The United States is facing a maternal and infant health crisis that disproportionally impacts the birth experience and outcomes of Black and Indigenous people who give birth. Indeed, many studies have shown that racism is a key force in maternal mortality. For Black women, income level, education, and insurance access do not serve as protective factors against maternal mortality as they do for White women. These stark and unacceptable inequities are due to structural and systemic racism as well as implicit and explicit bias.
As part of the Institute for Healthcare Improvement’s (IHI) Better Maternal Outcomes project, IHI is engaging four communities in an initiative called Redesigning Systems with Black Women to address inequities in maternal outcomes. By facilitating locally driven, co-designed, rapid improvements focused on ensuring equity, dignity, and safety, these four communities — Atlanta, Detroit, New Orleans, and Washington, DC — have identified and tested promising practices to reduce the inequities in birth experience and outcomes (maternal mortality and severe maternal morbidity) for Black women. One of the strategies that emerged from the Detroit team focused on improving the availability, accessibility, and reception of community-based doulas.
What Is a Doula?
According to DONA international, a doula is a trained, non-clinical, professional who provides continuous physical, emotional, and informational support to a pregnant person before, during, and after childbirth. Studies have shown that this type of personalized and continuous support for women improves not only the birth experience and the physical and psychological outcomes for a mother and baby, but also has a positive impact on the well-being of a whole family. A Cochrane review found that there are no downsides or adverse effects of doula support.
Despite the benefits of doula support, there can be significant financial barriers to accessing such services. Few health plans cover the costs of doulas, which can range from $800 to over $2,000, making doula support out of reach for many people giving birth.
What is a community-based doula?
Community-based doulas are trained community birth workers. They provide culturally appropriate and kindred-spirited non-clinical emotional, physical, and informational support before, during, and after birth.
In communities that typically experience significant inequities in maternal and infant health outcomes, community-based doula programs are reducing barriers to access and prioritizing peer support. These programs identify and train women who are trusted members of the community to provide doula services at low or no cost. They help improve prenatal care, raise breastfeeding rates, decrease unnecessary medical interventions, increase positive birth experiences, and improve parenting skills. Furthermore, community-based doulas play a critical role in combating the discrimination, racism, and loss of autonomy that Black people who give birth frequently report experiencing. Community-based doulas are trained to help those who are pregnant or giving birth to feel empowered to advocate for themselves.
In addition to improved outcomes, evidence suggests that this type of continuous, one-to-one support can also lower total medical expenditure by reducing the likelihood of complications and increasing the likelihood of a healthy mother and baby. While a handful of states (including Minnesota, New Jersey, Oregon, and Indiana) have implemented Medicaid coverage for doula services, private foundation grants fund 70 percent of doula programs serving communities that experience inequities in maternal newborn outcomes. However, expanded access may be coming soon for more families. New York is currently running a pilot project, and at least 17 states have proposed legislation or other state action to support Medicaid reimbursement of doula services.
How to Increase Availability, Accessibility, and Reception to Community-Based Doulas
Kiddada Green of the Black Mothers’ Breastfeeding Alliance led the Pregnancy Design Team in Detroit. This team comprised context experts (people with lived experience), content experts, hospital staff, and staff from several community-based organizations. “We centered the experience of Detroit mothers, amplifying their voices to work towards dismantling systems that fail to honor Black motherhood,” Green said.
The team collaborated to test ideas to improve the availability and accessibility of community-based doulas. “It was very rewarding to see the ideas and experiences of Black mothers actualized,” Green noted. “I am confident that elevating the lived experiences of Black mothers is imperative in our fight to improve maternal health outcomes.”
In a parallel process, the team also focused on changing the institutional practices and reception related to community-based doula care at local hospitals, such as considering doulas to be a “guest” of the person giving birth instead of a member of the care team. Some specific ideas for improvement that this group tested along with preliminary findings are below: