Faehling S, Phelan H, Smith S. How $250,000 could improve birth outcomes for black mothers and infants: a proposed interprofessional, coommunity-centered doula program. HPHR. 2021;36 DOI:10.54111/0001/JJ4
The purpose of this article is to examine the well-established body of evidence demonstrating significant racial inequities in Black maternal and infant morbidity and mortality, and to conduct further literature reviews to propose feasible solutions to lessen these inequalities. The factors contributing to racial inequities in maternal and infant health are complex. They include structural factors (i.e., public policies, institutional practices, cultural representations in healthcare), interpersonal factors (i.e., lack of diversity in the medical profession, interpersonal racism including that which happens in healthcare settings) and social factors (i.e., economic instability, lack of access to quality care, lack of reliable transportation, food insecurities, etc.). Therefore, efforts to address inequities require the interplay of professionals across many healthcare and non-healthcare disciplines. Our team proposes an interdisciplinary, community-centered doula program, consisting of doulas, social workers, and a community health educator. This program assumes an initial budget of $250,000 with multiple suggested avenues of financial sustainability. The goal of this hypothetical program is to support Black women and pregnant people and to lessen inequities in a way that is innovative, feasible, and financially sensible, all with the understanding that not all factors contributing to inequities can realistically be addressed through a single program.
Significant inequities exist in maternal and infant morbidity and mortality rates for Black women when compared to their white counterparts, and these inequities are getting worse. Across the United States, data by the Centers for Disease Control and Prevention shows that Black women are two to three times more likely to die from pregnancy related causes than their white counterparts, and for women ages 30 and older, the risk of pregnancy related death increases to five times that of their white counterparts (CDC Newsroom, 2016). These data also showed that these inequities are still significant even among Black women with higher levels of education and in regions of the country with historically lower rates of pregnancy related mortality. According to another longitudinal study by the CDC evaluating nation-wide data, pregnancy-related mortality has increased from 7.2 deaths per 100,000 births in 1987 to 17.3 in 2017 (CDC, 2020). Moreover, this study denoted a significant difference when considering racial/ethnic differences in pregnancy outcomes between 2014 to 2017; pregnancy related mortality per 100,000 births was 41.7 deaths for non-Hispanic Black women, and 13.4 deaths for non-Hispanic White women.
While nation-wide data provides an overview of this issue, certain regions of the country are disproportionately affected. Data from Wisconsin from 2006-2010 showed the pregnancy related death rate for Black women was five times higher than that of non-Hispanic White women, which is considerably higher than the national disparity rate of 3.2 times over the same period (Wisconsin Department of Health Services, 2021). Additionally, in Wisconsin, death rates for infants born to Black women and pregnant capable people were the highest in the nation at three times the rate of their White counterparts (Wisconsin Department of Health Services, 2019). Looking even deeper, Milwaukee, Wisconsin has been identified as one of the most segregated metropolitan areas in the country, with inequities tied to historically enacted housing covenants (Maternowski, 2017; Maternowski & Powers, 2017). Therefore, it becomes evident that interventions are paramount in this area of the county, and other similar areas that are disproportionately affected by racial inequities.
It is evident that significant inequities exist, and racial inequities in birth outcomes are a public health crisis in the United States. In order to achieve health equity among all pregnant capable people and infants, we must create a series of changes that are not only evidence-based, but that are also feasible and sustainable. One strategy that has been proposed to lower maternal mortality among Black women and pregnant capable people is expanding Medicaid coverage, particularly in the postpartum periods. Medicaid coverage typically ends 60 days postpartum, but some states have expanded coverage to one year postpartum. This is critical since rigorous reviews have shown that 17.5% of pregnancy related deaths occurred within 43 days and one year postpartum, and of these deaths, 58.3% were considered to be preventable (Nine Maternal Mortality Review Committees, 2018). Therefore, targeted efforts within this time period are necessary to reduce the number of preventable deaths. Upon examining data from 2006 to 2017, states that expanded Medicaid coverage were associated with significantly lower maternal mortality (p = .002) relative to non-expansion states, and the effect size was greatest among non-Hispanic Black women (Eliason, 2020). However, this study also showed that despite this reduction between groups, maternal mortality rates overall were increased in both groups over this time period. As a whole, this data indicates that while Medicaid expansion may play an important role in slowing the rise in maternal mortality rates, more interventions are necessary to both prevent rates from rising further and to decrease rates with time.
Overall, inequities in Black maternal and infant mortality are complex issues, and as such, addressing these inequities must require a multifaceted, interprofessional approach. Considering the well-established data conferring an elevation in inequities, maternal and infant death rates, and racial marginalization, we present a prioritized, innovative set of recommendations to improve the inequities in Black maternal and infant mortality rates. Assuming a budget of $250,000, we propose a program consisting of doulas, social workers, and a community health educator, along with the universal implementation of the Institute for Healthcare Improvement’s safety bundles, to help achieve health equity for Black people who give birth and their infants.
Of highest priority, we recommend implementing a doula program in which the cost of provided services are dependent on participant income level and range from in-home services offered free-of-charge, to referral to external doulas programs for standard fee services. As a whole, doulas are non-clinical professionals who provide emotional, educational, and physical support to pregnant people in the antepartum, intrapartum, and postpartum periods (Gebel & Hodin, 2020). They help women to develop a birth plan while educating women on their options and their health rights. Most importantly, doulas serve as patient advocates. Doulas facilitate communication between women and their healthcare providers by assisting women in articulating their questions, concerns, and preferences, while also addressing language and cultural gaps. In particular, research shows that Black women face barriers in communicating their concerns to their providers, or these providers are less likely to act on communicated preferences (Huesch & Doctor, 2015). For pregnant Black mothers, there is strong evidence that doulas can advocate against implicit bias that might be subconscious or otherwise difficult to recognize during labor (Gruber et al., 2013). For example, a doula can be an advocate when medical professionals do not recognize elevated blood pressure concerns, which can lead to hypertension in pregnancy or preeclampsia going untreated. Moreover, having doulas directly in the community would serve to increase care availability outside of hospitals and clinics. This is beneficial to reduce social barriers to care that often have been associated historically with inequities, such as transportation and the amount of time needed to be taken off of work.
Studies show that Black women are significantly more likely to have a cesarean delivery than their white counterparts, and cesarean births are 50% more costly than vaginal births (Strauss et al., 2016). It is also well established that with doula services, women have a 12% greater likelihood of having a spontaneous vaginal delivery (Hodnett et al., 2011). Rigorous studies also confirm that doula care reduces the likelihood of repeat cesareans, decreases epidural use, increases rates of breastfeeding, and is associated with higher infant Apgar scores all while promoting a positive childbirth experience (Hodnett et al., 2011). Another positive outcome that has been appreciated is that women with doula care had 22% lower odds of preterm birth (Kozhimannil et al., 2016). With this data, it is evident that doulas convey countless advantages and have direct financial benefits.
When considering both the potential impacts of doulas on birth outcomes and health equity and taking into account the sustainability of a community-centered doula program, we advocate for targeted legislation to obtain nationwide Medicaid reimbursement for doula support. Studies in three states have found that coverage of doulas would convey an estimated savings of $409.27 per birth (Strauss et al., 2016). However, doulas still are not covered by Medicaid within the vast majority of states despite this data since Medicaid reimbursement rates for doulas have historically been too low to support doulas (Nguyen, 2021). We plan to advocate for this change as part of our program and hope to reinforce that Medicaid reimbursement for doula care is beneficial regardless of financial benefits, since a positive return on investment is not a criterion used to determine Medicaid coverage of medical services. Additionally, one should consider the populations that Medicaid serves. In 2020, 12.4% of the United States population identified as Black or African American (U.S. Census Bureau, 2021). However, 34% of Medicaid enrollees are Black (National Committee to Preserve Social Security & Medicare, 2021). It is evident that Medicaid enrollment and coverage of appropriate services has racial and equity implications.
Overall, this proposed program would involve training and hiring four doulas within the first year of the program. Assuming each doula can attend five to six births per month, they could cover 260 births per year while allowing for flexibility with schedules. As an example, in 2018, 178 infants died within the first year of life in southern Wisconsin, and 108 women died from pregnancy related causes (WISH (Wisconsin Interactive Statistics on Health) Query System, 2014). Implementing this doula program to cover 260 births per year in this area of the country would have the potential to significantly reduce the morbidity and mortality associated with Black maternal healthcare in the region. Beyond this, our proposed program has the potential to impact far more than 260 women and 260 infants when considering the impact of the other components of the program (i.e., social workers, community health educator, universal implementation of safety bundles).
As part of this proposed program, we also recommend the implementation of a social worker, a social work intern, and a community health educator. The social work profession is adept at understanding and identifying how individuals, families, and communities are shaped by their environment. Furthermore, social workers play integral roles in helping address unmet social needs, such as housing, food security, and transportation among others. A 2017 systematic review showed that interprofessional teams with social workers showed improvement in health and utilization outcomes (Steketee et al., 2017). Community health education has also proven to be effective at achieving targeted outcomes. An example of this includes a randomized trial of 343 low-income women, in which those having received support packs and informative counseling had achieved higher rates of breastfeeding when compared to controls (Frank et al., 1987).
Social workers and health educators would be vital constituents of our program in not only continuing to raise awareness of this issue, but also ensuring the program runs smoothly. Their responsibilities would include program enrollment, creating resource connections, collecting and analyzing data to ensure the program is effective, and educating women, providers, and the community about our program and the importance of creating change in Black maternal and infant healthcare. They would also play crucial roles in connecting women and infants to resources that already exist within their communities.
Lastly, as a health system initiative, we recommend the universal implementation of safety bundles within all hospitals and birthing centers. Safety bundles were developed by the Institute for Healthcare Improvement (IHI), and they serve as a set of straightforward, evidence-based practices that improve patient outcomes when performed collectively and reliably. They include specific steps for readiness, recognition and prevention, response, and reporting/learning systems. Overall, this cost-free initiative assures the standardization of care for every patient, every single time, regardless of the healthcare facility. The use of bundles in general has long been applied in other areas of medicine, and they have shown to be effective in achieving primary outcomes. For example, a bundle approach to improve ventilator care and reduce the incidence of ventilator-associated pneumonia (VAP) was studied from 2002-2004; this study showed that units with consistent adherence to the bundle practices had a 44.5% reduction in VAP (Resar et al., 2005).
“Severe Hypertension in Pregnancy” is an example of a Safety Bundle that is currently implemented in various birthing centers. However, its implementation is voluntary and is at the discretion of each individual facility. It is our goal that every birthing facility in Wisconsin will apply this bundle to ensure the standardization of medical care for all women, regardless of where they reside. Using a consistent and evidence-based series of practices aids in negating implicit racial biases and ensures that every patient receives the same high-quality standard of care. We plan to achieve this goal through educating healthcare systems about the benefits of this free initiative, as well as advocating for mandated use of the IHI Severe Hypertension in Pregnancy bundle in birthing centers that receive Medicaid reimbursement throughout the state and nation.
The $250,000 budget breakdown for this program can be found in a Table 1, and the roles of program employees, including the doulas, social worker, social work intern, and community health educator can be found in Table 2. Wages were calculated based on typical industry rates and include standard benefits of insurance, leave, and vacation.
PERSONNEL (FTE WITH BENEFITS)
Four Community Centered Doulas
4 x $30,000.00
One Social Worker
One Social Work Intern
One Community Health Educator
Total Personnel Cost
7 x $250.00
7 x $100.00
7 x $150.00
7 x $100.00
Filing Cabinet/Shelving Units
2 x $100.00
Conference Room Table
10 x $100.00
Conference Room TV
Misc. Office Supplies
Total Supplies/Operating Cost
Doula Training & CE Funds
4 x $1,000.00
4 x $300.00
Total Travel/Training Cost
Office Space Rental (1000 sq ft)
12 months x $850.00
Electricity (utilities, water, internet)
12 months x $290.00
Office Phone Plans
12 months x $30.00
12 months x $100.00
Total Contractual Cost
Final Proposed Budget Total
Table 1. Budgetary breakdown for one year of program operations, including personnel, supplies/operating costs, travel/training, and contractual costs. Personnel wages were calculated based on typical industry rates in Wisconsin and include standard benefits of insurance, leave, and vacation. Doula salary was also calculated on the assumption that this is a part time job, following the sporadic nature of pregnancy, labor and delivery, allowing for other flexible employment options which is common in the field.
Complete culturally appropriate doula training from a certified organization, labor and delivery shadowing hours, and maintain continued education hours
Provide support during prenatal, perinatal, and postnatal period to women and infants within the home, clinic, hospital, and community
Advocate for pregnant people and infants, facilitate communication with providers, and educate birthing people of her/his/their options and rights
Decrease maternal stress by maintaining healthy 1:1 working relationship
Collaborate with healthcare professionals to create a patient-focused experience
Educate participants on childbirth, breastfeeding, and local resources and services
Assist in creating healthy and nurturing relationships within the family
Use automated devices to measure participants’ vitals during at-home pre and postnatal visits, and communicate abnormal values to the patients’ medical providers
Assess client needs, situation, strengths, and areas of support needed to improve affordability and accessibility of healthcare and services
Refer to community resources as appropriate including but not limited to public healthcare coverage programs, WIC, etc.
Maintain case records, following up with participants to ensure needs are met
Develop advocacy and policy change plan to gain Medicaid reimbursement
Work with interns to maintain accurate data collection and analysis modalities to measure program success
SOCIAL WORK INTERN
Complete 800 hours of experiential learning
Create data collection and analysis modalities to measure program success
COMMUNITY HEALTH EDUCATOR
Lead program enrollment and marketing, focusing marketing efforts on historically marginalized communities
Create collaborative programs to educate healthcare providers of racial inequities, Black maternal healthcare facts, and how this program can improve outcomes
Educate patients on their rights, pregnancy related mental health, and chronic disease management during pregnancy
Implement free maternal education programs, reproductive health, and patient rights within the community
Educate local health care systems on safety bundles and work to ensure universal implementation in all birthing centers in the region
Develop Black Maternal Health Week campaigns
Collaborate with social workers to influence policy change for Medicaid reimbursement of doulas and advocate Black maternal and infant healthcare
Maintain goal of reducing systemic racial inequities and addressing implicit bias in all program developments
Collaborate with preexisting public or private doula programs in the area to work towards the same common goal of eliminating Black maternal and infant morbidity and mortality
Table 2. Roles and responsibilities of program employees.
Pregnant Black, Indigenous, and People of Color (BIPOC) living within a predefined geographical area would be are eligible for the doula program. An example of this would be predefining the 16 counties that make up southeastern Wisconsin. The program would be available to people capable of pregnancy of any age and any stage of pregnancy through birth and one year postpartum. Participants can be enrolled in the doula program simply by contacting the office or by healthcare worker referral. Every referred person is to be connected with doula services either through this program, to other public doula programs, or a private doula business within their financially acceptable range. Low-income individuals and those with Medicaid may receive doula services free of charge. However, if participants have the ability to pay some toward doula care, this will enable our program to continue to reach underserved pregnant women.
For a community-centered doula program to be feasible, it must be sustainable. As previously stated, the financial benefits of universal Medicaid coverage for doula services would aid in ensuring sustainability; therefore, continuing to advocate for policy change for Medicaid reimbursement nationwide cannot be understated. To further program sustainability efforts, a sliding scale payment system could be utilized for doula care and donations could be accepted. This sliding scale system would first utilize the participant’s insurance, if doula care were covered, then the out-of-pocket cost would be determined by the household income in relation to the Federal Poverty Level (FPL). Patients at or below 100% of the FPL will receive doula services for free, while those above that limit will pay incrementally more until the maximum fee of $750 is reached (the average doula cost in Wisconsin).
Furthermore, to diversify our potential funding sources, our program is poised to partner with or become a Federally Qualified Health Center which would allow us to receive funds from the HRSA Health Center Program to provide our services in underserved areas. We have also identified many federal, state, and private funding sources that provide grants for maternal and infant healthcare. Lastly, we plan to develop healthcare system and community partnerships to further expand our program and identify other collaborative funding and sustainability options.
It is critical that data be collected and appropriately interpreted to measure the success of this program. Data surrounding mortality rates, cause of death, and risk factors, along with participants’ satisfaction should be collected by the social workers. The primary outcomes of the data analysis would hopefully indicate improving maternal and infant outcomes, as well as the improved health of communities as a whole. In the future, this data could be further leveraged to create a collaborative working relationship with hospital systems to have doula programs as standard offerings that are employed directly by hospitals and clinics. Here, they would see patients both within the healthcare settings and out in the community.
The hypothetical community-centered doula program that we proposed has the potential to make a significant impact in lessening racial inequities in healthcare when implemented in areas of the country most affected by Black maternal and infant inequalities, such as in southeastern Wisconsin. For a starting budget of only $250,000 with a myriad of potential sustainability options, a program like the one suggested here represents an innovative and evidence-based method to target inequities
When considering the structural, interprofessional, and social factors contributing to racial health inequities, a program like the one proposed here has the potential to alleviate some, but not all factors. The collective program personnel, along with the implementation of safety bundles, predominantly aid in lessening interpersonal racism and social inequities, however, overarching structural racism would remain largely untouched by this program.
Although our literature review, analysis, and program proposal necessitate the interplay across a myriad of professions, the ultimate solutions to this problem do not lie exclusively within the healthcare system. Black women and pregnant capable people today are still affected by institutional racism, which in effect causes more stress on the women’s health, opportunities, wealth, living situation, and much more. Until the issues of overt, implicit, and systemic racism are addressed, we cannot simply eradicate the inequities in Black maternal and infant morbidity and mortality.
This literature review and program proposal was developed by the authors while participating in the Wisconsin Area Health Education Center (AHEC) Interprofessional Case Competition. This competition featured a case developed by the University of Minnesota Center for Health Interprofessional Programs. The team won first place in the competition.
The author(s) have no relevant financial disclosures or conflicts of interest.
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Shannon Faehling is a student doctor in her final year of medical school at the Medical College of Wisconsin. Here, she is pursuing a career in Emergency Medicine. Her other areas of research include opioid harm reduction, medication disposal methods, and the clinical effects of COVID-19 infection.
Hannah Phelan is a student doctor in her final year of medical school at the Medical College of Wisconsin. Here, she is pursuing a career in General Surgery. Her other areas of research include phantom limb pain, arterial disease, and adaptive technology.
Sierra Smith is a student social worker in her final year at the University of Wisconsin-Stevens Point. She will her continue her education at the University of Wisconsin-Green Bay to pursue a masters in mental health. Her other areas of research include victimization of sex trafficking, the mental health effects of COVID-19 on the elderly population, and the assessment and engagement with children who have failure to thrive.