Community-Based Doula Support: A qualitative study at Valley Medical Center in South King County, WA

By PATTCh

All birthing people are susceptible to adverse birthing experiences including unnecessary episiotomies, cesarean sections, trauma, and maternal and infant morbidity and mortality. The United States is one of the wealthiest and industrialized countries in the world, however maternal mortality rates are on the rise particularly in marginalized communities including Black/African American, Latinx, Native American, and Pacific Islander. The most alarming rate is that of Black birthing people who are at a 3-4 times higher risk of dying than Caucasian birthing people (Neggers, 2016).

In 2000, the maternal death rate was estimated at 9.8 deaths per 100,000 live births. According to the Centers for Disease Control (CDC), in 2018, this rate increased to 17.4 deaths per 100,000. Non-Hispanic Black women are the most affected demographic, with mortality rates of 37.3 per 100,000, while rates for non-Hispanic white women are 14.9, and those of Hispanic women are 11.8 (Hoyert L., 2021). Organizations such as Black Mamas Matter claim that maternal health is in dire need of positive change and have put forth a call to action to address the inequitable and preventable maternal mortality in the United States (Black Mamas Matter Alliance, 2018).

While death is an example of a possible extreme outcome during birth, for most, the memories of what they experienced during birth live on in the minds of surviving birthing people. Due to the medicalization of childbirth following the transition to hospital deliveries as opposed to the midwifery model of care that had been previously universally utilized throughout the United States until the latter half of the 1800s, the voice and desires of the birthing person may be lost during labor and delivery without sufficient advocacy (Rooks, 2012). With this transition, the process of birth became a standardized procedure rather than allowing the birthing body and person to dictate their desires and needs. Against this background, creating and sharing a birthing plan with the members of the care team prior to labor beginning is a tool that can cultivate a positive birthing experience aligned with the anticipated experiences of the birthing person (Geddes, 2021).

The following is an example of when the birth plan was deviated from and the impact it had on the birthing person. Kimberly Turbin, a victim of an unsupportive and traumatic birth, lost her right to have her voice heard when the delivering obstetrician ignored her plea to avoid an episiotomy (Greenfield, 2017). In a tape of her delivery, which went viral in 2013, the audience can hear the provider cut her perineum 12 times as she begs for him to stop. Her mother, who is recording the situation, encourages the doctor to ignore the patient, her daughter, and continue to harm Turbin’s body. Eighty lawyers turned down Turbin’s case before she was able to find one who agreed to support her. Turbin filed charges against her provider for assault and battery which landed this case in court. Four years after the incident, the case finally ended when a judge ruled in favor of Turbin. Though the result in the above example was a case won in court, the long-term trauma that can result from obstetric violence and inadequate informed consent is difficult to measure. This case is just one example of the type of traumatic birthing experiences that patients can be subject to when they lack proper advocacy and support during labor and delivery.

Doulas are professional birth workers, trained to provide support to birthing families. Doulas complement maternity care providers by offering emotional and educational support for the birthing person and family, alleviating this role from clinical staff during labor and delivery. They offer knowledge of options for stress relief, position changes to facilitate decreased pain and labor progress, and act as an advocate for the birthing person and family (Steel et al., 2015). This care becomes extremely valuable during prolonged labors where partners or familial support people may develop fatigue and are unable to continue to support the needs of the birthing person.

Doulas are also more likely to be able to offer concordant or culturally matched care which is often unavailable from health care providers who typically do not represent the diverse patient population they are serving (Steel et al., 2015). When an array of doulas is made available to patients as an option, it allows birthing people to select an advocate they feel connected to whether through appearance and culture or other characteristics. Language and cultural appropriateness play a major role in patient comprehension and their ability to follow a care plan advised by a healthcare provider. Culturally matched community-based doulas have a heightened opportunity to bridge this gap and partner with both patient and care team providers to aid in providing the highest quality of care while reducing adverse outcomes (Timmins, 2002). This type of care may also increase client participation in prenatal care since, as Timmins (2002) pointed out, lack of access to culturally appropriate care can lead to the avoidance of seeking prenatal care. Avoidance or discontinuation of prenatal care due to a lack of culturally responsive care is more common among Black, Indigenous, and People of Color (BIPOC) including Latinx persons who often experience an increased level of language and cultural barriers.

Institutional racism is also deeply embedded in the foundation of the healthcare system in the United States (Bailey et al., 2020). Historical medical mistrust is widespread in BIPOC communities and has had devastating impacts on the health of persons and communities including those who are Black, Native American, Latinx, and Asian and Pacific Islander. Community-based doulas can help overcome these barriers to care because they act as advocates for patients, and they often come from marginalized communities themselves. They may be able to help address inappropriate care or identify gaps in care and areas for improvement through their knowledge of maternal care and of the barriers to quality care faced by members of their own community.

The use of a doula has shown a 36% reduction in cesarean sections, improving recovery rates and birthing outcomes for subsequent births (Block, 2019). Considering this benefit in the context of Valley Medical Center is possible using data from 2019 Preliminary Births as found in the Health Care Authority Delivery Statistics Report (2020). This report found that the Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate for Valley Medical Center is 22.7% (versus 24.2% overall for hospitals statewide). If the addition of doulas has the potential to reduce c-section rates by 36%, Valley Medical Center could reduce c-section rates to around 14.5% for this population, making Valley Medical Center a leading hospital for c-section rates in Washington State. This achievement has the potential to lead to a reduction in maternal morbidity and mortality rates, improved patient experiences, and reduced costs (Kozhimannil et al., 2016).

Integration of doula services within Valley Medical Center would be an impactful step towards combating unfavorable birthing outcomes of those delivering at Valley Medical Center. While maternal mortality is still relatively rare, the consequences of maternal death are deeply impactful. Families become unstable, children are left without a key figure in their life, and mental and emotional instability are prevalent. But one of the most concerning consequences is the impact on the survival rate of the newborn child if the birthing parent does not survive past childbirth (Molla et al., 2015). Molla et al. (2015) found that children who have lost their mothers encounter nutrition deficits, obstacles accessing healthcare, place an increased burden on older children or face adoption into another family.

The nurturing provided through direct interaction is difficult to measure, but skin-to-skin contact between parent and newborn while breastfeeding has been shown to have highly beneficial impacts on a child’s wellbeing (E. Moore et al., 2007). Skin-to-skin contact supports the cardio-respiratory system and promotes temperature regulation in newborns (Moore et al., 2016). These are intensely important bodily functions that are directly supported by the contact and interaction between birthing parent and baby. Doulas provide education and guidance surrounding these tactics that lead to improved health results.

Improving health and patient experiences while reducing costs are both possible with the addition of accessible doula services. These achievements meet the goals of the triple aim developed by the Institute for Healthcare Improvement (IHI). On the other hand, adverse birth outcomes are costly for the facility, parent, and community. Childbirth costs roughly $27 billion annually (Kozhimannil et al., 2014). Small service changes, such as providing integrated doula services, can increase patient satisfaction, as well as provider and staff satisfaction, and save money. Accessible doula services are a potential way to reduce both cost and maternal mortality and morbidity rates.

References:

  • Block, J. (2019). Everything Below the Waist: Why Health Care Needs a Feminist Revolution. St. Martin’s Press.
  • Greenfield, B. (2017). Woman Forced into Violent Episiotomy Settles with Doctor. Yahoo Life. https://www.yahoo.com/news/woman-forced-into-violent-episiotomy- settles-with-doctor-182947205.html
  • Health Care Authority. (2020). Delivery Statistics Report (2019 Preliminary Births) Valley Medical Center. https://www.hca.wa.gov/assets/program/delivery-statistics- ValleyMedicalCenter.pdf
  • Hoyert, D. (2021). Maternal Mortalirt Rates in the Unites States, 2019. National Center for Health Statistics
  • Kozhimannil, K. B., Attanasio, L. B., Jou, J., Joarnt, L. K., Johnson, P. J., & Gjerdingen, D. K. (2014). Potential benefits of increased access to doula support during
    childbirth. The American journal of managed care, 20(8), e340–e352.
  • Moore, E. R., Bergman, N., Anderson, G. C., & Medley, N. (2016). Early skin-to-skin contact for mothers and their healthy newborn infants. The Cochrane database of systematic reviews, 11(11), CD003519. https://doi.org/10.1002/14651858.CD003519.pub4
  • Neggers Y. H. (2016). Trends in maternal mortality in the United States. Reproductive toxicology (Elmsford, N.Y.), 64, 72–76. https://doi.org/10.1016/j.reprotox.2016.04.001
  • Steel, A., Frawley, J., Adams, J., & Diezel, H. (2015). Trained or professional doulas in the support and care of pregnant and birthing women: a critical integrative review. Health & social care in the community, 23(3), 225–241. https://doi.org/10.1111/hsc.12112

By: Sarah Davis, MA-MCHS

Posted in Birth Trauma and tagged ,