Doula care, birth outcomes, and costs among Medicaid beneficiaries

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections

BACKGROUND

Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections.

METHODS

We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits.

RESULTS

Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health.

CONCLUSION

Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity

OBJECTIVE

 This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants.

STUDY DESIGN

 This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races.

RESULTS

 The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model.

CONCLUSION

This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709).

KEY POINTS

· Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Florida Doulas' Perspectives on Their Role in Reducing Maternal Morbidity and Health Disparities

BACKGROUND

Maternal mortality rates continue to rise in the United States. Considerable racial disparities exist, as Black women face two to three times the risks of dying from pregnancy-related complications compared with white women. Doulas have been associated with improved maternal outcomes. This study aimed to 1) investigate Florida doulas' perspectives and influence on severe maternal morbidity/mortality and related inequities, as well as 2) identify opportunities for actionable change. The social ecological model, which acknowledges how individual, interpersonal, institutional, community, and public policy factors intersect, informed our analysis.

METHODS

This qualitative study included seven online in-depth interviews and seven focus groups with doulas (N = 31) in Florida. Interview guides investigated how doulas perceive their role in the context of a) maternal morbidity and b) health disparities.

RESULTS

Doulas associated maternal morbidity and health disparities with Black pregnant people, identifying racism as a major contributor. Doulas identified their role as one that most often intersects with the individual and interpersonal levels of the social ecological model. Doulas report providing positive social surveillance and emotional support, contributing education and resources, and championing for advocacy in health care settings. Actionable steps recommended by doulas to further mitigate health disparities include the integration of implicit bias training into doula certification programs, increasing public health funding to bolster a doula workforce that can serve racial and ethnic communities, establishing doula-hospital partnerships to improve relational communication, providing tailored resources for clients featuring representative messaging, and doulas' continued engagement in positive social surveillance of their clients.

CONCLUSIONS

Doulas perceived their role as integral to mitigating maternal morbidity and health disparities, particularly in the context of supporting and advocating for birthing persons on all levels of the social ecological model. Equitable access to doulas for low-income and/or minoritized populations may be one key strategy to improve maternal health equity.

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.

"We Are All There to Make Sure the Baby Comes Out Healthy":: A Qualitative Study of Doulas' and Licensed Providers' Views on Doula Care

Policymakers are exploring ways to expand access to doula care to address persistent inequities in maternal and infant health across the United States. Doulas are non-medical professionals who provide physical, emotional, and informational support to birthing people before, during and after childbirth. Growing evidence supports the role of doulas in improved birth outcomes. Delaware is among several states moving towards Medicaid reimbursement for doula care to serve those most at risk. Objective: To gain an in-depth understanding of key stakeholders' knowledge, attitudes, beliefs and experiences regarding doula training and certification, relationships among providers, and other potential needs related to infrastructure to identify areas of agreement and inform policy change in the state of Delaware. Methods: We conducted focus groups with 11 doulas and key-informant interviews with 12 licensed providers practicing in Delaware, including six nurses, four physicians and two certified nurse midwives. Qualitative data was collected via Zoom (video conferencing) between September 2022 and April 2023. Results: Analysis revealed themes related to training, credentials and competencies of doulas, including cultural competence; logistical, administrative, and financial considerations for policy and practice change; and the whole care team-relationships between doulas and medical partners, and opportunities for growth. Conclusions: Doulas and licensed providers agree on key elements of doula training, the value of certification, the need for financial support, and the importance of relationship-building across the care team. Policy implications: Areas of agreement among stakeholders provide a foundation for state leaders to move forward to ensure the delivery of the most accessible, high quality, and culturally competent doula care for birthing people in Delaware.

The intersection of traumatic childbirth and obstetric racism: A qualitative study

BACKGROUND

Traumatic childbirth experiences are common in the United States - affecting a third to a fourth of mothers - with significant negative impacts on maternal health. Yet most research on traumatic childbirth focuses on white mothers' experiences. Drawing on a racially and ethnically diverse sample of mothers who experienced traumatic childbirth, this exploratory qualitative study examined Black, Latina, and Asian mothers' traumatic birth experiences and the role of obstetric racism in shaping these experiences.

METHODS

In-depth, semi-structured interviews were conducted in 2019-2020 with 30 mothers who identified as women of color (37% Black, 40% Latina, and 23% Asian) who gave birth in the US and self-identified as having experienced a traumatic childbirth. Data were analyzed using qualitative content analysis.

RESULTS

Mothers reported obstetric racism as core to their traumatic birth experiences. This racism manifested through practitioners' use of gendered and racialized stereotypes, denying and delegitimizing mothers' needs. Mothers shared key consequences of the obstetric racism they experienced, including postpartum anxiety and depression, increased medical mistrust, and decreased desire for future children.

CONCLUSIONS

Mothers' reports suggest that obstetric racism played a role in their traumatic birth experiences. Particularly, practitioners' deployment of gendered and racialized stereotypes influenced mothers' treatment during birth. These findings point to opportunities to address obstetric racism during childbirth and improve patients' experiences through enhancing their agency and empowerment. The findings, in addition, highlight the need for increased practitioner training in anti-racist practice and cultural humility.

Readiness to Implement a Doula-Hospital Partnership Program

OBJECTIVE

To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program.

DESIGN

Survey of obstetric clinicians and leaders before implementation of the doula program.

SETTING/LOCAL PROBLEM

Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality.

PARTICIPANTS

Obstetric clinicians and leaders (N = 48).

INTERVENTION/MEASUREMENTS

We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis.

RESULTS

Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics.

CONCLUSION

Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

Providing doula support to publicly insured women in central Texas: A financial cost-benefit analysis

BACKGROUND

Disparities in birth outcomes continue to exist in the United States, particularly for low-income, publicly insured women. Doula support has been shown to be a cost-effective intervention in predominantly middle-to-upper income White populations, and across all publicly insured women at the state level. This analysis extends previous studies by providing an estimate of benefits that incorporates variations in averted outcomes by race and ethnicity in the context of one region in Texas. The objectives of this study were to determine (1) whether the financial value of benefits provided by doula support exceeds the costs of delivering it; (2) whether the cost-benefit ratio differs by race and ethnicity; and (3) how different doula reimbursement levels affect the cost-benefit results with respect to pregnant people covered by Medicaid in central Texas.

METHODS

We conducted a forward-looking cost-benefit analysis using secondary data carried out over a short-term time horizon taking a public payer perspective. We focused on a narrow set of health outcomes (preterm delivery and cesarean delivery) that was relatively straightforward to monetize. The current, usual care state was used as the comparison condition.

RESULTS

Providing pregnant people covered by Texas Medicaid with access to doulas during their pregnancies was cost-beneficial (benefit-to-cost ratio: 1.15) in the base model, and 65.7% of the time in probabilistic sensitivity analyses covering a feasible range of parameters. The intervention is most cost-beneficial for Black women. Reimbursing doulas at $869 per client or more yielded costs that were greater than benefits, holding other parameters constant.

CONCLUSIONS

Expanding Medicaid pregnancy-related coverage to include doula services would be cost-beneficial and improve health equity in Texas.

Critical Changes in the Maternal Health Landscape: Community Care, Doulas, and Coverage

In this commentary, we present an overview of the accelerating trend toward community-based models for pregnancy care. Doula services, as part of community care programs, are the major target for new coverage changes. Obstetric professionals who include community care providers in their treatment plans can benefit from these local resources in the prenatal, birthing, and postpartum stages of patient management. Including community care programs may help achieve goals of improving health outcomes and health equity.

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.

Doula Support and Pregnancy-Related Complications and Death Among Childbearing Women in the United States: A Scoping Review

INTRODUCTION

The potential benefits of perinatal doula support are many; however, doulas are underutilized, which may heighten pregnancy-related complications. In this scoping review, we assess the influence of perinatal doula support on pregnancy-related complications and death in the United States.

METHODS

We searched PubMed, CINAHL, Scopus, and Alt HealthWatch for literature on doula support and its influence on pregnancy-related complications (maternal fever or infection, postpartum hemorrhage, amniotic fluid embolism, complications from anesthesia, preeclampsia, eclampsia, cardiomyopathy, pulmonary or thrombotic embolism, and cerebrovascular accident). Peer-reviewed articles written in English and conducted in the United States from 1969 to 2021 were included. Screening at all levels was blinded. We extracted data based on title, author, year, design, population, sample size, methods, limitations, recommendations, and definition of doula support.

RESULTS

Following removal of duplicates, review of 3679 article titles and abstracts yielded 42 articles for full-text review; 3 articles met final inclusion criteria. One included study focused on intrapartum doula support and 2 on doula support that extended throughout the perinatal period. Within the included studies, doula support was associated with decreased rates of intrapartum maternal fever and gestational hypertension; however, it was not associated with decreased rates of gestational diabetes or depression.

DISCUSSION

The literature has addressed the benefits of perinatal doula support, but studies with validated tools to examine associations between doula support and pregnancy-related complications and death are lacking. The studies that addressed intrapartum and continuous doula care included large generalizable samples, from which future research can draw to improve the practice of caring for patients during the perinatal period. Extensive research shows that unfavorable conditions can influence perinatal outcomes across generations. Implementing doula support may offer a potential approach to reduce and help alleviate resulting disparities in perinatal health.

Black/African American Women's Woes: Women's Perspectives of Black/African American Maternal Mortality in the USA

BACKGROUND

Despite advances in perinatal care in the USA, maternal mortality is on the rise, and maternal death is higher than in any other high-income country. Maternal mortality in the USA is a persistent public health concern. This issue disproportionately affects Black/African American women, with their likelihood of pregnancy-related death being three times more likely compared to White women. This study aimed to explore the resources needed for Black/African American women to address the relatively higher maternal mortality rates recorded for them.

METHODS

An anonymous link with demographic and open-ended questions was sent to US women 18 years and older to participate in the study. A total of 140 participants responded to the survey. We retained a final sample of 118 responses after eliminating responses with missing data. Descriptive statistics are reported for closed-ended items. Open-ended responses were analyzed using content analysis procedures, where we coded and categorized the data into themes.

RESULTS

Six themes were identified from the study data: (1) Diversity, Equity, and Inclusion (DEI) training for health providers focused on racial bias and discrimination, (2) Advocacy, (3) Provider selection, (4) Researching doctors and delivery hospitals to inform women's birthing decision-making, (5) Women's care-seeking behaviors, and (6) Addressing the Social Determinants of Health.

CONCLUSION

Based on the study's findings, we recommend DEI training for healthcare professionals providing direct care to pregnant and postpartum women, advocacy and resource-awareness training for pregnant Black/African American women and their spouses/partners, or a family member, to assist them in their pregnancy and birthing journeys.

Place-Based Strategies Addressing Neighborhood Environments to Improve Perinatal and Preterm Infant Outcomes

Preterm birth (defined as birth <37 weeks of gestation) is a significant health concern globally, with lasting implications for individuals, families, and society. In the United States, high preterm birth rates among Black and low-income populations likely result from differences in environmental exposures. Structural racism and economic disadvantage have led to unequal distribution of polluting industrial sites and roadways across society as well as differential access to health-promoting resources which contribute to preterm birth risk. Once born, preterm infants remain at risk for numerous environmentally responsive adverse health outcomes that affect growth and development throughout childhood and adulthood. In this commentary, we describe associations of neighborhood environments with pregnancy and preterm infant health outcomes and propose strategies to address harmful exposures that affect families across the lifespan.

Providing Emotional Support and Physical Comfort During a Time of Social Distancing: A Thematic Analysis of Doulas' Experiences During the Coronavirus Pandemic

Doulas are trained, non-clinical professionals that provide a continuum of support for mothers. An interpretive phenomenological approach was used to explore the professional experiences of doulas (n = 17) during the COVID-19 pandemic in the US. Data were collected using brief intake surveys, in-depth semi-structured interviews, and an online discussion group. After a list of significant statements was created and grouped during emergent themes analysis, the reflections were summarized into three themes, (1) Doula Resilience, (2) Experiencing Vulnerability, and (3) Concern for Client Vulnerability that encapsulate the experiences of doulas during the COVID-19 pandemic. We conclude that as part of the COVID-19 recovery process, policy makers should look to non-clinical interventions for improving maternal health, such as promoting and supporting synergy between doulas and other maternal health service providers.

Bridging Health Disparities and Improving Reproductive Outcomes With Health Center-Affiliated Doula Programs

Doulas are community perinatal professionals trained in pregnancy health, childbirth preparation, labor support, lactation counseling, and postnatal care. Doulas serve as patient advocates and provide laboring patients with continuous one-to-one support including informational, physical, and emotional support. Research shows that access to continuous labor support contributes to positive health outcomes such as increasing rates of spontaneous vaginal delivery, shorter labor, less need for analgesics, and increased satisfaction with the birthing process. However, despite their benefits, socioeconomic, structural, and systemic factors limit doula accessibility and manifest in low utilization among patients who could benefit from doulas the most. Given the positive health implications of doula support and the need for these services in underserved populations, there is an urgency to increase the accessibility of doulas. Several health centers in the United States have created successful doula programs to meet the needs of their patient populations. To better understand these programs, we interviewed and collaborated on this paper with program representatives from Boston Medical Center's Birth Sisters and DREAM: Delivery Resources, Education, and Advocacy for Moms; UNC Health's Birth Partners; and Michigan Medicine's Dial-A-Doula. Because many health centers serve as large public safety-net hospitals, having more health center-affiliated doula programs nationwide could be a positive step in bridging disparities and improving maternal and child health.

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.

"I want…to serve those communities…[but] my price tag is…not what they can afford": The community-engaged Georgia doula study

INTRODUCTION

In Georgia, maternal mortality is relatively high, and Black women are three times as likely to die from pregnancy-related causes as white women. Doulas can improve perinatal health and reduce disparities, but doula accessibility in Georgia is unclear.

METHODS

This community-engaged mixed methods study surveyed and interviewed 17 doulas in Georgia. Surveys included structured questions on demographics, businesses, clientele, training, and challenges; we analyzed them using descriptive statistics. In-depth interviews included open-ended questions on doula care benefits, building their businesses, and improving access to doula care. We analyzed the content of transcripts using coding and memoing.

RESULTS

Our diverse doula participants described providing life-saving services including education, referral to care, and patient advocacy. Yet they described numerous challenges to providing care and building their businesses. Almost all participants reported having fewer than their ideal number of clients and all reported being insufficiently paid for their services. Although training, mentoring, and networking help build their businesses, many doulas want to serve Black women, transgender men, gender non-binary individuals, and families living on lower incomes. Participants suggested Medicaid reimbursement and community health worker models as potential interventions for increasing equitable doula care access.

DISCUSSION

Doulas can improve perinatal health outcomes and are urgently needed. Yet they face challenges in building businesses and finding clientele, especially from communities and groups at highest risk of negative outcomes during pregnancy, childbirth, and the postpartum period. Identifying avenues for supporting publicly-funded reimbursement, expanding equity-focused doula training, and fostering stronger doula networks with mentorship appears warranted.

The Experiences of Black Community-Based Doulas as They Mitigate Systems of Racism: A Qualitative Study

INTRODUCTION

Black pregnant individuals endure a disproportionate burden of preventable morbidity and mortality due to persistent, racially mediated social and systemic inequities. As patient advocates, Black community-based doulas help address these disparities via unique services not provided by conventional doulas. However, Black doulas themselves may encounter obstacles when providing care to Black perinatal clients. We characterized the barriers encountered by Black community-based doulas in Los Angeles, California.

METHODS

We partnered with a Black community-based doula program to conduct semistructured interviews with its community doulas and program directors, covering the following topics: motivations for becoming a doula, services provided, and challenges faced as a Black doula in perinatal settings. Interview transcripts were reviewed via directed content analysis, with attention to the influence of systemic racism on service provision. Additionally, our research team used Camara Jones' Levels of Racism, which describes race-associated differences in health outcomes to code data.

RESULTS

We interviewed 5 Black community-based doulas and 2 program directors, who all shared experiences of inequitable care and bias against Black clients that could be addressed with the support and advocacy of culturally congruent doulas. The community doulas shared experiences of stigma as Black doulas, compounded by racial prejudice. Interviewees noted sources of structural racism affecting program development, instances of interpersonal racism as they interacted with the health care system, and internalized racism that was revealed during culturally based doula trainings. Additionally, the doulas emphasized the importance of cultural concordance, or a shared identity with clients, which they considered integral to providing equitable care.

CONCLUSION

Despite facing institutionalized, interpersonal, and internalized forms of racism, Black community-based doulas provide avenues for Black birthing individuals to navigate systemic racism experienced during the perinatal process. However, these forms of racism need to be addressed for Black community doulas to flourish.

Supporting Birthing People and Supporting Doulas: The Impact of the COVID-19 Pandemic on a Community-Based Doula Organization in San Francisco

Background

Beginning in March 2020, health care systems in the United States restricted the number of support people who could be present during pregnancy-related care to reduce the spread of COVID-19. We aimed to describe how SisterWeb, a community-based doula organization that employs Black, Pacific Islander, and Latinx doulas in San Francisco, California, adapted to the COVID-19 pandemic.

Methods

As part of process and outcome evaluations conducted through an academic-community partnership, we interviewed SisterWeb doulas, mentors, and leaders in 2020, 2021, and 2022 (n=26 interviews). We identified preliminary themes using the Rapid Assessment Process and then conducted thematic analysis of data related to COVID-19.

Results

SisterWeb leadership remained committed to safeguarding doulas by shifting to virtual support until doulas were onboarded as benefitted employees. Doulas reported hospital policies impacted clients' pregnancy-related care. Initially, doulas adapted to virtual support by connecting with clients more frequently through phone and text. When permitted to meet in person, doulas adjusted to client preference. Finally, as the pandemic impacted doulas' well-being, they turned to mentors for emotional support.

Discussion and Health Equity Implications

This analysis contributes to a growing body of literature describing doulas' experiences during the pandemic. By shifting to virtual support, SisterWeb leaders prioritized the health, safety, and financial stability of doulas, who were members of communities disproportionately impacted by COVID-19. Our findings suggest that public health guidance, organizational COVID-19 precautions, and hospital policies hindered SisterWeb's goal of ensuring clients receive equitable medical care. In addition, we found that emotional support for doulas is vital to their work.

Structural Violence and Stress Experiences of Young Pregnant Black People

INTRODUCTION

Approximately 10-20% of individuals suffer from mental health concerns during the prenatal period due to their vulnerability and emotional responses to stressful events. Mental health disorders are more likely to be disabling and persistent for people of color, and they are less likely to seek treatment due to stigma. Young pregnant Black people report experiencing stress due to isolation, feelings of conflict, lack of material and emotional resources, and support from significant others. Although many studies have reported the types of stressors experienced, personal resources, emotional stress responses on pregnancy, and mental health outcomes, there is limited data on young Black women's perceptions of these factors.

METHODS

This study utilizes the Health Disparities Research Framework to conceptualize drivers of stress related to maternal health outcomes for young Black women. We conducted a thematic analysis to identify stressors for young Black women.

RESULTS

Findings revealed the following overarching themes: Societal stress of being young, Black, and pregnant; Community level systems that perpetuate stress and structural violence; Interpersonal level stressors; Individual level effects of stress on mom and baby; and Coping with stress.

DISCUSSION

Acknowledging and naming structural violence and addressing structures that create and fuel stress for young pregnant Black people are important first steps to interrogating systems that allow for nuanced power dynamics and for recognizing the full humanity of young pregnant Black people.

The Effect of Doulas on Maternal and Birth Outcomes: A Scoping Review

A source of support during birth could be the solution to negative outcomes for the mother and her baby. To improve the birthing experience and increase positive birthing outcomes, sources of support during pregnancy should be evaluated and understood. The goal of this review was to synthesize the existing literature on how doulas might improve birth outcomes. This scoping review also aimed to shed light on the positive impact emotional support during childbirth can have on the health and well-being of mother and child. PubMed and EBSCOhost were used to identify articles using the search words with Boolean operators "doulas" AND "labor support" AND "birth outcomes" AND "pregnancy" AND "effects during labor." The eligibility criteria for article selection included primary studies investigating how doulas contributed to birth outcomes. The studies in this review indicated that doula guidance in perinatal care was associated with positive delivery outcomes including reduced cesarean sections, premature deliveries, and length of labor. Moreover, the emotional support provided by doulas was seen to reduce anxiety and stress. Doula support, specifically in low-income women, was shown to improve breastfeeding success, with quicker lactogenesis and continued breastfeeding weeks after childbirth. Doulas can be a great resource for birthing mothers, and consideration should be given to using them more, as they may have a positive impact on the well-being of the mother and child. This study raised questions about the accessibility of doulas and how they may help mitigate health disparities among women from different socioeconomic levels.

Changes to Birth Plans Due to COVID-19: A Survey of Utah Midwives and Doulas

INTRODUCTION

This study seeks to understand the experiences of Utah midwives and doulas caring for patients during the recent coronavirus disease 2019 (COVID-19) pandemic. Specifically, the goal of the study was to describe the perceived impact on the community birth system and explore differences in the access and use of personal protective equipment (PPE) between in- and out-of-hospital births.

METHODS

This study used a cross-sectional, descriptive study design. A 26-item survey developed by the research team was sent via email to Utah birth workers, including nurse-midwives, community midwives, and doulas. Quantitative data were collected during December 2020 and January 2021. Descriptive statistics were used in the analysis.

RESULTS

Of the 409 birth workers who were sent a link to the survey, 120 (30%) responded: 38 (32%) CNMs, 30 (25%) direct-entry or community midwives, and 52 (43%) doulas. The majority (79%) reported changes to clinical practice during the COVID-19 pandemic. Community midwives (71%) who responded indicated practice volume increased. Survey participants reported an increased patient preference for home births (53%) and birth center births (43%). Among those with one or more patient transfers to the hospital, 61% experienced a change in the process. One participant reported that it took 43 minutes longer to transfer to the hospital. Community midwives and doulas reported poor access to a regular source of PPE.

DISCUSSION

Survey participants reported changes to planned birth locations during the COVID-19 pandemic. When necessary, transfers to hospitals were reported to be slower. Community midwives and doulas reported having insufficient access to PPE and reported limited knowledge about COVID-19 testing resources and resources for educating patients on COVID-19. This study adds an important perspective to the existing literature on COVID-19 by indicating that policymakers should include community birth partners in community planning for natural disasters and future pandemics.

The role of doulas in providing breastfeeding support during the COVID-19 pandemic

BACKGROUND

Doulas have been instrumental in providing breastfeeding support to nursing mothers before and during the COVID-19 pandemic, as they can significantly impact a mother's ability to initiate and maintain breastfeeding. However, the COVID-19 pandemic, subsequent lockdowns, and social isolation created challenges for nursing mothers to access doulas' services, usually provided in person. In this study, we examined the role of doulas in providing breastfeeding support during the COVID-19 pandemic, exploring adaptation to COVID-19 guidelines and the challenges doulas face in providing breastfeeding support during the pandemic.

METHODS

A systematic review was conducted following the PRISMA guidelines. Thirteen scientific databases and twenty peer-reviewed journals were searched for journal articles published in English between January 2020 and March 2022 using key search terms (e.g., Doula, Breastfeeding, COVID-19). Studies evaluating the role of doulas in providing breastfeeding support during COVID-19, and the impact of COVID-19 Guidelines on doula services, were included. Two reviewers independently performed the risk of bias assessment and data extraction. Summative content analysis was used to analyze the data.

RESULTS

The majority of studies were conducted in developed nations. This systematic review includes eight articles, four qualitative, one survey, two mixed-methods studies, and one prospective research study. Seven of the eight studies were conducted in the United States, and the eighth was conducted in multiple countries. These studies have three main themes: (1) virtual breastfeeding support provided by doulas during the pandemic; (2) remote social support provided by doulas to breastfeeding mothers during the pandemic; and (3) barriers to doula service delivery due to COVID-19 restrictions, primarily the exclusion of doulas as essential workers. The eight studies showed that doulas found innovative ways to serve the needs of birthing and nursing mothers during the difficulties brought on by the pandemic.

CONCLUSION

Doulas provided breastfeeding support during the COVID-19 pandemic by utilizing innovative service delivery methods while navigating changes in COVID-19 guidance. However, system-level integration of doulas' work and the acknowledgment of doulas as essential healthcare providers are needed to enhance doula service delivery capacity, especially during a pandemic, to help improve maternal health outcomes.

Birth equity on the front lines: Impact of a community-based doula program in Brooklyn, NY

BACKGROUND

We assessed whether participation in Healthy Start Brooklyn's By My Side Birth Support Program-a maternal-health program providing community-based doula support during pregnancy, labor and delivery, and the early postpartum period-was associated with improved birth outcomes. By My Side takes a strength-based approach that aligns with the doula principles of respecting the client's autonomy, providing culturally appropriate care without judgment or conditions, and promoting informed decision making.

METHODS

Using a matched cohort design, birth certificate records for By My Side participants from 2010 through 2017 (n = 603) were each matched to three controls who also lived in the program area (n = 1809). Controls were matched on maternal age, race/ethnicity, education level, and trimester of prenatal-care initiation, using the simple random sampling method. The sample was restricted to singleton births. The odds of preterm birth, low birthweight, and cesarean birth were estimated, using conditional logistic regression.

RESULTS

By My Side participants had lower odds of having a preterm birth (5.6% vs 11.9%, P < .0001) or a low-birthweight baby (5.8% vs 9.7%, P = .0031) than controls. There was no statistically significant difference in the odds of cesarean delivery.

CONCLUSION

Participation in the By My Side Birth Support Program was associated with lower odds of preterm birth and low birthweight for participants, who were predominantly Black and Hispanic. Investing in doula services is an important way to address birth inequities among higher risk populations such as birthing people of color and those living in poverty. It could also help shape a new vision of the maternal-health system, placing the needs and well-being of birthing people at the center.

Obstetric experiences of young black mothers: An intersectional perspective

BACKGROUND

In Chicago, maternal morbidity and mortality is six times more likely among Black birthing people than white, despite policy initiatives to promote maternal health equity. Disparities in maternal morbidity and mortality reflect experiences of structural inequities - including limited quality obstetric care, implicit bias, and racism resulting patient mistrust in the health care system, inadequate social support, and financial insecurity. Although there is published literature on Black women's experiences with obstetric care, including experiences with individual and structural racism, little is known about the intersection of age and race and experiences with health care. The purpose of this study was to explore the maternal health and pregnancy experiences of young Black women utilizing an intersectional theoretical lens.

METHODS

In this study, we conducted two focus groups in a sample of 11 young Black pregnant people. We conducted a thematic analysis to identify codes, themes, and subthemes of the data.

RESULTS

We developed two overarching themes: obstetric racism and obstetric resistance. To elucidate how obstetric racism framed our participants' healthcare experiences, we identified sub-themes: intersectional identities as young Black women, medical mistrust, and pregnancy trauma. The second major theme describes ways in which participants protected themselves against obstetric racism to engender positive health experiences. These methods of resistance included identifying advocates and relying on trusted providers.

CONCLUSIONS

The current standard of obstetric care in the US is suboptimal due to individual and structural racism. This study provides unique data on the experiences with health care for young, Black pregnant individuals and delivers valuable insight into how individual and structural racism impacts obstetric care for young Black women.

Black women's experiences with professional accompaniment at prenatal appointments

U.S. public health statistics report dismal Black infant and maternal mortality rates. Prenatal care alone, while essential, does not reduce such disparities.

OBJECTIVES

The purpose of the study was to explore Black women's experiences when a perinatal support professional (PSP) accompanies them to prenatal medical appointments.

DESIGN

This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

RESULTS

We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

CONCLUSIONS

Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

IMPaCT: A Pilot Randomized Trial of an Intervention to Reduce Preterm Birth Among Non-Hispanic Black Patients at High Risk

Introduction

Preterm birth is a major cause of neonatal morbidity and mortality rate. Non-Hispanic black patients disproportionately experience preterm birth and nonadherence to evidence-based preventive measures. Interventions tailored to non-Hispanic black birthing individuals (NHBBIs) that address barriers to preterm birth preventions are urgently needed.

Methods

Together with a community-engaged multidisciplinary stakeholder group, we developed an intervention to improve adherence to preterm birth preventions among black pregnant patients with prior preterm birth. The intervention included the following: (1) preterm birth prevention education, (2) an employment navigation toolkit, and (3) encouragement text messages. We piloted the intervention by recruiting self-identified non-Hispanic black patients at or before 20 weeks of gestation with a prior preterm birth and randomizing them to the intervention or an active control. The primary outcomes were feasibility and acceptability. Our secondary outcomes were preliminary efficacy based on birth outcomes, patient experience, and pregnancy-specific anxiety (PSA). Descriptive statistics, analysis of verbatim survey responses, Wilcoxon signed rank, and Fisher's exact were used to describe and compare quantitative and qualitative data.

Results

We identified 53 individuals who met the inclusion criteria, 35 were reachable remotely and 30 were enrolled and randomized. More than 80% (n=26) were retained throughout the study, and 100% of participants identified at least one intervention component as helpful. In this small pilot, there were no detectable differences in adherence to preterm birth preventive recommendations. No difference in preterm births, other pregnancy, or patient experience outcomes was detected between the intervention and active control participants.

Discussion

The intervention is feasible and acceptable. Larger, appropriately powered studies are needed to assess whether the intervention will decrease PSA and reduce preterm birth. This trial was registered with ClinicalTrials.gov (NCT04933812).

"Doulas shouldn't be considered visitors, we should be considered a part of [the] team": doula care in Georgia, USA during the COVID-19 pandemic

Doula support improves maternal-child health outcomes. However, during the COVID-19 pandemic, hospitals restricted the number of support people allowed during childbirth. An academic-community research team conducted 17 in-depth interviews and structured surveys with doulas in metro-Atlanta, Georgia, USA from November 2020 to January 2021. Surveys were analysed for descriptive statistics in Stata v. 14, and interviews were analysed in Dedoose using a codebook and memo-ing for thematic analysis. All 17 doulas reported COVID-19 changed their practices: most were unable to accompany clients to delivery (14), started using personal protective equipment (13), used virtual services (12), and had to limit the number of in-person prenatal/postpartum visits (11). Several attended more home births (6) because birthing people were afraid to have their babies in the hospital. Some stopped seeing clients altogether due to safety concerns (2). Many lost clientele who could no longer afford doula services, and some offered pro bono services. Most doulas pointed to restrictive hospital policies that excluded doulas and disallowed virtual support as they felt doulas should be considered a part of the team and clients should not be forced to decide between having their doula or their partner in the room. COVID-19 has severely impacted access to and provision of doula care, mostly due to economic hardship for clients and restrictive hospital policies. At the same time, doulas and their clients have been resourceful - using virtual technology, innovative payment models, and home births.

EngagINg the COmmunity to Reduce Preterm birth via Adherence To an Individualized Prematurity Prevention Plan (INCORPorATe IP3): intervention development and future pilot study design

OBJECTIVE

Non-Hispanic Black birthing individuals are at increased risk of preterm birth compared to other racial and ethnic groups. In our clinical setting, we offer a tailored package of recommendations to reduce the risk of preterm birth known as an individualized prematurity prevention plan (IP3). Patient-centered, community engaged interventions that address patient-perceived barriers to preterm birth prevention are urgently needed.

MATERIALS AND METHODS

We engaged a group of stakeholders to develop a mutli-level (patient-centered and community-involved) intervention that will increase adherence to an individualized prematurity prevention plan (IP3) by addressing barriers identified during our prior qualitative studies.

RESULTS

The intervention includes trained doulas from a community-led, Black owned doula group. The doulas will moderate group prenatal social support sessions. In between the group sessions, participants will be encouraged to continue interacting with one another and the doulas using a private Facebook™ group page. We will pilot test the intervention in a cohort of pregnant, self-identified non-Hispanic Black patients with a history of prior preterm birth.

CONCLUSION

We present a novel, patient-centered, community engaged intervention to reduce preterm birth in high-risk non-Hispanic Black birthing individuals. If the intervention is feasible based on the pilot study findings, we anticipate conducting an appropriately powered study to determine whether the intervention achieves our goal of reducing preterm birth.

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

BACKGROUND

Despite the tenets of rights-based, person-centered maternity care, racialized groups, low-income people, and people who receive Medicaid insurance in the United States experience mistreatment, discrimination, and disrespectful care more often than people with higher income or who identify as white. This study aimed to explore the relationship between the presence of a doula (a person who provides continuous support during childbirth) and respectful care during birth, especially for groups made vulnerable by systemic inequality.

METHODS

We used data from 1977 women interviewed in the Listening to Mothers in California survey (2018). Respondents who reported high levels of decision making, support, and communication during childbirth were classified as having "high" respectful care. To examine associations between respectful care and self-reported doula support, we conducted multivariable logistic regressions. Interactions by race/ethnicity and private or Medi-Cal (Medicaid) insurance status were assessed.

RESULTS

Overall, we found higher odds of respectful care among women supported by a doula than those without such support (odds ratios [OR]: 1.4, 95% CI: 1.0-1.8). By race/ethnicity, the association was largest for non-Hispanic Black women (2.7 [1.1-6.7]) and Asian/Pacific Islander women (2.3 [0.9-5.6]). Doula support predicts higher odds of respectful care among women with Medi-Cal (1.8 [1.3-2.5]), but not private insurance.

CONCLUSIONS

Doula support was associated with high respectful care, particularly for low-income and certain racial/ethnic groups in California. Policies supporting the expansion of doulas for low-income and marginalized groups are consistent with the right to respectful care and may address disparities in maternal experiences.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care

INTRODUCTION

The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families.

METHODS

Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors).

RESULTS

After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts.

DISCUSSION

The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Veterans' Perinatal Care and Mental Health Experiences During the COVID-19 Pandemic: An Examination of the Role of Prior Trauma and Pandemic-Related Stressors

Background: Many pregnant and postpartum Veterans have experienced multiple lifetime traumas, including military sexual trauma, intimate partner violence, and combat trauma. These women may be particularly vulnerable to increased post-traumatic stress disorder and other mental health problems following additional trauma exposures or stressful events, such as Coronavirus disease 2019 (COVID-19). This study sought to examine the impact of prior trauma exposures on the lived experience of pregnant and postpartum Veterans during the COVID-19 pandemic. Materials and Methods: Pregnant Veterans at 15 VA medical centers were surveyed at 20 weeks of pregnancy and 3 months postpartum asked about their COVID-19-related perinatal and mental health experiences, as well as the stressors that impacted them as a result of the COVID-19 pandemic. Results: Overall, 111 women Veterans completed both the pregnancy and postpartum surveys that included COVID-19 items. Sixty percent of our sample had experienced at least one potentially traumatic lifetime event, with 22% of our sample experiencing two or more of the included exposures. Women with a trauma history had 3.5 times increased odds of reporting their mental health as "much worse" compared to before the COVID-19 pandemic (95% confidence interval [CI]: 1.06-11.75) and were more likely to report that COVID-19 negatively affected their mental or emotional health "a lot" compared with women without a trauma history (odds ratio: 8.5; 95% CI: 1.93-37.48). Conclusions: COVID-19 has had a significant impact on pregnant and postpartum Veterans' mental health. Obstetricians should consider strategies to ensure women have access to mental health care during pregnancy, especially as the COVID-19 pandemic continues. Hospitals should also consider the importance of labor support companions during the COVID-19 pandemic and examine adjusting policies to allow for at least one labor support companion during labor and delivery.

"This work that we're doing is bigger than ourselves": A qualitative study with community-based birth doulas in the United States

CONTEXT

Community-based birth doulas support pregnant women, transgender men, and gender non-binary individuals during the perinatal period and provide essential services and expertise that address health inequities, often taking on additional roles to fill systemic gaps in perinatal care in the United States (US). Despite the benefits that community-based birth doulas provide, there is little research exploring the work-related conditions and stressors community-based doulas experience. To address this gap, we examined the work experiences, related stressors, and stress management strategies of individual community-based birth doulas.

METHODS

In this qualitative, descriptive study we conducted 18 interviews in March through June 2021 with individuals who self-identified as community-based doulas working in underserved communities in the US. We analyzed the interviews for themes, which we defined and finalized through team consensus.

RESULTS

The doulas reported engaging in specific strategies in their work to address perinatal inequities. They also described facing several work-related stressors, including witnessing discrimination against clients, experiencing discrimination in medical environments, and struggling with financial instability. To mitigate these stressors and job-related challenges, interviewees reported they relied on doula peer support and reconnected with their motivations for the work.

CONCLUSIONS

Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided is needed to strengthen and sustain this critical part of the perinatal workforce.

Health Equity Considerations in State Bills Related to Doula Care (2015-2020)

INTRODUCTION

Racial inequities in birth outcomes persist in the United States. Doula care may help to decrease inequities and improve some perinatal health indicators, but access remains a challenge. Recent doula-related state legislative action seeks to improve access, but the prioritization of equity is unknown. We reviewed recent trends in doula-related legislation and evaluated the extent to which new legislation addresses racial health equity.

METHODS

We conducted a landscape analysis of the LegiScan database to systematically evaluate state legislation mentioning the word "doula" between 2015 and 2020. We identified and applied nine criteria to assess the equity focus of the identified doula-related legislative proposals. Our final sample consisted of 73 bills across 24 states.

RESULTS

We observed a three-fold increase in doula-related state legislation introduced over the study period, with 15 bills proposed before 2019 and 58 proposed in 2019-2020. Proposed policies varied widely in content and scope, with 53.4% focusing on Medicaid reimbursement for doula care. In total, 12 bills in 7 states became law. Seven of these laws (58.3%) contained measures for Medicaid reimbursement for doula services, but none guaranteed a living wage based on the cost of living or through consultation with doulas. Only two states (28.6%; Virginia and Oregon) that passed Medicaid reimbursement for doulas also addressed other racial equity components.

CONCLUSIONS

There has been an increase in proposed doula-related legislation between 2015 and 2020, but racial health equity is not a focus among the laws that passed. States should consider using racial equity assessments to evaluate proposed doula-related legislation.

Perspectives on cultural competency and race concordance from perinatal patients and community-based doulas

BACKGROUND

As awareness of perinatal health disparities grows, many birthing people of color are seeking racially and/or culturally concordant providers. We described preferences for, and perceptions of, racial and/or cultural concordance and cultural competence in the context of the doula-client relationship.

METHODS

Seven focus group discussions (FGDs) with a total of 27 participants were conducted to investigate the perspectives of patients and doulas across Massachusetts, United States. An interdisciplinary stakeholder group informed the data collection instrument content and design. Two coders achieved 0.89 Kappa for inter-rater reliability prior to coding the remaining transcripts. We used a modified grounded theory approach and Dedoose software for coding.

RESULTS

Two major themes emerged. First, cultural competency in doula care is a learning process, with definitions consistent with terms such as "cultural humility" and "structural competency." Doulas discussed listening to clients' needs rather than making assumptions, the importance of understanding privilege and power dynamics, and self-initiating relevant education beyond formal doula training. Second, trust was most frequently cited as an indicator of successful doula-patient relationships.

CONCLUSIONS

Most study participants specified the importance of cultural humility in doula-client relationships. Doulas approaching the relationship humbly with a willingness to learn and challenge their own assumptions-regardless of the level of concordance-can make a meaningful impact on the perinatal experience.

Health Workforce Challenges Impact the Development of Robust Doula Services for Underserved and Marginalized Populations in the United States

Evidence of doulas' positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations' barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities.

Spontaneous Miscarriage Management Experience: A Systematic Review

Background: The estimated frequency of spontaneous miscarriage is about a quarter of all clinically identified pregnancies in the United States. Women typically go to the emergency department (ED) or outpatient clinic when they experience symptoms, including but not limited to vaginal bleeding, abdominal pain, and contractions. The care that is provided varies from place to place.

Methods: Researchers searched articles from 2010 to 2021 for reports mentioning treatment for spontaneous abortion. Search terms included "miscarriage aftercare" and "spontaneous abortion care," seeking articles addressing the psychological effects of miscarriage and reporting patient experiences in different clinical settings. Data were independently reviewed, graded for evidence quality, and assessed for risk bias using the AMSTAR checklist.

Results: The search strategy yielded 2,275 articles, six of which met the inclusion criteria. Conservative, medical, and surgical management were provided, with surgical management being more common among women with higher education and socioeconomic status. All qualitative studies reported dissatisfaction with care provided in the emergency department, partially due to a lack of emotional support. Structured bereavement intervention was beneficial for women experiencing early pregnancy loss and led to fewer reports of despair. The quantitative studies referenced interventions that aided patients in coping with pregnancy loss and identified several factors influencing the type of treatment received as well as the patient's ability to cope with feeling depressed following a miscarriage.

Conclusion: Psychological management is not regularly addressed in the emergency department, and protocols including bereavement education for healthcare providers as well as patient involvement in management would improve the overall patient experience with spontaneous miscarriage care.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

PURPOSE

The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.

METHODS

Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.

RESULTS

While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.

CONCLUSION

This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

The effect of backup midwife on maternal experience after vaginal childbirth - a qualitative study

One of the goals of reproductive health enhancement is to ensure the desired experience of safe childbirth by reducing possible complications, fears, and worries about delivery by ongoing midwife backup care. This study explains women's experiences with a backup midwife during labor and childbirth. This was a qualitative study involving 19 women who had natural childbirth in Hamadan, 2020. Purposeful sampling and data collection were performed using semi-structured in-depth interviews. Data were analyzed by conventional content analysis using MAXQDA software version 10. Data analysis showed three themes and six main categories. The themes included security, high-quality care, and respectful care, consisting of two main categories of perceived empowerment and support, physiological approach and reassuring care, and respect for the mother's privacy and optimal accountability. The presence of a backup midwife during labor caused a sense of security, control, and perceived empowerment, thus a positive childbirth experience. Therefore, it is necessary to train and employ midwifery in the healthcare system. It is recommended to train and employ midwifery graduates for this purpose and include it as one of the basic principles in the current planning to promote natural childbirth.

A Mixed-Methods Study of Experiences During Pregnancy Among Black Women During the COVID-19 Pandemic

Pregnant women experienced disruptions in their prenatal care during the coronavirus disease-2019 (COVID-19) pandemic. While there is emerging research about the impact of COVID-19 on experiences of pregnancy, the majority of studies that have reported on prenatal care and birth during COVID-19 have not incorporated the first-person accounts of Black women. The purpose of this mixed-methods study was to explore the perspectives of Black women on prenatal care, labor, and birth during the pandemic. A total of 33 participants completed questionnaires. Fourteen of these 33 women and an additional 2 participated in qualitative interviews. Descriptive statistics and a mixed-methods analysis were employed. Participants expressed disappointment about disruptions in their experiences of pregnancy including the way their prenatal care was experienced, cancellation of planned "rites of passage," and visitor policy restrictions during and after the birth. Forty-five percent of participants reported being worried about getting COVID-19 and (61%) about their infant getting COVID-19. Many participants experienced a sense of loss that may permeate through other aspects of their lives. Providing extra support and points of contact can help lessen feelings of isolation during the pandemic and can also offer more explanation for rapidly changing policies and procedures.

Salary and Workload of Midwives Across Birth Center Practice Types and State Regulatory Structures

INTRODUCTION

Expansion of the midwifery-led birth center model of care is one pathway to improving maternal and newborn health. There are a variety of practice types among birth centers and a range of state regulatory structures of midwifery practice across the United States. This study investigated how those variations relate to pay and workload for midwives at birth centers.

METHODS

Data from the American Association of Birth Centers Practice Survey and the Bureau of Labor Statistics' report on occupational employment and wage statistics were analyzed to explore how midwife salaries and workload at birth centers compare within and beyond the birth center model.

RESULTS

Survey results from 161 birth centers across the United States demonstrate wide variation in nurse-midwife salaries and are inconsistent with nurse-midwife salaries across all settings as reported by the Bureau of Labor Statistics. The reported number of hours worked by midwives within the birth center model is high. Salaries of midwives who work in birth center-only practices were consistently lower than salaries of midwives who worked in blended birth center and hospital practices, independent of the midwife's level of experience, geographic region of the country, and state regulatory structure.

DISCUSSION

Further research is needed to understand how to bring salaries and workload for midwives at birth centers into alignment with national averages.

Female Relatives as Lay Doulas and Birth Outcomes: A Systematic Review

Continuous labor support provided by professional doulas is associated with improved birth outcomes for pregnant women and their infants. However, there is limited data on the impact of using female relatives as lay doulas. This systematic review included nine published studies that examined the association between use of female relatives as lay doulas with childbirth outcomes. In some study populations, there was a decrease in the number of cesarean births and length of labor, and in all studies, there was improved maternal birth satisfaction. However, the woman’s chosen female relative often did not receive education regarding labor support skills before providing continuous support. Educational programs designed to teach labor support skills to female relatives are needed.

Current Resources for Evidence-Based Practice, March 2022

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South

Few studies have illustrated how racism influences Black women's use of reproductive health care services. This article presents findings of a collaborative study conducted by a research team and a reproductive justice organization to understand Black women's concerns with sexual and reproductive health services. The qualitative research was conducted with Black women living in Georgia and North Carolina, using a community-based participatory research approach. Themes were developed from participant accounts that highlight how racism, both structural and individual, influenced their reproductive health care access, utilization, and experience. Structural racism affected participants' finances and led some to forgo care or face barriers to obtaining care. Individual racism resulted in some women electing to receive care only from same-race medical providers. These findings suggest a need for policies and practices that address structural barriers to reproductive health care access and improve the reproductive health experience of Black women.

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States

Purpose: Birth doulas support pregnant people during the perinatal period. Evidence of doulas' positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services.

Methods: In addition to literature and policy reviews, we conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making. We analyzed data using qualitative analysis software to identify cross-cutting themes.

Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement.

Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

The need for sustainable funding for Indigenous doula services in Canada

Objectives:

To interview representatives from Indigenous doulas across Canada in order to document how they manage the logistics of providing community-based doula care and understand their challenges. These objectives inform the development of an Indigenous doula pilot programme as part of the project, ‘She Walks With Me: Supporting Urban Indigenous Expectant Mothers Through Culturally Based Doulas’.

Methods:

In 2020, semi-structured interviews were conducted with members of five Indigenous doula collectives across Canada. Interview transcripts were approved by participants and subsequently coded by the entire research team to identify key themes.

Results:

Our article explores one of the main themes that emerged from these interviews: sustainable funding for Indigenous doula services. Within this theme we identified two sub-themes: (1) limitations on and regulations for available funding and (2) negative impacts of limited funding on doula service.

Conclusion:

A major challenge to providing Indigenous community-based doula services is sustainable funding. Current models of funding for this work often do not provide livable wages and are bound by limited durations and regulations that are unsustainable and can be culturally inappropriate. Due to this lack of sustainable funding, Indigenous doula service in Canada faces challenges that include high staff turnover and burnout and lack of time and resources to provide culturally safe care, pursue professional development and additional training, and keep their services affordable for the families who need them. Future research is needed to ascertain potential programmes and funding streams for sustainable Indigenous doula support in Canada, including possible integration of doula care into the universal public health care system despite the jurisdictional challenges in providing health care for Indigenous peoples.

Community Perspectives on the Creation of a Hospital-Based Doula Program

Objective: Racial and ethnic inequities in perinatal health outcomes are pervasive. Doula support is an evidence-based practice for improving maternal outcomes. However, women in lower-income populations often do not have access to doulas. This study explored community perspectives on doula care to inform the development of a hospital-based doula program to serve primarily low-income women of color.

Methods: Four focus groups and four individual interviews were conducted with: (1) women who were pregnant or parenting a child under age 2 (n=20); (2) people who had provided support during a birth in the previous 2 years (n=5); and (3) women who had received doula training (n=4).

Results: Participants had generally positive perceptions of doula services. Many aspects of doula support desired by participants are core to birth doula services. Participants identified ways that doulas could potentially address critical gaps in health care services known to impact outcomes (e.g., continuity of care and advocacy), and provide much-needed support in the postpartum period. Responses also suggested that doula training and hospital-based doula programs may need to be adapted to address population-specific needs (e.g., women with substance use disorder and younger mothers). Novel program suggestions included “on call” informational doulas.

Conclusions: Findings suggested that women in racial/ethnic minority and lower income groups may be likely to utilize a hospital-based doula program and identified adaptations to traditional doula care that may be required to best meet the needs of women in groups with higher risk of poor maternal health and birth outcomes.

Group Prenatal Care and Emergency Room Utilization

Pregnancy-related complaints are a significant driver of emergency room (ER) utilization among women. Because of additional time for patient education and provider relationships, group prenatal care may reduce ER visits among pregnant women by helping them identify appropriate care settings, improving understanding of common pregnancy discomforts, and reducing risky health behaviors. We conducted a retrospective cohort study, utilizing Medicaid claims and birth certificate data from a statewide expansion of group care, to compare ER utilization between pregnant women participating in group prenatal care and individual prenatal care. Using propensity score matching methods, we found that group care was associated with a significant reduction in the likelihood of having any ER utilization (-5.9% among women receiving any group care and -6.0% among women attending at least five group care sessions). These findings suggest that group care may reduce ER utilization among pregnant women and encourage appropriate health care utilization during pregnancy.