In Cincinatti, a city plagued with poor racial disparities in birth outcomes, Dr. Jim Greenberg declared, "If you care about education, jobs, poverty or equity, you should start caring about birth."
As a birth doula and childbirth educator in New Jersey, I applaud the state’s recognition of the data of racial disparities in birth outcomes. Thus, it is time to incorporate and, finally, use a model that works to improve outcomes for mothers and babies — birth doula care.
Doula care has been used from the City of Baltimore to the state of Minnesota, from New York City to Oregon and beyond, but has never been fully scaled, implemented, nor embraced in New Jersey. And doula care, which provides nonclinical emotional, physical and informational support before, during and after a birth, is a proven key strategy to improve maternal and infant health used in public health systems throughout the United States.
Unlike midwives, who are licensed healthcare providers and as such offer clinical care in hospitals and federally qualified health centers, doulas have a different scope of care, providing patient education, labor support, and home visits within a community health worker model. Rigorous studies show that doula care reduces the likelihood of consequential and costly interventions like cesarean births while increasing the likelihood of a shorter labor, spontaneous vaginal birth, higher APGAR scores, and a more positive childbirth experience.
Other studies suggest support by trained, experienced doulas is associated with decreased postpartum depression and increased breastfeeding. Recognizing the well established benefits and absence of harms of doulas services, leading professional societies like the American College of Obstetrics and Gynecology, the Society for Maternal-Fetal Medicine, and agencies like the Centers for Disease Control and Prevention, Health Resources and Services Administration, and the Centers for Medicare and Medicaid Services identify the value of increased access to this form of care.
While New Jersey has had a few community doula programs that were funded for brief periods, it has not systematically adopted doula care in the way so many other states have. Studies of the effectiveness of doula care tell us that one of the most effective and far-reaching steps New Jersey could take to reduce disparities for both mothers and infants would be to follow the example of so many other states and scale up the training and use of birth doulas.
Obstetrician and former New Jersey resident Dr. Neel Shah reveals, “New Jersey has tremendous variation in C-section rates from place to place. Such extreme variation signals something is wrong... consumers have no way to make more informed choices and most women are unaware that one of the main risks for having a C-section is the hospital where they give birth.”
While C-sections of course can be lifesaving in true emergencies, routine C-sections carry many risks: for babies, they are associated with higher rates of infection, respiratory complications, and neonatal intensive care unit (NICU) stays. For mothers, they often mean higher rates of blood transfusions, blood clots, and postpartum depression.
Hemorrhage, cardiac arrest, and major infection occur three times more often in women who have surgical deliveries as compared to vaginal deliveries. Additionally, once a mother has had a C-section, she has a greater than 90 percent chance of having the procedure for subsequent births — leading to higher risks of major complications, such as hysterectomy and uterine rupture. Finally, to the detriment of both mother and baby, breastfeeding rates are lower following C-sections. With our state cesarean birth rate at close to 40 percent — meaning 40 percent of our mothers and babies face the risks associated with that procedure and many of them experience the complications — there is real opportunity for improvement in outcomes.
The New Jersey Senate and Assembly are considering numerous bills for improving maternity care in the state, including Assembly bill 1662 that provides a Medicaid waiver for doulas here. We also have untapped opportunities for cross-sector collaboration and to train community-based doulas with a New Jersey-specific curriculum in alignment with clinical mentors and supervision and with a focus on racial disparities.
There has never been a more pressing time to reimagine the perinatal time and newborn well-being in New Jersey. Doulas can help to eliminate barriers and accelerate linkages that new parents may need, including resources on safe sleep, compliance with pediatric visits, and support for recovering from childbirth. Doulas here are ready to collaborate and coordinate with policy makers and clinical care providers.