The Relationship Between Doula Support and Maternal Health
By: Bentley Porterfield-Finn
Pregnancy and childbirth are extraordinary gifts, but they can also present extraordinary mental and physical challenges to pregnant persons and their families. Nearly 4 million babies are born in the United States every year and childbirth continues to be one of the leading reasons why people seek medical care in this country . Moreover, many women face emotional and physical challenges during the postpartum period due to lack of adequate support, leading to concerning rates of postpartum mood disorders. The process of giving birth has changed over the years, and so has the type of support birth givers receive during pregnancy and postpartum. Doulas are professional support providers who can fill in these support gaps and improve maternal health outcomes.
Historically, people gave birth in community, surrounded by family, friends, and loved ones. Births started to get moved to hospital settings in the 1920s and today, about 98% of births occur in a hospital, where community support can be lacking . They say it takes a village to raise a baby, and more and more new parents find that village nowhere to be found. Research shows that quality social support can improve health and quality of life . In birthing contexts, doulas are an invaluable source of this social support. As such, doulas are an important factor to consider in conversations about how to lower rates of maternal mortality in the United States.
Doulas provide a crucial service for families. They are trained professionals who provide continuous, one-on-one emotional, physical, and informational support during the perinatal period. They are not medical professionals and do not provide medical services, but work alongside nurses, obstetricians, midwives and other health care providers to offer high quality care to birth givers. Doulas are often hired by families, not employed by hospitals (though some unique hospitals have doulas on staff), and they work collaboratively with care providers to ensure birthing persons feel adequately supported. Research supports the health improving potential of doula support. A 2017 Cochrane review of birth experiences of more than 15,000 women in the found that those with doula support experience:
- Shorter labors by 41 minutes;
- 15% increased likelihood of having a spontaneous vaginal birth;
- 39% decreased likelihood of having a cesarean birth;
- 10% decreased likelihood of needing pain medications;
- 31% decreased likelihood of reporting a negative birth experience;
- Increased rates of breastfeeding~~.~~
- Babies with higher five-minute Apgar scores 
Moreover, a 2013 study found that the odds of cesarean delivery were 40.9% lower for doula-supported births compared to birth without a doula present . Doulas seek to improve birth experiences and improved birth experiences are associated with increased parenting confidence, decreased depression, and improved quality of parent/child connection. Research on doulas also reveals the cost-saving benefits of doula support, for families and hospitals. A 2010 study out of the University of Wisconsin School of Medicine and Public Health found that if a professional doula attended every low-risk birth in-hospital, there would have been an estimated $29,000 in cost savings .
Despite the evidence on the benefits of doula support, their services are largely underutilized. A survey of parents who gave birth in 2012 showed that only 6% utilized doula support . Because doulas have not yet been integrated into our medical model of care, they currently operate using a fee-for-service model. Thus, many pregnant persons experience barriers to accessing doula support. Hiring a doula can be costly (ranging anywhere from $800 - $2,000) and most are not covered by insurance.
Of note, there is a need for more representation amongst doulas. It can be challenging to maintain the lifestyle of a doula without financial stability or support. One study reported that many doulas are White upper-class women supporting other White upper-class women . Overall, there is a large unmet demand for doula support among women in the U.S., many of whom would likely benefit substantially from the evidence-based benefits associated with continuous labor support. Additionally, one study showed “Black women (vs. white women), women with public health insurance (Medicaid and other government-funded programs which primarily serve low-income women, vs. private insurance), and women without health insurance (vs. those with private insurance) have higher risks of adverse birth outcomes but are often least able to afford doula care or access culturally competent care” . However, these are also the women who are often unable to afford doula support.
So, how can we make doula support more accessible? That is a question we have been exploring at Goldbug as we have been engaging in the maternal health space. One answer we have found is to fund hospital-based doula programs. While most hospitals do not yet have doulas on staff, some hospitals have volunteer doula programs. In this volunteer model, doulas can sign-up for shifts to be on-call to support births. These programs do not charge birth givers for doula support. Instead, doulas volunteer their time, making doula support accessible to birthing persons regardless of their ability to pay for it.
Given what we have learned together over the past six months, there is compelling evidence that doulas can play an instrumental role in supporting the health and well-being of both mother and child. Our challenge moving forward is to determine how to leverage and invest resources to maximize impact given the gaps in services we have identified through this blog series. Goldbug is excited to support mothers by increasing access to culturally competent doula support.
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