, too poor,” said Hummingbird founder Camie Goldhammer, a Sisseton-Wahpeton tribal citizen. “What that does is put the onus on the people who are dying. I really believe that moms and babies dying is the failure of our health care system.”
More than 80 percent of all maternal deaths, the report found, were preventable. Because the problem is deeply rooted in systemic inequity in the U.S., the solution is coming from the inside: In order to save Native mothers’ lives, Native mothers and aunties are taking on the cause themselves, by providing free physical, emotional, educational, and spiritual support to Indigenous mothers and their families before, during, and after their baby is born. Since 2019, Goldhammer has built a team of five Indigenous doulas, who have provided culture-specific help to more than 150 Native pregnant women and their babies in the first thousand days of their baby’s life. Their maternal and infant mortality rate is zero.
The word “doula” is a Western name for what Indigenous people have always done—care for their mothers. Goldhammer and her team use the term doula interchangeably with “Indigenous birth keeper,” and she explains her profession as “fulfilling the traditional role of an auntie,” by drawing upon Indigenous knowledge and experience to care for birthing mothers and, eventually, their babies. “We became doulas because we were sisters and aunties and cousins who would attend the births of our sisters and aunties and cousins,” Goldhammer said. “As you do more of those, you learn more, like, oh when the baby was breech, auntie did this for her.’”
Doulas are non-clinical, trained health care workers who support pregnant women before, during, and after pregnancy. While many women don’t meet their delivery doctor until they’re delivering, doulas build trusted relationships with their clients, and provide continuous care through the entire pregnancy, birth, and the postpartum experience. They have the specialized knowledge and experience to help facilitate conversations between their client and provider, and often help advocate for their client. Doulas help their clients write a birth plan, educate them on labor positions, and are often present as an advocate during birth. Unlike midwives—which is a title that requires a graduate degree in midwifery from a program accredited by the Accreditation Commission for Midwifery Education and means they can deliver babies themselves—there is no state-level legislation requiring certification for doulas, though there are national certifying boards.
Traditional birthing practices, including home births and Indigenous midwifery, were outlawed in the early 1900s by the federal government through a series of laws, licensing restrictions, and since-debunked medical research campaigning against the profession. By the 1920s, the Department of Indian Affairs passed legislation that moved births from the home to the hospital. It would be another half century until the profession saw a resurgence: Today, Indigenous midwifery is once again practiced in Indigenous communities and birth centers across the United States, Mexico, Canada, and New Zealand.
Indigenous birth keepers fill the gaps Native women are falling through in the Western health care system, in both the type of care they provide and when they provide it. Increasingly, medical research is recognizing doula care—and particularly community-based doula care, provided by doulas that identify as part of the community they serve—as a cost-saving measure that improves birth outcomes and reduces racial disparities.
Doula-assisted mothers are four times less likely to have a low-birth-weight baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding, according to a landmark 2013 study published in the Journal of Perinatal Education that has since been built upon (including research that shows doula care results in substantial cost savings by reducing the need for medical interventions including cesareans, instrument-assisted births, and pain medication, and that doulas spend six to 11 times as much time supporting their pregnant clients compared to their health care providers.) When specifically looked at in the community-based doula model, those improved birth outcomes were especially true.
“Health care systems that serve communities of color through a one-dimensional approach in birth continue to contribute to preventable death, complications, and illness,” a 2019 study on advancing birth justice through community-based doulas writes. “Community-led doula models reframe the current health care model by advancing policy and engagement that reflects improving the quality of medical care, cultural humility, and implicit bias awareness for providers and caregivers.”
The effectiveness of doulas is so convincing that numerous states—including, this year, Washington, after urging from Indigenous advocates—have passed bills to expand Medicaid coverage to include doula care. As of 2022, more than half of all states are either providing such coverage, in the process of implementing it, or taking some related action to expand access to doulas statewide, according to the National Health Law Program’s Doula Medicaid Project.
Alana Harris, 28, wanted her son’s first scent out of the womb to be of sweetgrass. So for his birth in early July 2023 at a hospital in Seattle, Harris, an Ojibwe tribal descendant from Chicago, tied a braid of the Indigenous sacred plant—“a soft scent that makes you feel like home”—around her neck, and stuck another in the bassinet that would hold him. Then, she prepared to give birth.
Harris, who moved to Seattle at the end of 2020 from Chicago, had an easy pregnancy. Her blood pressure never spiked, she made every prenatal appointment, and she was vigilant about monitoring for the gestational diabetes her mother suffered from when she was in utero. She enrolled in an Indigenous doula program, and had weekly visits from a doula named Kristin Lightfeather, a citizen of the Comanche and Ojibwe Nations, who helped guide her through what to expect in her birth. “I had a go-to plan or thought process, which helped with anxiety big time,” Harris said, four weeks postpartum. “All signs pointed to: everything should have been fine.” Which is why it was so shocking when it wasn’t.
Harris went into the hospital on a Friday night for an induction at 42 weeks, per her doctor’s recommendation. Her plan was to deliver vaginally, pending any emergency or risk to the baby. Throughout that Saturday, she began what would be the next 48 hours of dilation and pushing, with doctors periodically coming in to check on her. Lightfeather and Harris’ husband alternated massaging her pressure points to relieve the pain and help the baby drop for delivery.
It gave Harris confidence to know there was a professional there who she could turn to and be heard, and who already knew her wishes for her birth. “Not a lot of vocalization needed to happen,” Harris said afterwards. “I just looked at [Lightfeather] and she was like ‘yup, you’re in pain’ and started certain alleviation methods.”
On Saturday evening, a care team of nurses prescribed Harris Pitocin, a drug used to accelerate labor, after her dilation stalled at five centimeters. Lightfeather realized things weren’t going according to plan when she overheard the number 30. She knows Pitocin levels typically don’t exceed 20 units in a normal delivery because higher levels can cause fluid retention and even uterine rupture from hyperstimulation. “So I spoke up,” Lightfeather said. Advocacy in clinical settings is a critical aspect of her job as an Indigenous doula. “I was like, ‘Oh, wow. That’s really high. It’s supposed to be no higher than 20, correct?’ And the nurse kind of just turned around and walked over towards her computer, hollering over her shoulder towards me, saying ‘We can actually technically go to 40.’”
Although Pitocin levels in inducing birth can technically reach 40 units, they rarely do, to avoid the negative impacts they can have on a birthing woman’s body, said Goldhammer. Between her and the Hummingbird Birth Keeper Program Manager, Vanessa Lovejoy-Guron, who have attended a combined several hundred births, they have never seen Pitocin levels go above 25 units.
At every other birth she’s been to in her four years as an Indigenous birth keeper, Lightfeather says she has worked in partnership with a clinical team to care for their shared client. But at Harris’ birth, she felt dismissed by the team of nurses and the doctor who came in every few hours to check on Harris’ progress.
Harris had dilated to nine centimeters when her organs seized up from the Pitocin, and she stopped urinating completely. Her legs filled with fluid. She began to feel a sharp pain in her right kidney despite the numbing effects of her epidural anesthetic, and when she told the nurse, she was only offered a pillow to put under her. She developed pre-eclampsia, a hypertension condition that can be caused by Pitocin.
Harris’ baby boy weighed 12.5 pounds, and was delivered by emergency C-section on Sunday night, on her third day in the hospital. Harris lost two liters of blood during the delivery, which is double the average for cesarean deliveries, according to the National Library of Medicine. Postpartum hemorrhaging, one of the leading causes of maternal deaths in Native women, can be brought on by prolonged Pitocin or high levels of Pitocin, according to the American Journal of Obstetrics & Gynecology.
“There were so many points that [the nurses] should have gone and got a doctor, but the nurses were just like, ‘Oh the textbook says…’” Harris told me, four weeks postpartum. “They just felt like it was all so routine. And it’s like, people still die during childbirth. There’s no routine to this.”
Although Harris and her son, Makoniibin, which means “summer bear” in Ojibwe, are both healthy and recovering, her doula classifies the birth as a “near miss,” meaning it was nearly fatal, a reality that the new mom is only just beginning to process. “In the beginning, it was the feeling of: ‘I’m good. I’m okay. My baby is here,’” Lightfeather said of her client. Co-processing the birth has been a large part of Lightfeather’s job in the months since the delivery. “Then it went to the realm of: ‘why? How come it happened this way?’ And then it was: ‘what if? What if this didn’t happen?’ We had to do a lot of reflection together towards emotional healing.”
When it comes to Indigenous maternal mortality, according to Goldhammer, doulas can play an equally life-saving role in after-birth care. The largest portion of maternal deaths don’t happen during delivery, but afterwards: 60 percent occur within a year after the birth, CDC data shows. Among pregnancy-related deaths for which an underlying cause was identified, the most common were behavioral health conditions (suicide and overdose), which contributed to close to 20 percent of deaths. The fact that suicide and overdose surpass hemorrhaging, cardiac and coronary conditions, and infection as causes of maternal death points to a very specific kind of postpartum support that most women aren’t receiving—except for Indigenous women receiving doula care.
Camie Goldhammer, whose shield of hair swings over her shoulder when she picks up her client’s teetering two-year-old, is an activist by all standards. Before she started Hummingbird Indigenous Family Services, she served as an Indigenous social worker who specialized in the effects of intergenerational trauma on attachment, bonding, and parenting practices in the Native community. She has been a fierce advocate for breastfeeding as food sovereignty for nearly two decades, and ran an informal lactation group out of her Seattle living room for seven years before COVID hit. Goldhammer also travels across Indian country for her second business as an Indigenous lactation consultant, where she and her colleague, Kimberly Moore-Salas (Diné), train Native people as breastfeeding peer counselors, or “Indigi-LCs.” To date, they have trained over 550.
Most Native women she encountered, Goldhammer said, were disturbed by their birthing experiences. From Alaska to South Dakota and beyond, she said, “almost everyone is traumatized from their birth. That is: you didn’t die, but you were fucked up. You leave your birth broken. How does that impact your ability to freely love and attach to your child?”
Traditionally, Goldhammer says, Indigenous parents’ role was solely to love and attach to their child; it was the community’s job to help parent them. That’s the practice she’s reviving within Hummingbird’s framework, and one that she hopes will bring about intergenerational healing. “That is the essence of reproductive justice,” she said. “It’s not just the right to have a baby if you want to or not have a baby if you want to, but it’s also about the right to parent your baby in a safe and supportive environment.”
In July, Hummingbird launched a guaranteed basic income program to help reduce the burden of stress on Native families and improve health outcomes. Over the next five years, they will give up to 150 Indigenous pregnant women no-strings-attached payments of $1,250 a month, until their child’s third birthday.
Most obstetricians and primary care doctors don’t see new mothers and babies for follow-ups until 42 days after birth, which aligns exactly with the timeframe outlined in the Washington maternal health report, stating that 30 percent of mothers are dying.
Shanda Spencer, a citizen of the Navajo Nation of Arizona, is a mother of three. After she gave birth to her third baby in April, her typical spitfire personality was replaced by something more sinister. She felt depressed—like her life was over—and overwhelmed with responsibility to her children, her boyfriend, and her home.
“I felt helpless,” Spencer said, one month postpartum. “My baby’s crying, I had a C-section, I couldn’t move around too much. With my other two children crying, I felt like I didn’t have a breather.”
When T’leeuh Antone, Spencer’s doula, showed up two weeks after Spencer’s birth with her requested meal of BBQ ribs and spent a solid four hours with her, Spencer describes it as feeling like she could finally breathe and be herself again. In addition to adjusting to a newborn baby, Spencer said she was missing her Native community back home in Arizona. She felt that kind of community with Antone.
“It was a sense of relief,” Spencer said, her eyes flicking to Antone rocking her sleeping baby nearby. “It felt like: my people are here. I can do this.”
Jenna Kunze is a New York based journalist covering stories impacting Indigenous peoples across the US and Canada.