This post is part of “Inequities in Maternal Mortality in the U.S.,” a blog series hosted by the MHTF.
As is true worldwide, strategies to improve U.S. maternal health are widely known but remain unavailable to many women. New York City (NYC), known for its prestigious medical schools and high quality specialty care, is no exception to these disparities.
Statistics signal the need for change. The maternal mortality ratio in NYC has exceeded the national average for 40 years and racial disparities in pregnancy-related deaths also surpass national rates. Newly released department of health data show that from 2006 through 2010, black women in NYC were 12 times as likely to suffer a pregnancy-related death as white women (56.3 vs. 4.7 deaths per 100,000 live births), and Latinas and Asian American/Pacific Islander women faced three and four times the risk of white women, respectively. Black women’s cesarean rates (38.2%) in 2013 were one-third higher than that of white women (28.8%), and rates for all population groups were more than double the 10-15% rate recommended by the WHO, a rate shown to prevent the greatest number of maternal and newborn deaths while preventing the greatest number of complications.
Childbirth care needs to be improved—not through the high-tech, high-cost care at which the US excels—but through low-tech, high-touch approaches that are proven to serve most healthy women well. One strategy to mitigate over-medicalization; elevate women’s voices; and ensure families’ needs, values, and preferences are respected, is to expand access to doula support, especially for those women who need it most. Doula support—non-clinical, emotional, physical, and informational support before, during, and after birth—results in better health outcomes for women and babies, fosters women’s engagement in their care and patient satisfaction, and has the potential to reduce spending on unnecessary and unwanted medical procedures.
Community-based, publicly funded doula support for women in underserved communities has the potential to reduce disparities by addressing the needs of women at the greatest risk of poor outcomes. By training and hiring doulas from priority communities, community-based programs allow high-risk women access to doulas from their own community who speak their language and can provide care that is culturally sensitive.
Recognition of the benefits of doula support has grown in recent years, with a 2014 statement by the American College of Obstetricians and Gynecologists identifying doula support as “one of the most effective tools to improve labor and delivery outcomes.”
Randomized clinical trials back this up. A 2013 Cochrane systematic review analyzed data from 22 studies involving over 15,000 women and found that doula-provided labor support is linked to an average
- 28% reduction in cesarean delivery,
- 9% reduction in use of pain medications,
- 31% reduction in use of oxytocin to speed labor,
- 34% reduction in negative birth experiences, and
- 12% greater likelihood of spontaneous vaginal births.
Doulas achieve these results in part by helping women experience healthy birth practices, like walking and changing positions in labor, resulting in less use of interventions when they are not warranted. Avoiding unnecessary procedures reduces exposure to the risk of complications and improves long-term health outcomes. Doula support also increases the establishment and duration of breastfeeding and may help identify and reduce postpartum depression.
Equally as important, doula support enhances women’s engagement in decision-making by providing culturally and linguistically appropriate information, which facilitates positive communication with providers and fosters women’s ability to advocate for themselves.
For women most at risk for poor outcomes, doula support can reduce health disparities and improve equity. Publicly-funded doula programs in underserved communities have demonstrated positive outcomes and are expanding, but currently reach small numbers of women.
Studies in Minnesota, Oregon, and Wisconsin have reported that Medicaid coverage of doula support holds the potential to reduce spending through the expected reduction in cesareans alone. By increasing the likelihood of vaginal birth, doula support lowers costs while improving women’s and infants’ outcomes. Other factors that would contribute to cost savings, but have not yet been measured, include reduced use of pain medications and operative vaginal deliveries, increased breastfeeding, and a reduction in repeat cesarean births and associated complications.
Despite the evidence, doula support is rarely covered by private or public insurance. Minnesota and Oregon passed legislation to obtain Medicaid reimbursement for doulas, but other efforts to cover doula support have been limited.
Part of the challenge in recognizing the value of doulas may be that doula support falls outside of silos that often prevent the sharing of knowledge and experience across institutional or professional lines. The intrapartum period has historically been the exclusive terrain of clinicians, without significant engagement with public health or service professionals. Doulas are the only type of support service providers who are by a woman’s side during labor and birth.
Clinicians—physicians, midwives, and nurses—are not well positioned to provide the kind of uninterrupted, focused care and support that experienced doulas offer. Clinicians already have a complex set of professional responsibilities that require their attention and energy, and most have no training in providing the kind of emotional support or hands-on comfort measures that are a central component of doula care. Data from the Cochrane review confirms that trained doulas are the most effective provider of continuous labor support and that they get better results, on average, than nurses or family members serving in that role.
Even when public health and other support services are in place during the prenatal and postpartum periods, these programs generally exclude the time immediately before, during, and after birth. Case management and home visiting programs, for instance, may assist women prenatally and in the postpartum period, but in most cases program support stops toward the end of pregnancy and then resumes between one and several weeks postpartum.
By maintaining a steady presence prenatally, during labor and birth, and through the early postpartum period, doulas can play a role in bridging the gaps in the continuum of care in this fragmented system. Because of the lack of continuity of care in the U.S. maternity care system, a woman’s doula may be the only member of the maternity care team who the woman has met before arriving at the hospital and with whom she has developed a trusting relationship.
Ultimately, a doula is the only person by a woman’s side during labor and birth whose sole job is to ensure that the needs of the woman and her family are met. Women need more than safe care to have healthy births—they need care that is respectful, satisfying, and empowering—and doulas are perfectly situated to bridge the silos to make that ideal a reality.