Authors Argue for the Inclusion of Doulas to Improve Childbirth Outcomes

Jan. 3, 2024
A team of healthcare leaders argues in The New England Journal of Medicine for the inclusion of doulas to create a better childbirth experience for Black women and improve outcomes

Even as healthcare policy and clinician leaders work together to push the U.S. healthcare system forward into innovation along all dimensions—clinical, process, operational, and beyond—they need to consider as potential partners individuals whose role goes back centuries in time and in history—doulas. Doulas are individuals who support women in childbirth, as well as in miscarriage and stillbirth. That is the viewpoint of leaders at the Mountain Area Health Education Center in Asheville, N.C., and at the University of California San Diego.

In the “Perspective” opinion section in The New England Journal of Medicine, Dolly Pressley Byrd, Ph.D., C.N.M., Elizabeth Buys, M.D., Amanda Brickhouse Murphy, C.N.M., and Crystal Cené, M.D., write in “Community-Based Doulas—Can Clinicians Share Power to Improve Maternal and Infant Health Outcomes?” that engaging doulas could dramatically improve outcomes for Black women in childbirth.  They note in their Dec. 28 article that, “As health care professionals concerned with life-or-death outcomes, we easily label experiences that do not end in absolute failure as “successes.” For many patients, however, success requires more — especially for the thousands of Black patients each year who have [very negative] birth experiences. One way to improve perinatal outcomes — not only morbidity and mortality but also patients’ satisfaction — is to form partnerships between perinatal care providers and community-based doulas. Unfortunately, even in parts of the United States where such partnerships are possible, clinicians are often hesitant or unwilling to share power.”

The authors write that “Black birthing people in the United States have higher rates of severe complications than White birthing people. Black birthing patients and infants are two to three times as likely as their White counterparts to die within a year after delivery, even after adjustment for education or socioeconomic factors.1 Our current perinatal care model is not working. We continue to focus on standardization and technology aimed at enhancing safety, while outcomes worsen and racial inequities increase. We must reconsider the status quo and explore innovative solutions to this dire problem. One approach to addressing racial inequities in perinatal outcomes is to encourage partnerships between medical professionals, health care organizations, and community-based doulas,” they emphasize.

And the article’s authors so straight to the socioeconomic and sociocultural elements involved in this landscape, writing that “As trained nonclinical professionals, doulas provide physical, emotional, and educational support during the perinatal period, while advocating for patients. For the past few decades, most U.S. doulas have been White women from middle-income backgrounds serving well-resourced clients who can afford to pay out of pocket for their services. But for Black birthing people, doulas from their own communities engender trust because of their similar social positions and lived experiences. Like community health workers, community-based doulas can help mitigate the effects of systemic racism and discriminatory treatment. Research shows that doula support reduces C-section rates, NICU admissions, and preterm births while increasing breast-feeding rates and patient satisfaction,” they report.

Currently, 6 percent of childbirths are attended by doulas. And while one issue remains lack of reimbursement by Medicaid programs and by private health insurers, the authors note that “clinicians’ unwillingness to share power with nontraditional members of the health care team may also contribute” to the lack of doulas’ presence in so many labor and delivery suites. Their prescription? Clinicians need to welcome doulas accompanying patients to prenatal appointments and into the delivery room, while hospital administrators “can develop trainings for clinical staff in shared decision-making techniques and truly informed consent,” and can offer doulas “affiliate status” and can provide them with “name badges identifying their role.”



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