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

2020; Wiley; Volume: 52; Issue: 4 Linguagem: Inglês

10.1363/psrh.12169

1931-2393

S. Michelle Ogunwole, Wendy L. Bennett, Andrea Williams, Kelly M. Bower,

Reproductive Health and Contraception

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 disease5, 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, 21, 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. In this viewpoint, we describe emerging data concerning racial disparities in birth outcomes during the pandemic (and potential mechanisms for those disparities), highlight how use of community-based doulas can disrupt the pathways leading to racial disparities in COVID-19–related birth outcomes, and propose strategies for integrating doulas into health care teams and ensuring recognition of their role as essential health care workers through this pandemic and beyond. Early in the COVID-19 pandemic, there was a dearth of data focusing on the impact of the SARS-CoV-2 virus on birth outcomes and on racial and ethnic trends in COVID-19–related birth outcomes.24, 25 However, the available data on COVID-19 incidence and fatalities by race in the general population raised concerns. For example, compared with residents of predominantly White U.S. counties, residents of predominantly Black counties had three times the risk of infection and six times the risk of death from COVID-19.26, 27 Given the social and structural factors that result in higher prevalence of chronic disease among Black people, as well as the association between such diseases (e.g., diabetes mellitus, chronic hypertension, obesity, asthma, cardiovascular disease) and COVID-19 risk,26-28 public health experts became concerned that Black pregnant and postpartum people would have an elevated risk of contracting the SARS-CoV-2 virus, which in turn could lead to racial disparities in birth outcomes.29 Additionally, because of the historical legacy of racism, Black people in the United States are vulnerable to social risk factors that predispose them to adverse COVID-19–related outcomes.30 For example, compared with their counterparts in White communities, individuals in Black communities have a greater likelihood of exposure to the SARS-CoV-2 virus (because, for example, the proportions of residents who are essential workers or use public transportation to get to work are higher in Black households than in White ones) and less ability to socially distance (e.g., because of a higher number of residents per household).26, 28, 31 Moreover, their risk of adverse health outcomes is greater because they have less access to health care; for example, access to technology is lower among Black than White individuals, and this lack of access is a barrier to using telehealth services as in-person visits became less available.28, 31 Further, interruptions of health care and social support services, such as the repurposing of birthing hospitals in communities of color32 and the closure of community-based organizations that supplied diapers, cribs, meal assistance and other resources, have compounded these social and structural risk factors for pregnant and postpartum Black people. Recent data and news stories have confirmed public health concerns and demonstrated racial disparities in COVID-19–related pregnancy and birth outcomes. In Southwest Ohio, 70% of the 160 mothers at 14 area hospitals who tested positive for coronavirus were people of color (40% were Black and 30% Hispanic); although the racial composition of mothers who did not test positive is unavailable, only 18% of Ohio residents are people of color (14% Black and 4% Hispanic).33-35 Similarly, data from the Minnesota Department of Health showed that nearly 40% of the 900 pregnant people who tested positive for the SARS-CoV-2 virus were Black, even though the proportion of Black people in Minnesota is just 6%.36 A prospective cohort study of pregnant women at two academic hospitals in Philadelphia found greater seroprevalence of the SARS-CoV-2 virus among Black (9.7%) and Hispanic/Latino (10.4%) patients than among White (2.0%) and Asian (0.9%) patients.37 Three reports from the Centers for Disease Control and Prevention (CDC) provide additional context. The first report, released in June 2020, examined national data on 326,335 (pregnant and nonpregnant) people of reproductive age with laboratory-confirmed SARS-CoV-2 infection.38 Compared with nonpregnant individuals with COVID-19, pregnant individuals had 5.4 times the risk of being hospitalized, 1.5 times the risk of being admitted to an intensive care unit and 1.7 times the risk of receiving mechanical ventilation. Additionally, racial and ethnic disparities in the prevalence of SARS-CoV-2 were reported among pregnant women: Of those who tested positive for COVID-19, 46% were Hispanic, 22% were Black and 23% were White, whereas of the women who gave birth in 2019, 24% were Hispanic, 15% were Black and 51% were white. The other two CDC reports, which were released in September 2020, provided further evidence that Black and Hispanic pregnant people were disproportionately affected by COVID-19.39-41 Importantly, one of the reports included evidence of the impact of medical comorbidities on COVID-19 risk during pregnancy, as investigators found that pregnant people hospitalized for COVID-19 were more likely than their counterparts who were not hospitalized to have prepregnancy obesity and gestational diabetes mellitus.41 Beyond these immediate clinical implications, the COVID-19 pandemic has been the backdrop for the concurrent public crisis of racial and social injustice. The killings of Ahmaud Arbery, Breonna Taylor and George Floyd, among others, sparked outrage in the Black community and among allies across the country, and led to a nationwide discourse about the legacy of racism in the United States. Given the evidence that disparities in COVID-19 outcomes were being driven largely by social inequities, the issue of racism and health quickly became a large part of the public conversation. Many health organizations—including the American College of Obstetrics and Gynecology, the American Academy of Nurse-Midwives and the American Academy of Pediatrics—have called for the recognition of racism as a public health crisis.42-44 The twin pandemics of racism and COVID-19 continue to put vulnerable populations, such as pregnant and birthing individuals in communities of color, at heightened risk. The compelling data on pregnancy-related disparities during the pandemic do not fully capture the racial injustice of the U.S. health care system and the ways in which the COVID-19 pandemic exacerbates inequities. Anecdotes more clearly illustrate the personal cost. For example, Amber Isaac was a 26-year-old Black woman expecting her first child during the height of the COVID-19 pandemic in New York.45 During her pregnancy, Amber vehemently complained over social media platforms about the poor health care and neglect she experienced. She voiced concerns about restrictions that prevented her from seeing a provider in person for more than three months, and privately expressed fear that she would not survive the pregnancy. She was later diagnosed with HELLP syndrome (a hypertensive disorder of pregnancy defined by the presence of ruptured red blood cells, elevated liver enzymes and low platelet count) and died shortly after delivering her baby one month prematurely via emergency cesarean section. After her death, Amber's partner strongly asserted that the circumstances leading to her death were preventable, and that Amber would have received more attentive care had she been White.45 Amber's tragic story captures many of the contributors to disparities in adverse birth outcomes reported by Black people: inadequate access to care, health concerns not taken seriously and potential differential treatment by the health care team. Some of these factors have been magnified during the pandemic.46 Sadly, Amber's story is only one of the many instances of maternal and infant loss among Black and Latinx people during the pandemic.36, 47, 48 These stories help to highlight the urgent need to address the structural and interpersonal racism that drive birth inequities. A doula is a "professional who provides continuous physical, emotional, and informational support to a mother before, during and…after childbirth."49 A 2017 Cochrane systematic review analyzed data on 15,858 participants from 27 randomized or cluster randomized trials that examined the effects of continuous support throughout labor and delivery.50 The authors found that continuous labor and delivery support, provided by a trained professional such as a doula, was associated with improved patient satisfaction, lower rates of cesarean section, shorter labor periods and better infant Apgar scores. Among Black and low-income people, receipt of doula services results in greater feelings of autonomy and personal security, and reductions in the prevalence of such outcomes as preterm birth and low-birth-weight infants.21-23 Low-income individuals and people of color may especially benefit from receiving care from community-based doulas, who offer free or reduced-cost services to community members who are at risk for adverse birth outcomes but who may not be able to afford pregnancy and birth support services.20 These doulas are often trusted members of the communities they serve and offer culturally concordant care grounded in principles of social and reproductive justice.51 Community-based doulas typically provide frequent in-home visits, as well as services similar to those provided by community health workers: helping patients access social services (e.g., subsidized housing, nutrition assistance programs, intimate partner violence interventions) and navigate the complex components of care during and after pregnancy, and bridging communication divides between providers and patients.22, 51, 52 While randomized controlled trials assessing the impact of community-based doulas on birth outcomes are lacking, there is a substantial body of high-quality evidence supporting the role of community health workers in improving health outcomes among historically marginalized populations.53-56 A 2019 analysis of several community-based doula programs compared health outcomes between a racially and ethnically diverse sample (47% Hispanic, 33% Black) of 592 low-income individuals who received doula services and a comparison sample of participants from the population-based Pregnancy Risk Assessment Monitoring System (PRAMS).20 Compared with their counterparts in the PRAMS group, Black mothers enrolled in community-based doula programs were more likely to be exclusively breastfeeding at six weeks (71% vs. 56%), three months (52% vs. 38%) and six months (39% vs. 7%). Similar but more robust differentials were reported for Hispanic mothers: Compared with those in the PRAMS group, Hispanic mothers enrolled in community-based doula programs had higher exclusive breastfeeding rates at six weeks (90% vs. 66%), three months (79% vs. 51%) and six months (62% vs. 13%). Finally, mothers who were served by community-based doulas had lower rates of cesarean delivery than women in the PRAMS control group (24% vs. 30%). These findings are particularly important given that breastfeeding is associated with improvements in maternal and infant health and well-being (e.g., reduced levels of otitis media and respiratory tract infections in infants, and reduced risk of breast and ovarian cancer and type 2 diabetes mellitus in mothers),57, 58 and that the risk of certain adverse outcomes (e.g., maternal mortality) is higher for cesarean delivery than for vaginal delivery.59 Beyond these health benefits, community-based doulas can help improve the experience of care for Black birthing people. In a 2018 qualitative study assessing the pregnancy-related health care experiences of 54 women of color at risk for preterm birth, women reported experiencing disrespectful care, stressful social interactions, racial discrimination, lack of staff empathy, unmet informational needs and inconsistent social support.60 These are precisely the areas in which community-based doulas are trained to intervene and offer support. Taken together, the experiences of pregnant and birthing people of color, the literature demonstrating the beneficial effects of culturally concordant care on patient satisfaction and health outcomes,61, 62 and the evidence that racial discrimination and social and structural determinants perpetuate health disparities point to the potential pathways by which community-based doulas can intervene and ameliorate racial disparities in birth outcomes—a necessary goal during and beyond the pandemic.20, 51 Despite the many benefits of doula care, there are challenges to accessing doula services—some of which have been exacerbated during the COVID-19 pandemic. For example, early in the pandemic, hospitals and other health care entities had to make drastic adjustments to daily operations to limit spread of the SARS-CoV-2 virus, including limiting the number of support persons present during labor. These new restrictions meant that women who had created birthing plans that included doulas had to choose between their doulas and an untrained support person (such as a family member or partner). In the absence of proper legislation or hospital policies recognizing their critical work, doulas have been relegated to the role of visitor—largely unable to participate in deliveries as part of the labor and delivery team, even though birthing parents have grown to count on their support. Frequent in-home visits are also an important part of the doula model and similarly have had to be curtailed during the pandemic. One of the authors of this viewpoint (A.N.W.), a community-based doula in Baltimore, notes that while other hospital-based or institutionally funded services have shifted to virtual offerings during the pandemic, community-based doula organizations have struggled to make this transition because they lack the supporting infrastructure that is available to programs that are more integrated into health care systems. A.N.W. points out that these struggles underscore the lack of support from, partnership with and integration into the health care system that doulas face, even outside of the pandemic. Despite these challenges, community-based doulas have continued to provide valuable services to their clients. Whether through community fundraising, dropping off essential supplies or educating women on how to mitigate the spread of communicable disease, doulas have worked to find new ways to meet the needs of pregnant and birthing people who are facing the unforeseen challenges posed by the pandemic. Their actions also suggest that in overlooking doulas' contributions to care, the health care system has missed an opportunity to utilize a trusted workforce that can support public health interventions in times of crisis and aid in future public health efforts (e.g., forthcoming vaccination campaigns). A key to improving access to doula services, both during and after this pandemic has passed, will be hospitals' adoption of policies that recognize doulas as legitimate and essential health care workers who should not be displaced in times of emergency. Additionally, since many hospitals serve as anchor institutions within communities—that is, they have an "economic and social impact on their communities, and they also have an economic self-interest in making sure these communities are healthy and safe"63—there is increasing recognition that hospitals should invest directly in communities and community-based programs to promote health equity. Pregnancy, birthing and postpartum experiences are not bound by the social construct of race. The disparities we are witnessing are a result of racism at the structural, institutional and individual levels. This racism "saps the strength of the whole society through the waste of human resources"65 and makes health care potentially dangerous for birthing people of color. We cannot hope to topple the entire system in one fell swoop, but we can support interventions and services that address some of the injustice and in doing so create provisions for equitable care for all birthing people and their newborn children. S. Michelle Ogunwole is a research fellow and Wendy L. Bennett is associate professor, Division of General Internal Medicine, School of Medicine; and Kelly M. Bower is assistant professor, School of Nursing and Johns Hopkins Center for Health Disparities Solutions—all at Johns Hopkins University, Baltimore. Andrea N. Williams is the cofounder and director of the Nzuri Malkia Birth Cooperative and program director of Baltimore Community Doulas, Baltimore.