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Advocacy During Pregnancy - The Magee Doula Program Strengthens Care, Addresses Disparities, and Supports Patients

By: Gina Edwards

The experience of giving birth is monumental. A collaborative team of medical professionals and support people must work together to ensure the birthing parent is cared for along their journey.

Especially for new parents from underserved communities, having a dedicated support person who educates, encourages, and advocates for them throughout the process can make all the difference in ensuring a smooth pregnancy and birth. Enter, doulas.

Doulas are trained, nonmedical staff who provide advanced physical and emotional specialty care to pregnant patients. These birth coaches play an integral role in the care experience by providing ongoing information and advocacy, closing knowledge gaps, and assisting patients with overcoming barriers.

Leaders at UPMC Magee-Womens Hospital see doulas as one way to address known disparities in maternal health: Black women in Pittsburgh are more likely to die during pregnancy than Black women in 97% of similar U.S. cities, according to a 2019 report on Pittsburgh’s Inequality on Gender and Race.

Establishing the UPMC Magee Doula Program

The Birth Circle Doulas of Magee, a patient support program initially housed within the Family Medicine Health Center at Squirrel Hill, formed the backbone of the program that would eventually take shape at UPMC Magee.

“I’m grateful for the Department of Family Medicine who had the vision and foresight to have doulas available to at-risk individuals within the community setting and did a fantastic job of establishing that program and the connections to the UPMC Health Plan,” says Dr. Hyagriv Simhan, professor, Department of Obstetrics, Gynecology and Reproductive Sciences, executive vice chair of Obstetrical Services, University of Pittsburgh School of Medicine, and director of clinical innovation for the Women’s Health Service Line, UPMC.

In fact, the 10 doulas who were working at the Squirrel Hill center integrated with the Women‘s Health Service Line clinical care team at UPMC Magee as part of the effort to scale up the program. Since its launch in November 2020, the team has grown to 32 doulas, who provide their services free of charge.

The UPMC Magee doula program recruits candidates from the same communities as its patient population and frames the role as an exciting and valuable way to step into health care or into the workforce. Some patients supported by doulas end up deciding to become one themselves.

“Several [members] of our doula team have been with the program from before we took it on, so we have a lot of longevity on the team, but the few that have left have gone on to be nurses, or attend medical school,” says Beth Quinn, senior director, Women’s Health Operations at UPMC Magee.

Alleviating Fear and Supporting Exceptional Patient Experiences

For Dawndra Jones, chief nursing officer and vice president of Patient Care Services at UPMC Magee, the integration of doulas into the care teams help ensure that patient’s expectations are met, and their experience is positive.

“Everyone comes typically to deliver their baby with expectations of what it’s going to be like. This was an opportunity for us to put someone closely with our patients during the whole birthing process to really try to make sure that we can meet those expectations,” she says. “We’ve been really excited about adding this to our health care team to really ensure that patients not only have that quality of care but that exceptional experience.”

The doulas’ abilities to bridge knowledge and language gaps is critical for cultural concordance — a key piece of success for the doula-patient relationship and the program.

“Having somebody close to you that you can talk to that you feel comfortable sharing things with will hopefully also alleviate some of those fears so that we can make this the most enjoyable, joyous occasion and milestone in people’s lives,” Jones says.

Apart from bringing shared knowledge and experiences with the patients they serve, doulas also undergo specialized training in tandem with DONA International, a recognized leader in doula training and certification. UPMC Magee doulas in training learn methods for patient support and advocacy in areas like breastfeeding and lactation services, as well as functional clinical skills like documenting notes in an electronic health record.

Trainees get exposed to community resources for behavioral health and trauma, as well as places like the Pregnancy Recovery Center. They also benefit from real-time Q&A sessions with doctors on high-risk conditions like gestational diabetes. Trainees attend several live births with a mentoring doula during their orientation period, until they are comfortable doing so on their own.

“I also love the doula training because I think it also represents the art of labor and delivery,” Jones says. “It’s not those textbook science things. It’s really about alleviating fear and creating comfort for individuals so that they can take in this wonderful experience.”

Early Doula Program Outcomes

In various measures and outcomes, the doula program is already performing well. Among the data examined are value-specific measures like attendance at prenatal visits and engagement in the care process. The UPMC Magee team also monitors tangible health outcomes, such as cesarean section or cesarean delivery frequency, breastfeeding rates, and connectedness to ongoing postpartum care.

“We have seen in all three of those areas that our women who have received doula care have better rates of those things than a comparable group of women who have not gotten doula care,” Dr. Simhan says.

Quinn adds that outside of these measures, doulas have also positively impacted the care teams’ approach. “Doulas are really the eyes and ears to the patients that we have not had before,” she says.

She also says that the care team has benefited from a doula’s unique perspective, as it helps those from traditional health care backgrounds look at and approach patients more holistically and try to understand and work with them in a different way.

“I think [doulas have] taught our team to listen in a different way than we had ever before,” she says. “Everybody has a story and a reason, and it might not match what we know and what we believe, but we have to take that in, put our implicit bias aside, and move forward for the care of the patient.”

Building the Future of Doula Care

As the program celebrates its second birthday, program leaders are assessing how far they have come, while planning for what is next. Ultimately, the program would also like to roll out into other UPMC sites, providers, and hospitals, expanding this model of care across the entire UPMC system.

“We’d like to grow it out in terms of the number of doulas and patients served, but also the strategies in which we allocate the doula resources,” Dr. Simhan says. “To be able to do targeted, focused outreach to patients who would most benefit from doula services, we’d like to be able to level the playing field a bit and make the resource available and that takes resources to do.”

In the coming year, Dr. Simhan is planning a series of presentations and publications in both nursing and medical literature that highlight the program’s success. With an eye on the future, the doula program leaders are focused on scalability so that more patient populations can benefit — especially those who have been systematically failed by traditional models.

“Our program is a core part of improving engagement in the quality of prenatal care to improve pregnancy outcomes in the patient experience for all patients, particularly those who unfortunately have not had that as the expectation in health care,” he says.

Doula Q&A: Perspectives from Two Members of the Birth Circle Doulas of Magee

Tameka Vasser

How do doulas support patients ahead of the birthing process?

“It all starts with education, and as we know, typically the Black community or women of color, in general, do not have access to a lot of the things that the white population have, with education being a big one. Then after being educated, being empowered. Because you can know something is wrong and your intuition feels that it is not right, but not being empowered enough to speak up. I always tell my patients, This is your baby, your body, your birth.’”

What is something you teach patients when it comes to self-advocacy?

“I spend a lot of time with my clients teaching them how to advocate for themselves. Because, for example, we don’t send in a doula until they’re dilated about three to four centimeters. So before then, you have to be advocating for yourself. One thing that we use is this acronym called BRAIN.

B: What are the benefits of this procedure?
R: What are the risks of this procedure?
A: Is there any alternative or do I have any other options?
I: What does my intuition say? Do I agree with my doctor? Do I disagree?
N: What if I just say no? Or could we delay it?”

What is one of your favorite parts about being a doula?

“I love birth work so much, but I have to say that one of my favorite parts is honestly helping a mom be successful at breastfeeding. Lots of women, even pretty much all my clients, when we go over, ‘Are you planning to breastfeed or formula feed’ they almost always say ‘I am going to try breastfeeding. I am going to try.’ It’s rarely, ‘I’m going to breastfeed.’ They don’t really have that confidence that they can do it. So, when I’m there with them through that birth and then we get that baby latched on to the breast and they can feel the sensation of their milk coming out and baby feeding and they’re just so proud of themselves — that is definitely one of my favorite parts of my job.”

Memourie Cunningham

What inspired you to become a doula?

“I had my daughter almost two years ago. My doula is now my supervisor, Sachi Imai. She honestly inspired me to want to do this kind of birth work. In a time when I was very alone, and I needed extra support and encouragement, she was there. I’m just forever grateful for her and I wanted to be able to pass that along to other mothers and hopefully be that light that she was to me.”

What are some ways that you support patients as a doula?

“At the end of the day, we want to make sure our patients are healthy. And we want to make sure that we’re following the things that they want because it’s their birth, it’s not ours. We’re there for an extra boost of encouragement and love — that’s what I love most about my job. Even if it’s something as simple as getting them some cold water or cold rags when they’re overheating and in intense labor, it’s those things, and sometimes just listening. Well, that’s always what it is: listening to what our patients need or what their concerns are, then trying to make them feel more at ease and comfortable with this new huge transition that’s about to happen.”