Barriers and Facilitators to the Implementation of a Community Doula Program for Black and Pacific Islander Pregnant People in San Francisco: Findings from a Partnered Process Evaluation

Abstract

Introduction Increasingly, community-based models of doula care are receiving attention as possible interventions to address racial inequities in maternal health care experiences and outcomes. In 2018, community-based organization SisterWeb launched to provide free culturally congruent community doula care to advance birth equity for Black and Pacific Islander pregnant people, with funding from the San Francisco Department of Public Health. We conducted a process evaluation of SisterWeb’s first 1.5 years of existence to identify multilevel barriers and facilitators to implementation of their programs. Methods Guided by the Equitable Evaluation Framework™, we conducted 46 in-depth interviews with individuals from 5 groups: SisterWeb leadership, doulas, doula mentors, and clients, and external stakeholders. Results Barriers included having diverse clientele groups with unique needs, an ineffective payment model, and simultaneously building an organization and developing and implementing programs. Facilitators included the presence of established strategic partnerships, positive reception of services due to an unmet need for culturally and linguistically congruent pregnancy and birth support among SisterWeb’s clients, a clear organizational vision and mission, and a unique doula cohort model. Discussion Our findings suggest developing community doula programs pay close attention to the difference between launching a program versus an organization, including the required resources of each, the sustainability of payment models for community doulas, and the provision of culturally relevant, needed services within priority communities. Furthermore, strategic partnerships with maternal health stakeholders in birthing sites, particularly hospitals, are vital to the success of a community doula program.

Utilizing Community-Centered Approaches to Address Black Maternal Mortality

“…Such insight can guide researchers on the gaps that exist within the community in terms of resources, guiding research projects, and what interventions can be introduced to address the gaps for Black birthing people. While efforts have also been made to incorporate the work and expertise of doulas in the discussion of reducing maternal mortality, these have either been calls to action about investing in and incorporating community doulas into the health care system (McCloskey & Bernstein, 2021) or improving on current doula-based community programs by getting feedback from doulas and clients (Marshall et al, 2022).…”

Cultural brokering in pregnancy care: A critical review

“…38,47,51,58 Several articles reported concerns with sustainable funding and infrastructure for doula-type cultural brokers. 33,41,59 Challenges with per-birth contracted payment included doulas working more hours than anticipated and having unpaid administrative and professional development responsibilities. 34,47,59 Community-based doulas in Sweden identified financial insecurity as a barrier and described needing to work multiple jobs.…”

“…33,41,59 Challenges with per-birth contracted payment included doulas working more hours than anticipated and having unpaid administrative and professional development responsibilities. 34,47,59 Community-based doulas in Sweden identified financial insecurity as a barrier and described needing to work multiple jobs. 44 Acknowledging these financial challenges, some articles noted enhanced sustainability of cultural brokers when they were employed at hospitals or when they were paid hourly.…”

What, when, and how long? Doula time use in a community doula program in San Francisco, California

“…Since 2018, SisterWeb San Francisco Community Doula Network and researchers at the University of California, Berkeley and the University of California, San Francisco have been collaborating on process and outcome evaluations of SisterWeb’s programs, 42 which included qualitative interviews with SisterWeb doulas. A major finding was the importance of compensation and benefits structures and policies to advance equitable labor conditions and financial security for community doulas, which would allow them to dedicate more time to improving birth equity for their clients.…”

“…A major finding was the importance of compensation and benefits structures and policies to advance equitable labor conditions and financial security for community doulas, which would allow them to dedicate more time to improving birth equity for their clients. 42 , 43 SisterWeb then conducted an internal quality improvement project to understand the scope of activities that comprise the doulas’ workdays and how they apportion time among different activities. We present results from the doula time use quality improvement project here.…”