This article includes discussion of maternal mortality that may be challenging for some readers.

May 10, 2023
By Daneka Stryker, Drexel University College of Medicine

The maternal mortality ratio (MMR) in the United States has approximately doubled in the past two decades while the global MMR has decreased nearly 40%¹. This is a troubling statistic as the U.S. has the highest rate of maternal mortality in the developing world. Specifically, the pregnancy-related mortality ratios (PRMR) for Black and American Indian/Alaska Native (AI/AN) women are 41.7 and 28.3: more than 3 and 2 times higher, respectively, than the ratio of 13.4 for white women². Approximately 60% of these deaths are preventable and are due to causes such as cardiovascular conditions, infections, hemorrhage and hypertensive disorders³. Therefore, it is imperative for health care providers to find a solution to this ongoing and avertible public health crisis.

Factors contributing to these pregnancy-related deaths include lack of knowledge of warning signs and when to seek care, missed or delayed diagnoses, lack of continuity of care, and case coordination or management issues extending up to 12 months postpartum³. Experts on maternal and child health recommend combatting these risks by expanding team-based management of hypertension-related maternal morbidity to include doulas, obstetricians and midwives to improve care coordination⁴. Multiple studies that expand these teams via the introduction of doulas have demonstrated promising results. Mothers receiving prenatal doula assistance demonstrate better birth outcomes, such as the lower likelihood of birth complications or having a low-birthweight baby, and higher likelihood of initiating breastfeeding⁵. Women who received doula care via Medicaid in three U.S. states had lower odds of postpartum depression and anxiety⁶.

Doulas provide ancillary care services that include offering continuous emotional support to mothers through childbirth and enhancing their agency, knowledge and ability to communicate with their wider health care team: presenting an opportunity to mitigate preventive causes of maternal morbidity⁷. Doulas can uniquely provide trauma-informed care to mothers, as trauma-related health conditions, including PTSD, sexual assault, substance use and postpartum depression, are increasingly common occurrences amongst childbearing people and may be associated with nearly 1 out of 5 maternal deaths⁸.

Community-based doulas, integrated within communities they serve, can provide culturally and linguistically congruent care that supports communication between mothers and their health care team. This is a factor identified by Black women’s health organizations as an essential aspect of the birthing experience⁹. One such multiracial, culturally specific, community-based doula model demonstrated improved birthweight outcomes and decreased primary Cesarean rates in mothers who utilized the Yiya Vi Kagingdi Doula Project, as compared to Indigenous, Latinx and other mothers in New Mexico who did not utilize doula services¹⁰. Doulas can provide culturally competent care to Indigenous mothers by supporting Indigenous cultural practices that promote individual and intergenerational healing¹¹. Latinx mothers benefit from the immediate support of trained, Spanish-speaking interpreter/doulas who can offer timely, effective care while enhancing patient and staff satisfaction¹².

Professional organizations, including the American College of Obstetricians and Gynecologists, support evidence-based findings that “continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor”¹³. The doula licensing organization DONA International offers certification programs for both birth and postpartum doulas that involve educational courses, workshops, live birthing experiences, and annual maintenance recertification¹⁴ The support that doulas provide is different from that of midwives, who are trained to provide medical care, promote healthy births and facilitate access to medical care for mother and child¹⁵. Thus, doulas offer the unique potential to supplement health care teams in the provision of care for mothers at risk.

States including New York, Nebraska, Minnesota, Oregon and Indiana have implemented strategies to provide doula service reimbursement through Medicaid, with varying monetary reimbursements and degrees of coverage^{16, 17}. Both Minnesota and Oregon funded doula reimbursements through Medicaid and outlined requirements for doula qualification, which include undergoing licensing and training through a choice of government-approved organizations¹⁶. The resulting cost-saving potential of doula care, reimbursed through Medicaid at an average of approximately $1,000, results from reduced rates of Cesarean sections and preterm births¹⁸. This demonstrates an overall potential cost savings of $58.4 million, representing an important opportunity for investment in the lives of mothers in the U.S. and in our health care system.

Doula care remains underutilized due to barriers regarding information about services provided, access to services, cost, and diversity of the doula workforce, as assessed by national surveys¹⁹. Variable coverage for number of doula visits, as well as low reimbursement rates, may hinder the financial viability and effectiveness of doula care integration efforts²⁰. Therefore, a solution to decreasing barriers to access is improving cost through increased reimbursement through health insurance.

Only twelve states and Washington, D.C., have introduced legislation regarding doula certification and doula service coverage through Medicaid²¹. National support to increase access to doula services from pregnancy through one-year postpartum is outlined in the Black Maternal Health Momnibus Act of 2021, which was reintroduced at the 117th Congress and was referred by the House to the Subcommittee on Crime, Terrorism, and Homeland Security²². In April 2022, the U.S. Department of Health and Human Services allocated $4.5 million for hiring, training and compensating doulas to combat the maternal mortality crisis²³. This funding will increase the number of nationwide Healthy Start doula programs and will hopefully continue to grow with its demonstrated effectiveness.

The COVID-19 pandemic highlighted significant shortages in health care personnel that could potentially be supplemented by doulas²⁴. Both health outcomes and cost-effectiveness data have shown that the use of doulas presents a promising strategy for reducing maternal mortality disparities in the U.S. The statewide trials of doula insurance coverage through Medicaid are a step toward increasing access to doulas for the populations most at risk. The American Medical Association has existing policy that supports the inclusion, regulation and complementary role of midwives as allied health professionals, but none that outlines the role of doulas, revealing an area for advocacy at the national level²⁵. This represents an avenue for medical student and physician advocacy, both state- and nationwide, to increase access to doula care for all pregnant and postpartum people.

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