What Do We Want? Doulas! When Do We Want Them? Now!

By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, CLE

A Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing, authored by 17 leading maternity experts and released on June 28, 2018, by the National Partnership for Women & Families hopes to promote “well-tested, evidence-informed strategies” that can be used by researchers and consumers alike as a guide to addressing inadequacies in existing maternity care systems. Current care systems are failing families during the childbearing year. The subsequent result is poor outcomes for both pregnant people and babies, with families of color bearing a disproportionately higher burden resulting in dismal mortality and morbidity rates.

The foundation of the report is”six strategies to advance high-value maternity care by promoting, supporting and protecting women’s innate capacity for healthy childbearing and by safely limiting use of consequential interventions around the time of birth.” The comprehensive blueprint outlines actions that can be taken by maternal-infant health systems, policymakers, clinicians, administrators, health plans, employers, researchers, birth workers, advocates and women and families themselves. The actions are thoughtful, do-able, evidence-based and comprehensive. The six strategies are as follows:

1. Reward health care providers and systems that deliver quality, woman-centered maternity care. Through innovation in how we pay for and deliver maternity care, health care leaders can improve the quality and lower the cost of this care by minimizing both overuse and underuse and encouraging the adoption of high-performing elements of maternity care – such as continuous labor support and breastfeeding support.
2. Prioritize measuring – and reporting on – the quality of maternity care. Performance measurement experts and decision-makers should fill gaps in standardized performance measures to enable providers, women and others to obtain and use quality information.
3. Meaningfully engage women and families in maternity care. Consistent, widespread use of shared care planning and shared decision-making, among other tools, would help ensure that women and families are at the center of – and fully engaged in – efforts to improve maternity care.
4. Change how we educate the maternity care workforce. All levels of education should support maternity care clinicians in shared knowledge and skills for physiologic childbearing, effective team-based care and shared decision-making.
5. Build up the maternity care workforce. To address the growing shortage of maternity care providers in United States and better meet the needs of an increasingly diverse population of childbearing women, we need to better retain and deploy physicians, increase use of midwives and build a workforce that better reflects the diversity of childbearing families.
6. Prioritize and support research to advance the science of physiologic childbearing and its effect on maternal and child health. Research on perinatal physiology, clinical epidemiology and implementation science is critical for driving meaningful improvements in maternity care and strengthening maternity care policies, programs and services.

Doulas play a critical role in improving birth outcomes. This statement has been validated time and time again by comprehensive peer-reviewed research. This blueprint acknowledges this fact and doulas are highlighted in the following ways:

• Strategy 1 – “encourage participants to redesign care and improve performance, including by using high-performing elements of care such as birth centers and doulas.”
• Barriers that need to be addressed include – “too few payments for maternal newborn services are tied to the quality of care and desirable outcomes. In addition, health plans and fee for service fee schedules do not reliably reimburse crucial high-value services such as those offered by doulas, birth centers, certified professional midwives and peer breastfeeding counselors.”
• Action Step 1a – includes recommendations to “integrate high-performing elements of maternity care, such as midwifery care, birth center, and doulas, to advance high-value care and excel in episode program performance, where appropriate.”
• Action Step 1b – urges using “high-performing elements of maternity care, such as midwifery care, birth centers and doulas, in maternity care home programs and reimburse them sustainably.”
• Action Step 1c – “Include both reimbursed services such as midwifery and birth center care and enhanced benefits that are not reliably reimbursed such as doula support.” and “develop and make widely available model contracts to facilitate access to birth centers, midwives and doulas within alternative maternity care payment programs and within Medicaid and commercial health plans”  Also “educate all stakeholders about sustainable reimbursement levels for midwives, birth centers, doulas, community health workers and other time-intensive care models.”
• Strategy 3 – “Enhanced services such as care coordination, high-quality childbirth education and doula support foster engagement of women and families and can improve health equity.”
• Action Step 3a – “Increase women’s access to and reimbursement for care that most readily facilitates healthy perinatal physiologic processes, for example, midwives, out-of-hospital birth settings and doulas.” Also, “conduct preliminary background formative research, then design, test, refine and publish results about effective messaging about priority topics. These include…doulas.”
• Action Step 3b – “Develop, make freely available and publicize a healthy physiologic birth module for childbirth educators, doulas and clinicians.”
• Action Step 3c – “Until Shared Decision Making is routinely incorporated into maternity care practice, develop and make freely available (e.g., via websites, childbirth educators and doulas) evidence-based direct-to-women decision aids.
• Action step 4a -“Ensure that all levels of education provide opportunities for doctors, midwives and nurses to interact with other members of the maternity care team, including doulas, childbirth educators, lactation personnel, social workers and mental health counselors to further foster understanding about respective roles, responsibilities, skills and expertise and high-functioning teams.”

One can not help but appreciate how the role of the doula is repeatedly recognized in this document as an important part of improving outcomes. The doula is called out for their valuable contribution. The time for this low-tech, positive solution is now.  Maternal-infant outcomes cannot afford to wait any longer for the introduction of the doula as a requirement to be added to maternity care systems to influence improved outcomes. There should no longer be any resistance to including the doula (both birth and postpartum) as a necessary and relevant member of the maternity care team.