Community‐Based Doulas and COVID‐19: Addressing Structural and Institutional Barriers to Maternal Health Equity

Abstract

The Black-White racial disparities in maternal and infant health outcomes are among the largest disparities seen in traditional perinatal health measures. 1,2 Black pregnant and postpartum people * have a pregnancy-related mortality ratio that is three to four times that of their White counterparts, and disparities in severe maternal morbidity are similar. 3-5 Additionally, the infant mortality rate among Black neonates is more than twice that of White neonates (10.8 vs. 4.6 per 1,000 live births), 6,7 and the proportion of births that are preterm is more than 50% higher among Blacks than among Whites (14% vs. 9%). 8 The reasons for these disparities are multifactorial, but have been linked to Black individuals having higher prevalence of preexisting chronic disease 5,9 and less access to primary and prenatal care, 10 as well as to social and structural determinants of health (e.g., poor housing, food insecurity, high-crime neighborhoods) 11-13 and to racial discrimination that results in poor patient-provider communication, disrespectful care, delayed medical intervention and lower quality of care. 14-18 As the United States battles the COVID-19 pandemic, racial disparities in COVID-related deaths have risen alarmingly, 19 and mounting data suggest that similar increases are occurring for disparities in birth outcomes. Providing pregnant individuals with support to mitigate the social and structural factors that are key drivers of COVID-19-related health inequities may help ameliorate these disparities. For pregnant and birthing people, community-based doulas are a potential source of such support. Community-based doulas are a type of health worker who focuses on the care of pregnant people and their infants, and use of their services is associated with improved birth outcomes among low-income and marginalized racial and ethnic populations. 20-23 Despite evidence suggesting they can improve maternal and infant health, community-based doulas have been deemed nonessential workers during the pandemic, and pregnant patients have often had limited access to their services in hospital labor and delivery settings. This lack of access could have serious implications for maternal and infant health outcomes and threatens to worsen the already extensive racial disparities. * We use "people" as a gender-inclusive term to refer to individuals with the capacity for pregnancy and childbirth, and use "woman, " "women, " "mother" and "maternal" when reporting the results of studies that used these terms.

Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching

“…Prior studies also have shown that pregnant women who interact with their doulas early in pregnancy are more engaged in their prenatal care and have better birth outcomes. 24 Doula care received during early in pregnancy, therefore, may shift women into a trajectory that ultimately results in improved health outcomes during childbirth.…”

Centering the Right to Health of Childbearing People in the US During the COVID-19 Pandemic

“…While some institutions facilitated connections to outside doula support, other healthcare settings restricted even video calls during delivery ( 19 ). The challenges faced by community-based doula organizations to transition to virtual services and the lack of technological access among mothers continue to hinder virtual doula support, and compound existing inequities ( 20 ). Moreover, Combellick et al ( 21 ) have documented lack of clear information from healthcare providers and unnecessary interventions during the pandemic.…”

Anesthesia Considerations for Pregnant People With COVID-19 Infection

“…21 The syndemic of health care disparities among ethnic/ racial minorities and COVID-19 further increases the risk of serious maternal morbidity and death. [22][23][24][25][26][27][28] Acknowledging the crucial opportunity to develop resources to support equitable obstetric care during the COVID-19 pandemic, SMFM outlined challenges to overcome, which include telehealth access and confronting bias, among many others. 29…”