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

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.

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.

Adapting the Role of Doulas to Enhance Supports for Perinatal People with Substance Use Disorders

PURPOPSE

There is a gap in the current literature regarding how doula care may be implemented into existing systems in Montana to best address the needs of individuals with substance use disorders (SUDs) during the perinatal period. Doulas may be particularly well positioned to reach a diverse range of patients, allowing them to feel supported and advocated for within the medical system. This study aims to illustrate the perspectives and experiences of doulas, individuals who have experienced perinatal SUDs, and maternal and mental health providers.

MATERIALS AND METHODS

A qualitative descriptive research methodology was used to conduct qualitative semi-structured interviews with 29 participants.

RESULTS

Through these interviews, three overarching themes emerged: the necessity of doula workforce development to enhance sustainability when working with individuals with SUDs; reducing financial and structural barriers that prevent clients with SUDs from accessing doula care; and working to promote the acceptability of SUD-focused doulas in the healthcare system.

DISCUSSION AND CONCLUSION

These findings highlight areas of possible intervention to broaden the use of doulas for perinatal individuals with SUDs.

Utilizing machine learning to predict the risk factors of episiotomy in parturient women

Background

Episiotomy has specific indications that, if properly followed, can effectively prevent women from experiencing severe lacerations that may result in significant complications like anal incontinence. However, the risk factors related to episiotomy has been the center of much debate in the medical field in the past few years.

Objective

The present study used a machine learning model to predict the factors that put women at the risk of having episiotomy using intrapartum data.

Study design

This was a retrospective cohort study design. Factors such as age, educational level, residency place, medical insurance, nationality, attendance at prenatal education courses, parity, gestational age, onset of labor, presence of a doula during labor, maternal health conditions like anemia, diabetes, preeclampsia, prolonged rupture of membrane, placenta abruption, presence of meconium in amniotic fluid, intrauterine growth retardation, intrauterine fetal death, maternal body mass index, and fetal distress were extracted from the electronic health record system of a tertiary-care medical center in Iran, from January 2022 to January 2023. The criteria for inclusion were vaginal delivery of a single pregnancy. Deliveries done through scheduled/emergency cesarean section or at the mother's request were excluded. The participants were divided into two groups: those who had vaginal deliveries with episiotomy and those who had vaginal deliveries without episiotomy. The significant variables, as determined by their P-values, were selected as features for the eight machine-learning models. The evaluation of performance included area under the curve (AUC), accuracy, precision, recall, and F1-Score.

Results

During the study period, out of 1775 vaginal deliveries, 629 (35.4%) required an episiotomy. Each model had an AUC value assigned to it: linear regression (0.85), deep learning (0.82), support vector machine (0.79), light gradient-boosting (0.79), logistic regression (0.78), XGBoost classification (0.77), random forest classification (0.76), decision tree classification (0.75), and permutation classification-knn (0.70). Linear regression had a better diagnostic performance among all the models with the area under the ROC curve (AUC): 0.85, accuracy: 0.80, precision: 0.74, recall: 0.86, and F_1 score: 0.79). Parity, labor onset, gestational age, body mass index, and doula support were the leading clinical factors related to episiotomy, according to their importance rankings.

Conclusions

Utilizing a clinical dataset and various machine learning models to assess the risk factors of episiotomy resulted in promising results. Further research, focusing on intrapartum clinical data and perspectives of the birth attendant, is necessary to enhance the accuracy of predictions.

Finding My Way: Black Doulas' Communication with Other Birthing Care Providers in an Interprofessional Work Environment

Black women suffer more complications and birthing harms compared to other race-ethnic groups. Even when birthing equity initiatives are implemented, many Black families choose to work with a Black doula to reduce harms linked to obstetric racism. Most Black doulas described their role as helping women have the kind of birth they want; however, problems doulas experience in communicating with other birthing team members are not well understood. Situated in the interprofessional team communication model, this study asked fifty Black doulas to respond to two open-ended questions about their communication experiences with other birthing care providers. Thematic analysis identified six themes including efforts to establish legitimacy as a doula, responding to provider use of power strategies, negotiating roles and responsibilities on the birthing team, conflict from difference in birthing philosophies, impact of hospital regulation of doulas on their practice, and how doula advocacy was conducted. While Black doulas reported successful communication with other providers, they also described microaggressions experienced from members of predominantly White birthing teams. Preemptive communication strategies that doulas used to encourage other birthing team members to accept them onto the team were identified. Suggestions for how Black doulas can be more fully integrated into birthing teams were also presented.

The system can change: a feasibility study of a doula-clinician collaborative at a large tertiary hospital in the United States

BACKGROUND

Doulas, non-clinical professionals who provide support throughout the perinatal period, can positively impact patient experiences and clinical outcomes during birth. Doulas often support hospital-based births without being employed by the hospital system, resulting in varied relationships with hospitals and clinicians. Systems-level changes are needed to maximize collaboration between hospitals and doulas to ensure facilitation of, and not barriers to, doula support. We implemented and evaluated a new program, called the "Supportive Birth Collaborative," to maximize effectiveness of doula support in hospital settings.

METHODS

We conducted a single-site feasibility study of the use of implementation mapping to make systemic changes to clinician-doula collaboration for labor and delivery. Implementation mapping consisted of five steps: developing a collaborative of program implementers and knowledge holders, conducting a needs assessment, developing a logic model, applying implementation strategies, and evaluating changes in outcomes. To evaluate change, process data were collected throughout, and implementation outcomes were measured in 2022 and again after one year of implementation via online surveys to all clinicians who provided labor and delivery care. Descriptive statistics were calculated and change over time was analyzed in Stata using log-binomial regression models with clustering to account for respondents who completed both surveys.

RESULTS

The "Supportive Birth Collaborative" (SBC) was founded in November 2021. The first meeting included 19 people, who were obstetricians, anesthesiologists, nurses, doulas, students, social workers, administrators, researchers, and individuals who had given birth at the study hospital. From 2022-2023, the SBC adopted 11 implementation strategies and piloted or fully implemented 10 of them. Implementation strategies ranged from making training dynamic, to changes in the physical environment, to changes in formal policy. In 2022, 104 clinicians participated in the survey; 97 participated in 2023. There was significant improvement in clinician-reported trust in doulas (0.23, 95% CI: 0.12, 0.34) and doula-clinician communication (0.25, 95% CI: 0.12, 0.38). Clinicians had a limited understanding of the doula's role, and that understanding did not significantly improve.

CONCLUSIONS

Using implementation mapping as a guide to collaborative work can lead to meaningful health system changes. Regular review of implementation outcomes could allow for adaptation and tailoring of implementation strategies.

Commentary on the Adaptive Significance of Sociality Around Parturition Events, and Conspecific Support of Parturient Females in Some Social Mammals

In recent decades, it has become apparent that during parturition events in a number of social mammals, social support behaviours from group mates can be directed to parturient females (and their newborn neonates). Such behaviour has been documented in diverse taxa, across non-human primates, Elephantidae, Cetacea, and Chiroptera, living in a range of social group organisations, from matrilineal groups to cooperatively breeding groups and multi-male, multi-female groups. Since sociality, in association with parturition, has been demonstrated to confer several health benefits to human mothers and neonates, here, we also consider the potential adaptive significance of social support behaviours for other, non-human, social mammals. If appropriate social environments reduce a parturient female's dystocia risk and improve her responsiveness to her neonate following a successful birth, then the impacts of the peri-parturient social environment may ultimately have far-reaching impacts on the mother-neonate dyad's fitness. This seems a logical sequela since the health condition of a neonate at birth and the successful establishment of a strong maternal-neonate bond are often the most critical factors influencing mammalian offspring survival to independence. The principles of kin selection and alliance enhancement may serve to explain the fitness benefits to individuals who support group mates during their parturition and thus the selective advantage conferred to those exhibiting such behaviours. Older, multiparous females appear to hold a particularly important role in the assistance they can provide during the parturition of their group mates, given their greater level of experience of these events. Furthermore, a social birth may have an important influence on horizontal information transfer within a group. In particular, in long-lived, cognitively advanced social mammals (e.g., non-human primates, Elephantidae, Cetacea), witnessing birth events, early neonate responses, and maternal care, and engaging in allomaternal care with young neonates may be essential for nulliparous females' normal development. Such events may serve to prepare them for their own parturition and may improve their own parturition-related survivorship and that of their first-born offspring. Thus, it is vital that a better understanding is gained of the importance and salient features of social births in improving the health and survivorship outcomes for both the mother and her offspring in highly social species. The aim of this commentary is to assemble our current understanding of these highly interconnected themes. We suggest in the future, insights gained through observation of non-human social parturition in domestic and non-domestic species, by a wide and highly interdisciplinary range of stakeholders (including zookeepers, wildlife tourism guides, breeders of domestic animals, indigenous people, and ethologists), will be critical for enhancing our understanding of the influence of social environment on this rarely witnessed, yet highly important life event.

Promoting Maternal Health in the Postpartum Period to Advance Birth Equity

Black birthing people experience lower rates of postpartum follow-up care. The objective of this study was to examine factors associated with postpartum follow-up care and explore suggestions for improving the quality and experience of care during the postpartum period. A survey was conducted among Black birthing people in the Boston area who had delivered an infant within two years of the study. Our survey comprised the Jackson, Hogue, Phillips Contextualized Stress Measure (JHPCSM), the Power as Knowing Participation in Change Tool (PKPCT), and demographic questions. One hundred and twenty-one self-identified Black birthing people completed the survey. One-third of participants did not attend their postpartum appointment. Those with public insurance, an educational level of less than a college degree, or were working outside the home were significantly less likely to have a postpartum follow-up visit. Participants who attended postpartum visits had higher scores on the JHPCSM (lower stress) and PKPCT. Inability to take time off from work, COVID-19 concerns, and lack of childcare were the most frequently reported barriers to attending appointments. There is a need for better institutional and policy support for Black parents in the postpartum period.

Brain care bundles applied over each and successive generations

Worldwide polycrises continue to challenge the World Health Organization's proposed 2030 sustainable development goals. Continuity of brain care bundles helps attain these goals by sustaining brain health over successive generations. Factors representing social drivers of health must incorporate transdisciplinary care into equitable intervention choices. Drivers are more effectively addressed by combining maternal and pediatric assessments to address morbidity and mortality across each lifespan. Care bundles comprise at least three evidenced-based interventions collectively implemented during a clinical experience to achieve a desired outcome. Synergy among stakeholders prioritize communication, responsibility, compliance and trust when choosing bundles in response to changing clinical conditions. A prenatal transdisciplinary model continues after birth with infant and family-centered developmental care practices through discharge to supplement essential skin-to-skin contact. Fetal-neonatal neurology training encourages participation in this model of brain health care to more effectively choose neurodiagnostic and neuroprotective options. Shared clinical decisions evaluate interventions from conception through the first 1000 days. At least eighty percent of brain connectivity will have been completed during this first critical/sensitive period of neuroplasticity. The developmental origins of health and disease concept offers neurology subspecialists a life-course perspective when choosing brain health strategies. Toxic stressor interplay from reproductive and pregnancy diseases and adversities potentially impairs embryonic, fetal and neonatal brain development. Continued exposures throughout maturation and aging worsen outcome risks, particularly during adolescence and reproductive senescence. Intragenerational and transgenerational use of care bundles will guide neuromonitoring and neuroprotection choices that strengthen preventive neurology strategies.

Perceptions of Rural Access to Prenatal Care in the United States by Patients, Nurses, Midwives, and Physicians: An Integrative Review

BACKGROUND

Despite substantial investments in maternity care, the United States continues to experience higher maternal mortality rates than most high-income countries. Rural regions lack adequate prenatal care services, a contributing factor to disparate maternal health outcomes.

METHODS

This integrative review on patient, nurse, midwife, physician, and community perspectives on accessing prenatal care in rural areas of the United States follows Whittemore and Knafl's integrative review framework, including a systematic literature search in various databases from January 1, 2010, to May 1, 2024. Eligible articles were published in English, peer-reviewed, and focused on subjective accounts of accessing prenatal care in rural areas of the United States. Seven articles met inclusion criteria and were assessed for quality using the Joanna Briggs Institute checklists.

RESULTS

Three major categories influencing access to prenatal care in rural areas were developed. Individual factors included transportation, family support, motivation, and work commitments. Socioeconomic factors encompass health insurance, rurality, income, and housing. System factors involved the qualities of nurses, midwives, physicians, the clinic environment, and collaboration within the health care system. The findings emphasized the complexity of rural prenatal care access.

CONCLUSIONS

Understanding patient and care giver perspectives on accessing prenatal care in rural areas is crucial for addressing the factors influencing maternal outcomes. Rural pregnant women face unique challenges, contributing to an increased risk of maternal morbidity and mortality. Further research is needed to explore their experiences and develop interventions to improve access and outcomes in rural areas.

Models of care: Opportunities and challenges

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

Recommendations for Integrating Traditional Birth Attendants to Improve Maternal Health Outcomes in Low- and Middle-Income Countries

Adverse maternal health outcomes and high rates of maternal mortality continue to disproportionately affect low- and middle-income countries (LMICs). With limited access to health facility care, many women in LMICs rely on traditional birth attendants (TBAs) to meet their maternal health needs. While some studies consider the use of TBAs to be problematic, others suggest the integration of TBAs into maternal healthcare to improve health outcomes. The aim of this study is to utilize extant research to provide recommendations for optimizing the role of TBAs in maternal healthcare in Haiti, a LMIC. Each recommendation builds upon previous global health research, programmatic work, and a series of research studies conducted in Haiti to better understand and improve maternal healthcare in low-resource settings. Recommendations for integrating TBAs in maternal health include: (1) Integrate TBAs throughout prenatal, perinatal, and postpartum care to provide culturally relevant physical and emotional support to mothers; (2) Build capacity among TBAs to identify high-risk situations and link patients to care; (3) create TBA-led efforts to improve coordination and care; (4) Establish a collaborative pipeline from TBAs to facility-based care; and (5) create inclusive facility environments for TBAs to help reduce medical mistrust among patients. TBAs occupy an important role in the maternal health of women in LMICs and have the potential to contribute toward improved maternal health outcomes. The recommendations provided herein can be used to aid practitioners and researchers in reducing maternal morbidity and mortality globally.

Assessing the Impact of a Culturally Congruent Perinatal Home-Visiting Program on Gestational Age at Delivery for Black Women

Purpose

There is a Black maternal health crisis in America, with significant racial disparities in birth outcomes for Black women in Washington, DC. Programs designed to reduce these inequities must intentionally address the role of systemic racism and the ongoing legacy of oppression that is endemic to traditional perinatal care services. This article describes the findings from the quantitative analysis of an innovative perinatal program (Mothers Rising) designed by and for Black women in the Washington, DC, metropolitan area that was part of a larger mixed methods study.

Methods

Using data provided by a Medicaid managed care organization that insured program participants and women who did not receive Mothers Rising, program participants (n = 102) were matched with a group of Black women who did not receive the program (n = 102) using propensity scores matching. Perinatal outcomes were extracted from electronic health records from the managed care dataset, including birth weight and gestational age.

Results

Statistical analyses of the differences in birth outcomes between program participants and their matched peers demonstrated small but statistically significant differences in gestational age, favoring the Mothers Rising group.

Conclusions

This study adds to the evidence base for the effectiveness of culturally tailored interventions to successfully address persistent racial disparities in Black women's perinatal health outcomes that result from persistent racism. Hyperlocal, community-developed home-visiting programs, such as Mothers Rising, should be funded to sustain impact and optimize maternal health outcomes.

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024)

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Perinatal and Postpartum Health Among People With Intellectual and Developmental Disabilities

Importance

Small, geographically limited studies report that people with intellectual and developmental disabilities (IDD) have increased risk for serious pregnancy-related and birth-related challenges, including preeclampsia, preterm birth, and increased anxiety and depression, than their peers. United States-based population-level data among people with IDD are lacking.

Objectives

To identify perinatal and postpartum outcomes among a national, longitudinal sample of people with IDD enrolled in public health insurance, compare subgroups of people with IDD, and compare outcomes among people with IDD with those of peers without IDD.

Design, Setting, and Participants

This retrospective cohort study used national Medicaid claims from January 1, 2008, to December 31, 2019, for 55 440 birthing people with IDD and a random sample of 438 557 birthing people without IDD. Medicaid funds almost half of all births and is the largest behavioral health insurer in the US, covering a robust array of services for people with IDD. Statistical analysis was performed from July 2023 to June 2024.

Exposure

People who had a documented birth in Medicaid during the study years.

Main Outcome and Measures

Perinatal outcomes were compared across groups using univariate and multivariate logistic regression. The probability of postpartum anxiety and depression was estimated using Kaplan-Meier and Cox proportional hazards regression.

Results

The study sample included 55 440 birthing people with IDD (including 41 854 with intellectual disabilities [ID] and 13 586 with autism; mean [SD] age at first delivery, 24.9 [6.7] years) and a random sample of 438 557 birthing people without IDD (mean [SD] age at first delivery, 26.4 [6.3] years). People with IDD were younger at first observed delivery, had a lower prevalence of live births (66.6% vs 76.7%), and higher rates of obstetric conditions (gestational diabetes, 10.3% vs 9.9%; gestational hypertension, 8.7% vs 6.1%; preeclampsia, 6.1% vs 4.4%) and co-occurring physical conditions (heart failure, 1.4% vs 0.4%; hyperlipidemia, 5.3% vs 1.7%; ischemic heart disease, 1.5% vs 0.4%; obesity, 16.3% vs 7.4%) and mental health conditions (anxiety disorders, 27.9% vs 6.5%; depressive disorders, 32.1% vs 7.5%; posttraumatic stress disorder, 9.5% vs 1.2%) than people without IDD. The probability of postpartum anxiety (adjusted hazard ratio [AHR], 3.2 [95% CI, 2.9-3.4]) and postpartum depression (AHR, 2.4 [95% CI, 2.3-2.6]) was significantly higher among autistic people compared with people with ID only and people without IDD.

Conclusions and Relevance

In this retrospective cohort study, people with IDD had a younger mean age at first delivery, had lower prevalence of live births, and had poor obstetric, mental health, and medical outcomes compared with people without IDD, pointing toward a need for clinician training and timely delivery of maternal health care. Results highlight needed reproductive health education, increasing clinician knowledge, and expanding Medicaid to ensure access to care for people with IDD.

Medicaid Reimbursement for Doula Care: Policy Considerations From a Scoping Review

Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.

New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care

Background

In 2023, the World Health Organization (WHO) published a Global Position Paper on Kangaroo Mother Care (KMC), which is applicable to all countries worldwide: from the moment of birth, every "small and sick" newborn should remain with mother in immediate and continuous skin-to-skin contact (SSC), receiving all required clinical care in that place. This was prompted by the startling results of a randomized controlled trial published in 2021: in which 1,609 infants receiving immediate SSC were compared with 1,602 controls that were separated from their mothers but otherwise received identical conventional state-of-the-art care. The intervention infants showed a 25% reduction in mortality after 28 days.

New perspectives

The new WHO guidelines are a significant change from earlier guidance and common clinical practice. The author presents that separating mothers and babies is assumed to be "normal" (a paradigm) but actually puts newborns at increased risk for morbidity and mortality. The author presents arguments and ethical perspectives for a new perspective on what is "normal," keeping newborns with their mothers is the infant's physiological expectation and critical requirement for healthy development. The author reviews the scientific rationale for changing the paradigm, based on synchronous interactions of oxytocin on both mother and infant. This follows a critique of the new policies that highlights the role of immediate SSC.

Actionable recommendations

This critique strengthens the case for implementing the WHO guidelines on KMC for small and sick babies. System changes will be necessary in both obstetric and neonatal settings to ensure seamless perinatal care. Based on the role of oxytocin, the author identifies that many current routine care practices may actually contribute to stress and increased vulnerability to the newborn. WHO has actionable recommendations about family involvement and presence in newborn intensive care units.

Discussion

The concepts of resilience and vulnerability have specific definitions well known in perinatal care: the key outcome of care should be resilience rather than merely the absence of vulnerability. Newborns in all settings and contexts need us to re-evaluate our paradigms and adopt and implement the new WHO guidelines on KMC in perinatal care.

Effects of Doula Care on Mother and Infant Health Outcomes in Al-Ahsa Region, Saudi Arabia: A Retrospective Cohort Study

Introduction Continued supportive care during childbirth may be the key to preventing unfavorable outcomes for both mother and child. It is important to assess and comprehend the sources of assistance available during pregnancy in order to enhance the birthing process and promote favorable outcomes. Objectives The current study aimed to assess the impact of ongoing doula support on mother and infant health outcomes compared to standard care. Methods A retrospective cohort study using both medical records and direct interviews based on information in the data collection form was carried out in the Eastern Province of Saudi Arabia, Al-Ahsa Region. The data that were collected included demographic information, obstetric history, delivery data, and postpartum outcome. Results A total of 50 pregnant women receiving doula care and 100 pregnant women receiving standard care were included. Regarding the mode of delivery, 43 (86%) of the doula group had vaginal deliveries compared to 73 (73%) of the standard care group, while CSs were needed for seven (14%) and 27 (27%), respectively (P = 0.78). Only seven (14%) neonates in the doula group required neonatal intensive care unit admission, versus 22 (22%) in the standard care group (P = 0.246). Additionally, initial breastfeeding within the golden hour occurred in 27 (54%) of the doula group compared to 16 (16%) of the standard care group, while exclusive breastfeeding was reported in 32 (64%) of the doula group compared to 26 (26%) of the standard care group (P < 0.001). Conclusion The current study showed more advantageous delivery and postpartum outcomes among doula care women and their infants compared to standard care, mainly for increasing the rate of initiated breastfeeding within the golden hour, exclusive breastfeeding, and reducing postpartum depression.

The Implementation of a Doula Grant Program Directed at Families from Economically Vulnerable Backgrounds: A Process Evaluation

Purpose

The purpose of this study was to evaluate the process and overall feasibility of a doula grant program for expectant families from economically vulnerable backgrounds.

Design

A mixed-methods process evaluation framework was utilized to examine program feasibility and focused on constructs related to fidelity, dose delivered/dose received, reach, program satisfaction, and limited efficacy testing.

Measures

Evaluation constructs were measured using a program tracking document. Program satisfaction and efficacy were examined through a mixed methodology approach utilizing doula surveys and birthing parent interviews.

Analysis

Related to survey data, analysis focused on presenting descriptive counts and percentages related to the number of doulas that participated and clients served. Continuous variables were calculated as means and standard deviations and categorical data as counts and percentages. Qualitative data analyses were conducted using a structured deductive thematic approach.

Results

The grant program was successfully implemented over an 18-month period, and the program had a high rate of fidelity to the grant processes developed by a Midwestern-based nonprofit organization. The program was satisfactory to doulas and parents, and the largest barrier was communication. A high incidence of prenatal anxiety among the birthing parents was reported. Thematic findings from the birthing parent interviews included the following: the grant application process was effective and easy, birth doulas were greatly valued, and a financial burden was lifted.

Conclusion

This grant process can be replicated by other organizations seeking to fill a gap between doula services and the economically vulnerable.

Advancing Equity in Maternal Health With Virtual Doula Care

This Viewpoint reviews the advantages and limitations of virtual doula services and discusses their potential to address the maternal health crisis.