Effectiveness of an Enhanced Community Doula Intervention in a Safety Net Setting: A Randomized Controlled Trial.

Background: Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent. Methods: We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race-ethnicity. Results: Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants. Discussion: While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates. Conclusion: This study demonstrates the need for larger studies of community doula support for Black birthing people. Clinicaltrials.gov ID: NCT02550730.

COVID-19 pandemic impacts on mental health, burnout, and longevity in the workplace among healthcare workers: A mixed methods study.

To explore the mental health impacts of the COVID-19 pandemic on healthcare workers in Massachusetts and identify potential strategies to maintain the healthcare workforce we conducted a sequential exploratory mixed methods study. Fifty-two individuals completed interviews from April 22nd - September 7th, 2021; 209 individuals completed an online survey from February 17th - March 23rd, 2022. Interviews and surveys asked about the mental health impacts of working in healthcare during the COVID-19 pandemic, burnout, longevity in the workplace, and strategies for reducing attrition. Interview and survey participants were predominantly White (56%; 73%, respectively), female (79%; 81%) and worked as physicians (37%; 34%). Interviewees indicated high stress and anxiety levels due to frequent exposure to patient deaths from COVID-19. Among survey respondents, 55% reported worse mental health than before the pandemic, 29% reported a new/worsening mental health condition for themselves or their family, 59% reported feeling burned out at least weekly, and 37% intended to leave healthcare in less than 5 years. To decrease attrition, respondents suggested higher salaries (91%), flexible schedules (90%), and increased support to care for patients (89%). Healthcare workers' experiences with death, feeling unvalued, and overworked resulted in unprecedented rates of burnout and intention to leave healthcare.

Implementation of a pharmacological prophylaxis bundle to prevent obstetric-associated venous thromboembolism.

PURPOSE: Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population. SUMMARY: This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home. CONCLUSION: An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Dyadic Care Mobile Units: A Collaborative Midwifery and Pediatric Response to the COVID-19 Pandemic.

Often dubbed the fourth trimester, the first 6 weeks of the postpartum period is a critical time that sets the stage for future health outcomes for both women and children. Leading maternal and child health advocates agree that intervention in the first 6 weeks of life is crucial. Although most new parents prioritize their newborn's well-care, many postpartum patients do not attend appointments for themselves, missing critical opportunities for identification and treatment of leading causes of maternal morbidity and mortality. Racial disparities in rates of postpartum complications highlight the increased importance of close postpartum follow-up for women of color. Barriers to attending routine postpartum visits were exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Additionally, in traditional models of care, maternal-infant dyads experience fragmented care across multiple departments and patient care settings and only 1 to 2 routine visits for the postpartum patient. To address the challenges of providing in-person postpartum care during the COVID-19 pandemic in Boston, the Midwifery Service, and the Pediatrics Department of Boston Medical Center partnered to launch a mobile postpartum clinic that provided comprehensive, high-touch, dyadic care to postpartum patients and newborns in the first 6 weeks of life. Integrative mobile visits catered to the interplay of maternal and newborn health in the early postpartum period, providing an average of 3 visits to each dyad. This novel clinic concept addresses structural inequities by decreasing barriers to care and reimagines an ideal state of postpartum dyadic care with frequent visits addressing the complete needs of each postpartum patient and newborn. For more than 2 decades, maternal health advocates have been calling for change from health care birth systems to improve health care outcomes. This collaborative, interdepartmental initiative-conceived in the context of a pandemic-is an answer to that call.

The Birth Sisters Program: A Model of Hospital-Based Doula Support to Promote Health Equity.

Maternity care in the United States is characterized by racial and income disparities in maternal and infant outcomes. This article describes an innovative, hospital-based doula model serving a racially and ethnically diverse, low-income population. The program's history, program model, administration requirements, training, and evaluations are described.

Multidisciplinary collaborative development of a plain-language prenatal education book.

During pregnancy, women actively seek out health information that promotes the well-being of themselves and their fetuses. For those with health literacy challenges, access to understandable health information can be difficult. Written information, in particular, needs to be readable and usable by the women served. Plain language is an essential component of effective health education material. In an effort to create standardized prenatal education materials for a diverse population of childbearing women, Boston Medical Center's midwifery service led a multidisciplinary initiative to develop a comprehensive plain-language prenatal education book. Midwives, obstetricians, family physicians, nurses, and community doulas contributed to the content of the book; art students provided graphic design skills; and a literacy consultant assisted in the wording and layout. The Hey Mama! book provides women with woman-centered, readable, comprehensive information about pregnancy, labor, postpartum, and newborn care.

The birth of a collaborative model: obstetricians, midwives, and family physicians.

In the United States, the challenges of maternity care include provider workforce, cost containment, and equal access to quality care. This article describes a collaborative model of care involving midwives, family physicians, and obstetricians at the Boston Medical Center, which serves a low-income multicultural population. Leadership investment in a collaborative model of care from the Department of Obstetrics and Gynecology, Section of Midwifery, and the Department of Family Medicine created a culture of safety and commitment to patient-centered care. Essential elements of the authors' successful model include a commitment to excellence in patient care, communication, and interdisciplinary education.

Relationship of obesity to outcome of medical abortion.

OBJECTIVE: The purpose of this study was to compare the outcome of medical abortion for obese women and nonobese women. STUDY DESIGN: We conducted a chart review of women having medical abortions in 2005-2007. Outcomes were classified as surgical intervention, need for additional visits, and complete abortion. The rate of surgical intervention was compared for women with BMI less than 30 to women with BMI greater than 30. RESULTS: Of the 1202 eligible procedures using mifepristone and misoprostol, there were 861 women with BMI less than 30 and 341 women with BMI greater than 30. Women with BMI less than 30, and women with BMI greater than 30 had identical rates of surgical intervention, 5% and 6%, respectively (P = .72). CONCLUSION: In light of the additional risks of surgical abortion to obese women, medical abortion should be considered for these women.

A hospital-based doula program and childbirth outcomes in an urban, multicultural setting.

OBJECTIVES: The objective of this study is to determine whether there are differences in birth and breastfeeding outcomes for women who received labor support through a hospital-based doula program, compared with those who did not receive doula support in labor. METHODS: We conducted a retrospective program evaluation to compare differences in birth outcomes between births at 37 weeks or greater with doula support and births at 37 weeks or greater without doula support through the first seven years of a hospital-based doula support program. Log-binomial regression models were used to compare differences in cesarean delivery rates, epidural use, operative vaginal delivery, Apgar scores, breastfeeding intent and early breastfeeding initiation after controlling for demographic and medical risk factors. The propensity score was included as an additional covariate in our regression model to minimize issues of selection bias. Analyses were conducted for the whole cohort of 11,471 women and by parity and provider service in subgroup analyses. Cochran-Mantel-Haenszel test was performed to detect differences in effects over time. RESULTS: For the whole cohort, women with doula support had significantly higher rates of breastfeeding intent and early initiation. Subgroup analysis showed that having doula support was significantly related to: (a) higher rates of breastfeeding intent and early initiation rates for all women regardless of parity or provider with the exception of multiparous women with physician providers; (b) lower rates of cesarean deliveries for primiparous women with midwife providers. CONCLUSION: A hospital-based doula support program is strongly related to improved breastfeeding outcomes in an urban, multicultural setting.

Bleeding after medication-induced termination of pregnancy with two dosing schedules of mifepristone and misoprostol.

OBJECTIVE: This study examines bleeding pattern following medication-induced termination of pregnancy, comparing two different dosing schedules of mifepristone and misoprostol. STUDY DESIGN: Diary information was analyzed from a randomized, multicenter trial in which women used vaginal misoprostol 800 mug either 6-8 or 24 h following 200 mg of oral mifepristone. PARTICIPANTS AND METHODS: One thousand eighty women with pregnancies up to 63 days' gestation were recruited for the study; 540 were randomized to the 6- to 8-h dosing schedule, and 540 were randomized to the 24-h dosing schedule. Subjects recorded daily bleeding in a diary over 5 weeks. RESULTS: Total duration of bleeding ranged from 1 to 54 days, with a median of 7 days. Duration of spotting ranged from 1 to 80 days, with a median of 5 and 6 days (NS) in each of the two groups. Neither duration of bleeding nor duration of spotting were related to interval between mifepristone and misoprostol. Bleeding and spotting durations were not correlated with maternal age or smoking. Increased gestational age was correlated with longer bleeding and spotting times. Nulliparity was associated with longer bleeding time. CONCLUSION: Varying the interval between mifepristone and misoprostol in medication abortion does not affect duration or quantity of bleeding.

Women's public health policy in the 21st century.

Midwives share a historic commitment with maternal and child public health (MCH) agencies to protect and improve perinatal health among vulnerable populations. Both professions are now beginning to broaden their responsibilities to include the comprehensive health needs of women. Because midwifery's unique woman-centered primary care practices reflect the goals and aims of the developing MCH women's health agenda, continued partnerships between midwives and the maternal and child public health community are imperative to promote the health of women and their families. To facilitate such collaboration, this article presents an overview of women's public health policy and articulates the unique contributions midwives can and do make to women's health care and public health policy.