As the United States grapples with the staggering inequities in maternal mortality rates that disproportionately affect Black women, doulas have taken center stage as a proposed near-panacea for the crisis. Policymakers across the country, reporters and health care providers have all encouraged rapid expansion of doula access for all pregnant women, especially low-income Black women. But a fundamental question remains: how exactly will doulas prevent or reduce these deaths?
To answer this question, we first need to step back and examine why we have a Black maternal mortality crisis in the first place. Between 2007-2016, Black women experienced 40.8 pregnancy-related deaths per 100,000 live births, a rate more than three times higher than among White women.
One cannot understand or examine the Black American maternal mortality crisis without understanding and examining how the intersection of racism and sexism has infiltrated every aspect of our society, from health care policy at the macro level to the implicit biases harbored among health care providers at the micro level. The following non-exhaustive list outlines a few of the factors that have contributed to this crisis:
- Hospitals that predominantly serve Black women tend to be under-resourced and therefore lower quality than those with a more racially diverse or a whiter patient population. According to an analysis from ProPublica, women who experience hemorrhage at hospitals predominantly serving Black patients face a higher risk of severe complications than those who receive care at hospitals with more White clientele.
- Structural inequities in health coverage access mean that today, about 5 percent of Black clients are uninsured compared to 7.5 percent of White women, impacting their access to services.
- Black women are much more likely to receive no prenatal care, or to receive it later than the first trimester, than women of any race besides American Indian/Alaska Native and Native Hawaiian. Access to adequate prenatal care has demonstrable health benefits to both the mother and baby.
- Black women are more likely to suffer from hypertension and pre-eclampsia, which increase the chances of adverse health outcomes for mothers and babies.
So, now we return to doulas. Doulas provide physical, emotional, and relational support to people undergoing significant health experiences and are most commonly used in the context of pregnancy and birthing. As was previously written on our blog, in response to grassroots advocacy efforts across the country, policymakers at the state and federal levels have proposed a slew of legislation aimed at expanding access to doulas, primarily through greater reimbursement for their services through Medicaid.
However, the fundamental question remains: how exactly will doulas drive down the Black maternal mortality rate? Which factors contributing to this crisis do they address? We have evidence to suggest that continuous support during childbirth can decrease risk of cesarean and instrumental birth, as well as intrapartum analgesia. These are significant maternal health outcomes, however these may not represent the substantial contributing factors in the risk of mortality.
Let’s look at hemorrhage, one of the leading drivers of maternal mortality. Black women are at higher risk of severe morbidity and mortality following a postpartum hemorrhage than non-Hispanic white, Hispanic, or Asian or Pacific Islander women. A doula can provide vital emotional and relationship support during childbirth, but they are not charged with treating a hemorrhage. One could posit that doulas serve as effective advocates for women who aren’t believed to be in real pain and can therefore garner medical attention before a hemorrhage turns fatal, however, we have no evidence to conclude that deploying doulas would substantially reduce the risk of hemorrhage. The same can also be said for hypertension-related conditions such as preeclampsia.
Another possible direct impact would be that the emotional and relational support that doulas provide wards against some maternal depression and suicide, which remains a serious issue, but this is an under-studied area and far fewer women die by suicide during pregnancy than through hemorrhage or hypertension-related complications.
According to a 2017 Cochrane review of about 26 studies from high- and middle-income countries, there are no known adverse effects of continuous support care that doulas provide. While some benefits of doula care are documented, the quality and breadth of studies on how they could theoretically impact maternal mortality, particularly among Black American women, remain limited . And so far there is no published literature demonstrating that doulas actually reduce maternal mortality. This lack of data should give pause to leaders interested in reducing the Black American maternal mortality crisis through evidence-based policymaking. There are many good reasons to support the call for more doula care but there are also many questions that would be important to answer before designing programs and interventions that scale up access to doula care; these include:
- Are Black, Brown, and Indigenous doulas, particularly Black doulas, more effective at promoting maternal health outcomes and preventing mortality when serving Black women?
- Is there a birth setting in which the benefits of doulas are most impactful? For example, do they provide the greatest benefit during generally safe home births where a C-section is likely not required, and fewer benefits in high-risk pregnancies and deliveries or vice versa?
- What is the particular impact of doulas acting by themselves vs. working with a midwife?
- How cost-effective is the expansion of doula care compared to other efforts to reduce maternal mortality, such as maternal mortality review committees and robust accountability standards for hospitals and health systems?
Finally, even after all of these questions have been answered and appropriately influenced the policy response, there are many important challenges to consider within the field of doula care. Many of the proposals center on expanding access to doula care among the Medicaid population. However, we know that many lower and middle income Black women do not qualify for Medicaid, particularly in states that have not expanded the program. What is the plan to ensure that these services are more broadly available? These challenges should be considered and addressed if we are going to start incorporating doulas into health care delivery at a large scale.
This, of course, is not a referendum on doula care. There is no known evidence that doulas make birth outcomes worse and plenty to suggest that they provide real value in the birthing context. Doulas have long been used in Black and Brown communities, and there are many anecdotes among Black women describing the value that their doulas brought to their deliveries—anecdotes that should not be discounted. However, we should ensure that we are not throwing a band-aid on a large, complicated issue without a strong foundation of evidence demonstrating how the policy change will move the needle. Without real investment in impacting the other systemic factors that contribute to this crisis, we’ll continue to unnecessarily lose hundreds of Black lives each year.