New research eyes closer integration of doulas and hospital maternity care

Long outliers in the modern world of hospital maternity care units, doulas have been making increasing inroads into those clinical spaces as the U.S. struggles to address its maternal mortality crisis. Those advances are likely to be further broadened by the March of Dimes' funding of a new University of Pennsylvania Research Center for Advancing Maternal Health Equity and its research project aimed at determining how doulas can be more closely integrated into maternal care teams.

Originally established in 1938 to address polio, in 2005 the March of Dimes made premature births the primary focus of its funding and has continued to expand programs for mothers and babies ever since. Its latest report notes that an average of two women die every day from pregnancy-related causes in the U.S. and two babies die every hour. The organization characterizes the situation as a "crisis fueled by many factors, including structural racism, poor maternal health, and socio-economic status."

LDI Senior Fellow and Chair of the Penn Department of Obstetrics and Gynecology Elizabeth Howell, MD, MPP, is the Chair of the Scientific Advisory Committee and Principal Investigator of the new center.

"Disparities research has traditionally shown that Black women are three to four times more likely to die of pregnancy-related causes than white women," said Howell. "So, we have a lot of data on disparities but what we haven't been hearing as much about is: 'What can we do to change this? How are we going to intervene? What are the action steps that we can take?' That's what this new March of Dimes center at Penn is about. It's focused on action-oriented solutions and thinking about new models of care."

And, in that spirit, one of the center's first two research projects is focused on expanding the evidence base related to the positive effect of doulas in maternal care. These non-medical support people provide guidance and comfort measures to help women cope with the physical and emotional demands and stresses of labor and childbirth. They can also provide education and advocacy, helping women make informed decisions about their care.

The doula research project is headed by LDI Senior Fellow Sindhu Srinivas, MD, MSCE, Professor of Obstetrics and Gynecology at the Perelman School of Medicine, Vice-chair for Quality and Safety, and Associate Chief Medical Officer for the Hospital of the University of Pennsylvania for Quality and Safety.

"The first goal of the project is to understand various stakeholder perspectives in working toward creating more integrated obstetric care delivery models in which doulas are part of the care team," said Srinivas. "The stakeholders we're talking about are birthing patients, trusted community partners including community-based doulas, and clinical providers, including physicians, midwives, and nurses."

"No one is quite sure what the best approach is," Srinivas continued. "We know some hospitals are considering hiring doulas themselves but we're not really sure if hospitals hiring doulas is going to have the same impact as a hospital partnering with a community organization that has doulas. So, there are many structural questions around this. We're doing our research in complete partnership with CocoLife."

The CocoLife Foundation is a Philadelphia community organization focused on all aspects of before, during and after delivery care for pregnant women of color. It has become well known for its innovative use of "Mombassadors," or birthing support people, many of whom are doulas.

"Doula"—a Greek word meaning servant-woman—was popularized in the 1970s through the work of neonatologist Marshall Klaus, MD, of Case Western University. His research focused on the connections between a mother's emotional well-being and outcomes in birthing for both her and the child. He found that the presence of trained non-medical helpers before, during, and after delivery "shortened labor, reduced demand for pain relievers, decreased the number of Cesarean births, and promoted an early and enduring attachment between mother and child."

A subsequent body of research around the world over the last 40 years has repeatedly confirmed doulas' positive effects on the birth experience. Some researchers have pointed out that modern hospital maternity units have become increasingly isolated places as nursing services have been cut back. One study found that less than 10% of maternity unit nurses' time is spent with the mother. In its 2017 report, the Cochrane Library concluded that the "Lack of continuous support during childbirth has led to concerns that the experience of labor and birth may have become dehumanized."

A recent Dartmouth College 2020 survey of a cross section of nearly 1,800 pregnant women found that 62% of them reported high levels of fear and worry about childbirth—a condition known as tokophobia. Black women were almost twice as likely to experience strong fears of childbirth as white women.

A 2022 Lancet retrospective cohort study found that "Evidence collectively suggests that doulas can decrease risk of adverse maternal health outcomes, particularly among women whose sociodemographic and clinical characteristics place them at higher risk for maternal morbidity and mortality."

Nevertheless, historically there has been friction between OB/GYN clinicians and doulas. For instance, a 2004 Wall Street Journal report headlined "As Doulas Enter Delivery Rooms, Conflicts Arise" detailed the tension, citing the rising "turf battle" between physicians and doulas who "aren't licensed and aren't required to have any formal medical training. They are sparking protests in the medical community… Some new mothers and doulas complain that hospital staffers are hostile toward doulas." Since 2004, attitudes have begun to change and there is currently a growing recognition in the medical community that doulas serve an important role.

"Fear drives unhealthy levels of stress," said Howell. "The fear that pregnant women have about coming in for delivery is now quite palpable because of all they hear every day about the mortality crisis—this is true for white women as well. The other part to remember is that for every maternal death, 100 other women experience what we call severe maternal morbidity. These are life-threatening diagnoses—seizing, having a stroke, or a hemorrhage resulting in the loss of your uterus. These are real things that occur at a much higher prevalence than people used to think about."

"It's easy to understand why birthing people from all racial and ethnic backgrounds are apprehensive and why the idea of having a doula to provide close, ongoing empathetic support to help with that stress and the communication failures that we know are part of the problem, makes a lot of sense," said Howell.

Doula training, reimbursement, and geographic spread

Doulas are trained on evidence-based techniques in providing physical, emotional, and informational support throughout pregnancy, labor, delivery, and postpartum care.

Eight states currently require doulas to be trained and certified to qualify for Medicaid reimbursement. The training and certification are done by several private programs, the first and largest of which is Doulas of North America (DONA) established in the 1990s by Dr. Klaus and associates. The organization rebranded itself "DONA International" in 2004 and now trains and certifies doulas in 50 countries.

When hired by individual patients, certified doulas can cost up to $1,500 and are not covered by many insurance companies, making them unavailable to many of the marginalized women who derive the greatest risk-lowering benefit from them.

This issue has taken on new importance as the maternal mortality crisis has gained more public attention. A growing number of states have sought the Centers for Medicare and Medicaid Services' (CMS) approval to add reimbursement for doula services to their Medicaid programs.

According to the National Health Law Program's doula Medicaid tracking project:

• 15 states have or are now implementing Medicaid reimbursement for doula services. (Have: CA, DC, FL, MD, MN, NJ, NV, OR, RI, and VA; Implementing: CT, OH, IL, MA, and PA).
• 14 states are taking some kind of initial exploratory or adjacent action (AZ, CO, GA, HI, IA, IN, KS, LA, MO, NY, TN, TX, WA, and WI).
• 7 states have proposed action but made no progress (NC, NH, OK, SC, UT, VT, and WV).
• 9 states have no information available on the Medicaid doula coverage issue (AK, AR, ID, MS, MT, ND, NM, SD, and WY).

Provided by University of Pennsylvania