Characterizing the utilization of doula support services among birthing people of color in the United States: a scoping review.

BACKGROUND: Birthing people of color experience disproportionately higher rates of infant and maternal mortality during pregnancy and birth compared to their white counterparts. The utilization of doula support services may lead to improvements in the birthing experiences of birthing people of color. Yet, the research in this area is sparse. Thus, the purpose of this review is to characterize the research on doula utilization among birthing people of color, identify gaps in the field, and provide recommendations for future research. METHODS: Utilizing PRISMA guidelines, we conducted a scoping review, searching PubMed, PsycINFO, CINAHL, and Google Scholar for peer-reviewed articles published between January 1, 2016, to July 3, 2022. RESULTS: Twenty-five articles met inclusion criteria. We identified the three themes characterizing included studies: (1) how doulas support (HDS) their clients, (2) doula support outcomes (DSO), and (3) considerations for implementing doula support services (CIDS). Despite doulas being described as agents of empowerment, and providing social support, education, and advocacy, birthing people of color reported low utilization of doula support services and findings regarding their effectiveness in improving birthing outcomes were mixed. CONCLUSIONS: While some studies suggest that doulas may offer important services to birthing people of color, doulas are largely under-utilized, with many birthing people reporting low knowledge of their potential roles during the pre- and post-partum periods. Moreover, few studies were designed to assess intervention effects, limiting our ability to draw firm conclusions. Birthing people of color are at elevated risk for maternal mortality. As such, interventions are needed to support this population and improve outcomes. Our review suggests that, while doulas have the potential to make important contributions to the birthing support team, they are underutilized, and intervention studies are needed to enable estimates of their true effectiveness.

The role of doulas and community birth workers in abortion and contraception care: An international scoping review.

OBJECTIVES: Equitable and safe access to abortion and contraception is essential to protecting reproductive autonomy. Despite this, barriers to access remain. Nonclinical support people, may be able to facilitate access to abortion and contraception services and care, but evidence on the scope and efficacy of doulas in abortion and contraception care is lacking. The aim of this scoping review was to synthesize what is known about the role of doulas in abortion and contraception care. STUDY DESIGN: We followed the Joanna Briggs Institute methodology for scoping reviews. A clinical librarian performed an initial search of all relevant databases. Three reviewers independently screened the titles and abstracts for assessment against the inclusion and exclusion criteria. The populations of interest included doulas, and/or untrained birth attendants and birth companions, and patients who use doula services. The concept of interest was the doula and the context was access to abortion or contraception. RESULTS: Our review identified relevant studies conducted in different countries, published between 1976 and 2023. Studies broadly focused on three key themes: doulas performing procedural abortions, doulas supporting abortion care, and doulas supporting contraception. Outcomes of interest included client outcomes, barriers to access, doula training, and attitudes. CONCLUSIONS: Doulas have the potential to improve client satisfaction and mitigate barriers to accessing abortion and contraception services. Further research is needed to identify the training needs of doulas, the potential for their integration into interdisciplinary care teams, and the role in supporting medication abortion.

Reframing the experience of childbirth: Black doula communication strategies and client responses during delivery hospitalization.

Doulas, or birth coaches, are said to be "changing the world, one birth at a time." Black doulas have been suggested to mitigate against lack of representation in obstetric care, limited identity acknowledgement and accommodation, and obstetric racism. However, scientific inquiry into the specific communication strategies and messages used by Black doulas to advocate for clients was non-existent in extant literature. Guided by the Agency-Identity Model, we analyzed 20 diary-interviews of nine Black doulas who recently served Black clients. Specifically, we explored Black doulas' communication strategies and whether these strategies had an impact on client agency. We found that Black doulas prepare their clients for patient-provider interactions, including conversations about certain medical treatments and procedures and the risks for Black women and birthing people, the importance of informed consent, how to be heard, and how to resist neglect or abuse. We found that, in turn, most Black clients were able to enact agentic responses. We describe the specific doula messages, and contextualize our findings, considering how these collective interpersonal communication strategies of Black doulas, and their clients' agentic transformations, may index a sociopolitical movement to reframe the experience of childbirth in America.

Impact of doula's continuous support on serotonin release in parturients: a pilot randomized clinical trial.

Objective: To evaluate whether the continuous support provided by doulas influences the endogenous release of serotonin in parturients. Methods: This pilot study included 24 primigravidae at term. Of these, 12 women received continuous doula support (Experimental Group), whereas the other 12 received the usual assistance without doula support (Control Group). Blood samples were collected from all the women at the active and expulsion stages of labor and at the fourth period of labor (Greenberg period) for evaluation of their serotonin levels using high-performance liquid chromatography. Results: The average serotonin concentrations in the control and experimental groups were respectively 159.33 and 150.02 ng/mL at the active stage, 179.13 and 162.65 ng/mL at the expulsion stage, and 198.94 and 221.21 ng/mL at the Greenberg period. There were no statistically significant differences in serotonin concentrations between the two groups at the active and expulsion stages of labor. By contrast, within the experimental group, a significant increase in serotonin concentration was observed in the Greenberg period compared with the levels in the active and expulsion stages (p < 0.05). Conclusion: The novelty of this study relies on the ability to correlate the influence of the continuous support offered by doulas with the release of serotonin in parturients, with the results suggesting that the assistance received during labor can modulate the levels of hormone release in the Greenberg period. Brazilian Registry of Clinical Trials: RBR-4zjjm4h.

Beyond Birth Work: Addressing Social Determinants of Health With Community Perinatal Support Doulas.

Adverse maternal and infant health outcomes among African Americans are increasingly recognized as indicators of a critical public health crisis in the United States. Research has found that stress is related to structural racism and the social determinants of health (SDOH) that cause avoidable, unfair inequities in resources, education, power, and opportunities across ethnic groups. This paper describes the SDOH needs and experiences of pregnant Black women from the perspective of doulas and Birthing Beautiful Communities (BBC) clients. The design was a qualitative description, using data collected over time (2017-2018, 2020-2021, and 2023). This study took place in Cleveland and Akron, Ohio and the sample included 58 clients, 26 doulas, and 2 resource intake specialist assistants (RISAs). Qualitative data included individual client interviews, three doula focus groups, and one interview with two BBC RISAs. Three coders used content analysis to deductively identify SDOHs and calculate the number of interviews that contained information about specific SDOHs. Although the sample reported issues with all SDOH, particular ones caused a cascade of SDOH effects. Transportation issues, for example, impeded women from being able to make it to work, doctor's appointments, and to purchase essential baby items (e.g., food, infant supplies). An inability to work-whether because of transportation challenges or pregnancy-related health complications-led to unstable housing and an inability to deal with transportation challenges. Many clients mentioned that housing was a major issue, with many clients experiencing housing instability. Implications include ensuring SDOH information is collected from a trusted source who can advocate and ensure access to a wide range of local resources, ensuring policies protect pregnant women from experiencing a cascade of SDOH that may contribute to continuing health disparate infant and maternal health outcomes in African American women.

The infant health effects of doulas: Leveraging big data and machine learning to inform cost-effective targeting.

Doula services represent an underutilized maternal and child health intervention with the potential to improve outcomes through the provision of physical, emotional, and informational support. However, there is limited evidence of the infant health effects of doulas despite well-established connections between maternal and infant health. Moreover, because the availability of doulas is limited and often not covered by insurers, existing evidence leaves unclear if or how doula services should be allocated to achieve the greatest improvements in outcomes. We use unique data and machine learning to develop accurate predictive models of infant health and doula service participation. We then combine these predictive models within the double machine learning method to estimate the effects of doula services. We show that while doula services reduce risk on average, the benefits of doula services increase as the risk of negative infant health outcomes increases. We compare these benefits to the costs of doula services under alternative allocation schemes and show that leveraging the risk predictions dramatically increases the cost effectiveness of doula services. Our results show the potential of big data and novel analytic methods to provide cost-effective support to those at greatest risk of poor outcomes.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.