The role of doulas in respectful care for communities of color and Medicaid recipients

Caring for Women of Color: Community-Based Doulas' Strategies in Hospital Birth in Los Angeles

In the United States, women of color experience worse pregnancy and birth outcomes than white women. Likewise, many women of color report facing discrimination from perinatal health providers, and many experience precarity that can negatively impact birth experiences and outcomes. In this context, more women of color now embrace the use of community-based doulas. Using ethnographic data, I argue that community-based doulas, as members of the communities in which they offer their services, are uniquely able to negotiate the tensions between their clients and biomedical birth practitioners to engender acts of transformative agency and forward the cause of reproductive justice.

Implementation Barriers to Incorporating a Community-Based Doula Program to Improve Birth Outcomes for Black Patients in an Academic Medical Center

There are significant racial disparities in maternal health and birth outcomes in the USA that disproportionately affect Black individuals. Incorporating community-based doula programs into hospital settings may be an effective intervention to reduce these disparities. However, little research has examined potential barriers and identified strategies to optimize the implementation of a community-based doula program in an academic hospital setting. This study used in-depth interviews with clinicians and nurses (n = 19) and focus groups with doulas (n = 11) to identify multi-level barriers to implementing a doula program for Black pregnant patients in a single academic hospital setting in Milwaukee, WI. Data were analyzed using thematic analysis, and we developed four themes that highlight potential implementation barriers: (1) doulas' advocacy efforts were met with resistance from the healthcare team; (2) there was a lack of trust and established relationships between doulas, clinicians, and nurses; (3) there was a hierarchy of knowledge within medical settings that diminished the value of doulas' expertise; and (4) system-level barriers prevented sustained integration of doula programs. Despite the promise of community-based doula programs, significant investment and resources are needed to support implementation and ensure sustainability.

The role of nurses, midwives, and doulas on breastfeeding: changes during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has significantly altered maternal healthcare delivery, including breastfeeding practices. Our study investigated the influence of nurses, midwives, and doulas on breastfeeding education and rates, with a specific focus on changes that transpired during the COVID-19 pandemic.

Methods

Using a cross-sectional design, we performed a secondary data analysis on a stratified systematic sample of forty-six U.S. states and New York City respondents who completed the Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 (2012-2015) and Phase 8 (2016-2020) surveys (n = 193,068). Descriptive analyses and adjusted multivariable logistic regression models reporting adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were used to assess associations between the provision of breastfeeding guidance to mothers from nurses, doulas, or midwife healthcare professionals; breastfeeding/pumping rates; and the COVID-19 pandemic. Cox-proportional hazard models were used to examine the association between breastfeeding guidance and breastfeeding duration.

Results

Our findings revealed that participants who received breastfeeding guidance from nurses, midwives, or doulas were twice as likely to have engaged in breastfeeding or milk pumping for their infants than participants who did not receive breastfeeding education (aOR = 1.99, 95% CI: 1.89-2.11, p < 0.0001). Additionally, participants who gave birth during the COVID-19 pandemic were notably less likely to receive breastfeeding education from a nurse, midwife, or doula than were those who gave birth before the pandemic (aOR = 0.92, 95% CI: 0.88-0.96, p < 0.0001). We also find that the hazard of stopping breastfeeding was lower among participants who received breastfeeding guidance (HR = 0.94, 95% CI: 0.91-0.97, p < 0.0001). Additionally, the hazard of stopping breastfeeding was lower during COVID-19 (HR = 0.94, 95% CI: 0.91-0.97, p = 0.001).

Discussion

Our study underscores the vital role that healthcare professionals play in educating, advocating for, and promoting breastfeeding behaviors. This further highlights the pressing need for sustained efforts to support breastfeeding initiatives and address disparities in maternal and child health, particularly in the context of the challenges presented by the COVID-19 pandemic.

A Narrative Review of Culturally Informed Breastfeeding Interventions for African American Women

PURPOSE

The aim of this narrative review was to map the current literature on culturally informed breastfeeding interventions for African American women.

BACKGROUND

Breastfeeding is associated with positive health outcomes for women and infants. Nonetheless, despite interventions aimed at improving breastfeeding for African American women, they continue to have lower breastfeeding rates compared to Hispanic and Non-Hispanic White women. Therefore, there is a need for culturally informed interventions to promote exclusive breastfeeding in African American women.

METHODS

PubMed, EmCare, CINAHL complete, APA PsycInfo, Scopus and Web of Science were systematically searched for articles published between 2001 and 2024. Preprints were searched in medRxiv; dissertations were searched in ProQuest Dissertations & Theses and EBSCO Open Dissertations; and other gray literatures were searched in governmental/organizational websites. Hand searches of reference lists were conducted. Data were synthesized using narrative synthesis.

RESULTS

Sixteen articles that met inclusion criteria were included. Randomized controlled trial design was used in 7 studies and community-based participatory research design was used in 4 studies. Multilevel breastfeeding education and support provided mostly in-person across 4 socioecological levels (individual, interpersonal, community, and culture) was associated with increased breastfeeding knowledge, self-efficacy, intention, initiation, duration, and exclusivity in African American women. No policy-level intervention was identified. Seven different terms were used to describe the incorporation of culture into breastfeeding interventions.

CONCLUSION

This narrative review provides evidence on the utility and essence of culturally informed breastfeeding interventions for African American women. Multilevel breastfeeding education provided across the perinatal period is effective to promote breastfeeding outcomes in African American women.

Increasing commercial coverage of doula services: perspectives from health plans and large employers in California

Although Medicaid coverage of doula services has expanded since 2014, commercial coverage remains nascent. Little is known about what motivates private payers to cover doula support. Through qualitative interviews with staff members (n = 11) from health plans and employers that operate in California, we aimed to identify factors that could influence commercial coverage of doula services. In our first theme, we describe how a health plan or employer's commitment to birth equity can serve as a catalyst for commercial coverage of doula services. Second, participants noted that when considering new benefits, payers would review evidence related to doula support and weigh cost. The third theme centers on how consumer demand could impact a health plan or employer's appetite for adding a commercial doula benefit. The final theme highlights the operational considerations health plans and employers are contemplating, such as how to prioritize populations that could most benefit from doula support. Our findings suggest that the decision to cover doula support largely hinges on payer priorities. However, we found that health plans and employers interested in advancing birth equity were compelled by evidence supporting doula care, suggesting there may be opportunities to increase commercial coverage of doula services.

Experiences of Hmong Women in the Perinatal Period

OBJECTIVE

To explore Hmong women's experiences in the perinatal period and how their cultural practices intersect with Western health care in the United States.

DESIGN

Descriptive qualitative study.

SETTING

In-person and online interviews in several geographic locations in the United States.

PARTICIPANTS

Twenty-five Hmong women with a mean age of 35.7 years (SD = 4.1 years) from Wisconsin, California, Minnesota, Michigan, Oklahoma, Arkansas, and Kansas. Most had at least a bachelor's degree and one to seven children.

METHODS

We recruited participants using purposive sampling through social media and word of mouth, collected data via semistructured interviews with audio recording, used verbatim transcription, and conducted reflexive thematic analysis.

RESULTS

Participants' experiences focused on three overarching themes: Navigating the Hmong Traditional World, Navigating Adverse Perinatal Experiences in the Medical World, and Walking Two Worlds Alone. While navigating the traditional Hmong world, participants managed cultural expectations and experienced cultural silencing about certain perinatal topics. Simultaneously, participants navigated adverse experiences such as a lack of shared decision-making and support from health care providers in the Western medical world. They often encountered challenges with navigating the intersection of both worlds alone and reported inadequate support and guidance.

CONCLUSION

We found that participants' experiences in the perinatal period were shaped by cultural, social, and health care-related factors. More culturally responsive care is needed to improve the health outcomes of Hmong women in the perinatal period.

The role of doulas in abortion care in Canada: A qualitative study

INTRODUCTION

Equitable and safe access to abortion is essential for reproductive autonomy. Despite decriminalization in 1988, barriers to accessing abortion in Canada persist, particularly for people in underserved groups. Doulas, working in a non-clinical and unregulated supportive role, may facilitate access to family planning services, but evidence about the scope, role, training, and efficacy of doulas in abortion care is lacking. The goal of this study was to understand the experience of abortion doulas in Canada with respect to their role and facilitators and challenges faced in practice.

METHOD

For this community-based, qualitative national study of abortion doula practice, we first created a national directory of all doulas in Canada in 2023 using publicly available online information. From this directory, we extracted contact information for doulas who indicated they provide abortion support and sent invitations for a one-time qualitative interview. Questions addressed current role and responsibilities, gaps in doula training and knowledge, and challenges and opportunities they perceived with respect to client support. We used reflexive thematic analysis to generate key themes. Our research team includes abortion doula experts.

RESULTS

Among 73 abortion doulas with public listings in Canada in 2023 to whom we sent invitations, 15 completed an interview. We developed six key themes: Inter and intra-systems navigation; After-care; In over their heads; Balancing act; Support for the supporter; and Beyond the individual. Abortion doulas navigate fragmented systems and support clients experiencing intersecting forms of oppression and exclusion. These complex logistics include locating care providers, securing transportation, and obtaining funds for clients' out-of-pocket costs. Doulas faced challenges acquiring adequate training, understanding local health systems, forging relationships and supporting clients facing structural barriers to care. Abortion doula work is facilitated by peer and organizational support, connections to clinics and providers, and comprehensive and contextually appropriate training.

CONCLUSIONS

Abortion doulas express needs for comprehensive, evidence-based training, meaningful partnerships and sustainable remuneration. Future research should explore abortion provider and clinic staff perspectives with respect to the potential role of doulas in wrap-around client support services.

Respectful Maternity Care in the United States: A Scoping Review of the Research and Birthing People's Experiences

INTRODUCTION

Birthing people around the world experience mistreatment during labor and birth, contributing to adverse maternal health outcomes. The adoption of respectful maternity care (RMC) has been recommended to address this mistreatment and improve care quality. Most RMC and mistreatment research has been conducted internationally. The purpose of this scoping review was to (1) explore the extent of RMC research and (2) describe labor and birth experiences in the United States.

METHODS

Embase, Scopus, and CINAHL databases were searched for concepts relating to RMC and mistreatment. A total of 66 studies met review inclusion criteria. Two reviewers screened titles, abstracts, and full-text articles. Data were extracted and categorized using the Bohren et al typology of mistreatment. Summary statistics and narrative summaries were used to describe study characteristics and birthing people's experiences.

RESULTS

Most studies represented national or urban samples and Western or Northeastern US regions. Few were from the South, and only one represented rural participants specifically. Few studies represented the unique experiences of justice-involved birthing people, and none represented sexual and gender minorities or Indigenous people. Qualitative methods were predominant. The most common forms of mistreatment included (1) poor rapport between women and health care providers (88% of studies), (2) stigma and discrimination (79%), and (3) a failure to meet professional standards of care (73%).

DISCUSSION

The extent of mistreatment in the United States highlights the need for robust programs and policies targeting provision of RMC. Additional research is needed to better understand the experiences of additional minority communities and those living rural areas and in the Southern United States.

One Hundred Years of Seeking Respectful Maternity Care: History and Evolution

Growing awareness of poor maternal health outcomes and maternal health disparities in the United States has heightened urgency around the need to promote Respectful Maternity Care (RMC) as a fundamental tenet of obstetric/midwifery care and standardize efforts to improve safety, eliminate obstetric violence and racism, and optimize health outcomes for all birthing people. The historical context of prior and contemporary perspectives around childbirth influences our understanding of RMC and are shaped by varying scholarly, clinical, and community standards (e.g., religion, human rights, government, public health, midwifery, ethics, activism, and the law), which have changed significantly since the mid-19th century. In this commentary, we share results of a contextual question scoped as part of a larger systematic review of RMC to help inform consensus around a shared definition and development of a metric to standardize delivery and evaluation of RMC. Synthesis of this literature identified landmark historical influences on RMC over the past 100 years, highlighting the multidisciplinary scholarship and historical context influencing the progress toward RMC. Further understanding of this history may also inform policies and guidance for ongoing efforts to center respect and accountability in all aspects of maternity care, with particular attention to populations who are disproportionally impacted by disrespectful care.

"Someone is there with you through this [pregnancy] that isn't seeing you through a negative lens": Considerations for integrating doula referrals into opioid treatment programs

INTRODUCTION

Pregnancy-associated mortality involving opioids represents a significant public health issue. Limited social support is a known factor, contributing to a more complex recovery and a greater risk for relapse and overdose. Community-based doulas have been used in other marginalized populations yet are under-studied among pregnant and parenting persons with Opioid Use Disorder (OUD). Therefore, we aimed to investigate the perspectives of Opioid Treatment Program (OTP) clinical staff and community doulas about doula support for persons with perinatal OUD to 1) describe the perceived utility of doula support and 2) identify structural considerations for integrating doula support at an OTP.

METHODS

This study conducted focus groups and utilized domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Purposive sampling recruited 10 participants (5 doulas, 5 OTP staff: 1 clinical director, two counselors, one nurse, and one Community Health Worker) from an OTP program and a Philadelphia Department of Public Health Community Doula Support Program (CDSP). One focus group was held for doula staff, and two focus groups were held for OTP clinical staff. Thematic analytic procedures were used to analyze data using NVivo and an interdisciplinary coding team.

RESULTS

Five key themes were identified from the focus group data: 1) Role of advocacy in the court system, 2) Need for collaborative care, 3) Use of doulas to de-stigmatize healthcare experiences, 4) Impact of doula support on recovery, 5) Considerations to integrating doula referrals into OTPs.

CONCLUSION

Perinatal doula support among persons with OUD is perceived as beneficial by critical stakeholders to advocate in healthcare and legal systems, de-stigmatize healthcare experiences, and promote recovery engagement. The implementation recommendations outlined may guide other OTPs looking to integrate doula support to improve maternal outcomes associated with opioid use.

An Interprofessional Collaboration Between a Community-Based Doula Organization and Clinical Partners: The Champion Dyad Initiative

As access to doula services expands through state Medicaid coverage and specific initiatives aimed at improving maternal health equity, there is a need to build and improve upon relationships between the doula community, hospital leaders, and clinical staff. Previous research and reports suggest rapport-building, provider education, and forming partnerships between community-based organizations and hospitals can improve such relationships. However, few interventions or programs incorporating such approaches are described in the literature. This article describes the development and 5 core components of the Champion Dyad Initiative (CDI), a novel program that uses bidirectional feedback between SisterWeb, a community-based doula organization, and 5 clinical sites (4 hospitals and one birthing center) to ensure pregnant and birthing people receive fair and equitable treatment. We also describe implementation challenges related to documentation, funding, and institutional support. The CDI is a promising model for community-based doula organizations and health care institutions to develop collaborative partnerships, build respectful doula-provider relationships, and work toward improving the pregnancy-related care that Black, Indigenous, and people of color receive in hospital and birth center settings. It is our hope that this innovative initiative can serve as a model that can be adapted for other locales, organizations, and hospitals.

The Age of the Soft-Girl Era: How Public Health Scholars May Seize Opportunity of Innovatively Promoting Reproductive Health and Nutritional Health Among Black Women of Color

In the current soft-girl era, a soft lifestyle promotes living with ease, comfort, healing, and joy. As health equity programs evolve, they should provide safe spaces for participants' experiences, desires, and motivations for wellness living. Contributions of the soft-girl era movement challenge the notions for historically marginalized women to thrive in their health rather than merely surviving through it. If public health fields are to expand, including the fields of Black maternal health and Black food justice, Black participation is critical. The movement offers researchers to acknowledge participant voice, thereby gaining their trust, interest, and on-going participation in health programs.

Leveraging an equity birth plan as a communication tool to address health equity and improve health outcomes in black birthing people

BACKGROUND

Black birthing people in the United States are disproportionately impacted by maternal mortality and more frequently report physical and verbal mistreatment during intrapartum care. Birth plans for prenatal and postpartum care promote autonomy and agency but have not been used as tools to address disparities in perinatal care.

METHODS

We reviewed the literature on the use of birth plans and communication in the pregnancy care setting. We provide an expert analysis and a recommendation for a comprehensive birth plan that incorporates patient preferences and individualizes patient risks as a communication tool.

RESULTS

In this expert opinion we outline how an equity birth plan can address social determinants of health, promote respectful communication and prioritize attention to patient narratives. This instrument can be used to address systemic problems that result in health inequities on a community, provider and institutional level.

CONCLUSIONS

A birth plan with attention to equity serves as a new paradigm for care which can empower patients and reduce racial inequities in perinatal and postpartum outcomes.

Indigenous women's experiences about the pregnancy-puerperal cycle

OBJECTIVES

to understand the experiences of indigenous women regarding the pregnancy-puerperal cycle.

METHODS

qualitative, exploratory and descriptive research, carried out between May and August 2023 with 27 pregnant women from Indigenous Villages in Mato Grosso, Brazil, through open individual interviews. The data was analyzed using Reflexive thematic analysis.

RESULTS

data analysis resulted in the following themes: Cultivation of labor and birth in its natural and sacred path; Unique practices and beliefs associated with breastfeeding; Evolved or reductive thinking? The participants suggest inviolable practices and beliefs, which must be welcomed, respected and enhanced by indigenous health teams.

FINAL CONSIDERATIONS

the experiences of indigenous women regarding the pregnancy-puerperal cycle are unique and motivated by inviolable cultural and religious beliefs, which transcend scientific knowledge, certainties and the linearity of contemporary approaches, normally established as order.

Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs

BACKGROUND

Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity.

METHODS

We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes.

DISCUSSION

Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Exploring the Experiences of Community-Based Doulas That Serve Immigrant, Migrant, and Refugee Clients in Arkansas

Immigrant women in the United States often have poorer maternal and infant outcomes and suboptimal experiences of maternity care compared to non-immigrant women in the same setting. The purpose of this study was to explore community-based doulas' experiences of working with immigrant clients and maternal health care providers in Arkansas. A descriptive qualitative design was used. Themes emerged within three categories: 1) experiences with immigrant clients; 2) experiences with maternal health care providers; and 3) suggestions to improve support for immigrant clients. Within the first theme, three subthemes emerged: 1) language barriers; 2) transportation; and 3) access to food and housing. Within the second theme, two subthemes emerged: 1) dismissive; and 2) takes time to build rapport. Within the third theme, two subthemes emerged: 1) listen to the client and improve communication; and 2) more community-based doulas. Community-based doula programs may help address poorer health outcomes faced by immigrant women.

Characterizing the utilization of doula support services among birthing people of color in the United States: a scoping review

BACKGROUND

Birthing people of color experience disproportionately higher rates of infant and maternal mortality during pregnancy and birth compared to their white counterparts. The utilization of doula support services may lead to improvements in the birthing experiences of birthing people of color. Yet, the research in this area is sparse. Thus, the purpose of this review is to characterize the research on doula utilization among birthing people of color, identify gaps in the field, and provide recommendations for future research.

METHODS

Utilizing PRISMA guidelines, we conducted a scoping review, searching PubMed, PsycINFO, CINAHL, and Google Scholar for peer-reviewed articles published between January 1, 2016, to July 3, 2022.

RESULTS

Twenty-five articles met inclusion criteria. We identified the three themes characterizing included studies: (1) how doulas support (HDS) their clients, (2) doula support outcomes (DSO), and (3) considerations for implementing doula support services (CIDS). Despite doulas being described as agents of empowerment, and providing social support, education, and advocacy, birthing people of color reported low utilization of doula support services and findings regarding their effectiveness in improving birthing outcomes were mixed.

CONCLUSIONS

While some studies suggest that doulas may offer important services to birthing people of color, doulas are largely under-utilized, with many birthing people reporting low knowledge of their potential roles during the pre- and post-partum periods. Moreover, few studies were designed to assess intervention effects, limiting our ability to draw firm conclusions. Birthing people of color are at elevated risk for maternal mortality. As such, interventions are needed to support this population and improve outcomes. Our review suggests that, while doulas have the potential to make important contributions to the birthing support team, they are underutilized, and intervention studies are needed to enable estimates of their true effectiveness.

Building Capacity for Research on Community Doula Care: A Stakeholder-Engaged Process in California

PURPOSE

In an effort to address persistent inequities in maternal and infant health, policymakers and advocates have pushed to expand access to doula care. Several states, including California, now cover doula services through Medicaid. As coverage expands, research on the impact of doula care will likely increase. To develop best practices for research, it is critical to engage community doulas, clients, and other key stakeholders.

DESCRIPTION

Our overarching goal was to build capacity for future doula- and client-centered research on community doula care. First, we established a Steering Committee with members from seven relevant stakeholder groups: community doulas, former or potential doula clients, clinicians, payers, advocates, researchers, and public health professionals. Second, we conducted a needs assessment to identify and understand stakeholders' needs and values for research on community doula care. Findings from the needs assessment informed our third step, conducting a research prioritization to develop a shared research agenda related to community doula care with the Steering Committee. We adapted the Research Prioritization by Affected Communities protocol to guide this process, which resulted in a final list of 21 priority research questions. Lastly, we offered a training to increase capacity among community doulas to engage in research on community doula care.

ASSESSMENT

Our findings provide direction for those interested in conducting research on doula care, as well as policymakers and funders.

CONCLUSION

The findings of our stakeholder-engaged process provide a roadmap that will lead to equity-oriented research centering clients, doulas, and their communities.

Association Between Doula Use on a Digital Health Platform and Birth Outcomes

OBJECTIVE

To examine the association between the use of virtual doula appointments on a comprehensive digital health platform and users' mode of birth and their birth experiences, among all platform users and Black platform users.

METHODS

Data for this retrospective cohort study were extracted from individuals who enrolled in a comprehensive digital health platform, between January 1, 2020, and April 22, 2023. Multivariable logistic regression models were used to estimate the association between number of virtual doula appointments completed on the digital health platform and odds of cesarean birth and user-reported birth experience outcomes, which included help deciding a birth preference, receiving a high level of support during pregnancy, learning medically accurate information about pregnancy complications and warning signs, and managing mental health during pregnancy, stratified by parity. The interaction of doula utilization by race for each outcome was also tested.

RESULTS

Overall 8,989 platform users were included. The completion of at least two appointments with a virtual doula on the digital health platform was associated with a reduction in odds of cesarean birth among all users (adjusted odds ratio [aOR] 0.80, 95% CI, 0.65-0.99) and among Black users (aOR 0.32, 95% CI, 0.14-0.72). Among platform users with a history of cesarean birth, completion of any number of doula visits was associated with a reduction in odds of repeat cesarean birth (one visit: aOR 0.35, 95% CI, 0.17-0.72; two or more visits: aOR 0.37, 95% CI, 0.17-0.83). Analyses among all users indicated dose-response associations between increased virtual doula use and greater odds of users reporting support in deciding a birth preference (one visit: aOR 2.35, 95% CI, 2.02-2.74; two or more visits: aOR 3.67, 95% CI, 3.03-4.44), receiving a high level of emotional support during pregnancy (one visit: aOR 1.99, 95% CI, 1.74-2.28; two or more visits: aOR 3.26, 95% CI, 2.70-3.94), learning medically accurate information about pregnancy complications and warning signs (one visit: aOR 1.26, 95% CI, 1.10-1.44; two or more visits: aOR 1.55, 95% CI, 1.29-1.88), and help managing mental health during pregnancy (one visit: aOR 1.28, 95% CI, 1.05-1.56; two or more visits: aOR 1.78, 95% CI, 1.40-2.26).

CONCLUSION

This analysis demonstrates that virtual doula support on a digital health platform is associated with lower odds of cesarean birth and an improved birth experience. Positive findings among Black users and users with vaginal birth after cesarean suggest that doula support is critical for patient advocacy, and that digital health may play a meaningful role in increasing health equity in birth outcomes.

The Power of Language in Hospital Care for Pregnant and Birthing People: A Vision for Change

Language is commonly defined as the principal method of human communication made up of words and conveyed by writing, speech, or nonverbal expression. In the context of clinical care, language has power and meaning and reflects priorities, beliefs, values, and culture. Stigmatizing language can communicate unintended meanings that perpetuate socially constructed power dynamics and result in bias. This bias may harm pregnant and birthing people by centering positions of power and privilege and by reflecting cultural priorities in the United States, including judgments of demographic and reproductive health characteristics. This commentary builds on relationship-centered care and reproductive justice frameworks to analyze the role and use of language in pregnancy and birth care in the United States, particularly regarding people with marginalized identities. We describe the use of language in written documentation, verbal communication, and behaviors associated with caring for pregnant people. We also present recommendations for change, including alternative language at the individual, clinician, hospital, health systems, and policy levels. We define birth as the emergence of a new individual from the body of its parent, no matter what intervention or pathology may be involved. Thus, we propose a cultural shift in hospital-based care for birthing people that centers the birthing person and reconceptualizes all births as physiologic events, approached with a spirit of care, partnership, and support.

Effectiveness of an Enhanced Community Doula Intervention in a Safety Net Setting: A Randomized Controlled Trial

Background

Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent.

Methods

We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race-ethnicity.

Results

Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants.

Discussion

While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates.

Conclusion

This study demonstrates the need for larger studies of community doula support for Black birthing people. Clinicaltrials.gov ID: NCT02550730.

The association of doula support and patient experiences with hospital staff during birth in a sample of California women: An exploratory analysis

BACKGROUND

Research suggests that doula support improves birth outcomes, contributing to lower rates of preterm birth, low birthweight, and nonindicated cesarean delivery. Few studies investigate whether doula support is associated with the quality of patient-reported birth experiences in hospital settings.

METHODS

This study uses data from Listening to Mothers in California, a statewide representative survey of women who gave birth in 2016 in Californian hospitals. The analytic sample included 1345 English-speaking participants. We used multivariable logistic regression to test for associations between doula support and self-reported unfair treatment, abuse, and rapport with delivery staff. We also examined associations between these experiences and openness to doula support in a future birth. Models adjusted for maternal sociodemographic characteristics and views about medical intervention in birth.

RESULTS

Just over 9% of women had doula support during birth. During their hospital stay, 6.3% reported unfair treatment, 11.5% reported abuse by providers, and 5.7% reported no rapport with delivery room staff. There were no statistically significant relationships between doula support and unfair treatment, abuse, or delivery staff rapport in our models. Participants who reported no rapport with hospital staff were more likely to express openness to doula support in a future birth (AOR: 2.59; 95% CI: 1.15, 5.79).

CONCLUSIONS

Despite their best efforts, doulas may not be able to mitigate all negative interactions between their clients and hospital staff. These experiences may also influence desires for additional support from doulas in future births. Hospital policies and practices should include doulas as valuable members of the care team to help ensure positive experiences during birth.

Vital Signs: Maternity Care Experiences - United States, April 2023

Introduction

Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths.

Methods

CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care.

Results

Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider.

Conclusions and implications for public health practice

Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor

OBJECTIVE

To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth.

METHODS

A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0-10 points), and a composite of perinatal death or severe neonatal complications. Significant variables ( P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated.

RESULTS

Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (-6.4 [-10.5 to -2.3]) or Hispanic (-3.7 [-5.7 to -1.7]) compared with White, smoked compared with did not smoke (-2.8 [-5.5 to -0.1]), had BMIs of 35 or higher compared with less than 30 (-2.0 [-3.8 to -0.2]), were unemployed (-3.15 [-4.76 to -1.55]), did not have private health insurance (-2.61 [-4.47 to -0.76]), underwent operative vaginal (-5.1 [-7.7 to -2.6]) or cesarean (-14.4 [-16.1 to -12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (-11.9 [-13.4 to -10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6-4.8]) and had private compared with nonprivate insurance (2.6 [0.76-4.5]).

CONCLUSION

In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01990612.

Fair compensation and the affective costs for indigenous doulas in Canada: A qualitative study

BACKGROUND

In Canada, Indigenous doulas, or birth workers, who provide continuous, culturally appropriate perinatal support to Indigenous families, build on a long history of Indigenous birth work to provide accessible care to their underserviced communities, but there is little research on how these doulas organize and administer their services.

METHODS

Semi-structured interviews were conducted in 2020 with five participants who each represented an Indigenous doula collective in Canada. One interview was conducted in person while the remaining four were conducted over Zoom due to COVID-19. Participants were selected through Internet searches and purposive sampling. Interview transcripts were approved by participants and subsequently coded by the entire research team to identify key themes.

RESULTS

One of the five emergent themes in these responses is the issue of fair compensation, which includes two sub-themes: the need for fair payment models and the high cost of affective labour in the context of cultural responsibility and racial discrimination.

DISCUSSION

Specifically, participants discuss the challenges and limitations of providing high quality care to families with complex needs and who cannot afford to pay for their services while ensuring that they are fairly compensated for their labour. An additional tension arises from these doulas' sense of cultural responsibility to support their kinship networks during one of the most sacred and vulnerable times in their lives within a colonial context of racism and a Western capitalist economy that financializes and medicalizes birth.

CONCLUSION

These Indigenous birth workers regularly expend more affective labour than mainstream non-racialized counterparts yet are often paid less than a living wage. Though there are community-based doula models across the United States, the United Kingdom, and Sweden that serve underrepresented communities, further research needs to be conducted in the Canadian context to determine an equitable, sustainable pay model for community-based Indigenous doulas that is accessible for all Indigenous families.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample's (n = 93) median SVI score [IQR] was 0.55 [0.25-0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88-0.98] compared with 0.38 [0.19-0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13-0.97), midwifery care (aOR 0.35, 95% CI 0.12-0.99), doula support (aOR 0.30, 95% CI 0.11-0.84), postpartum support groups (aOR 0.25, 95% CI 0.09-0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01-0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.