Evaluation of the East Bay Community Birth Support Project, a Community- Based Program to Decrease Recidivism in Previously Incarcerated Women

United States Doula Programs and Their Outcomes: A Scoping Review to Inform State-Level Policies

BACKGROUND

The field of maternal health has advanced significantly over the past decades. However, the United States continues to have poor outcomes in comparison with other industrialized nations. With emerging evidence on the promise of doula care, states are including doula care under their Medicaid programs.

METHODS

We conducted a scoping review across four academic databases and gray literature published between January 1, 2012, and March 10, 2022, to describe the landscape of literature on U.S. doula programs and their outcomes in order to inform state policy makers considering laws or programs related to doula care.

FINDINGS

Of 740 records identified, 100 met inclusion criteria. Outcomes fell into four areas: birthing people's outcomes, infant outcomes, systems of care and implementation, and cross-cutting issues. Data on outcomes related to doula care in the literature were predominantly clinical, even though doulas are not clinical providers. Although some studies have found associations between doula care and improved clinical outcomes for birthing people and infants, the evidence is limited due to small sample sizes, study methodology, or conflicting conclusions. Doula outcomes are underexplored in the literature, with mainly qualitative data describing low levels of diversity and equity within the doula workforce and ineffective payment models. When cost-effectiveness estimates have been calculated, they largely rely on savings realized from averted cesarean births, preterm births, and neonatal intensive care unit admissions.

CONCLUSIONS

As state Medicaid programs expand to include doula care, policymakers should be aware of the limitations in the evidence as they plan for successful implementation, such as the narrow focus on certain clinical outcomes to quantify cost savings and conflicting conclusions on the impact of doula care. An important consideration is the impact of the reimbursement rate on the adoption of doula care, which is why it is important to engage doulas in compensation determinations, as well as the development of improved metrics to untangle the components that contribute to maternal health outcomes in the United States.

How and when doula support increases confidence in women experiencing socioeconomic adversity: Findings from a realist evaluation of an Australian volunteer doula program

How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity—when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman’s confidence via two possible pathways—by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula’s recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence.

Alcohol and other substance use disorder recovery during pregnancy among patients with posttraumatic stress disorder symptoms: A qualitative study

Background

About 5% of women are pregnant at substance use disorder (SUD) treatment entry, and pregnant women with SUD often belong to marginalized groups experiencing social, economic, and health care barriers associated with stigma from prenatal substance use. Pregnant women in SUD treatment have high rates of trauma and posttraumatic stress disorder (PTSD). This study sought to (1) examine the lived experiences of pregnant individuals with PTSD symptoms in SUD treatment and (2) understand the roles of systematic or contextual barriers to the pursuit of prenatal abstinence.

Methods

We draw upon in-depth semi-structured interviews to examine relationships between SUD, psychological trauma/PTSD experience, social resources, and lived experiences among patients in prenatal SUD treatment with PTSD symptoms. Our sample was pregnant patients (N = 13) with prior DSM-5 Criterion A trauma and current PTSD symptoms enrolled in a comprehensive program integrating prenatal care, substance use counseling, medication for opioid use disorder and case management at three sites affiliated with an urban academic medical center in New Mexico.

Results

Using thematic analysis, four main themes identified structural forces influencing alcohol and drug use: (a) lack of access or ability to obtain resources, (b) substance use to cope with negative affect, (c) social stigma, and (d) interpersonal relationships.

Conclusions

Despite receiving high-quality integrated prenatal and SUD care, these pregnant patients with PTSD symptoms in SUD treatment still experienced substantial social and structural hurdles to achieving abstinence during pregnancy.

Peer doula support training for Black and Indigenous groups in Nova Scotia, Canada: A community-based qualitative study

OBJECTIVES

The objectives of this qualitative study were to explore participant experiences of doula training programs offered by a prisoner health advocacy organization and Indigenous and Black community groups.

DESIGN

This investigation employed a qualitative design. Recruitment was conducted through email. Interviews were conducted in Winter 2020. Data were analyzed using thematic analysis.

SAMPLE

A total of 12 participants were recruited to participate in this study. Six participants identify as Black and six identify as Indigenous. All participants identify as women.

MEASUREMENTS

Qualitative interviews were conducted using a semi-structured interview guide to elicit a breadth of information.

RESULTS

Key themes included training experiences, training improvements and ''bridging the gap''. The training validated participants' experiences of birth and began to address the exclusion of Black and Indigenous people from birth work. However, participants expressed concerns about not being adequately positioned for sustained participation in birth work.

CONCLUSIONS

Participants expressed receiving great value from the training programs. These trainings, which were fully subsidized, removed a financial barrier. However, these trainings do not address the exclusion of Black and Indigenous people from perinatal work or the lack or sustainable support systems for Black and Indigenous communities. This study makes several recommendations for future interventions.

Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

Experiences of Community Doulas Working with Low-Income, African American Mothers

Purpose: The aim of this study was to learn from doulas the components of their services that might best serve low-income, African American (AA) women and to show the significance of doulas in helping these women have healthy, positive, birth experiences.

Methods: Ten doulas were recruited from a local community doula program and through word-of-mouth referrals from participants and completed in-depth interviews. Interviews were transcribed verbatim and analyzed using Atlas.ti software to identify emerging themes. Thematic saturation was achieved in interviews.

Results: Several themes emerged from the interviews including: (1) The influence of similarities of race, culture, and lived experience on doula care; (2) How doulas often provide birthing persons with support and resources beyond birth; and (3) How doulas recognize the institutional biases that exist in the health care system and try to mediate their effect on birthing persons.

Conclusions: These themes highlight how doulas can support birthing persons to mitigate the negative effects of social determinants of health, specifically racism and classism, and highlight potential avenues for doulas to consider when working with birthing persons who have low income and are AA.

An Alternative to Mother and Infants Behind Bars: How One Prison Nursery Program Impacted Attachment and Nurturing for Mothers Who Gave Birth While Incarcerated

The number of women in United States prisons has increased, with the most rapid growth among women of childbearing age. Detrimental effects on maternal-infant attachment have been shown to exist when mothers and infants are separated at birth. The purpose of this exploratory study was to examine the impact of an out-of-prison nursery program, Baby and Mother Bonding Initiative (BAMBI), on maternal-infant attachment and nurturing competencies among women who gave birth while incarcerated. A sample of 41 participants was recruited through a "Closed" BAMBI Alumni Facebook page and nonprobability snowball sampling. Participants were surveyed, and responses were submitted online or via mail. Data were analyzed using descriptive statistics, correlation coefficients, multiple regression, and logistic regression. Results indicated that the number of children living in the mother's household was a significant predictor of positive maternal nurturance. Inversely, the high number of children in the household was the most significant predictor of increased risk for infants to have insecure attachment to mothers. As the number of women giving birth in prisons continues to trend upward, the need for more programs to promote best outcomes for both mother and infants is crucial.

Making the case for innovative reentry employment programs: previously incarcerated women as birth doulas - a case study

Purpose The purpose of this paper is to make a case for novel and innovative reentry programs focused on women of color and to describe policy recommendations that are necessary to support the sustainability of these programs and in turn the success of the women who participate in them. Design/methodology/approach A review and analysis of the literature that described job-training opportunities specifically targeted to women exiting jail and the impact on recidivism provided limited information. The authors developed, implemented, and evaluated doula training program for low-income and women of color to determine if birth work could provide stable income and decrease recidivism. Findings Training low-income formerly incarcerated women to become birth doulas is an innovative strategy to solve employment barriers faced by women reentering communities from jail. Realigning women within communities via birth support to other women also provides culturally relevant and appropriate members of the healthcare team for traditionally vulnerable populations. Doulas are important members of the healthcare workforce and can improve birth outcomes. The authors' work testing doula training, as a reentry vocational program has been successful in producing 16 culturally relevant and appropriate doulas of color that experienced no re-arrests and to date no program participant has experienced recidivism. Originality/value To be successful, the intersections of race, gender, and poverty, for women of color should be considered in the design of reentry programs for individuals exiting jail. The authors' work provided formerly incarcerated and low-income women of color with vocational skills that provide consistent income, serve as a gateway to the health professions, and increase the numbers of well-trained people of color who serve as providers of care.