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In debates about reproductive health, listen to Black women

Catholic doula Rebecca Christian on how her faith informs her work for reproductive justice.

On June 21, 2022, the U.S. Supreme Court reversed Roe v. Wade, declaring, in Justice Samuel Alito’s 78-page opinion, that the U.S. Constitution does not provide for any inherent right to privacy or personal autonomy. This decision, which removes constitutional protection of abortion, leaving the decision up to the states, has provoked protests across the nation and sparked heated debate between pro-choice and pro-life advocates.

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Rebecca Christian is a Catholic doula dedicated to improving maternal health care access, empowering women, and creating a truly life-affirming culture.

But on both sides of the debate, religious and secular media platforms tend to center the arguments and experiences of white, middle-class persons. Much public discourse ignores the complex realities that nonwhite women and low-income women face when making decisions about their bodies, reproduction, and family life.

For Rebecca Christian, a Black doula in California, the pro-life versus pro-choice binary is unhelpful, especially for Black women facing unique challenges in reproductive health. For Christian, a better approach is to address the topic of abortion in terms of reproductive justice and health equity.

Christian also unapologetically identifies as a Catholic doula. On her website, Christian states that her faith guides her approach to her work, and her philosophy on treating birthing families and babies “with respect, awe, and reverence no matter who they are or where they are choosing to birth.”

Since she started working as a doula in 2016, Christian has served more than 150 families and supported women facing diverse outcomes. She works with families of all backgrounds and sexual orientations and is dedicated to improving maternal health care access, empowering women, and creating a truly life-affirming culture.

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Your website describes you as a Catholic doula. What does your faith bring to your work?

I’m a product of Jesuit education, and the Jesuits drill into you the importance of care for the person. This is how I approach life. I know that I would not have gotten this far doing this work without the grace of God. Birth work can be exhausting and emotionally taxing. Most doulas only last a year or two.

I named my business Fiat Doula Services because I love our Lady and want to honor her. I try to teach my clients the power of saying yes as a foundation for building their families.

Christian families do seek me out, but most of my clients are not religious. Over the years I’ve had people tell me they like that I’m open about my religion and values. This is especially true when I’m working with someone who has experienced loss. They know I’ll listen.

Could you expand on what you do as a doula, for those unfamiliar with the work?

Doulas are perinatal health professionals. Different doulas assist with different things: pregnancy, birth, postpartum, loss, abortion. We’re not medical clinicians, but we work alongside them. I’m a birth and postpartum doula and a lactation counselor. I also do a little sleep consulting.

What I do for a family depends on their needs. Family A might have lactation or sleep issues. Family B might be hoping for a peaceful birth after a traumatic one. Family C might be transitioning out of the NICU after a premature birth.

My clientele varies greatly in terms of socioeconomics, race, and family dynamics, but the basics of care are universal. When a parent goes home from the hospital and wonders, “Now what?” I can show them options. Practically speaking, a doula is a pastor, therapist, social worker, and health professional all in one.

How do doulas and other birth workers counter inequalities in health access, especially among communities of color and/or low-income communities?

Having a doula is basically a life hack. We can deliver individualized care because we get to know families personally. If someone tells me they want an unmedicated vaginal birth after a cesarean section, and I know they’re going to a hospital where that isn’t likely, I can help them try to get in somewhere else. Several times, I’ve directed a client to the emergency room because they did not realize they were experiencing a medical emergency. I reduce trauma before it starts.

It’s common for a family to see multiple providers during pregnancy, so I might be the only familiar face providing continuous care. A low-income woman might not even have a primary care provider. Postpartum, the average patient doesn’t see a medical professional until her six-week checkup. Doulas fill in that gap. And every doula I know provides a sliding scale or does pro bono work.

What unique challenges do Black women and their families face when having a baby?

Having a Black baby in America, especially now, is unlike any other experience. Non-Black families don’t have to deal with going on Instagram to look at a baby page and seeing an onslaught of articles about medical racism or videos of police murdering their own people. The United States has the highest maternal mortality rate in the developed world, and it is even higher among Black women. In some places it’s three times the rate of death among white women, or even six times as high in some Southern states.

Black women have all heard that they might die in labor or be treated unfairly, which are real, terrifying issues to consider when you’re pregnant, especially for the first time. So, when I work with Black families, I talk about the normal stuff but also about how their providers treat them, whether they’re comfortable with their birthing location, and what this birth means to them and their families.

A lot of my Black clients are only one or two generations removed from Jim Crow and a segregated hospital system—and segregation was about more than water fountains. Many Black people couldn’t access care or were even experimented on. This might be the first time a mother in their family has been free from violence and able to be intentional about having a baby.

What are common misconceptions you encounter in your work?

Sex education and body literacy vary dramatically, so some people may be dealing with a lot of completely incorrect assumptions. Some have heard horror stories from family members or friends. And even well-meaning providers can spread medical disinformation.

A couple of years ago an upset client called me because she was planning a home birth and her obstetrician told her, “Well, that’s not a good idea because Black women die at a higher rate of postpartum hemorrhage.”

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That’s technically correct. We do die at a higher rate, but not because we bleed more. It’s because we’re more likely to be in hospitals where people are unaware of medical racism and less likely to listen to us. We are more likely to be in hospitals that have not retrained their staff around something called “active management of the third stage,” which is the primary way to reduce postpartum hemorrhage at any birth—at home, a birth center, or a hospital.

The OB wasn’t trying to scare my client, but not understanding how to explain those things creates fear. It also does nothing to correct the problem, which has been researched and has evidence-based solutions, if only we would implement them.

Maternal mortality relates to any pregnancy-related death, including during birth and postpartum. Around 60 percent of these deaths are preventable.

How can our society start to fix some of these problems?

Families need access to birthing options. In America, obstetric care is the primary model. Around the world, midwifery, which is associated with lower mortality rates for low-risk pregnancies, is standard. That’s one reason we’re trying to increase the number of midwives, which is embarrassingly low in the United States. Having access to a doula helps. Having access to a clinician, preferably the same clinician and the same birth team, also dramatically reduces maternal and infant mortality.

We need to reimagine our care systems. Clinicians and health care professionals need to drop their egos and work together. In other countries, midwives and obstetrician-gynecologists work collaboratively, and their work is covered by insurance. These countries have significantly lower mortality rates than ours does. We needed universal health care and paid family leave decades ago.

Is having a doula accessible to everyone?

Not entirely. I provide sliding scale services, but my standard birth fee is in the thousands, which is the market rate for someone with my experience level in my city. Since this is my full-time job, I have to take some clients at the full rate to subsidize the sliding scale clients. In one month, I might have three to five clients, but I can only afford one or two of them to be at a sliding scale.

There are volunteer doula programs, but if you’re volunteering and have a regular nine-to-five job and a family, you can’t take five clients a month. Many doulas do pro bono work and extra things they aren’t compensated for. I have a lending library of items like baby carriers and breastfeeding pillows because those can get expensive. I’ve had clients offer to pay for other families’ care. But it shouldn’t have to be like that.

Doula organizations have been pushing for insurance companies to cover our services. A new law in California will allocate some Medicaid funds for doula work. Similar laws have passed in other states, but the compensation often isn’t close to market rate.

One difficulty of doing this work is that it can be hard financially. I have a corporate background, which is helpful in building my business. But I also don’t have kids to feed.

It’s a hard time for parents and families right now, especially lower-income ones. Do you have any practical advice for how communities can support new families?

The best people to lead a community are the people from that community. We need to ask people what they want and need, and we shouldn’t be means testing or making people feel guilty. I’ve seen some crisis pregnancy centers do things such as give a parent diapers and formula but only if they sit through a class that may not be evidence-based.

Just give people what they need. If I see someone lying on the street not breathing, I’m not going to ask them for their baptismal certificate before I deliver CPR.

I would like to see more Catholic organizations, especially hospitals, implement wraparound services such as doula programs, mental health care, and perinatal palliative care. I want to see support for medical education and professionals. And we need to evaluate our politics. It’s OK to change your mind based on new information. That critical thinking mixed with a little guilt is a good thing. It’s what got me where I am today.

How will the overturn of Roe v. Wade impact Black women?

My first thought when I heard the news was: This is going to make everything worse. The situation for women in this country is already bad. People don’t like to hear this, but abortion care is health care. There’s no difference between the treatments someone receives when they have a miscarriage and those they receive when they have an abortion. Professionals in reproductive health care will affirm that efforts to criminalize elective abortion inevitably affect all women. Even under Roe women were arrested for miscarriage. Pharmacies already denied patients drugs like misoprostol, which can be used for abortion but also for postpartum hemorrhage.

An assault on one reproductive right is an assault on them all, and that’s why many birth workers advocate for reproductive justice. The states with draconian abortion laws also restrict midwifery care and have disgustingly high maternal and infant mortality rates as a result. These aren’t coincidences. A state that restricts bodily autonomy in one area is going to do so in others as well.

The logical conclusion of ending Roe is not that abortion instantly goes away, but that a uterus becomes a potential crime scene. Every pregnancy will be subject to scrutiny. In some states, a judge might even order an unwanted C-section, something that already happened under Roe, albeit rarely. I keep asking people: How exactly is this going to work? Birth is a physiological, hormonal process. If the hormones that start labor don’t flow naturally, we have to augment them. In some states, we’ll have to strap people down, start their IVs with oxytocin, and force them to give birth. If we did this in any other area, it would be assault.

When a uterus becomes a potential crime scene, Black and brown women are disproportionately impacted. The U.S. justice system isn’t fair. The health care system isn’t fair. For Black women, not being able to make decisions about pregnancy without fear and coercion is going to exacerbate our problems.

Let’s say it’s post-Roe and a Black woman is seeking an abortion. She lives in a state with trigger laws, or bounty hunter laws, so if she tells a health care provider she will be denied or even reported to the government. If it’s still early, she might order abortion pills through the mail—a practice that is problematic for many reasons. Sure, she might have access to telehealth or a primary care provider. But lots of people don’t. So, what happens in an emergency? If she’s in a state where abortion carries penalties, does she “self-manage” at home? What if she already has kids? Will this trigger a child protective services investigation? She’ll likely get a visit from a case worker and intrusive questions from nurses. I’ve seen this happen to Black and brown families, and I live in “liberal California.”

Let’s say she can’t access abortion care. Is this supposed to magically transform her into wanting her baby? Will it magically transform her circumstances? Her pregnancy might continue, but is she supposed to trust her providers, knowing medical racism puts her life at risk?

There has been talk lately about how Catholic media often centers the voices of white, middle-class persons when discussing abortion and pro-life advocacy. What stories and perspectives are we missing?

I’d like Catholic media to step away from 1980s culture war rhetoric, find more balanced perspectives, and reinforce actual Catholic teaching. I grew up hearing that Catholics are not antiscience, but it doesn’t seem like it right now. Many conversations around pregnancy and abortion lack any understanding of health care, or how laws are applied to anyone who isn’t white or middle-class.

I’d like to see engagement with culturally competent medical professionals, racial justice activists, and birth workers of color. They have a much deeper understanding of reproductive rights—namely, that what frees Black women frees us all. Solutions that decrease the maternal mortality rate for Black women improve the general maternal mortality rate.

It’s also vital to correct misinformation. I did a panel recently for FemCatholic where someone said, “I thought abortion was never medically necessary because you could just remove the baby.” And I had to say, “Sorry, but you’ve been lied to.” The American College of Obstetricians and Gynecologists (ACOG), the governing body of obstetric care in the United States, just released a FAQ sheet about all of this that any person who considers themself to be pro-life needs to read.

There are many reasons why someone might seek abortion care even for a wanted pregnancy. A couple of years ago, I knew someone who had a fatal fetal diagnosis. The plan was to watch and wait, but she started hemorrhaging and went to the ER. A heartbeat could be detected, so the hospital didn’t want to perform an abortion. She could have died. Seconds matter in situations like this. This was a secular hospital too. These things happen everywhere, even under Roe, due in part to viability laws.

I’ve noticed the “love them both” rhetoric seems to have died down. It’s difficult to “love them both” when your knowledge of women’s health care is so limited. Catholics revere motherhood, and for a good reason. But pregnancy is a health condition, a potentially dangerous one, especially if you’re poor.

I went to Catholic schools my entire life, including for university. I went to marches and used to counsel outside abortion clinics. Becoming a doula and seeing real-life situations shattered my worldview. I haven’t changed what I think about church teaching on human dignity. I have changed what I think about politics and praxis.

Could you expand on that a little bit?

First, I reject the pro-life/pro-choice dichotomy, which is unhelpful. Reproductive justice provides a better framework.

Reproductive justice is a Black feminist framework combining social justice with reproductive rights. Reproductive justice says that we have the right to bodily sovereignty, but also to live our lives and parent our children in safe and sustainable communities. We have the right to access service and care. Reproductive justice organizations partner with other organizations focused on birth justice, environmental justice, and racial justice because they understand that these issues intersect.

If I see another, “Now that Roe is overturned, the real work begins!” article from pro-lifers, I’m going to have an aneurysm. The movement that elected Trump, that elected the officials who are passing bounty hunter abortion laws, is not concerned about the “real work.” The work has always existed: White Catholics just ignored it. Black and Indigenous women and other impoverished communities have always fought for a better life for themselves and their children. It’s reproductive justice activists, not the Knights of Columbus, exposing sterilization of women of color and fighting for housing and clean water. These are what people need to live healthy lives and raise healthy families—not just one “save” outside a clinic.

I’ve been told my entire life that we must be disciples of Jesus Christ and build the kingdom of God on Earth. What have we built? What are we offering in a world where people are barely surviving?

Having a baby in her life has a dramatic impact on a woman’s mental, social, and economic well-being. Unwanted pregnancy is a contributing factor to postpartum mental illness and child abuse. These are facts. Misogyny, patriarchy, and bourgeois Christian culture have produced our abortion statistics just as much as Roe has.

To cultivate a culture where any of this is possible under the guise of being pro-life is atrocious. It’s especially an injustice to Black people, who have lived under reproductive coercion from the second we were brought to this country. I’m not arguing in favor of abortion. I’m trying to protect women who already face 20 different intersecting issues that most of your readers are probably unaware of. And when we talk about Black maternal mortality, we’re looking at all Black people, regardless of socioeconomic status. Serena Williams had to advocate to save her own life.

Media perspectives need to engage the real-world conclusions of overturning Roe and realize when they lack the expertise to speak with authority on the issue. People have abortions for many reasons. People support legalized abortion for many reasons. Many of those people are deeply religious.

I understand why pro-lifers want to save babies—because so do I. But babies don’t come out of primordial ooze. I was born into a Black family. There are intersecting issues involving generational traumas that most pro-lifers are unaware of. I agree with pro-life ethics and try to apply them, but many pro-life activists do not live in the real world.

I also get agitated with pro-choicers who don’t understand reproductive justice. Their views veer into ableism and eugenics. Some of the best comments I’ve seen on reproductive justice are from Black disability rights activists who are reproductive justice advocates. These are the people we need to talk to and build bridges with.


Header image: Unsplash/Tembinkosi Sikupela

Portrait: Courtesy of Rebecca Christian