Summary and Purpose
Consistent with its mission to fight for the health of all moms and babies, March of Dimes issued a July 2018 Position Statement on Maternal Mortality and Morbidity , released a report on maternity care deserts, and is developing an approach to address the “poor quality and differential care” that contributes to the higher rates of maternal morbidity and mortality experienced by women of color.1 This interim Position Statement on Doulas and Birth Outcomes will be part of a broader March of Dimes approach to these issues that is under development. It provides evidence and guidance to support March of Dimes participation in advocacy efforts related to doula care as they arise nationally and locally. It also can serve as an education tool about the importance of doulas as a part of the birth team.
In summary, this document states that:
March of Dimes supports increased access to doula care as one tool to help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States.
March of Dimes advocates for all payers to provide coverage for doula services.
March of Dimes recognizes the importance of increased training, support and capacity
development for doulas, including doulas from racially, ethnically, socioeconomically and culturally diverse communities.
Doulas are non-clinical professionals who provide physical, emotional and informational support to mothers before, during and after childbirth, including continuous labor support.2 Six percent of birthing women in the U.S. said they used a doula during childbirth in a 2012 survey.3 While there is no reliable estimate of the number of doulas in the U.S., a centralized online doula registration service, not affiliated with any one certifying organization, had 9,000 registered doulas in 2018.4
Studies suggest that increased access to doula care, especially in under-resourced communities, can improve a range of health outcomes for mothers and babies, lower healthcare costs, reduce c-sections (cesarean sections), decrease maternal anxiety and depression, and help improve communication between low-income, racially/ethnically diverse pregnant women and their health care providers.
The role of doula care in reducing c-sections is important, because c-sections contribute to the risk of maternal morbidity and mortality in initial and subsequent pregnancies. March of Dimes supports increased access to doula care as one tool to help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States.
Doula support is not routinely covered by health insurance. Since one of the barriers to having doula support is cost, insurance coverage for doula support through Medicaid, the Children’s
Health Insurance Program, private insurance, and other programs may be a way to improve birth outcomes and close the gap in birth outcomes between African American and white women.5 March of Dimes supports all payers providing coverage for doula services.
Evidence: doulas and birth outcomes
A 2017 Cochrane review of 26 trials of continuous labor support and doula care involving over 15,000 women in 17 different countries in high and middle-income settings found some improved outcomes for women and infants including: “increased spontaneous vaginal birth, shorter duration of labor, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support.”6
The American College of Obstetrics and Gynecologists (ACOG) acknowledges the potential benefits of continuous labor support by doulas in its Committee Opinion on Approaches to Limit Intervention During Labor and Birth, and the Obstetric Care Consensus (with Society for Maternal-Fetal Medicine) on Safe Prevention of the Primary Cesarean Delivery.7,8 Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.9 Benefits found in randomized trials.10,11 include shortened labor, decreased need for analgesia, fewer operative deliveries, and increased maternal satisfaction post labor.
Available literature discusses how increasing access to doula care, especially in under- resourced communities, may improve birth outcomes, improve the experience of care, and lower costs by reducing non-beneficial and unwanted medical interventions. For example:
A doula support program in New York City found that among almost 500 infants born to non-Hispanic Black women over a 5 year period (2010-2015), doula-supported women had lower rates of preterm birth and low birthweight.12 The program served women in a neighborhood with the highest rates of infant mortality, prematurity and low birthweight in New York City. Program participants also felt highly valued and felt they had a voice in consequential childbirth decisions.
A study that compared outcomes for doula-supported Medicaid recipients with a national sample of similar women who did not receive doula care found lower c -section and preterm birth rates for doula-supported births among subgroups including Black women, suggesting the “role doulas could play in reducing persistent racial/ethnic disparities” in outcomes.13
A focus group study of low-income pregnant women found that access to doulas can mitigate the effects of social determinants of health by addressing health literacy and social support needs. For example, doulas can help improve communication between low-income, racially/ethnically diverse pregnant women and their health care providers.14
Safely reducing primary c-sections can play a role in reducing maternal morbidity in initial and future pregnancies. ACOG’s 2014 consensus statement on Safe Prevention of the Primary Cesarean Delivery states that: “although the initial cesarean delivery is associated with some increases in morbidity and mortality, the downstream effects are even greater because of the risks from repeat cesareans in future pregnancies.”8 Given the evidence that doula care may
reduce c-sections, it can be inferred to play a role in reducing the future effects cited by ACOG of increased maternal morbidity and mortality in future pregnancies.
Reimbursement of doula care
March of Dimes supports coverage of doula services under the full range of private and public insurance programs, including Medicaid, the Children’s Health Insurance Program (CHIP), TRICARE, and others. Payment levels should be sufficient to support the care provided.15 March of Dimes supports the availability of doula care services during the prenatal, childbirth, and postpartum periods, in accordance with the needs and wishes of the mother.
March of Dimes believes that doula care can be a valuable supplement to, but not a substitute for, appropriate medical care during pregnancy, childbirth, and postpartum recovery, as a doula does not serve a clinical role in the relationship with the mother. A doula can be a powerful liaison, connecting the mother to appropriate care providers and remaining a constant presence of support, even when the mother may have inconsistent providers. A woman must still retain insurance coverage and access to all necessary services from health care providers and should keep a regular schedule of prenatal and postpartum medical checkups, as well as coverage for childbirth in a setting appropriate to meet the needs of both her and her baby.
Sustainability of doula care
March of Dimes recognizes the importance of increased training, support and capacity development for doulas, including doulas from racially, ethnically, socioeconomically and culturally diverse communities. Studies indicate that the “women who stand to benefit the most from doula care have the least access to it—both financially and culturally. Most doulas are white middle-class women serving white middle-class women.”5,16 The cost of training may be a potential barrier for people interested in becoming doulas. Efforts should be made to make the doula profession more accessible to people of diverse socio-economic backgrounds. Making doula work sustainable is an important goal to ensure that women with the highest rates of adverse birth and maternal health outcomes have support before, during and after pregnancy.
1 Jain JA, Temming LA, D'Alton ME, et al. SMFM Special Report: Putting the "M" back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: A call to action. Am J Obste Gynecol 2018 Feb;218(2):B9-B17.
2 DONA International. What is a doula? Available at: https://www.dona.org/what-is-a-doula/
3 Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers SM III: Pregnancy and Birth. New York: Childbirth Connection, May 2013.
4 DoulaMatch.net. Available at: https://doulamatch.net/
5 Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health 2013 Apr;103(4):e113-21. 6 Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017 Jul 6;7:CD003766.
7 ACOG Committee Opinion No. 687. Approaches to Limit Intervention During Labor and Birth. February 2017.
8 ACOG Obstetric Care Consensus No. 1. Safe Prevention of the Primary Cesarean Delivery. March 2014(Reaffirmed2016).
9 Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
10 Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controlled trial. JAMA 1991 May 1;265(17):2197-201.
11 Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013 Jul 15;7:CD003766.
12 Strauss N, Giessler K, McAllister E. How Doula Care Can Advance the Goals of the
Affordable Care Act: A Snapshot From New York City. J Perinat Educ 2015;24(1):8-15.
13 Thomas MP, Ammann G, Brazier E, Noyes P, Maybank A. Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Matern Child Health J 2017;21(Suppl 1):59-64.
14 Kozhimannil KB, Vogelsang CA, Hardeman RR, Prasad S. Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. J Am Board Fam Med 2016;29(3):308-17. 21.
15 Kozhimannil KB and Hardeman RR, Coverage for Doula Services: How State Medicaid Programs Can Address Concerns about Maternity Care Costs and Quality. Birth 2016; 43: 97-99. 16 Lantz PM, Low LK, Varkey S,Watson RL. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues 2005;15(3):109-116.
January 30, 2019