By Colleen Senterfitt, CNM, Sr. Director, Clinical Quality and Specialties at CCA

As childbirth became medicalized in the early 1900s, the use of midwives during labor declined. Today, nurses are trained to provide excellent labor and delivery support, but their workload does not allow for one-to-one individualized attention during the pre- and postpartum stages of the pregnancy. While a mother’s partner or family members can provide social and emotional support, these individuals typically lack a deep understanding of the physiologic process of labor and birth, or the terminology, technology, and staff that greatly affect the experience.  

Doulas can fill this critical gap.

What are Doulas?

Doulas are non-clinical support staff who have a deep knowledge of the pregnancy and labor process, including the normal changes that occur during pregnancy and postpartum support needs. The doula and mother work together to create a birth plan that incorporates the mother’s preferences and goals. Through this process, the mother and the doula explore all pregnancy options, identify pain points, and ensure appropriate communication with the mother’s care team. The doula can also provide critical information and education about cesarean sections, comfort measures during labor, infant care, and breastfeeding.

The doula serves as a trusted resource for the mother throughout labor, birth, and the postpartum period. They do not give medical advice or make medical decisions; they help the mother and family to make informed decisions.

DONA International, the world’s leading training, certification, and continuing education organization for doulas, defines a doula as “a trained professional who provides continuous physical, emotional, and informational support to a mother before, during and shortly after childbirth to help…achieve the healthiest, most satisfying experience possible.”

The Impact of Doulas on Pregnancy Outcomes and Satisfaction

A 2017 Cochrane review of randomized and quasi-randomized trials comparing continuous one-to-one labor support versus usual care found significant benefits associated with continuous intrapartum support, including lower rates of cesarean sections and less use of intrapartum analgesia. Additionally, this level of support often leads to shorter labor and improved patient satisfaction with the childbirth experience¹.

A concerning trend in maternal health is racial disparities in outcomes. These are well-documented,² particularly the rising pregnancy-related mortality that disproportionately affects non-Hispanic black mothers.³ When analyzing the causes of this higher mortality, evidence points to the increasing burden of chronic health conditions in pregnant individuals, which may lead to higher rates of complications.³ Doulas are trained to provide individualized support and to advocate for the mother’s preference-sensitive decisions.

The Dilemma: Awareness, Access, and Affordability  

Awareness of doulas is not widespread and doula care is usually provided for middle and upper-income individuals. Doula care is not routinely available to individuals in lower socioeconomic groups—those who often need it the most. Cost is a barrier because doula services are not typically covered by insurance, including Medicaid.⁴ Those who most need this assistance may lack the awareness, access, and the means to pay for these services.

Doulas can navigate the healthcare system and educate, support, and empower mothers to ensure their wishes for labor and delivery are known to the maternity care team in advance. This is particularly helpful for women who are marginalized based on education, race, ethnicity, and other socioeconomic characteristics. Private doulas who serve middle or upper-class mothers are neither affordable nor prepared to meet the needs of those impacted by social determinants of health—including poverty, low education, unstable housing, or unsafe communities.

Disability compounds these challenges and has been shown to increase a mother’s risk for a “broad spectrum of adverse maternal outcomes and obstetric intervention that may increase risk for mortality.”⁵ For this population, the benefits of having access to a doula may be even greater.

Improving Equity and Access: CCA’s uncommon care®

As part of a broad women’s health quality improvement strategy, Commonwealth Care Alliance® (CCA) considered the needs of its pregnant members, whose complex health and social determinants have been shown to increase risk of adverse outcomes for both mothers and their infants. While excellent obstetric care is available and accessible to our members, affordable doula services are limited to only a few hospitals. Therefore, to increase access for members, CCA launched a doula program in 2018 that leveraged the trusting relationship between members and our Community Health Outreach Workers (CHWs). 

CHWs play a critical role in the CCA interdisciplinary care team by helping members address their social determinants of health and overcome barriers to care. CCA’s CHWs, who have a deep understanding of our members’ unique needs and challenges, completed a DONA Childbirth Doula program that prepared them to provide education and support throughout the maternity cycle—from pregnancy to labor and postpartum. 

CCA doula services can begin at any time during pregnancy or postpartum. There are no limits to the number of visits. The mother and the doula decide what is needed and visits are scheduled in the mother’s home or other community-based location. While postpartum doula support is typically offered for up to three months, CCA extends support for a full year, recognizing that the mother–baby relationship is key to the family’s health and well-being.   

As part of the CCA doula program, the CHWs collaborate with an integrated interdisciplinary team to:

• Build trusting relationships with participants that foster open and honest communication
• Deliver critical education and information that mothers (and their social supports) need to make important decisions during and after pregnancy
• Serve as advocates for mothers, ensuring appropriate communication of values and preferences with the clinical teams
• Work to eliminate barriers to care, helping mothers receive the appropriate medical and behavioral health services they need for a healthy pregnancy. Support includes helping to schedule appointments, transportation, and more  
• Connect mothers to social support services they may need, such as food pantries, CPR and first aid courses, Lamaze classes, lactation consultants, family planning programs, parenting classes, women’s shelters and support groups, early intervention programs for babies with special needs, and more

Additionally, since many CCA members who receive doula care also have complicated health conditions and/or behavioral health and substance use issues, CCA doulas recognize the burden of these factors and work with mothers to lessen stigma and establish community supports.

“Your support was so needed—I’m so grateful that you helped me.” 

CCA Member

Families who have been served by the CCA doula program value the information and support they received. During post-program discussions, many of the participants expressed feeling grateful for the emotional support that was given—especially as many lacked a steady social support system at home.

Many program participants also expressed gratitude for the knowledge and confidence they gained to be better prepared for their birth and parenting. The trusting relationship formed empowers the mother, leads to a more positive birth experience, and increases confidence that extends well beyond the birth of the baby.

References

¹ Bohren MA, Hofmeyr  GJ, Sakala  C, Fukuzawa  RK, Cuthbert  A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6.

² Moaddab A, Dildy, GA, Brown HL, et al. Health care disparity and pregnancy-related mortality in the United States, 2005-2014. Obstet Gynecol. 2018;131:707-712.

³ Pregnancy mortality surveillance system. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Published November 25, 2020. Accessed January 19, 2022.  

⁴ “Doula Care Saves Lives, Improves Equity, And Empowers Mothers. State Medicaid Programs Should Pay For It,” Health Affairs Blog, May 26, 2021.

⁵ Gleason JL, Grewal J, Chen Z, Cernich AN, Grantz KL. Risk of Adverse Maternal Outcomes in Pregnant Women With Disabilities. JAMA Netw Open. 2021;4(12):e2138414. Published 2021 Dec 1. doi:10.1001/jamanetworkopen.2021.38414