A traditional model of pregnancy care shows promise in reaching disadvantaged women

The idea of using community health workers, or nonprofessionals, to provide health-related education and support to disadvantaged populations with chronic disease is becoming more popular. A growing number of healthcare organizations have discovered that people are more receptive to outreach from individuals who share the same cultural or socioeconomic background.

However, although the concept is relatively new with respect to managing chronic disease, it has been used informally for generations to provide care and support to women giving birth. In most instances, insurance does not cover this type of care, but many groups are experimenting with models that make use of doulas, or laypersons who have received special training to provide care and support to pregnant women—especially during labor. Medical professionals do not always welcome such support. However, some data suggest that doula-style care can make a considerable dent in the number of cesarean sections that are performed, and many advocates believe that the approach can offer even more dividends to women from high-risk groups.

Pilot results prompt replication

The doula model is receiving significant support from the Chicago Health Connection, a health education and advocacy group that has worked with partnering organizations to implement doula models at 28 sites in nine states. The organization’s work accelerated following a pilot study, showing that a doula-based intervention produced significant benefits in a population of teen mothers.

“[The participants] were almost entirely low-income, and they represented a very diverse group,” says Rachel Abramson, RN, MS, executive director of the Chicago Health Connection. “There were three different sites in three parts of the city: One was mostly African American, one was mostly Mexican American, and one served various neighborhoods on the north side.”

The study, which was funded by the Robert Wood Johnson Foundation and the Irving Harris Foundation, showed that of the 259 women served at the project’s three sites, only 8.1% of the mothers who had a doula present at birth had a cesarean section, compared to 12.9% for Chicago’s teen mothers as a whole. Researchers also reported that fewer doula-assisted mothers opted for epidural anesthesia, compared with national statistics, and more of them initiated breast-feeding.

Following the pilot, the Illinois Department of Human Services agreed to continue funding the doula model at the three pilot sites, and the Chicago Health Connection formed the Harris Doula Institute to work toward replicating the model around the country.

Doulas are skilled advocates

Whereas many doula-interventions focus narrowly on providing support to the mother during labor, the Chicago Health Connection’s model aims for a more comprehensive interaction. “The idea is to get the [doula involved] as early as possible in the pregnancy, so that she can help the mother get prenatal care, she can develop a trusting relationship with the mother, and so that she really has the time to help the mother attach to the baby,” says Abramson.

In addition, she explains that the doula can help the mother think through her plans for delivery, as well as which type of care she wants to give her new baby. This typically includes discussions about breast-feeding, as well as issues related to parenting.

Although doulas are not required to have any type of formal education, Abramson emphasizes that they need to be members of the community they will serve, and they need to be skilled at advocating for themselves and their neighbors.

“They tend to be experienced women who are natural leaders,” she says. “They are very committed to helping other women, and for the most part they reflect the same kinds of values, the same language, and the same issues that are faced by their neighbors. So to a certain extent, you could say that they are women who have survived the same challenges and gotten stronger. And now they are able to use that experience and that strength to support others around them.”

However, investigators learned during the pilot involving teen mothers that great care needs to be taken in selecting appropriate doula candidates, because several of the initial hires quit the program and had to be replaced.

“We got a lot better at working with the agencies to help them describe the program clearly both to potential clients and also to doulas they were recruiting,” says Abramson, noting that it is important to be clear about the work that is involved, including the fact that doulas need to be on call to attend deliveries at all hours. “It really is as much a mission as it is a job, and we helped our partner agencies . . . to develop questions to help potential doulas think about what the work might be like, what might be hard for them, and what supports they might need in their lives to allow them to do the work.”

A number of organizations provide doula training, but the largest such group is Doulas of North America (DONA), based in Jasper, IN (www.dona.org). The training offered through the Chicago Health Connection includes extensive community-based work, enabling doula candidates to pick up baseline knowledge of pregnancy, labor and delivery, the postpartum period for mothers, breast-feeding, and promotion of mother and infant attachment, Abramson says.

Nursing students take on doula role

Another doula model, Birth Companions, has received national recognition for the support it provides to underserved pregnant women in the Baltimore area.

The program, established in 1999 through the Johns Hopkins University School of Nursing in Baltimore, pairs nursing students who have received doula training from a DONA-certified instructor with expectant mothers as part of its community nursing program. Data suggest that mothers involved with the program are less likely to have preterm or low-birth-weight babies and are less likely to have a cesarean delivery when compared to regional and national benchmarks.

“Our focus is really with women who are underserved or who will be alone during the birth process, but we really don’t limit our services,” says Elizabeth Jordan, DNSc, RNC, assistant professor at the Johns Hopkins University School of Nursing and a faculty mentor to students participating in the Birth Compan-ions program. “If someone calls and has a need for the program, we certainly provide the service to them.”

The program maintains an English- and Spanish-speaking phone line that women can call to request the service. In addition, program staff maintain relationships with more than 40 community sites and practice groups that typically refer patients in need of pregnancy support to the program.

The stage at which student nurses get involved with an expectant mother depends on how early in her pregnancy a woman contacts the program. However, Jordan says that 70% of the time, student nurses are able to do at least one prenatal visit with the woman.

“They may meet at the doctor’s office or a testing center, but the student nurse sits down with the pregnant woman and really develops what the mom would like for her birth plan,” says Jordan. “And if at that time there is any need to help the patient navigate the healthcare system or identify community resources, that will be set into action as well.”

Staying in touch is a challenge

As with the Chicago Health Connection’s program, Birth Companions will individualize the care and support according to the woman’s needs and where she is in her pregnancy. For example, if the woman is diabetic, Birth Companions provides counseling and education that is pertinent.

“I and another faculty member are always there as support for the students, so if they are not sure about something, they can always call us,” adds Jordan. “That is our role—to help the student understand what might be available for the client, and what the situation is because every situation is a little bit different.”

Many of the women who call or are referred into the program are at very high risk for adverse birth outcomes, because of either psychosocial or medical problems. Jordan recalls one case that involved a woman with a limited education who was mentally retarded, for example. Other cases involve women struggling with addictions or abusive situations in the home.

“We may not provide the actual resources [that the women need], but we help them know whom to call, when to call, and how to call, so we really help them navigate,” says Jordan, noting that sometimes the Birth Companion will actually accompany the women to the appropriate agencies to fill out paperwork needed to obtain benefits. “We may even pick up the phone and help them work through an initial phone call or make that initial appointment.”

Within two weeks of delivery, the Birth Companion tries to visit the mother in her home to make sure that she and her child have gotten off to a good start. However, this is not always easily accomplished, as many of the women stay with friends or relatives immediately following the birth. However, the doula will make every attempt to connect with the woman in some fashion and assess how she is doing.

Jordan adds that throughout the entire process, just staying in contact with the women is a real challenge for the doulas. “These women move so much and change phone numbers so much that the nursing students often cannot find their clients,” she says. “When that happens, we tell the student to go back to where they got the referrals from and try to track them down.”

Patients connect with dedicated students

Because the Birth Companions program fills a variety of needs for its clients, it is difficult to determine which elements are responsible for the improvement in birth outcomes. Jordan says that both the education and support functions probably play a role.

“It could be that we have done a better job of explaining to the women what preterm labor is so that they don’t show up in labor at 8 cm, but rather when they are having a few contractions so that [medical treatment] can stop the labor,” she says. “We know when we provide that kind of education we are hopeful that these babies weigh more and are healthier as a result.”

Birth Companions has been so well-received that other communities are modeling their own efforts after the program. Jordan believes the success of the effort stems largely from the fact that the nursing students elect to become Birth Companions because they have a strong interest in women’s health, and many of them go on to become nurse practitioners or nurse-midwives.

“These are very dedicated students who want to learn and understand the needs of women in the community, and they are very motivated to get out there and help women,” she says. “It’s a passion for them and they want to do it, and I think that’s why patients connect.”

Doula advocates target high cesarean rate

Although the student nurses involved with the Birth Companions program have a high degree of medical expertise as well as doula training, most of the studies focusing on doula care have looked at the effect of utilizing modestly trained members of the community, as in the Chicago Health Connection’s model. And data show that the intervention not only results in fewer medical interventions during delivery, but it also produces a more positive birth experience for mothers, according to Carol Sakala, PhD, MSPH, director of programs at Childbirth Connection, a New York City–based, nonprofit organization focused on improving maternity care, and coauthor of the Cochrane Review on continuous labor support.

Of particular concern to Sakala and other advocates of the doula model is the high rate of cesarean deliveries in the United States. Statistics suggest that cesarean deliveries account for as much as 30% of all deliveries—a figure Sakala attributes to system pressures rather than medical need.

“The bar is shifting to where there is more and more causal use of this procedure,” she says. “So there is something going on that has nothing to do with the need, interest, or capacity of women and their preferences. It has much more to do with the healthcare system.”

Sakala points to reimbursement policies, time constraints, and fear of litigation as contributing to an unnecessarily high cesarean rate. “The pressure is to practice in an efficient manner, and the most efficient of all is a planned cesarean,” she says. “You know when it is going to happen, and you can provide scheduling for the nursing staff and operating room, so that is a very efficient way to do it.”

Further, although a routine cesarean delivery costs almost twice as much as a routine vaginal delivery, there is little incentive for hospitals to curb the rate of cesareans because the procedure provides an important revenue stream. However, Sakala points out that a doula-style intervention should have strong appeal to policymakers interested in lowering overall medical costs. “The ROI is a no-brainer,” she says. “It is really very simple, because for every four women who are getting doula support, you save a cesarean.”

In an effort to develop a much larger database on outcomes related to different doula practices, the Chicago Health Connection is developing a Web-based collection system so that partnering organizations can enter client-based data and compare the results of various process factors with those employed by other models. The idea is to facilitate a network of community-based doula programs around the country so that best practices can be identified and disseminated, explains Abramson.

“It is in all of our best interests to share the data, use it to advocate for the model, and attract funding for further expansion around the country,” she says.

Web-based support: An avenue for intervention in low-income pregnant women

For reasons that are not entirely clear, African American babies are twice as likely as Caucasian babies to be born with a low birth weight, making them much more vulnerable to medical complications and developmental disabilities. Some researchers theorize that a strong contributing factor to this discrepancy may be higher levels of stress in mothers.

“There is a lot of new literature on the relationship between stress and preterm labor,” says JoAnne Herman, PhD, RN, CSME, an associate professor at the University of South Carolina, who has researched the issue extensively. “Some of the stress hormones that are produced can trigger preterm labor.”

Given that there is also ample evidence that social support can buffer the impact of stress, Herman decided to investigate whether an interactive Web site could potentially have an effect on the rate of preterm births in a low-income, African American population. To answer this question, Herman first conducted a feasibility study to assess whether her target population would take advantage of a Healthy Pregnancy Web site, designed with their particular needs in mind and offered via phone lines and Web-TV.1

At the time (December 2001–August 2003), the prevailing view was that African American women with low incomes would not use such a resource, says Herman, but she discovered that this view was not necessarily correct. In fact, participants accessed the Web site 11 times, on average, during the study period.

“Just the fact that I can document that they used it and had a lot of discussion through the discussionboard feature helped [people] get over the idea that this particular population wouldn’t use such a resource,” says Herman.

Herman was also able to assess which features of the Web site were most popular and, therefore, potentially the most useful in getting important information and support across to the target population. She noticed, for example, that users particularly liked interactive features in which they could input information about themselves and receive feedback. Features that fit this description included a tool with which users could calculate the gestational age of their baby, and a nutritional assessment tool in which they could enter what they had eaten on a given day and receive dietary recommendations in return.

Users also liked being able to post ultrasound images of their babies to share with other users—a feature they actually suggested to site administrators. “They liked having something about themselves on the Web site; that was really powerful,” says Herman.

The most popular feature was the discussion board, on which users could interact with each other and share solutions to problems. Consequently, for the next phase of her research, Herman hopes to leverage the popularity of this feature to communicate important educational topics to users, perhaps through the use of moderated discussions.

Herman is still waiting for grant funding so that she can move on to the next phase of her research, which will not only look at specific birth outcomes in women who have had access to Web-based support, but also pre- and postmeasures of stress.


1Herman J, Mock K, Blackwell D, et al. “Use of a Pregnancy Support Web Site by Low-Income African American Women.” JOGNN 2005; 34:713-720.




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