Health Net Community Doula Program
The Association for Wholistic Maternal and Newborn Health, a 501 c 3 non-profit organization, has partnered with Health Net, one of the largest Medi-Cal HMO providers in California, in an innovative, pilot program to help improve birth outcomes for African-American women and infants in Los Angeles County. This pilot program will provide 150 African-American women enrolled in Health Net Medi-Cal with African-American Doulas. The objectives of the program are to reduce rates of cesarean section, maternal mortality, low birth weight and prematurity and reduce maternal stress and anxiety. Other objectives are to increase rates of breastfeeding initiation, increase maternal satisfaction with the childbirth experience. Learn more about the work of African-American Doulas who work with African-American women to ward off discrimination in the birthing suite. Read Article
WATCH VIDEO FROM CHICAGO’S HEALTH CONNECT ONE ABOUT COMMUNITY-BASED DOULAS
WHAT IS A DOULA?
Doulas are professional childbirth companions who provide emotional support, physical comfort and advocacy to women and persons
during pregnancy, childbirth and postpartum. Doulas are also trained to recognize and refer clients who have medical problems so that theycan get medical attention in a timely manner. Doula support does not replace the medical care provided by a doctor, midwife or nurse. Studies show that the presence of a Doula can:
- Reduce Length of Labor
- Reduce Pain Medication Use
- Reduce Cesarean Section
- Reduce Medical Interventions (i.e., induction, episiotomy, etc.).
- Reduce Postpartum Depression
- Increase Breastfeeding Success
- Increase Maternal Satisfaction with Birth Experience
WHAT DOES THE PROGRAM OFFER?
Clients will receive a Doula who will provide home visitation in pregnancy and postpartum, and labor and birth support, including health education sessions. Health Net Doulas will provide:
- Prenatal Visits
- Labor and Birth Support
- Postpartum Care
- Health Education
- Screening for Perinatal Mood and Anxiety Disorders
Why is this program only for African-Americans? Don’t other races deserve support as well?
Of course, all childbearing persons deserve support. However, American-born, Non-Hispanic Black women and infants have the worst birth outcomes in the USA and Los Angeles County is no exception. This is why this program is needed.
Premature Births and Infant Mortality are Higher for African-American Infants.
- Rates of African-American premature birth and infant mortality (death of a baby within the first year of life) are 2-1/2 times higher than for Caucasian infants. African-American infants are 2-1/2 times more likely to be born low birth weight than Caucasian infants.
- Almost 13% of African American babies in Los Angeles County were born preterm compared to 7.4% of Asian/Pacific Islander babies which has the lowest rate of preterm births in 2013.
- Service Planning Areas 1 and 6 in Los Angeles County have the highest rate of preterm births both at 11.0% compared to 9.1% of countywide.
- When comparing the four major races/ethnicities, African American babies in 2013 have the highest rate of low birth weight births at 12.1% compared to 6.5% of Hispanic and White babies.
Cesarean Rates are Highest Among African-American Women.
While cesarean section is sometimes needed and can be life-saving in some situations, repeat cesareans increase the risk of maternal death and disability and infant death. Experts agree that the cesarean rate for any population, the c-section rate should not be over or below 15% .
In California in 2012-2014, Black women have the highest rates of cesarean section, as they do nationally. In California, the rate is 37.7% for Blacks compared to 32.4% for Whites, and 33.1% overall in the state. The US overall rate is 32.6%, and for Black women it is 35.5% and 32% for White women from 2012-2014.
Maternal Deaths are the Highest Among African-American Women.
- Rates of African-American Maternal Mortality (pregnancy-related deaths) are 4-5 times higher than for Caucasian women.
- African-American women make up 9.2% of all women in LA County, but 31.8% of all maternal deaths. White women make up 28.9% of women in LA County, but only 4.5% of maternal deaths.
- Maternal mortality rates vary by zip code in Los Angeles County. Rates are higher in South Los Angeles than they are in Metro Los Angeles and Westside Los Angeles.
Breastfeeding Rates are Lower Among African-American Women.
- African-American women have the lowest rates of initiating breastfeeding (79.0%) in Los Angeles County compared to 95.0% of Asian and Non-Hispanic White women in the county.
- Breastfeeding rates differ by zip codes as well. Mothers living in South Los Angeles are less likely to initiate breastfeeding than women in other areas of the county.
EXPLAINING AFRICAN-AMERICAN PERINATAL HEALTH DISPARITIES
These differences between Caucasians and African-Americans persist no matter the African-American woman’s age, occupation, income or level of education, lifestyle and health behaviors. Experts believe the cause of these disparities have to do with discrimination and racism that African-American women experience, which cause undue stress during pregnancy and trigger preterm labor. Premature birth is associated with low birth weight and can result in infant mortality.
Studies also show that many African-American pregnant women experience disrespectful and unequal care during maternity care contributing to poorer birth outcomes.
Of course, all childbearing persons deserve support. Yet persistent disparities exist. That is why a program such as this is needed.
But, why is this so, you may ask. Some suggest that the cause of African-American premature birth is genetic.
Still others claim that African-American/Black women are “more irresponsible” than Caucasian women about getting recommended prenatal care, avoiding nicotine, alcohol and illicit drugs.
Yet others have suggested that the cause of these disparities is that more African-Americans live in poverty (assumedly because are “unmotivated” to “pull themselves up by the boot straps” and achieve their American Dream).
But none of these things are the causes of seemingly intractable poor birth outcomes in the African-American communities.
Explanations such as these blame the individual for their poor birth outcomes instead of social causes. Programs like ours are needed to make up for historical injustices and make reparations to African-Americans.
Microaggressions have been defined as brief and common daily verbal, behavioral, and environmental communications, whether intentional or unintentional, that transmit hostile, derogatory, or negative messages to a target person because they belong to a stigmatized group. Although these communications typically appear harmless to observers, they are considered a form of covert racism or everyday discrimination.”
Then what are the causes of the disparities in African-American women and infants health?
A growing body of research supports the theory that chronic stress experienced by African-American women over a lifetime arises from experiences of racism and discrimination. This chronic stress (or “allostatic load“) wears and tears on the body and interferes with the body’s ability to stay in balance and maintain homeostasis, leading to disease mechanisms. For African-American pregnant women, this often shows up as a strain on the arterial blood pressure, leading to vasoconstriction and vasodilation of the arteries, which increases blood pressure, and disrupts the function of the placenta which triggers stress hormones initiating preterm labor (Geronimus, Hicken, Keene & Bound, 2006).
In addition, researchers are discovering that experiences of racism experienced by African-American women’s mothers and grandmothers has an impact on their wellbeing and pregnancy health, and their unborn babies. The impact of intergenerational historical trauma is becoming more understood in African-American pregnant women.
“The Lifecourse Model is both an innovation and a strategic approach to equity.”
(Association of Maternal and Child Health Programs, 2015)
What is The Lifecourse Model?
This model developed by Halfron and Lu (2003) explain disparities in African-American Premature Births. Halfron & Lu suggest ” that these disparities result from differences in protective and risk factors between groups of women over the course of their lives. As a result, the health and socioeconomic status of one generation directly affect the health status of the next one” (2005, p.1).The growing body of research shows that chronic stress incurred by a lifetime exposure to racism, discrimination, and microagressions cause African-American women to have increased risk of preterm labor and prematurity (Collins & David, 2003). The Lifecourse Model describes a ” complex interplay of biological, behavioral, psychological, and social protective and risk factors [which] contribute to health outcomes across the span of a person’s life” (Association of Maternal and Child Health Programs, 2015, p.1).
The Lifecourse Model is an updated and broader way of looking at health because it considers health across the life span, not just individual stages or periods. This model emphasizes the social determinants of health (the conditions in which people live, learn, work and age which influence lifelong health and wellness); it considers the complex interplay of biological, social, and environmental factors in health outcomes.
From a macro perspective, “the life course model is both an innovation and a strategic approach to equity.” (Association of Maternal and Child Health Programs, 2015). So if we really want to end African-American prematurity and infant mortality, then we have to address the root causes of inequality in our society: racism.
But what about individual responsibility?
While being born and living in poverty contribute to poor birth outcomes for all ethnicities, this is not the case for African-American women. Certainly, an individual’s unhealthy behaviors are a contributor to prematurity, but these factors do not explain persistent disparities in African-American maternal and infant health, which remain significantly worse than Caucasians. Strangely, college-educated African-American/Black women with advanced degrees who earn high incomes and lead healthy lifestyles still have twice the risk of prematurity than White women with less than a high school degree (Collins & David, 2003).
There is something about being born Black in America that is not good for the health of pregnant women and their infants”.
Are genetics to blame?
The answer is no. If genetics were the reason, then Black female immigrants to the USA would also have higher rates of premature births. But that is not what the statistics reveal. African, Afro-Caribbean and Afro-Latino immigrants to the USA have better birth outcomes than American-born women of African descent. In other words, there is something about being born Black in America that is not good for the health of pregnant women and their infants.
In most populations, higher education and economic status produces better health and longevity. However, Researchers studying African-American perinatal health disparities found that even when controlling for socioeconomic and educational status, African-American/Black women remain 2-1/2 times more likely than Caucasian women to deliver prematurely (Halfron & Lu, 2003, Collins & David, 2003). Babies who are born too small and too soon are more likely to develop a multitude of problems and are at risk of dying before their first birthday. From 2005 to 2012, the infant mortality rate for black infants decreased from 14.3 to 11.6 per 1,000 births, then plateaued before increasing from 11.4 to 11.7 per 1,000 births from 2014 to 2015 (CDC, 2016). Comparatively, among Caucasian infants, the mortality rate decreased from 5.7 to 4.8 per 1,000 births from 2005 to 2015. This is a statistic which has not changed since 1900 when these statistics were first begun to be first tracked!
African-American maternal mortality is the leading perinatal health disparity between Blacks and Whites in the USA, a statistic that has not changed in five decades”
In California in 2012-2014, Black women had the highest rates of cesarean section, as they do nationally.”
(National Center for Health Statistics, 2017)
Why do African-American women have the highest rates of Cesarean Section?
One of the reasons for the high rate of maternal deaths among African-American women is that they also have the highest rates of cesarean section in the U.S. In the past decade, in part due to repeat cesareans and low rates of Vaginal Birth After Cesarean (VBAC), repeat cesareans have risen for all populations which has made matters worse for African-American women. Vaginal Birth After Cesarean (VBAC) were relatively few and decreased from 3.75% in 1999 to 1.41% in 2005 (p<0.0001). This represents a significant 62% decrease in VBAC over the study period (Maternal Quality Indicators Project, 2011, p. 38 ). In California in 2012-2014, Black women have the highest rates of cesarean section, as they do nationally. In California, the rate is 37.7% for Blacks compared to 32.4% for Whites, and 33.1% overall in the state. The US overall rate is 32.6%, and for Black women it is 35.5% and 32% for White women from 2012-2014. (National Center for Health Statistics, 2017). There are also significant differences in cesarean section by neighborhood in Los Angeles. The cesarean section rate by Los Angeles Service Planning Area ( SPA ) is 37% in SPA 7 (South Los Angeles) compared to 34.8 in Metro LA (SPA 4), which is the lowest in the county and 38.3% in the San Fernando Valley, which is 2nd highest. The highest in the county is 39% in San Gabriel Valley, and the most significant increase is among Asian-American women at 726% increase (California Department of Public Health, Center for Health Statistics, OHIR Vital Statistics Section, 2003-2012).
Research that reveals that Black Americans receive an inferior quality of medical care than Whites, especially when caregivers are not of the same race. Thus, racially-induced stressors and differences in quality of medical care received by African-American women explain the significant differences in birth outcomes compared to Whites (Amnesty International, 2005).
One of the most effective tools to improve labor and delivery outcomes is the presence of continuous one-on-one support during labor and delivery [which Doulas provide] was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery but this approach is”under-utilized”
(American College of Obstetricians and Gynecologists, 2014)
What is a Doula?
Doula is a Greek word meaning “woman servant”. Doulas are professional labor companions who provide emotional support, physical comfort and advocacy for childbearing persons. In numerous studies, continuous support during labor by a professional childbirth companion has had a positive effect on birth outcomes and maternal wellbeing.
Doulas are not medical providers and do not provide any clinical skills such as vaginal exams or fetal heart rate monitoring. Instead, they offer encouragement, information, and physical comfort during pregnancy and labor and postpartum and help reduce maternal stress during pregnancy through encouragement and emotional support.
Building upon two decades of research into the benefits of Doula Support, the Community-Based Doula movement seeks to integrate Doula care into public health programs. Community-Based Doulas differ from conventional Doulas in several significant ways. These are:
Community-Based Doulas are from the same community as the women they serve and therefore have cultural competency and linguistic capabilities to work in the ethnic community served. The understanding and empathy provided to pregnant women experiencing discrimination may alleviate the stress they experience, which has positive outcomes on maternal and newborn health.
Community-Based Doulas have a longer relationship with the client than conventional Doulas do, providing support from early pregnancy to several weeks or months after the birth.
There are nine strategies that Doulas and Nurses do alike. However, five were original and described as only being used by Doulas. Professional doulas utilize intricate and complex emotional support skills when providing continuous support for women in labor. Application of these skills may provide an explanation for the positive ‘Doula Effect’”
But isn’t the Labor and Delivery Nurse supposed to help?
Yes, It is true that labor and delivery nurses offer women support during labor. However, while there are some similarities between what Nurses and Doulas do, Gilliand (2011) found that there were nine strategies that Doulas and Nurses both do. Reassurance, encouragement, praise, and explaining were similar to those attributed to nurses in published research. However, Five were original and described as only being used by Doulas: mirroring, acceptance, reinforcing, reframing, debriefing. (Not to mention the benefit of having a companion continuously by the woman’s side in labor, which only Doulas do). For more information about Doulas, read here on Evidence-Based Birth’s website.
Conclusions from Gilliand’s research are that emotional support by professional birth Doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labor.
Implications for practice are great. The Doula’s role in providing emotional support is distinct from the obstetric nurse and midwife. “Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive ‘doula effect’ on obstetric and neonatal outcomes in certain settings” (Gilliand, 2011).
Childbirth Connection’s Cochrane Review of studies on continuous labor support* (2003, 2007) summarized outcomes reported in at least 4 studies involving at least 1,000 women. Women who received continuous support were less likely than women who did not to:
- Have regional analgesia
- Have any analgesia/anesthesia
- Give birth with vacuum extraction or forceps
- Give birth by cesarean
- Report dissatisfaction or a negative rating of their experience.
American College of Obstetricians and Gynecologists (2014). Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a Doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery but acknowledges that this approach is “under-utilized.” Until Now.
Our Solution: Community Doula Support
In this community-based participatory research project, we expect to show how African-American Doulas working with African-American pregnant women can improve birth outcomes through social support, health education and advocacy, thus ameliorating the racism stressors experienced by African-American women.
If this program is successful in Los Angeles County, Health Net plans to expand the program to offer Doulas to all their members in California. This program will be located in Los Angeles County and is aimed at African-American/Black women who have Health Net Medi-Cal insurance. Ten Doulas will be assigned to work with 150-women during the childbearing year. They will provide three prenatal visits, labor, birth and breastfeeding support, and three postpartum home visits. Prenatal education classes and father’s support and discussion groups are also planned.
For more information, contact Cordelia Hanna, MPH, Program Director at Cordelia.Hanna@motherbabysupport.net or call (626) 388-2191 ext. 1.
Amnesty International USA (2010). Deadly Delivery: The Maternal Health Care Crisis in the USA. Retrieved from: http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf
Association of Maternal and Child Health Programs (2015). Life Course Indicators Tip Sheet: Talking About Life Course, Retrieved from:http://www.amchp.org/programsandtopics/data-assessment/Documents/Talking%20about%20LC%20Tip%20Sheet_Final.pdf.
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Kassebaum N, Barber N, Zulfiqar, A Bhutta, A et.al (2016). Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015, The Lancet. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31470-2/fulltext