This post is part four in a 10-part series on care model innovation.
What good could come from childbirth?
It almost seems ludicrous to ask what good can come from childbirth, since birth results in a new human being, an event celebrated across every culture. But it is a worthy question to consider in the context of healthcare. When we talk about birth outcomes, the framework is usually morbidity and mortality: preterm birth, birth injury, hemorrhage, infections, and so on. But birth is the perfect opportunity to look through the salutogenic and life course lenses.
One good thing that can come from birth is a woman who feels vital, resilient, and ready to take on motherhood. As a midwife, I’ve seen the “If I can do that, I can do anything” phenomenon many times after the raw intensity of a natural birth and the “birth high” that follows. But I’ve also seen it after the physical and emotional drama of a high-risk pregnancy and high-tech birth. The common ingredient is a woman who is a full participant in her experience, given plenty of support, and treated with dignity and respect.
Birth can also set physiologic events in motion that promote lifelong health for both the infant and the mother.
- There is growing evidence that bacteria the baby encounters around the time of birth have a crucial role in the child’s immune system and overall health, with disruption of normal bacteria a potential pathway for chronic diseases ranging from asthma to obesity. There is growing consensus that our high cesarean rate is contributing to chronic disease, at least in part via disruption of gut flora.
- A mother’s ability to hold her baby immediately after birth, which can be preserved or disrupted by her birth environment, has far-reaching impact. Infants who experience early skin-to-skin contact with their mothers establish effective breastfeeding sooner and breastfeed longer than infants without such early contact. Holding a newborn skin-to-skin also reduces physiologic stress (evidenced by reduced crying and more stable blood sugar) and improves attachment and bonding. Again, cesareans disrupt this process, although some hospitals are working to change that.
- Breastfeeding, in turn, affects lifelong health. While the focus is often on the myriad benefits for babies, breastfeeding also promotes maternal health. For example, it reduces the risk of breast cancer in women, especially a form of cancer that disproportionately affects black women.
Birth Creating Health: The Impact of Doulas
The longer I study birth, the more obvious it is that birth matters to health. From a “health creation” standpoint, we should be ensuring that women are empowered, engaged, and supported while giving birth. And we absolutely should work to preserve, whenever safely possible, vaginal birth, and to remove impediments to successful breastfeeding.
Our healthcare system, however, doesn’t deliver on any of this very well. And one of the most promising interventions that could change that is a word many people have never heard of: doulas.
Doulas are trained companions who provide continuous physical, emotional, and informational support to women during labor and birth. They are perhaps one of the most potent examples of what Berwick referred to as the power of “loving kindness” in creating health. A Cochrane Systematic Review found that continuous labor support results in:
- fewer cesareans
- fewer instrumental vaginal births
- more spontaneous vaginal births
- less regional anesthesia (e.g. epidurals)
- less analgesia of any kind
- shorter labors
- fewer low Apgar scores
- less dissatisfaction with the birth experience
Although this body of evidence has existed for years, it wasn’t until 2014 that obstetrical guidelines promoted the use of doulas. In a joint statement on reducing primary cesarean delivery, ACOG and the Society for Maternal Fetal Medicine declared, “[O]ne of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”
No one knows for sure why doulas reduce cesareans, but if you know doulas and spend much time with them (as I do) a theory emerges. They have some physical tricks up their sleeves – positions and techniques to help rotate a baby and promote descent, for example. But I think the impact is mostly physiological and psychological.
The kind of support doulas give is borne out of love, and love promotes oxytocin, and oxytocin promotes labor. And, I think most importantly, doulas help women find their voice – to ask for what they want, question routines, and speak up when something isn’t right. When the majority of c-sections are for subjective reasons – meaning two doctors might look at the same situation and have different opinions about whether to operate – having a voice can mean having a vaginal birth. Even when it doesn’t, it leads to that resilience factor. It’s also a skill that will pay dividends as the woman navigates both parenthood and ongoing health care for herself and her family.
Community-based Doulas: Addressing Health Disparities
So doulas have a range of benefits – some easier to measure (mode of birth, use of anesthesia) than others (resilience? parenting confidence? feeling loved on the most intense and important day of a woman’s life?). There are no downsides of doula support – the Cochrane review found no adverse effects.
The one downside is cost, and doulas charge anything from $300 to $1000+ for their services. With vanishingly few health plans covering any part of this cost, doula care is squarely out of reach of most birthing women. In a national survey, only 6% of women had a doula at birth. With many other demands on family finances around the time of birth, doulas are a luxury.
Community-based doula programs are changing this. These programs identify leaders from communities that experience significant health disparities, train them as doulas, and provide free doula services to women from that community. These doulas provide continuous support during labor, but their services are typically both broader and deeper than that. They often work with women beginning early in pregnancy and continue with support and care for several weeks or months postpartum.
A report published this summer by HealthConnect One, an agency that provides technical support to community-based doula programs, showed that in addition to the expected reductions in cesarean deliveries, such programs had a dramatic impact on breastfeeding rates. In both black and Hispanic women, duration and exclusivity of breastfeeding was higher in the women with doula support than in similar women in national reporting databases, and even exceeded Healthy People 2020 goals.
Another report published just this month by Choices in Childbirth looks at the potential role of community-based doula programs to reduce health disparities in New York City, where low-income women and women of color are at excess risk for maternal mortality, not breastfeeding, obesity, inadequate prenatal care, and having a premature or low birthweight baby. Community-based doula programs can help provide needed continuity through prenatal care, birth, and postpartum recovery and adjustment, help connect women to social services in the community, and give a voice to disenfranchised women.
In my essay examining the case for maternity care model innovation, we learned that the driver of high costs is intrapartum hospital care, especially c-sections, while the drivers of poor outcomes are lack of social care and health-creating opportunities. Community-based doulas work on both sides of this equation, while dramatically improving experiences, too. In other words, they deliver on the elusive healthcare Triple Aim.
Although Medicaid programs seem to be taking notice, the vast majority of community-based doula services are grant funded and/or volunteer-driven, making them vulnerable to disruptions in service. Finding a sustainable model to integrate doula support, especially for the most vulnerable women, should be an urgent aim of our maternity care reform efforts.