Striving for Equitable Birth Outcomes Through Doula Care

In the fall of 2020, Mass General Brigham introduced United Against Racism, an initiative that includes supporting antiracist pilots and projects across Mass General Brigham hospitals to ensure patients receive equitable care. Allison Bryant Mantha, MD, MPH, maternal-fetal medicine specialist in the Obstetrics and Gynecology Department at Massachusetts General Hospital and senior medical director for Health Equity at Mass General Brigham, helped to develop a proposal aimed at closing the gap in obstetric outcomes (including maternal morbidity, rate of cesarean deliveries among first time mothers and breastfeeding) for women at risk of adverse outcomes: Striving Towards Equity in Obstetric Outcomes Through Cultural and Language Concordant Doula Care.

Dr. Bryant and a team of doctors, nurses and midwives across Mass General Brigham, including Dana Cvrk, CNM, collaborated to implement an initiative based on the original proposal: The Birth Partners Doula pilot project provides culturally and linguistically concordant doulas to eligible pregnant people delivering at Mass General, Brigham and Women’s Hospital, Salem Hospital and Newton-Wellesley Hospital. Another component of the program provides virtual doula-like training sessions for an eligible pregnant person’s friend or family member who will serve as their birth partner and provide continuous support during labor and delivery.

Maternal health outcomes demonstrate the inequality experienced by some women in America. In addition to their high risk of maternal mortality, Black women, for example, also have the highest rate of unplanned cesarean deliveries. Latinx individuals often have lower rates of breastfeeding, an important consideration in this time of infant formula shortage. The good news is that there is mounting evidence that continuous labor support — such as doula care — can improve birth and postpartum outcomes and the experience of birthing people at risk.

A doula is a trained, non-clinical companion who supports another individual through a significant health care-related experience. Birth doulas support a birthing parent through pregnancy and their goal is to help families have a safe, healthy and positive birth experience by providing non-clinical, emotional, physical and informational support to new and expectant parents before, during and after birth, and in the early post-partum period. During labor and delivery, they can provide physical and emotional resources, serve as an advocate for the birthing individual, aid in communications between the patient and their health care team and empower the birthing individual.

The financial investment of hiring a doula compounds the socioeconomic disparities that can impact maternal health outcomes. Doula care — which can cost around $2,000 or more in the Boston area — typically isn’t covered by health insurance plans, making hiring a doula potentially out of reach for those who may benefit from it most. Studies have shown that concordance between provider race and patient race is an important determinant of outcomes. Currently, more certified doulas tend to identify as White than people of color, a racial disparity which makes providing culturally and linguistically concordant care to birthing people of color challenging. One contributing factor for the racial disparity is the cost associated with doula training which can make the profession harder to access for some people. Read more about the work to expand doula care in Massachusetts in this report from The Betsy Lehman Center which includes current economic barriers and workforce development issues.

Research shows that the benefits of continuous labor support, like a doula can provide, includes an increase in spontaneous vaginal births and shorter labors, and a decrease in the use of pain medications, regional anesthesia, instrumental vaginal delivery, Cesarean sections, and most importantly, a negative birth experience.

While there is not one simple solution for eliminating unsatisfactory obstetrical outcomes for women at risk, the implementation of this pilot program can further the goal of greater equity in maternal health outcomes.