HealthConnectOne, 3 Collaborators Issue Report Entitled 'Improving Our Maternity Care Now Through Doula Support' (Part 1 of 2)
Here are excerpts:
* * *
TABLE OF CONTENTS
ii...Executive summary
1...Introduction
2...Doula support in
2...Rise of the private-pay birth doula
4...Longitudinal community-based doula support
4...What is birth justice?
6...Doula support during the COVID-19 pandemic
7...Doula skills and knowledge for non-doulas
7...Evidence supports the important benefits and value of doula services
7...Evidence about effects of supportive companions during childbirth
8...Evidence about effects of extended doula support
10...How doula support attains these exemplary outcomes
11...Cost of doula support
13...Spotlight on Success: Open Arms Perinatal Services
15...Birthing women and people's positive experience of doula support
17...Spotlight on Success: Tewa Women United
19...Widespread interest and unmet need for doula services
21...
24...Figure. Medicaid and private insurance coverage of doula support services
26...Recommendations
26...Federal policymakers
28...State policymakers
29...Private sector decisionmakers
33...Resource directory
38...Endnotes
45...About the partnering organizations
47...Acknowledgments
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EXECUTIVE SUMMARY
Our nation's maternity care system fails to provide many childbearing women and people* and their newborns with equitable, accessible, respectful, safe, effective, and affordable care. More people die per capita from pregnancy and childbirth in this country than in any other high-income country in the world. Our maternity care system spectacularly fails communities struggling with the burden of structural inequities due to histories of racist oppression and other forms of disadvantage, including Indigenous, Black, and Communities of color; rural communities; and people with low incomes.
Both the maternal mortality rate and the much higher severe maternal morbidity rate (often reflecting a "near miss" of dying) have been increasing, and reveal inequities by race and ethnicity. Relative to white non- Hispanic women, Black women are more than three times as likely, and Indigenous women are more than twice as likely, to experience pregnancy-related deaths. Moreover, Black, Indigenous, Hispanic, and Asian and Pacific Islander women disproportionately experience births with severe maternal morbidity relative to white non-Hispanic women.
This dire maternal health crisis, which has been compounded by the COVID-19 pandemic, demands that we mitigate needless harm now.
Fortunately, research shows that specific care models can make a concrete difference in improving maternity care quality and producing better outcomes, especially for Indigenous, Black and other birthing women and people of color. One such model is doula support. This report outlines the evidence that supports the unique value of doula support across different communities, the safety and effectiveness of doula support in improving maternal and infant outcomes, the interest of birthing women and people in use of doula support, and the current availability of, and access to, doula services in
Research shows that doula support during childbirth offers benefits to childbearing families relative to usual care without doula support with respect to many key indicators, including higher rates of spontaneous vaginal birth, fewer cesarean births, less use of pain medications, and higher birthing-person satisfaction with care. When extended to support during pregnancy and the postpartum period, doula services have been associated with such benefits as less likelihood of preterm birth and low birthweight, and greater likelihood of initiating breastfeeding. Community- based and -led doula services are especially powerful and are essential components of a just and effective maternity care system. In addition to these important health benefits, a series of analyses suggests that these services are cost-effective. Yet in
Expanding the availability of doula support is a cost-effective solution to providing better maternal experiences and birth outcomes. Barriers to access to doula services must be eliminated. These include: lack of funding for doula training; an inadequate supply of doulas and especially doulas that offer culturally congruent support; limited Medicaid and private insurance reimbursement for doula services; unsustainable reimbursement levels for doula services; failure to provide payment, professional support, and conditions of work that enable doulas and their families to thrive and doulas to provide sustained services over time; overly restrictive laws and regulations determining doula eligibility for reimbursement; and the unaffordability of private-pay doula services for many childbearing families. Enabling more birthing people to receive the support of doulas while diversifying and appropriately supporting the doula workforce should be top priorities for decisionmakers at the local, state, and federal levels. To achieve this, we recommend the following:/
Federal policymakers:
*
*
* Members of
* Federal research and evaluation programs should support research to more fully understand effects of community- based and -led doula training and support programs in communities of color and others facing structural precarity.
State and territorial policymakers:
* State legislators should enact, and regulators should provide, guidance for establishing doula services as a covered benefit through Medicaid (both fee-for-service and managed care) and CHIP.
* In parallel with coverage of doula services, states should allocate resources to build, support, and mentor the doula workforce.
* States and tribes should ensure that community-based doulas are eligible and encouraged to deliver MIECHV services.
Private-sector decisionmakers, health care purchasers, and health plans, should:
* Designate doula support as a covered service.
* Require employers to ensure that employees have access to doula support.
* Require Medicaid managed care, hospitals, and other organizations to support community-based organizations in the development and ability to provide doula training programs to increase the doula workforce.
* Philanthropy should support community-based doula models by growing and supporting the doula workforce and reducing barriers to obtaining doula support.
* The
* * *
INTRODUCTION
The
More people die per capita as a result of pregnancy and childbirth in this country than in any other high-income nation./2
Our maternity care system spectacularly fails communities struggling with the burden of structural inequities due to histories of racist oppression and other forms of disadvantage, including Indigenous, Black, Communities of color; rural communities; and people with low incomes./3
Rates of maternal death and severe maternal morbidity in
Between 1987 and 2017, pregnancy-related deaths in
Between 2006 and 2015, severe maternal morbidity (SMM), often reflecting a "near miss" of dying, rose by 45 percent, from 101.3 to 146.6 per 10,000 hospitalizations for birth./6
Following the 2015 shift to a new clinical coding system (ICD10-CM/PCS), SMM continued to increase, both overall and for people of color, from 2016 to 2019./7
In communities of color, the crisis is extreme. Compared to white non-Hispanic women, Black women are more than three times as likely, and Indigenous women are more than twice as likely, to experience pregnancy- related deaths. Moreover, Hispanic, Black non-Hispanic, and Asian and Pacific Islander non-Hispanic women disproportionately experience births with SMM relative to white non-Hispanic women./8
In 2015, relative to white non-Hispanic women, the rate of SMM was 2.1 times higher for Black women, 1.3 times higher for Hispanic women, and 1.2 times higher for Asian and Pacific Islander women./9
From 2012 through 2015, Indigenous women experienced 1.8 times the SMM rate of white women./10
Many factors drive maternal mortality and morbidity and the related deep racial, ethnic, and geographic inequities. These include gaps in health care coverage and access to care; poor quality care, including implicit biases and explicit discrimination; unmet social needs, like safe and stable housing, reliable transportation, paid family and medical leave, and time off from paid work for medical visits; and for people of color, the effects of contending with systemic, institutional, and interpersonal racism./11
The terrible impacts of these inequities are unconscionable, especially considering that about 60 percent of pregnancy-related deaths are preventable, and there are opportunities to improve care in a large proportion of people with SMM./12
In the long term, we must transform the maternity care system through delivery system and payment reform, performance measurement, consumer engagement, health professions education, and improving the workforce composition and distribution. However, our dire maternal health crisis, which has been compounded by the COVID-19 pandemic, demands that we mitigate preventable harm now.
Fortunately, research shows that specific care models make a concrete difference in providing higher quality care and improving birth outcomes. Support provided by doulas is one high-performing model that we must make widely available, especially for birthing women, people and families of color.
* * *
RECOMMENDATIONS
There is a strong evidence base to support including doula services in the standard package of essential maternity care services available to all pregnant, birthing, and parenting women and people. Culturally congruent doulas appear to offer exceptional benefits to women of color and other groups facing structural, institutional, and interpersonal discrimination. Yet doula services are often out of reach for many pregnant people because insurance coverage for these services is limited. Moreover, the number of doulas, including community doulas, is almost certainly inadequate to provide support to those who want it. Given the ongoing maternal health crisis, especially in communities of color, financial support of doula services, as well as support to grow, diversify, and sustain the community doula workforce, are essential policy strategies.
Federal policymakers:
*
- These programs include Medicaid, Medicare, the Child Health Insurance Program (CHIP), the Federal Employee Health Benefits (FEHB) Program, TRICARE, the
- As desired by pregnant women and people, these services should include pregnancy, birth, and postpartum support.
- Eligibility criteria for program participation, covered services, payment model and levels, and other program features should not be overly restrictive and should be determined through close consultation with community doulas, doula organizations, and doula clients. Programs should be designed to attract and retain these critical birthworkers and to contribute to community development through services and jobs.
- Doula compensation should provide a thriving wage that reflects the working conditions, scope of services provided, scheduling logistics, realistic caseload of clients, and cost of living.
- The respective programs should educate beneficiaries about the doula role, the evidence about doulas, and the availability of this covered benefit.
- Programs should educate health professionals about doula support as a complement to clinical services, the evidence about benefits of doulas for women and birthing families, and availability of this covered benefit.
*
* Members of
*
- Outcomes of interest include, but are not limited to, indicators of perinatal mental health, maternal confidence and agency, identification and fulfillment of social needs, child development, adverse childhood experiences, the ability to break cycles of intergenerational trauma, pipeline for midwifery and other maternal care clinical and support professions, other benefits to doulas themselves, and longitudinal economic evaluation of return on investment, as well as continued preterm birth, low birthweight, and breast/chestfeeding research.
- This research should consistently collect, measure, and publicly report the ability of doula services to advance equity across these outcomes, by race and ethnicity, socioeconomic status, sexual orientation, gender identity, language, and disability status.
- The research should be co-created and carried out through community-based participatory modalities to strengthen results and avoid overburdening doulas and their provision of crucial services.
State policymakers:
* State legislators should enact, and regulators should provide, guidance for establishing doula services as a covered benefit through Medicaid (both fee-for-service and managed care) and CHIP.
- As desired by birthing women and people, these services should include pregnancy, birth, and postpartum support.
- Eligibility criteria for program participation, covered services, payment model and levels, and other program features should not be overly restrictive and should be determined through close consultation with community doulas, doula organizations, and doula clients. Programs should be designed to attract and retain these critically important birthworkers and contribute to community development through services and jobs.
- Doula compensation should provide a thriving wage that reflects their working conditions, scope of services provided, scheduling logistics, realistic caseload of clients, and cost of living.
- States should educate beneficiaries about the doula role, the evidence about doulas, and the availability of this benefit.
- The respective programs should educate health professionals about doula support as a complement to clinical services, the evidence about benefits of doulas for women and birthing families, and availability of this covered benefit.
- In establishing these programs, states should glean lessons from the successes and challenges of pioneering states (e.g.,
* In parallel with coverage of doula services, states should allocate resources to build, support, and mentor the doula workforce.
- States should support a diversity of community-based training models and programs and should ensure that doula training is tailored to the needs of the childbearing population (including trauma-informed care, maternal mood disorders, intimate partner violence, social services navigation, birth justice, and understanding and mitigating systemic racism).
- States should ensure racial, ethnic, linguistic, and geographic (including rural) diversity in the doula workforce that aligns with the childbearing population covered by Medicaid and CHIP. Every effort should be made to ensure cultural congruence among trainers, doulas in training, doula mentors, and doula clients.
- To foster growth and diversity of the doula workforce, states should minimize financial barriers to entry and provide mentorship support.
- States should determine eligibility criteria for program participation, covered services, payment model and levels, and other program features in partnership with doulas, doula organizations, and doula clients.
- Any doula certifications should be offered through training programs. * States and tribes should ensure that community doulas are eligible and encouraged to deliver Maternal, Infant, and Early Childhood Home Visiting services.
Private-sector decisionmakers, including health care purchasers, and health plans, should:
* Designate doula support as a covered service.
- As desired by birthing women and people, these services should include pregnancy, birth, and postpartum support.
- Eligibility criteria for program participation, covered services, payment model and levels, and other program features should not be overly restrictive and should be determined through close consultation with community doulas, doula organizations, and doula clients. Programs should be designed to attract and retain these critically important birthworkers and contribute to community development through services and jobs.
- Doula compensation should provide a thriving wage that reflects their working conditions, scope of services provided, scheduling logistics, realistic caseload of clients, and cost of living.
- Health plans should educate beneficiaries about the doula role, evidence about doula support, and the availability of this covered benefit.
- Health plans should educate health professionals about doula support as a complement to clinical services, the evidence about benefits of doulas for birthing women and families, and availability of this covered benefit.
- Health plans should ensure that plan directories maintain up-to-date listings for available doulas or doula agencies.
* Require employers to ensure that employees have access to doula support.
- Options for employee access include doula support as a benefit of employment or as a covered service through their contracted health plans.
- As desired by birthing women and people, these services should include pregnancy, birth, and postpartum support.
- Employers should incorporate clear expectations into purchaser- payer contracts about sustainable plan payment for extended model doula services.
- Employers should educate beneficiaries about the doula role, evidence about doula support, and the availability of this covered benefit.
* Require Medicaid managed care, hospitals, and other organizations to support community-based organizations in the development of doula training programs to increase the doula workforce.
- In addition to educating about emotional, informational, and hands- on support, curricula should include trauma-informed care, impact and mitigation of racism, culturally congruent support, birth and reproductive justice, intimate partner violence, perinatal mood disorders, and other skills and knowledge for providing optimal community-focused support.
- Organizations should ensure racial, ethnic, linguistic, and geographic (including rural) diversity in the doula workforce that aligns with the childbearing population covered by Medicaid and CHIP. Cultural congruence among trainers, doulas in training, doula mentors, and doula clients is optimal.
- As relevant, community-based training programs should encourage doulas to join Indigenous, Black, Latinx, and Communities of color in reclaiming their birthing traditions.
- Any doula certifications should be offered through training programs.
* Philanthropy should support community-based doula models by growing and supporting the doula workforce and reducing barriers to obtaining doula support.
- Philanthropy should support training programs, access to doula support for those without other sources of coverage, doula mentorship, the development and evaluation of community doula services, infrastructure, organizational capacity building, and other programming to increase access to doula support.
- Community doula services should be free or low-cost.
* The
- Outcomes of interest include, but are not limited to, indicators of perinatal mental health, maternal confidence and agency, identification and fulfillment of social needs, child development, adverse childhood experiences, the ability to break cycles of intergenerational trauma, pipeline for midwifery and other maternal care clinical and support professions, other benefits to doulas themselves, and longitudinal economic evaluations of return on investment, as well as continued research into preterm birth, low birthweight, and breast/chestfeeding.
- The research should be co-created and carried out through community-based participatory modalities to strengthen results and avoid overburdening doulas and their provision of crucial services.
- This research should consistently collect, measure, and publicly report the ability of doula services to advance equity across these outcomes, by race and ethnicity, socioeconomic status, sexual orientation, gender identity, language, and disability status.
* * *
(Continues with Part 2 of 2)
The report is posted at: https://www.nationalpartnership.org/our-work/resources/health-care/maternity/improving-maternity-doula-support.pdf
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