By Christina Ratleff
Senior Program Manager, Women's and Infant Health; AMCHP
By Sherry Payne
Executive Director, Uzazi Village
Infant mortality and birth outcomes are considered important indicators of a community's well-being1. Although the U.S. spends significantly more on health care than other industrialized nations, we experience one of the highest rates of infant mortality. Extremely high rates of non-medically indicated cesarean births and preterm birth are considered drivers of both suboptimal outcomes and high medical costs.
Nationally, the rate of maternal and infant morbidity and mortality alike are two to three times higher among black mothers and babies than their white peers. Moreover, black women are more likely to face significant barriers in realizing their breastfeeding goals compared with all other racial and ethnic groups.
A promising intervention to improve maternal and infant health outcomes and reduce perinatal health inequities is peer support during pregnancy, labor, birth and postpartum, often referred to as "doula" care.
The benefits of labor support and doula care are demonstrated by a growing body of research. In 2013, a Cochrane Database systematic review of 23 studies indicated that "all women should have continuous support during labor," and found that trained doulas are the most effective at providing continuous labor support. Similarly, in 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine concluded that "one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula."
Moreover, studies have shown that having the support of a doula decreases a women's time in labor and reduces a women's likelihood of having a cesarean birth by 28 percent. Doula care has also been associated with increasing rates of breastfeeding initiation and duration.
Despite the many evidence-based benefits associated with doula care, it remains an underutilized strategy to improve birth outcomes and reduce health inequities. Women of color and women from economically disadvantaged communities are more likely to desire a doula during labor and less likely to have access to these services.
One organization that is expanding access to doula care for women of color and economically disadvantaged women is Uzazi Village.
In December 2011, Uzazi Village was born from the need for effective strategies to combat persistent and intractable high infant mortality rates in communities of color. Sherry Payne, a nurse and educator, and a small group of women committed to improving birth outcomes in the urban core of Kansas City, Missouri, gathered to ask, "If this community created its own maternity care system, what would that look like?" The meeting drew a cross-section of stakeholders, from providers to community activists and leaders to childbearing women. The resulting document, A Community Visioning, outlined ideas from the meeting about what a culturally and community-specific maternity care system would look like.
"'Uzazi' is a Swahili word meaning 'birth,'" explains executive director Sherry Payne. "We endeavor to make birth safe for childbearing women and their babies through development and promotion of evidence-based clinical care and community-based education and support."
Payne explains this model of care that works in partnership with the community this way: "While health care focuses on standards such as cultural sensitivity, what is required is community-level intervention: garnering the embedded strengths of a community and bringing them to bear on health outcomes."
To carry out this mission, Uzazi Village employs a three-pronged approach to decrease health inequities in communities of color: 1. Culturally congruent, community-based education and services to pregnant women in the community; 2. Anti-racism training and cultural respect training for clinicians and service providers; and 3. Support, guidance and nurturance for candidates of color entering the perinatal fields.
One of the first programs established at Uzazi Village was the Perinatal Community Health Worker program, also referred to as the Sister Doulas. The program uses a community-based public health approach to improve perinatal outcomes for clients, a large majority of whom are eligible for Medicaid. Women from the community are trained to become perinatal community health workers (PCHW). They work with pregnant women from their communities to provide physical and emotional supportive care and education, from pregnancy through postpartum. The Perinatal Community Health Workers receive over 164 hours of training in childbirth education, doula training, contraceptive counseling and breastfeeding.
The PCHWs provide expectant mothers with personalized education including childbirth education, breastfeeding support, community resources and parenting skills through home visits – and accompany them on prenatal medical appointments. The care plan includes three prenatal visits, labor and birth assistance, and two postpartum visits, with services reimbursed by two Medicaid-managed care organizations. The Sister Doulas have had a direct impact on promoting better birth outcomes, with an emphasis on reducing preterm labor, low birthweight and non-medically indicated C-sections, and increasing breastfeeding rates among the families they serve.
After speaking with Ms. Payne and some of the Sister Doulas during the AMCHP-sponsored reception at the AMCHP Annual Conference, I left with a feeling of hope. There is something incredible that happens when we pause and listen to the voices of those we are trying to serve. As Ms. Payne has so eloquently stated, "The solution to save our communities is within our communities, with community-led solutions. Health care systems must learn to work with communities rather than around them. Health inequities must be replaced with systems of care that honor the woman, her baby, her community and her ways of being."
Uzazi Village is expanding services and moving to a larger building. Currently, the organization is raising funds to support rent for the new facility so that staff may continue to focus on programming.
Learn more about Uzazi Village.
To learn more about Medicaid and Coverage of Doula Care to Strengthen Maternal and Infant Health and view the Issue Brief created by Choices in Childbirth and National Partnership for Women and Families click here.
To learn more about AMCHP's work to reduce perinatal health inequities, please contact Christina Ratleff at firstname.lastname@example.org.
1. Infant Mortality | Maternal and Infant Health | Reproductive Health | CDC. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm. Accessed March 24, 2017.