Current Resources for Evidence-Based Practice, July 2020

Abstract

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of whether it is ethical not to offer doula care to all women, and commentaries on reviews focused on folic acid and autism spectrum disorder, and timing of influenza vaccination during pregnancy.

A review of new resources to support the provision of evidence-based care for women and infants.

Marit L. Bovbjerg, PhD, MS

The Questionable Ethics Behind Lack of Universal Doula Care in the United States

At the end of January, the Centers for Disease Control and Prevention published the U.S. maternal mortality rate for the first time in 13 years (Hoyert & Minino, 2020). The reasons behind the lapse in reporting have been documented (Hoyert and Minino, 2020, MacDorman et al., 2016) and are primarily related to the fact that the United States does not require all states to use the same birth and death certificates. Nonetheless, the newly-published data reveal what many of us had long suspected: the United States has a higher maternal mortality rate than all other high-resource countries (17.4/100,000), and the rate for Black women is much higher (37.1/100,000; Hoyert & Minino, 2020).

In addition to elevated rates of maternal mortality, communities of color in the United States have poorer birth outcomes generally. For instance, women of color bear a disproportionate burden of preterm birth and intrauterine growth restriction (Bryant et al., 2010, Crawford et al., 2017, National Academies of Sciences Engineering and Medicine, 2020). We also observe poor birth outcomes in women with low socio-economic status (Amjad et al., 2019). Based on the work done on fetal origins of adult disease and the microbiome, it is clear that the circumstances surrounding one’s birth matter a great deal for later health for the individual and her or his children and grandchildren (Cresci and Bawden, 2015, Fernandez-Twinn et al., 2019, Yarde et al., 2013). These inequities at birth reinforce the more generalized health inequities shouldered by communities of color in the United States across generations.

Ideally, midwifery care would be a pillar in any strategy designed to reduce inequities in maternal and child health outcomes (Sandall et al., 2016). However, the U.S. midwifery workforce is not currently extensive enough or sufficiently diverse to offer every pregnant woman a midwife in and from her own community, despite decades of robust evidence indicating such an approach could dramatically improve outcomes (Allen et al., 2016, Cheyney et al., 2015, Homer et al., 2014, National Academies of Sciences Engineering and Medicine, 2020, Sandall et al., 2016). Furthermore, even if we decided tomorrow to quadruple the midwifery workforce (it is, after all, the year of the Nurse and Midwife; World Health Assembly, 2019), training midwives takes several years and our existing nursing and midwifery schools do not currently have the capacity to sufficiently increase their enrollments (Accreditation Commission for Midwifery Education, 2019).

In the meantime, we could offer doulas to all childbearing families. These traditional health workers can be trained in a matter of weeks, and once in practice they provide the health education, social support, and continuity of care midwives are often unable to provide because they are constrained by hospital policies (Dahlen et al., 2011). Excellent maternal and child outcomes have been associated with the use of doulas (Bohren et al., 2017), and depending on the particular state in question, reimbursement of $929–$1,047 (average $986) is cost effective because of the vast reductions in preterm and cesarean births (Kozhimannil et al., 2016).

Universal access to doulas during childbirth could be operationalized in practice in a few different ways. First, hospitals could employ doulas as part of their maternity care teams and include their services for all childbearing women as part of the overall care package. As accountability to quality of care has become more prominent since the Affordable Care Act, most hospital administrators are interested in reducing cesarean rates. Doulas would almost certainly help achieve this goal (Bohren et al., 2017). Doula care is a cost-effective, evidence-based solution—the proverbial magic bullet.

The other way doula care could be made more accessible is by enabling individual doulas or multi-doula practices (call doula “hubs” in some states) to bill insurers for services. In practice, this means state Medicaid programs would need to begin to reimburse for doula care; private insurers would likely follow suit. Oregon is one of the few states that has done this via a state Traditional Health Worker Registry. Doulas who meet the training standards set by the state can apply to be on the Registry, after which they can bill for services. Implementation of this system has not been entirely smooth sailing. However, it now seems to be working in at least some areas of the state, since more families from traditionally underrepresented groups can access doula care without cost to themselves.

It is not yet clear which of these two implementation methods would be more effective in the U.S. healthcare system. Addressing the systemic racism underpinning centuries of poorer health outcomes for minority families should be our nation’s top priority. One way to immediately begin to move the needle on maternal and child health outcomes for communities of color is to provide every childbearing woman who wants one with a socially and linguistically matched doula. As Dr. Christiane Northrup wrote in her iconic book Women’s Bodies, Women’s Wisdom, if doulas were a drug, it would be unethical not to use them (Northrup, 2010).

Acknowledgment

The authors acknowledge Sabrina Pillai, MPH, for assistance with the literature searches for this column.

Biographies

Marit L. Bovbjerg, PhD, MS, is an assistant professor of epidemiology in the College of Public Health and Human Sciences, Oregon State University, Corvallis, OR.

Melissa Cheyney, PhD, LDM, is an associate professor of anthropology in the College of Liberal Arts, Oregon State University, Corvallis, OR.