Doulas, Disparities, and Disentangling Maternal Mortality

The United States is home to the highest rate of maternal mortality in the developed world. In particular, African American women suffer the worst health outcomes in birthing and pregnancy. African American women are three to four times more likely to die during childbirth than non-Hispanic white women, experiencing 42.4 maternal deaths per 100,000 births compared to 13 per 100,000 births respectively. One attempt to tackle this complex inequality is the introduction of Medicaid-subsidized doulas, trained patient companions who provide support and guidance for the duration of a pregnancy. This an initiative which would support the health outcomes of disadvantaged women in addition to yielding long-term cost saving measures.

The Doula Organization of North American (DONA) defines a doula as a “person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during, and just after birth”. The doula is knowledgeable on physical comfort measures such as labor positions, exercises, nutrition, and stress relief and can offer a range of other advice relevant to achieving a successful pregnancy and birth, even accompanying mothers to doctors’ appointments.  Research on doulas has been extremely positive, illustrating beneficial effects such as fewer complications during pregnancy, less pain and fewer C-sections, and higher rates of satisfaction. Yet these doulas remain out of reach, only currently covered by Medicaid in three states: Oregon, Minnesota, and New York. In light of the positive effects of doulas, their use and accessibility should be expanded to more state Medicaid insurance plans in order to reach more women. 

A continuous support model in pregnancy and birthing is nothing new. A recurring theme throughout history is that of expecting mothers being cared for and accompanied by other women such as midwives throughout their pregnancy and birthing process. However, continuous support is now somewhat of an exception in our current medical practices. Yet, the positive effects of these powerful agents of the continuous support model have been well documented. Doula-supported births have been associated with a 40.9 percent lower occurrence of C-sections, lower rates of anesthesia use, lower use of instrument-assisted delivery, shorter labor, and higher levels of patient satisfaction

A Cochrane review of 26 studies of more than 15,000 women in 17 countries found that women receiving “continuous labor support” through the assistance of doulas were more likely to give birth “spontaneously” (vaginally), more likely to be satisfied and in less pain, and less likely to have low five-minute Apgar scores–a test given after birth to check vital signs. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published a consensus statement stating: “Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.” In June 2012, the Expert Panel of Center for Medicare and Medicaid Services on Improving Maternal and Infant Health Outcomes in Medicaid/CHIP (Children’s Health Insurance Program) identified Medicaid coverage for continuous doula support as a recommended strategy to provide care for mothers enrolled in Medicaid and CHIP. 

Doulas may be especially valuable in communities of women of color and low-income women, which suffer disparities in maternal mortality rates and maternal care. Yet doulas are often out of reach for these women: only six  percent of U.S. women are supported by a doula during pregnancy and birth. Most private doulas charge $700 – $1500 per birth, a hefty price tag. When economic access is not curtailed, geographic access can be an issue. Half a million births occur in rural areas per year, where doulas are not distributed evenly.  Women of color and low-income women are among the most likely to report wanting, but not having access to, doula services

" Greater accessibility to doulas through Medicaid has the potential to revitalize women’s health, allowing healthy and safe births while potentially providing a cost-efficient strategy to meet patient needs. "

Structural violence against women of color means that this healthcare experience must be contextualized within institutionalized systems of disadvantage. Disparities in access to care, toxic chronic stress in U.S. society, and bias in healthcare have contributed to disparities experienced by this group. Obstetrician and bioethicist Anne Lyerly describes women suffering from these disparities as unable to achieve a “‘good birth:’ a birth experience characterized by person agency and security, connectedness, respect, and knowledge.” 

Positive effects of doulas when it comes to minimizing disparities are documented around the world. In Sweden, immigrant women suffer stressors such as language, cultural and social barriers before, during, and after childbirth and are six times more likely to die from pregnancy-related complications than Swedish-born women. Case studies of culturally-attuned doulas in Sweden for immigrant women have illustrated drastically positive effects in birthing, comfort, and stress relief. 

The challenge remains of how to integrate doulas into current health insurance systems. The U.S. healthcare system values cost-efficient measures, meaning that the goal would be a strategy that contains costs while promoting medically and socially-beneficial interventions. The issue of expanding doula coverage presents obstacles regarding billing and network development. For one, a general lack of awareness surrounding the role and effects of doulas clouds their ability to become mainstream. Moreover, doulas under Medicaid are subject to low reimbursement rates ($411 per birth), and obtaining a license to be reimbursed through Medicaid can be complicated–both of which present obstacles to sustainably employing doulas. 

Researchers have asserted, however, that once these barriers in doula Medicaid expansion are overcome, the rewards will outweigh the costs to implement this national intervention. A November 2014 study of four focus groups of pregnant Medicaid beneficiaries illustrated how doula use leads to cost savings due to the lesser use of speciality-trained providers and resource-intensive procedures such as C-sections.  “Having doula support would make it better–having [a chance to ask] questions instead of going to the doctor or to the hospital over and over again. Sometimes you don’t really need to go to the doctor … sitting for hours to have [the] ER doctor tell you something your doula could have told you.”

Moreover, about two million annual U.S. births, half of the national total, are financed by state Medicaid programs. A 28% reduction in C-section births thanks to doula support would relay to about $2.4 billion saved in childbirth costs per year combined between Medicaid and private insurance births. Doula support would allow reductions in spending on non-beneficial medical procedures, avoidable complications such as use of epidural pain relief, and preventable chronic conditions.

Greater accessibility to doulas through Medicaid has the potential to revitalize women’s health, allowing healthy and safe births while potentially providing a cost-efficient strategy to meet patient needs. Greater accessibility for the women who suffer from disparities in care and outcome would help redress deeply rooted inequities.

Photo: Image via Adobe Stock Images

About the Author

Madeline Noh '22 is a Staff Writer for the Culture Section of the Brown Political Review. Madeline can be reached at madeline_noh@brown.edu

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