Djäkamirr: Exploring principles used in piloting the training of First Nations doulas in a remote multilingual Northern Australian community setting.

PROBLEM AND BACKGROUND: There is growing evidence in First Nations doula care as a strategy to address perinatal inequities and improve maternal care experiences. However, there is no evidence around the approach and principals required to successfully deliver First Nations doula (childbirth) training. QUESTION/AIM: To explore and describe the approach and principles used in piloting the training of First Nations doulas in remote, multilingual Northern Australian community settings. METHODS: Case study with participant interviews to identify principles underpinning our Decolonising Participatory Action Research (D-PAR) approach and training delivery. FINDINGS: Reflections on our D-PAR research process identified enabling principles: 1) Use of metaphors for knowledge reflexivity, 2) Accommodate cultural constructions of time 3) Practice mental agility at the Cultural Interface, 4) Advocate and address inequities, 5) Prioritise meaningful curriculums and resources, 6) Establish cross-cultural recognition and validity; and 7) Ensure continuity of First Nations culture and language. DISCUSSION: The success of our doula training pilot disrupts a pervasive colonial narrative of First Nation deficit and demonstrates that respectful, genuine, and authentic partnerships can power transformative individual and collective community change. Our D-PAR approach assumes mutual learning and expertise between community and researchers. It is well suited to collaborative design and delivery of First Nations reproductive health training.

Doula Services and Birth Outcomes: A Scoping Review.

BACKGROUND: Doulas offer support and advice to some women during the childbirth process, however access to doula care is not available to all due to availability and cost. METHODS: This scoping review synthesizes literature related to the use of doula services and the experiences and outcomes of those who used the services. Eligibility criteria included peer-reviewed studies conducted in the United States and published between 2010 and 2022 that specified use of doulas and assessed maternal experiences and outcomes. Articles were accessed through PubMed, Google Scholar, and PsycInfo. RESULTS: Nineteen articles met the criteria and were included in the review. Findings across eligible articles included qualitative analyses related to psychosocial aspects of experience and quantitative findings on birth experience, complications, breastfeeding initiation, and emotional health. DISCUSSION: Findings suggest having doula support can improve experiences and outcomes. However, further implementation and evaluation is needed as well as greater access to doula services among the childbearing population who are historically marginalized and minoritized.

The Impact of Covid-19 on Community Perinatal Doula Support Services for Black Women.

OBJECTIVES: To better understand the experiences of Black pregnant women during COVID-19, we examined Black pregnant clients' and doulas' experiences with perinatal support services amid COVID-19's social distancing protocols. METHODS: We used qualitative description, employing a social constructionist framework to interview 12 perinatal support doulas and 29 Black women who were pregnant or gave birth during the pandemic about their experiences during the pandemic, when social distancing was required. RESULTS: Three key themes were identified: (1) Clients experienced increased social isolation; (2) Doulas' exclusion from medical visits limited women's access to support and advocacy; (3) Doula support as a sisterhood helped clients mitigate effects of COVID isolation. CONCLUSIONS FOR PRACTICE: Doulas should be considered essential support persons for Black pregnant women and should not be excluded from the birthing team. Support through technology is acceptable for some clients but less desirable for others and restricted doula's ability to build rapport and be hands on with their clients.

Critical Changes in the Maternal Health Landscape: Community Care, Doulas, and Coverage.

In this commentary, we present an overview of the accelerating trend toward community-based models for pregnancy care. Doula services, as part of community care programs, are the major target for new coverage changes. Obstetric professionals who include community care providers in their treatment plans can benefit from these local resources in the prenatal, birthing, and postpartum stages of patient management. Including community care programs may help achieve goals of improving health outcomes and health equity.

Building Capacity for Research on Community Doula Care: A Stakeholder-Engaged Process in California.

PURPOSE: In an effort to address persistent inequities in maternal and infant health, policymakers and advocates have pushed to expand access to doula care. Several states, including California, now cover doula services through Medicaid. As coverage expands, research on the impact of doula care will likely increase. To develop best practices for research, it is critical to engage community doulas, clients, and other key stakeholders. DESCRIPTION: Our overarching goal was to build capacity for future doula- and client-centered research on community doula care. First, we established a Steering Committee with members from seven relevant stakeholder groups: community doulas, former or potential doula clients, clinicians, payers, advocates, researchers, and public health professionals. Second, we conducted a needs assessment to identify and understand stakeholders' needs and values for research on community doula care. Findings from the needs assessment informed our third step, conducting a research prioritization to develop a shared research agenda related to community doula care with the Steering Committee. We adapted the Research Prioritization by Affected Communities protocol to guide this process, which resulted in a final list of 21 priority research questions. Lastly, we offered a training to increase capacity among community doulas to engage in research on community doula care. ASSESSMENT: Our findings provide direction for those interested in conducting research on doula care, as well as policymakers and funders. CONCLUSION: The findings of our stakeholder-engaged process provide a roadmap that will lead to equity-oriented research centering clients, doulas, and their communities.

Advancing Equity in Maternal Health With Virtual Doula Care.

This Viewpoint reviews the advantages and limitations of virtual doula services and discusses their potential to address the maternal health crisis.

Using Prevention Research to Reduce Racial Disparities in Health Through Innovative Funding Strategies: The Case of Doula Care.

Racial disparities in maternal birth outcomes are substantial even when comparing women with similar levels of education. While racial differences in maternal death at birth or shortly afterward have attracted significant attention from researchers, non-fatal but potentially life-threatening pregnancy complications are 30-40 times more common than maternal deaths. Black women have the worst maternal health outcomes. Only recently have health researchers started to view structural racism rather than race as the critical factor underlying these persistent inequities. We discuss the economic framework that prevention scientists can use to convince policymakers to make sustainable investments in maternal health by expanding funding for doula care. While a few states allow Medicaid to fund doula services, most women at risk of poor maternal health outcomes arising from structural racism lack access to culturally sensitive caregivers during the pre-and post-partum periods as well as during birth. We provide a guide to how research in health services can be more readily translated to policy recommendations by describing two innovative ways that cost-benefit analysis can help direct private and public funding to support doula care for Black women and others at risk of poor birth outcomes.

Association Between Doula Use on a Digital Health Platform and Birth Outcomes.

OBJECTIVE: To examine the association between the use of virtual doula appointments on a comprehensive digital health platform and users' mode of birth and their birth experiences, among all platform users and Black platform users. METHODS: Data for this retrospective cohort study were extracted from individuals who enrolled in a comprehensive digital health platform, between January 1, 2020, and April 22, 2023. Multivariable logistic regression models were used to estimate the association between number of virtual doula appointments completed on the digital health platform and odds of cesarean birth and user-reported birth experience outcomes, which included help deciding a birth preference, receiving a high level of support during pregnancy, learning medically accurate information about pregnancy complications and warning signs, and managing mental health during pregnancy, stratified by parity. The interaction of doula utilization by race for each outcome was also tested. RESULTS: Overall 8,989 platform users were included. The completion of at least two appointments with a virtual doula on the digital health platform was associated with a reduction in odds of cesarean birth among all users (adjusted odds ratio [aOR] 0.80, 95% CI, 0.65-0.99) and among Black users (aOR 0.32, 95% CI, 0.14-0.72). Among platform users with a history of cesarean birth, completion of any number of doula visits was associated with a reduction in odds of repeat cesarean birth (one visit: aOR 0.35, 95% CI, 0.17-0.72; two or more visits: aOR 0.37, 95% CI, 0.17-0.83). Analyses among all users indicated dose-response associations between increased virtual doula use and greater odds of users reporting support in deciding a birth preference (one visit: aOR 2.35, 95% CI, 2.02-2.74; two or more visits: aOR 3.67, 95% CI, 3.03-4.44), receiving a high level of emotional support during pregnancy (one visit: aOR 1.99, 95% CI, 1.74-2.28; two or more visits: aOR 3.26, 95% CI, 2.70-3.94), learning medically accurate information about pregnancy complications and warning signs (one visit: aOR 1.26, 95% CI, 1.10-1.44; two or more visits: aOR 1.55, 95% CI, 1.29-1.88), and help managing mental health during pregnancy (one visit: aOR 1.28, 95% CI, 1.05-1.56; two or more visits: aOR 1.78, 95% CI, 1.40-2.26). CONCLUSION: This analysis demonstrates that virtual doula support on a digital health platform is associated with lower odds of cesarean birth and an improved birth experience. Positive findings among Black users and users with vaginal birth after cesarean suggest that doula support is critical for patient advocacy, and that digital health may play a meaningful role in increasing health equity in birth outcomes.

Addressing Gaps and Saving Lives: Doulas' Role in Addressing Substance Use and Mental Health Challenges Among Pregnant and Postpartum Clients-A Scoping Review.

OBJECTIVES: Doulas are a potential resource for addressing substance use and mental health challenges that pregnant and postpartum individuals experience. We sought to review peer-reviewed literature that examines Doulas' role in addressing these challenges to highlight the need for more research in this area. METHODS: We conducted a scoping review (2001-2021) to identify articles that examine the way in which Doulas address maternal substance use and mental health challenges in their clients. The articles were reviewed by two members of the research team. RESULTS: Nine articles describing Doulas' role in addressing substance use and mental health challenges were identified. Six described Doulas' role in addressing mental health, five of which saw positive mental health outcomes due to Doula involvement. One additional article recommended Doulas be considered in the future to address mental health challenges. While the minority of articles addressed substance use (n = 2), it was reported that Doulas were a positive addition to interdisciplinary teams addressing substance use challenges with pregnant individuals. CONCLUSIONS: While the literature showed that Doulas can improve substance use and mental health outcomes among pregnant or postpartum individuals, a significant gap remains in research, practice, and peer-reviewed literature addressing this issue.

Providing doula support to publicly insured women in central Texas: A financial cost-benefit analysis.

BACKGROUND: Disparities in birth outcomes continue to exist in the United States, particularly for low-income, publicly insured women. Doula support has been shown to be a cost-effective intervention in predominantly middle-to-upper income White populations, and across all publicly insured women at the state level. This analysis extends previous studies by providing an estimate of benefits that incorporates variations in averted outcomes by race and ethnicity in the context of one region in Texas. The objectives of this study were to determine (1) whether the financial value of benefits provided by doula support exceeds the costs of delivering it; (2) whether the cost-benefit ratio differs by race and ethnicity; and (3) how different doula reimbursement levels affect the cost-benefit results with respect to pregnant people covered by Medicaid in central Texas. METHODS: We conducted a forward-looking cost-benefit analysis using secondary data carried out over a short-term time horizon taking a public payer perspective. We focused on a narrow set of health outcomes (preterm delivery and cesarean delivery) that was relatively straightforward to monetize. The current, usual care state was used as the comparison condition. RESULTS: Providing pregnant people covered by Texas Medicaid with access to doulas during their pregnancies was cost-beneficial (benefit-to-cost ratio: 1.15) in the base model, and 65.7% of the time in probabilistic sensitivity analyses covering a feasible range of parameters. The intervention is most cost-beneficial for Black women. Reimbursing doulas at $869 per client or more yielded costs that were greater than benefits, holding other parameters constant. CONCLUSIONS: Expanding Medicaid pregnancy-related coverage to include doula services would be cost-beneficial and improve health equity in Texas.

Community-Based Doulas' Roles Within the Birth Support System: Young Black Mothers' Perspectives.

INTRODUCTION: Doulas have been found to be beneficial to pregnant adolescents during childbirth, but little is known about their role within the larger system of people providing birth support, including family and health care providers. The purpose of this study was to examine, from the perspectives of young mothers, the role of the doula within their broader birth support system. METHODS: One hundred pregnant Black adolescents and young women (aged 13 to 21) who were provided perinatal community-based and racially concordant doula services at no cost to them were interviewed after the birth of their newborn, prior to hospital discharge. Interviews generated birth story narratives and responses to focused questions about their experiences of birth support. Thematic analysis was conducted to examine the role of the doula within the context of the broader system of birth support. RESULTS: Doulas functioned in 2 primary ways within the birth support system by (1) providing tandem support alongside family and health care providers and (2) filling gaps in health care not provided by family and providers. Laboring adolescents sometimes described their family members and doulas working in tandem to provide multiple types of support such as comfort measures, coaching, and help with pushing. They also identified gaps in their care or support filled by the doula, in particular gaps due to family members' physical or emotional unavailability or health care providers' many responsibilities. DISCUSSION: The findings highlight the ways in which doulas support pregnant adolescents during childbirth through their deft navigation of the existing support system. Well-being was enhanced by the inclusion of the doula in the birth support system. The findings align with existing research that underscores the valuable role doulas play in supporting individuals during childbirth, particularly for those most affected by processes of marginalization.

Doula Support and Pregnancy-Related Complications and Death Among Childbearing Women in the United States: A Scoping Review.

INTRODUCTION: The potential benefits of perinatal doula support are many; however, doulas are underutilized, which may heighten pregnancy-related complications. In this scoping review, we assess the influence of perinatal doula support on pregnancy-related complications and death in the United States. METHODS: We searched PubMed, CINAHL, Scopus, and Alt HealthWatch for literature on doula support and its influence on pregnancy-related complications (maternal fever or infection, postpartum hemorrhage, amniotic fluid embolism, complications from anesthesia, preeclampsia, eclampsia, cardiomyopathy, pulmonary or thrombotic embolism, and cerebrovascular accident). Peer-reviewed articles written in English and conducted in the United States from 1969 to 2021 were included. Screening at all levels was blinded. We extracted data based on title, author, year, design, population, sample size, methods, limitations, recommendations, and definition of doula support. RESULTS: Following removal of duplicates, review of 3679 article titles and abstracts yielded 42 articles for full-text review; 3 articles met final inclusion criteria. One included study focused on intrapartum doula support and 2 on doula support that extended throughout the perinatal period. Within the included studies, doula support was associated with decreased rates of intrapartum maternal fever and gestational hypertension; however, it was not associated with decreased rates of gestational diabetes or depression. DISCUSSION: The literature has addressed the benefits of perinatal doula support, but studies with validated tools to examine associations between doula support and pregnancy-related complications and death are lacking. The studies that addressed intrapartum and continuous doula care included large generalizable samples, from which future research can draw to improve the practice of caring for patients during the perinatal period. Extensive research shows that unfavorable conditions can influence perinatal outcomes across generations. Implementing doula support may offer a potential approach to reduce and help alleviate resulting disparities in perinatal health.

Increasing U.S. Maternal Health Equity Among Immigrant Populations Through Community Engagement.

Immigrant women in the United States are at an elevated risk of poor maternal health outcomes due to cultural, linguistic, or socioeconomic barriers that may lead to critical delays in obtaining adequate health care. Ensuring access to high-quality, culturally appropriate perinatal health care is crucial to improve the health and well-being of immigrant mothers and their children. Various aspects of perinatal health care for immigrant women can be improved through community engagement strategies. Barriers can be addressed by involving community members in designing and delivering culturally appropriate maternal health services. Some strategies discussed in this commentary include working with community health workers, encouraging telehealth through community health workers, providing breastfeeding and mental health support within cultural norms, and involving community-based doulas and midwives.

Readiness to Implement a Doula-Hospital Partnership Program.

OBJECTIVE: To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program. DESIGN: Survey of obstetric clinicians and leaders before implementation of the doula program. SETTING/LOCAL PROBLEM: Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality. PARTICIPANTS: Obstetric clinicians and leaders (N = 48). INTERVENTION/MEASUREMENTS: We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis. RESULTS: Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics. CONCLUSION: Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

Philadelphia Department of Health Doula Support Program: Early Successes and Challenges of a Program Serving Birthing People Affected by Substance Use Disorder.

PURPOSE: Maternal substance use and deaths due to overdoses are increasing nationwide. Evidence suggests that the rate of resumed substance use, and fatal and non-fatal overdose is greatest in the first year after birth, particularly around six months postpartum, compared to other parts of the perinatal period. Doula care has been linked to improvements in perinatal health and outcomes. DESCRIPTION: In response to the opioid epidemic, the Philadelphia Department of Public Health developed and implemented the Doula Support Program (DSP), with a focus on one year of postpartum care for birthing people with a substance use disorder (SUD). In this paper, we describe the program and its formation and report on the early challenges and successes of the program implementation, based on information we received from program founders and managers in a group interview. ASSESSMENT: Early successes of the program include partnering with local community-based programs to recruit and retain doulas, supplementing traditional doula education with perinatal SUD-specific trainings, and maximizing client referrals by collaborating with local organizations and treatment centers that serve birthing people with SUD. Client retention, however, has proven to be challenging, especially during the COVID-19 pandemic. CONCLUSION: The DSP continues to grow, and lessons learned will facilitate program improvements. The goal of this paper is to outline the development and launch of the DSP and to act as a model for other state and local health departments interested in providing doula care for birthing people with SUD.

Comparison of maternal outcomes in caring by Doula, trained lay companion and routine midwifery care.

INTRODUCTION: The aim of this study was to compare maternal and neonatal outcomes in the care provided by Doula, trained lay companion, and routine midwifery care in the labor and obstetric units. In this study, only results related to maternal outcomes were presented. METHOD: This is a quasi-experimental study, which was conducted on 150 women with low-risk pregnancies who had been selected for vaginal birth at private clinics and public hospitals of Arak, Iran. Participants were divided into three groups, two intervention groups, doula and trained lay companion, and one control group, midwife's routine care. The intervention groups, in addition to receiving routine care from the labor and maternity units, also received support and training by doula or a trained lay companion, but 50 the control group received only routine midwifery care. In the control group and the trained companion, the samples were taken from 10 clinics of different parts of the city by random sampling method using the SIB center system. Then, among selected numbers, we randomly selected samples for each group. But in Doula group, because of limited number of samples, convenience sampling was used and all women enrolled in doula care were included in the study until the number reached 50. In each group, outcomes such as the duration of active phase and second stage of labor, as well as the severity of pain, anxiety and maternal satisfaction with birth were measured and compared with other groups. Data were collected by a researcher-made checklist, the Spielberger's State-Trait Anxiety Inventory (STAI), the Pain Visual Assessment Scale (VAS), and the Hollins Martin's Birth Satisfaction Scale-Revised (BSS-R). Data were analyzed by SPSS-22 statistical software using Kruskal Wallis, Chi-Square, ANOVA and Fisher's exact tests. FINDINGS: Based on the results, the mean duration of active phase between three groups was 234.68 ± 118.74, 256.66 ± 108.75 and 279 ± 94.37 min, respectively (p = 0.022). Also, the mean duration of second stage in three groups was 10 ± 5.61, 10.35 ± 5.1 and 22.30 ± 75.57 min, respectively (p < 0.001). The difference between mean pain scores in the first, second, third, fourth and fifth hours was not statistically significant. The average difference in anxiety score in the two stages of labor was higher in the lay companion group, and this difference was statistically significant (p < 0.001); however, the level of satisfaction in doula group was higher compared to the lay companion and control groups (p < 0.00 1). CONCLUSION: According to present study, doula care has a greater effect on reducing the duration of labor than other care models. Based on the study, there was no statistically significant difference between the three groups in terms of variables such as the severity of labor pain. However, the level of anxiety of pregnant mothers in the group supported by lay companion was lower than the other two groups, which indicates the positive effect of mothers' training on increasing maternal comfort and satisfaction. It is suggested that further research investigate the severity of labor pain in groups supported by different care models and also we recommend the use of lay companion' support during childbearing of mothers who could not afford doula. TRAIL REGISTRATION: This article has been registered in Iran's Clinical Trial Center with the code: IRCT20230620058548N1. 2023/08/29.

End-of-Life Doulas.

Doula is a Greek word meaning "woman caregiver", and an "experienced woman who helps other women" [4].