J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest.

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ORIGINAL RESEARCH

Disrupting the Pathways of Social Determinants of

Health: Doula Support during Pregnancy and
Childbirth
Katy B. Kozhimannil, PhD, MPA, Carrie A. Vogelsang, MPH,
Rachel R. Hardeman, PhD, MPH, and Shailendra Prasad, MD, MPH

Purpose: The goal of this study was to assess perspectives of racially/ethnically diverse, low-income
pregnant women on how doula services (nonmedical maternal support) may influence the outcomes of
pregnancy and childbirth.
Methods: We conducted 4 in-depth focus group discussions with low-income pregnant women. We
used a selective coding scheme based on 5 themes (agency, personal security, connectedness, respect,
and knowledge) identified in the Good Birth framework, and we analyzed salient themes in the context
of the Gelberg-Anderson behavioral model and the social determinants of health.
Results: Participants identified the role doulas played in mitigating the effects of social determinants.
The 5 themes of the Good Birth framework characterized the means by which nonmedical support from
doulas influenced the pathways between social determinants of health and birth outcomes. By address-
ing health literacy and social support needs, pregnant women noted that doulas affect access to and the
quality of health care services received during pregnancy and birth.
Conclusions: Access to doula services for pregnant women who are at risk of poor birth outcomes
may help to disrupt the pervasive influence of social determinants as predisposing factors for health
during pregnancy and childbirth. (J Am Board Fam Med 2016;29:308 –317.)

Keywords: Birth; Cultural Diversity; Health Care Disparities; Populations, Underserved; Social Determinants of Health

Social determinants of health (SDOHs), including interactions,1 are predisposing factors that influ-
economic stability, level of education, neighbor- ence health outcomes.2– 4 The impact of SDOHs is
hood and environment, and social relationships and heightened among vulnerable populations, and
they play a crucial role in maternal and infant
health outcomes.5
This article was externally peer reviewed. For example, women who have or develop
Submitted 12 September 2015; revised 3 November 2015; conditions such as diabetes or hypertension dur-
accepted 19 November 2015.
From the Division of Health Policy and Management, ing pregnancy are more likely to have a primary
University of Minnesota School of Public Health, Minne- cesarean delivery or preterm birth.6 Develop-
apolis (KBK, CAV); the Division of Health Care Policy &
Research, Mayo Clinic College of Medicine, Rochester, MN ment of these and related conditions, including
(RRH); and the Department of Family Medicine and Com- obesity, relates to the structural and environmen-
munity Health, University of Minnesota Medical School,
Minneapolis (SP). tal factors that affect access to exercise and nu-
Funding: Research reported in this article was supported a trition.6 Women who experience intimate part-
Community Health Collaborative Grant from the National
Center for Advancing Translational Sciences of the National ner violence and exposure to abuse are more likely
Institutes of Health (award no. UL1TR000114). to have little or no prenatal care, be hospitalized
Conflict of interest: none declared.
Disclaimer: The content of this article is solely the respon- during pregnancy, and give birth to low-birth-
sibility of the authors and does not necessarily represent the weight infants.7,8 Unsafe neighborhoods and ad-
official views of the National Institutes of Health.
Corresponding author: Katy B. Kozhimannil, PhD, MPA, verse environmental exposures increase the likeli-
Division of Health Policy & Management, University of hood of preterm birth.9 –11 Low health literacy
Minnesota School of Public Health, 420 Delaware St SE,
D359 Mayo, MMC 729, Minneapolis, MN 55455 共E-mail:
among pregnant women is associated with low at-
kbk@umn.edu). tendance of prenatal care visits and poor birth out-

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 J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest. Protected by copyright.
Figure 1. Conceptual model of the pathways between social determinants of health and birth outcomes and the
role of non-medical support.

comes.12,13 Women with low socioeconomic status evidence base is lacking effective means of mitigat-
have greater chances of having a low-birth-weight ing the effects of SDOHs on birth outcomes for
infant or a preterm birth.14 In addition, pregnant these high-risk populations. The goal of this study
women with limited social support are more likely was to assess perspectives among racially/ethnically
to have a low-birth-weight infant.15 diverse, low-income pregnant women of how ac-
The pathways between SDOHs and birth out- cess to and support from a doula may influence the
comes have contributed to pervasive racial/ethnic outcomes of pregnancy and childbirth.
disparities in maternal health and health care.16 –18
Longstanding and complex sociodemographic and
historic factors perpetuate the challenges women of Methods
color face in achieving positive birth out- Conceptual Model
comes.19 –20 These disparities have persisted despite We used the Gelberg-Anderson model of health
clinical and nonclinical approaches and interven- behavior4, and components of the Good Birth
tions in the health care setting, and few solutions framework28 to create a conceptual model to de-
with the potential to effectively disrupt the pathway scribe the role of doulas—and of medical care—in
between SDOHs and poor birth outcomes have the pathway between SDOHs and birth outcomes.
been identified.16,21 SDOHs are present before, during, and after preg-
Nonmedical interventions are preferred options nancy, but their effects on birth outcomes may be
in addressing SDOHs.22 Doulas are trained profes- moderated by the quality of clinical care and the
sionals who provide continuous, 1-on-1 emotional nonmedical support a woman receives (Figure 1).
and informational support during the perinatal pe- The Gelberg-Anderson model of health behav-
riod. Similar to community health workers, they ior focuses on vulnerable populations.4 The Predis-
are not medical professionals and do not provide posing, Enabling, and Need components of this
medical services, but work alongside health care model predict personal health practices, including
providers. Studies show that doula care is associ- the use of health services. The Predisposing do-
ated with lower epidural use and cesarean delivery main includes “demographic characteristics” and
rates, shorter labors, higher rates of spontaneous “social structure patterned social arrangements in
vaginal birth, and higher levels of satisfaction.23–27 society that are both emergent from and determi-
Low-income women and women of color, who nant of the actions of the individuals.”4 Social
have the highest risk of poor birth outcomes, are structure includes a variety of components that
also the most likely groups to report wanting, but create the context by which SDOHs are manifested
not having, access to doula services.26 The current and maintained. Thus our study considers the

doi: 10.3122/jabfm.2016.03.150300 Doula Support during Pregnancy 309

 J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest. Protected by copyright.
SDOHs1 to be a component of the Predisposing cluded participation for several women in the first
domain. The Predisposing variables affect En- scheduled focus group, so we scheduled a fourth
abling variables (eg, social support, health services focus group meeting to allow their participation.
resources, ability to negotiate the system), which Data saturation was achieved with 4 focus groups.
subsequently affect Need. In our framework the All of the focus group discussions were recorded
Enabling variables include doula services, which are and transcribed using CaptionSync Professional
directly associated with a pregnant woman’s per- Transcription, a service provided by Automatic
ceived need for help. Gelberg and colleagues4 sug- Sync Technologies, LLC (Seattle, WA). Manual
gest that health behaviors and health outcomes will notes taken by the facilitators (RRH, CAV) were
subsequently be impacted by Need. When placing used to augment the transcripts where comments
this model within the context of childbirth within were inaudible during the recording.
vulnerable populations, we also consider the ele- Questions focused on reasons for and barriers to
ments of Agency, Personal Security, Connected- doula support, and the ways doulas influence preg-
ness, Respect, and Knowledge that Dr. Anne Ly- nancy and birth, based on prior research.24 –27,29
erly identified as characteristic of a good birth.28 We used the themes of the good birth framework
These elements of a good birth can inform strate- (agency, personal security, respect, knowledge,
gies to meet the physical and emotional needs of connectedness)28 in a deductive approach to code
women during pregnancy and childbirth.28 Our the transcripts. We also created and used separate
model frames the context in which the trajectory of codes that highlighted (1) the mechanisms associ-
a woman’s pregnancy and the SDOHs may be ated with doula support and healthy pregnancy, and
influenced by the support of a doula, the clinical (2) the relationship of these mechanisms with
care she receives, and potentially by the interac- SDOHs.
tions between the doula and the patient’s clinician.
Analysis
Study Participants
The initial coding was separately and indepen-
Thirteen racially/ethnically diverse, low-income
dently validated using a coanalysis method among
pregnant women participated in 4 focus group dis-
the authors (CV, RRH, KBK).30 Coding was con-
cussions that were held at 3 locations in Minneap-
ducted in a shared Microsoft Excel document (Mi-
olis, Minnesota, in November and December 2014.
crosoft Corp., Redmond, WA). After the first
Multiple methods (flyers, E-mails, and word of
round of coding, we met to discuss differences
mouth) were used for recruitment. Inclusion crite-
among coders and to refine codes and definitions
ria included pregnancy and fluency in English. The
for clarity. Then, one of the authors (CAV) led a
role of a doula was explained at the outset of the
second round of coding, grouping each of the codes
interview, and prior experience with a doula was
to identify which themes emerged as patterns
not required so as not to exclude potential partici-
across the focus groups. We then followed the same
pants who may not have been able to afford or
2-step process to code the transcripts for specific
access doula services. All participants consented to
mechanisms of doula support that were associated
participate using a human subjects protection pro-
with birth outcomes.
cess approved by the University of Minnesota in-
stitutional review board (code no. 1403S49085).
Results
Data and Measurement The study participants represented a racial/ethni-
In collaboration with community-based partners, cally diverse group of women, as described in Table
we developed and pilot-tested a questionnaire to 1. Participants were nearly evenly split between
guide semistructured focus group discussions. nulliparous and parous, and three quarters of par-
These discussions were facilitated by 2 investiga- ticipants had a doula supporting them during their
tors (RRH and CAV), both of whom are trained current pregnancy. Nearly 40% of women who
and experienced in qualitative data collection and participated in the focus groups voluntarily dis-
analysis. Each focus group included between 2 and closed that their pregnancy was complicated by a
6 participants. We had planned for 3 focus groups medical condition (such as hypertension, prior pre-
of 5 to 7 women; however, inclement weather pre- term birth, or gestational diabetes).

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Table 1. Descriptive Characteristics of Focus Group women contending with complex social circum-
Participants stances (eg, an unstable living situation, an unsup-
Participants,
portive partner). As reflected in the above quote,
Characteristics n (%) the respondent’s doula contributed to her personal
security by addressing her health concerns after an
Race/ethnicity
encounter with her provider. This concept of se-
African American 5 (38.5)
curity extends to the incorporation of culturally
African 4 (30.7)
Native American 2 (15.4)
concordant beliefs about childbirth and personal
White 2 (15.4) safety (Table 2, quote 5).
Parity
First pregnancy (nulliparous) 6 (46.2) Respect
Experienced mother (parous) 7 (53.8) “. . . Having someone that is not only knowledge-
Doula with current pregnancy able, but can put things in layman’s terms, in a
Yes 10 (76.9) way that you understand it and respects your cul-
No 3 (23.1) ture . . . your well-being, your upbringing and
Voluntarily disclosed high-risk medical status things about you . . . to make sure that the baby is
Yes 5 (38.5)
okay too.”
No 8 (61.5)
Respect is critical to a patient-centered experi-
ence, and a physician’s respect of a patient’s auton-
omy is often cited as an important goal of the
Table 2 contains information on each of the key birthing process.28 Further, respect is the basis of
themes, with illustrative quotes, as described below. informed consent.28 Autonomy in decision making
is a marker of respect and was discussed among
Agency focus group participants as a key component (Table
“[Having a doula] helps prepare you mentally; like 2, quote 8). This theme was echoed throughout the
it is gotten me more in the mind-set of . . . the groups, and there was consensus that a doula’s
confidence throughout the pregnancy knowing that presence, particularly during the childbirth process,
I can do this. . . .” would facilitate greater autonomy and respect in
Agency is the capacity of an individual to act or decision making.
to make his/her own choices (as opposed to being
someone to whom things happen).28 Low-income Knowledge
and racially/ethnically diverse women suffer a lack “My reasons for wanting a doula. [It is] because I do
of agency in their medical care.31,32 Our findings not have nobody right now, and if I go into labor,
suggest that doulas play an important role in equip- . . . I do not know the techniques or how to calm
ping low-income, diverse pregnant women with down.”
agency by either prompting the expression of con- Our findings suggest that doulas play a critical
cerns or by facilitating interactions with the health role in imparting knowledge to their clients and
care provider (Table 2, quote 2). Having a doula empowering them to become knowledgeable about
plays an important role in a woman’s ability to the physiologic process of pregnancy. Some women
make an informed decision while positively influ- gain this knowledge from their health care provid-
encing her belief in herself (Table 2 quote 1). ers; however, many of the participants suggested
that they often did not fully understand some of the
Personal Security things their provider shared with them. In these
“. . . I talk to the doctor . . . and I am calling the instances they relied on their doula to help “trans-
doula right after that. . . . Like, I am scared. . . and late” their clinical encounters. In addition, having a
she’s like, oh, no do not be. . . . It is very comforting doula present to share techniques and pass on wis-
to know that you have somebody [who] has your dom and birth strategies is important (Table 2,
back.” quote 12). Doulas also play an important role in
Physical and emotional safety plays an important connecting women with resources to gain new
role in pregnancy and childbirth. Feeling secure, knowledge as they prepare for childbirth (Table 2,
comfortable, and calm is particularly crucial for quotes 11 and 13).

doi: 10.3122/jabfm.2016.03.150300 Doula Support during Pregnancy 311

 Table 2. Exemplary Quotations on Key Themes of the Qualitative Analysis
Social Determinants of Health
5 Themes from Categories: Traditional and
the Good Birth Vulnerable Domains Personal/Family/Community
Framework Definition of Theme (Predisposing Factors) Resources (Enabling Factors) Exemplary Quotations

Agency How a woman makes choices • Social and community context • Social support and 1. “I think it 关having a doula兴 helps prepare you mentally; like it’s
and the ability she has to (social structure: social cohesion, culture, self-help gotten me more in the mind-set of, you know . . . the
make choices and be in networks) skills, ability to negotiate confidence throughout the pregnancy knowing that like I can
control • Health and health care (health system, competing needs, do this. . . .”
beliefs: values, attitudes, information sources, social

312 JABFM May–June 2016

2. “And it’s 关a doula is兴 someone that can help you with
knowledge) services resources education, learn about yourself and the baby, but also ensure
• Psychological resources • Access to health care that what you want is heard.”
services, health literacy, 3. “My husband and I are taking childbirth classes but we still
perceived barriers to care, feel need for a doula. You can’t remember everything and
regular sources of care, having experienced person around is important. Especially if
health services resources we want to avoid a c-section. . . .”

Vol. 29 No. 3
Personal security How safe a woman feels in • Social and community context • Social support and 4. “. . . Having people there who make me feel good and feel like
her environment and with (social structure: social cohesion, culture, self-help I can do it, not making me feel anxious, or scared, or, you
the people in her life networks) skills, ability to negotiate know, like, ‘Oh . . . it’s going to be really hard,’ more like 关a兴
• Health and health care (health system, competing needs, positive outlook on it, which I think a doula really has helped.
beliefs: values, attitudes, information sources, social . . . You know, so just using her and the techniques to kind of
knowledge) services resources cope with labor. . . .”
• Psychological resources • Access to health care 5. “Cultural differences are a big deal too. If I have choices then
services, health literacy, I will want someone with my culture to make me feel
perceived barriers to care, comfortable and understand what we do.”
regular sources of care, 6. “. . . I talk to the doctor, I see the doctor and I’m calling
health services resources the doula right after that. What does that mean? Like, I’m
scared . . . And she’s like, ‘Oh, no don’t be’ . . . It’s very
comforting to know that you have somebody 关who兴 has your
back and explaining everything.”
Respect How engaged a woman is in • Social and community context • Social support and 7. “Having someone that is not only knowledgeable, but can put
the decision-making (social structure: social cohesion, culture, self-help things I guess in layman’s terms, but also in a way that you
process and the sense of networks) skills, ability to negotiate understand it and respects your culture . . . your well-being,
dignity she has from the • Health and health care (health system, competing needs, your upbringing and things about you that you like to make
level of respect for herself beliefs: values, attitudes, information sources, social sure that the baby is okay too.”
and the way others treat knowledge) services resources 8. “关A doula兴 can help you make pregnancy plans if you don’t
her • Psychological resources • Access to health care have someone. Your doula can make sure it is being followed.
services, health literacy, Like if you say you don’t want an epidural and she can make
perceived barriers to care, sure that the anesthesiologist doesn’t come to do that.”
regular sources of care, 9. “When you call the doctor then the doctor don’t have time关, the兴
health services resources doula takes time with you. When you are staying at home the
doula helps with stress. . . .”

Continued

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 Table 2. Continued
Social Determinants of Health
5 Themes from Categories: Traditional and
the Good Birth Vulnerable Domains Personal/Family/Community
Framework Definition of Theme (Predisposing Factors) Resources (Enabling Factors) Exemplary Quotations

Knowledge How prepared a woman is • Social and community context • Social support and 10. “关The兴 doula was coming on all my appointments with me
for childbirth based on the (social structure: social cohesion, culture, self-help and I was like, I don’t speak medical terminology, like what
information she receives networks) skills, ability to negotiate just happened? And she’d break it down and 关be兴 like, ‘It’s
and being informed about • Health and health care (health system, competing needs, okay.’”
what is happening to her beliefs: values, attitudes, information sources, social 11. “I also had like a class, like we got together with other

doi: 10.3122/jabfm.2016.03.150300
body and around her knowledge) services resources pregnant moms and had like, discussions and education and
• Psychological resources • Access to health care actually healthy food. So it was kind of cool because you’re
services, health literacy, seeing other moms, but then also having my doula talk about
perceived barriers to care, more than just what was going on with me, but talk about
regular sources of care, being a mom and changes and family and different things like
health services resources that. . . . So, in that sense, I think that doulas provide a lot of
education.”
12. “My reasons for wanting a doula 关are兴 because I don’t have
nobody right now and if I go into labor, I didn’t pay
attention to my breathing class, I don’t know the techniques
or how to calm down.”
13. “. . . They 关doulas兴 refer you to classes and the breastfeeding
classes, birthing classes, any class you can think of that has to
do with pregnancy, they have a referral for it.”
Connectedness How alone a woman feels • Social and community context • Social support and 14. “I definitely think doulas are helpful like with
versus having people in (social structure: social cohesion, culture, self-help mental—especially with stress because even if you’re not
her life she can trust. networks) skills, ability to negotiate alone, sometimes you may feel alone. You might not want to
• Health and health care (health system, competing needs talk to anyone else except for the person that actually wants
beliefs: values, attitudes, information sources, social to talk about babies.”
knowledge) services resources 15. “I’m really stressed out and worry about things a lot and 关a兴
• Psychological resources • Access to health care doula is there to support you and help you through stressful
services, health literacy, moments. 关A兴 doula won’t judge you or say anything bad
perceived barriers to care, about you—关she is兴 there to be supportive and tell you how it
regular sources of care, is—if this is going to happen and if this will hurt and what
health services resources I’m supposed to feel when this happens. 关She兴 communicates
with you and helps you along the way. . . .”
16. “It’s good to have a doula because the doctors will say this
and your family may say this, but the doula is mindful of who
you are.”
17. “I think it makes perfect sense. You want someone 关a doula兴
who knows why you are doing things with the same culture.
If they don’t understand your culture then you have to

Doula Support during Pregnancy

educate them.”

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 J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest. Protected by copyright.
Connectedness disparities despite medically focused interventions.
“. . . It is good to have a doula because the doctors For example, a community-based project in Cali-
will say this and your family may say this, but the fornia serves as a model for successfully addressing
doula is mindful of who you are.” SDOHs to reduce racial disparities and improve
Connectedness considers the level at which a birth outcomes for African American women.34
woman feels connected to the resources that are This program shifted prenatal care and case man-
available, her clinicians, her infant, and the support agement to include support groups that educate,
people in her life—including her doula. Partici- inform, empower, and connect women socially,
pants observed that doulas play an important role in culturally, and financially.34 Our findings are con-
ensuring that women who lack social support do sistent with the those that emerged from the Cal-
not feel isolated (Table 2, quote 14). Women ex- ifornia initiative. However, our findings extend the
pressed that the connection with their doula would learnings gleaned from individual projects and pro-
make a difference in their pregnancy and child- grams to explore a concept (nonmedical support)
birth, sometimes even more so than a health care that can be integrated within health care financing
provider or family member (Table 2, quote 16). and delivery systems to affect system change and
Women found the connection with their doula to potentially create long-term, sustainable solutions
be important for the general support that the doula to persistent disparities in birth outcomes.
provides, beyond specific knowledge or guidance in Much prior research on doula care has been
the birth process (Table 2, quote 15). Many of the conducted among white, upper-middle-class
participants described stressful life situations and women and/or in a randomized controlled trial
emphasized the desire to connect with a person context.23,29 While emerging research shows that
who shared their culture and background (Table 2, the known benefits of doula care may be even
quote 17). greater among vulnerable populations,24,26 those
who could most benefit from doula care frequently
have the least access to it.23 Future work should
Discussion examine the perspectives of doulas and of clinicians
Participant responses revealed that nonmedical to further inform the conceptual model developed
support from a doula could play a role in helping here. In addition, policy and clinical efforts to in-
women overcome barriers to achieving a healthy crease access to doula services should address cul-
pregnancy and childbirth. Women’s responses tural, financial, and geographic barriers to care
aligned with 2 key categories of SDOHs defined in identified by pregnant women.
HealthyPeople 20201: health and health care; and
social and community context. While the skills they Implications for Policy
bring and the support they provide are nonmedical, Access to culturally concordant care and support
doulas play a role in pregnant women’s ability to during childbirth was noted as a potential benefit of
access health services and in the quality of care they doula services by the women in our study, but a lack
receive by addressing the women’s health literacy of diversity among the doula workforce was seen as
and social support needs, as well as through inter- a potential barrier. Difficulty in ensuring represen-
action with prenatal and intrapartum care provid- tativeness among doulas is likely exacerbated by the
ers. While clinicians provide direct patient care in fact that doula services are rarely covered by health
the context of the health and health care SDOH insurance, thus creating a barrier to entry into this
category, study participants also identified doulas as profession that disproportionately affects low-in-
facilitators of improved patient–provider interac- come communities.29,35 Recent research on doula
tions that influence satisfaction with the birth ex- care and cost savings, especially among low-income
perience and favorable birth outcomes. women, has ignited discussion regarding reim-
Much of the current research on successful in- bursement of doula care by health insurance pro-
terventions to address SDOHs at the time of child- grams, including Medicaid.24,26,27 Two states (Or-
birth come from the international context,33 but egon and Minnesota) currently allow Medicaid
programs addressing SDOHs for maternal and reimbursement for doula services. Minnesota
child health are increasingly being adopted in the passed legislation in May 2013 establishing Medic-
United States, largely owing to the persistence of aid reimbursement for doulas, which became effec-

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tive starting September 25, 2014, upon federal ap- broad generalizations cannot be made. This ex-
proval.36 Implementation challenges have been ploratory study helped to generate a conceptual
substantial and include alack of awareness about model that sets forth hypotheses for future work
doula services on the part of pregnant women, but does not establish a causal pathway. The
maternity care clinicians, hospitals, and clinics, and focus groups took place during the early phases
the health insurance plans that provide coverage to of implementation of Medicaid coverage of doula
Medicaid beneficiaries.37 This research provides a services in Minnesota and do not reflect full im-
framework for understanding how doula care may plementation of that policy, which may influence
influence the pathways between SDOHs and birth access to doula care by vulnerable populations.
outcome, which may inform future efforts to ex- These results indicate the need for further inves-
pand health insurance coverage of doula services tigation of the role of nonmedical support in
and integrate nonmedical support within health addressing SDOHs.
care delivery systems.
Conclusions
Implications for Clinical Practice Improving access to doula services by pregnant
Means of addressing SDOHs are not inherently women who are at risk of poor birth outcomes may
present in current health care delivery models. In enhance clinical efforts to overcome the pervasive
childbirth in particular there is a tendency toward a influence of SDOHs on pregnancy and childbirth.
“technocratic” approach that privileges medical This study contributes to the growing body of
care over nonmedical support.38 Pregnancy and evidence that doulas are a social support interven-
childbirth are critical junctures in the life course, tion that can influence the pathways between social
when the impacts of social determinants are height- determinants and birth outcomes by addressing
ened. Increasingly, women giving birth in the some of the underlying issues that evade clinical
United States are doing so in isolation, with a lack approaches to persistent disparities.
of personal, social, and emotional support.39,40 Re-
cent studies have highlighted the importance of
trust within the patient–provider relationship, the The authors gratefully acknowledge data entry support from
Shruthi Kamisetty and input and feedback provided by Amanda
challenges this presents for low-income women, Huber, CMN; Rita O’Reilly, CNM; Debby Prudhomme; and
and the resulting effects on overall quality and Mary Williams, LPN. This research would not have been pos-
disparities in maternal and child health out- sible without the collaboration of our community partners, Ev-
eryday Miracles, Cultural Wellness Center, and Missionaries of
comes.41,42 Charity, all located in Minneapolis, MN.
Prior research has suggested the need for ade-
quate clinical care, as well as personal support at the References
individual level, during pregnancy.41 Doulas were 1. HealthyPeople 2020. Social determinants of health.
seen in our study as providing social support to help Washington, DC: U.S. Department of Health and
improve communication between low-income, ra- Human Services, Office of Disease Prevention and
cially/ethnically diverse pregnant women and their Health Promotion. Available from: http://
health care providers via an increase in women’s www.healthypeople.gov/2020/topics-objectives/topic/
social-determinants-health. Accessed July 16, 2015.
agency and knowledge during pregnancy. Women
2. Babitsch B, Gohl D, von Lengerke T. Re-revisiting
in our study indicated that doulas helped to create
Andersen’s Behavioral Model of Health Services
an environment of trust. Our study reflected the Use: a systematic review of studies from 1998 –2011.
sense of engagement and connectedness partici- Psychosoc Med 2012;9:Doc11.
pants felt in the presence of doulas, and noted that 3. Andersen RM. Revisiting the behavioral model and
this presence can enhance the clinical encounter via access to medical care: does it matter? J Health Soc
improving the process of informed consent and Behav 1995;36:1–10.
increasing patient satisfaction.23 4. Gelberg L, Andersen RM, Leake BD. The Behav-
ioral Model for Vulnerable Populations: application
to medical care use and outcomes for homeless peo-
Limitations ple. Health Serv Res 2000;34:1273–302.
The sample used for this study included 13 5. Halfon L, Larson K, Lu M, Tullis E, Russ S. Life-
women and was a convenience sample from 1 course health development: past, present and future.
metropolitan area of the United States; thus Child Health J 2014;18:344 – 65.

doi: 10.3122/jabfm.2016.03.150300 Doula Support during Pregnancy 315

 J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest. Protected by copyright.
6. Rosenberg TJ, Garbers S, Lipkind H, Chiasson MA. cations for disparity elimination. In: Handler A,
Maternal obesity and diabetes as risk factors for adverse Kennelly J, Peacock N, eds. Reducing racial/ethnic
pregnancy outcomes: differences among 4 racial/ethnic disparities in reproductive and perinatal outcomes:
groups. Am J Public Health 2005;95:1545–51. the evidence from population-based interventions.
7. Parker B, McFarlane J, Soeken K. Abuse during New York, NY: Springer; 2011:181–207.
pregnancy: effects on maternal complications and 21. Livingood WC, Brady C, Pierce K, Atrash H, Hou
birth weight in adult and teenage women. Obstet T, Bryant T III. Impact of pre-conception health
Gynecol 1994;84.3:323– 8. care: evaluation of a social determinants focused in-
8. Cokkinides VE, Coker AL, Sanderson M, Addy C, tervention. Matern Child Health J 2010;14:382–91.
Bethea L. Physical violence during pregnancy: ma- 22. Braveman P, Egerter S, Williams DR. The social
ternal complications and birth outcomes. Obstet Gy- determinants of health: coming of age. Annu Rev
necol 1999;93(5 Pt 1):661– 6. Public Health 2011;32:381–98.
9. Farley TA, Mason K, Rice J, Habel JD, Scribner R, 23. Hodnett E, Gates S, Hofmeyr G, Sakala C. Contin-
Cohen DA. The relationship between the neigh- uous support for women during childbirth (review).
bourhood environment and adverse birth outcomes. Cochrane Database Syst Rev 2013;7:CD003766.
Paediatr Perinat Epidemiol 2006;20:188 –200.
24. Kozhimannil KB, Hardeman RR, Attanasio LB,
10. Stillerman KP, Mattison DR, Guidice LC, Wood- Blauer-Peterson C, O’Brien M. Doula care, birth
ruff TJ. Environmental exposures and adverse preg- outcomes, and costs among Medicaid beneficiaries.
nancy outcomes: a review of the science. Reprod Sci Am J Public Health 2013;103:e113–21.
2008;15.7:631–50.
25. Kozhimannil KB, Attanasio LB, Hardeman RR,
11. Kruger DJ, Munsell MA, French-Turner T. Using a
O’Brien M. Doula care supports near-universal
life history framework to understand the relationship
breastfeeding initiation among diverse, low-income
between neighborhood structural deterioration and
women. J Midwifery Womens Health 2013;58:378 –
adverse birth outcomes. J Soc Evolut Cult Psychol
82.
2011;5:260 –74.
26. Kozhimannil KB. Attanasio LB, Jou J, Joarnt LK,
12. Bennett IM, Switzer J, Aguirre A, Evans K, Barg F.
Johnson PJ, Gjerdingen DK. Potential benefits of
“Breaking it down”: patient-clinician communica-
increased access to doula support during childbirth.
tion and prenatal care among African women of
Am J Manag Care 2014;20:e340 –52.
low and higher literacy. Ann Fam Med 2006;4:
334 – 40. 27. Kozhimannil KB, Hardeman RR, Alarid-Escudero
13. Endres LK, Sharp LK, Haney E, Dooley SL. Health F, Vogelsang CA, Blauer-Peterson C, Howell EA.
literacy and pregnancy preparedness in pregesta- Modeling the cost-effectiveness of doula care asso-
tional diabetes. Diabetes Care 2004;27:331– 4. ciated with reductions in preterm birth and cesarean
delivery. Birth 2016;43:20 –7.
14. Luo Z-C, Wilkins R, Kramer MS; Fetal and Infant
Health Study Group of the Canadian Perinatal Sur- 28. Lyerly AD. A good birth: finding the positive and
veillance System. Effect of neighbourhood income profound in your childbirth experience. Penguin;
and maternal education on birth outcomes: a popu- 2013.
lation-based study. CMAJ 2006;174:1415–20. 29. Lantz PM, Low LK, Varkey S, Watson RL. Doulas as
15. Feldman PJ, Dunkel-Schetter C, Sandman CA, childbirth paraprofessionals: results from a national
Wadhwa PD. Maternal social support predicts birth survey. Womens Health Issues 2005;15:109 –16.
weight and fetal growth in human pregnancy. Psy- 30. Creswell JW, Maietta RC. Systematic procedures of
chosom Med 2000;62:715–25. inquiry and computer data analysis software for qual-
16. Lu MC, Halfon N. Racial and ethnic disparities in itative research. Handbook of Research Design and
birth outcomes: a life-course perspective. Matern Social Measurement. Thousand Oaks, CA: Sage
Child Health J 2003;7:13–30. Publications; 2001;6:143– 84.
17. ACOG Committee on Health Care for Underserved 31. O’Malley AS, Sheppard VB, Schwartz M, Mandel-
Women. ACOG committee opinion. Number 317, blatt J. The role of trust in use of preventive services
October 2005. Racial and ethnic disparities in wom- among low-income African-American women. Prev
en’s health. Obstet Gynecol 2005;106:889 –92. Med 2004;38:777– 85.
18. ACOG committee opinion no. 586: health dispari- 32. Sword W. A socio-ecological approach to under-
ties in rural women. Obstet Gynecol 2014;123(2 Pt standing barriers to prenatal care for women of low-
1):384 – 8. income. J Adv Nurs 1999;29:1170 –7.
19. Giscombé CL, Lobel M. Explaining disproportionately 33. United Nations Development Program, Bureau of
high rates of adverse birth outcomes among African Development Policy. Discussion paper: a social de-
Americans: the impact of stress, racism, and related factors terminants approach to maternal health. Roles for
in pregnancy. Psychol Bull 2005;131:662–83. development actors. October 19, 2011. Available
20. Hogan VK, Shanahan ME, Rowley DL. Current from: http://www.undp.org/content/dam/undp/
approaches to reducing premature births and impli- library/Democratic%20Governance/Discussion%20

316 JABFM May–June 2016 Vol. 29 No. 3 http://www.jabfm.org

 J Am Board Fam Med: first published as 10.3122/jabfm.2016.03.150300 on 11 May 2016. Downloaded from http://www.jabfm.org/ on 8 October 2023 by guest. Protected by copyright.
Paper%20MaternalHealth.pdf. Accessed August 10, Minnesota. December 2015. Available at http://sph
2015. .umn.edu/faculty1/hpm/name/katy-kozhimannil/.
34. California Black Infant Health Program. Available 38. Davis-Floyd R. The technocratic, humanistic, and
from: http://www.cdph.ca.gov/programs/BIH/Pages/ holistic paradigms of childbirth. Int J Gynecol Ob-
default.aspx. Accessed March 25, 2016 stet 2001;75:S5–23.
35. Morton CH, Basile M. Medicaid coverage for doula care: 39. Leavitt JW. The growth of medical authority: tech-
re-examining the arguments through a reproductive jus- nology and morals in turn-of-the-century obstetrics.
tice lens, part one. Science & Sensibility, March 28, 2013. Med Anthropol Q 1987;1:230 –55.
Available from: http://www.scienceandsensibility.
org/?p⫽6461. Accessed March 31, 2014. 40. Leavitt JW. Women and health in America: histor-
ical readings. Madison: University of Wisconsin
36. Doula services medical assistance (MA) coverage re-
Press; 1999.
quirement. Minnesota Senate bill 699, section
256B.0625, subdivision 28b. Available from: https:// 41. Aved BM, Irwin MM, Cummings LS, Findeisen N.
legiscan.com/MN/text/SF699/id/752534. Accessed Barriers to prenatal care for low-income women.
June 29, 2015. West J Med 1993;158:493– 8.
37. Kozhimannil KB, Almanza J, Vogelsang CA, Harde- 42. Sheppard VB, Zambrana RE, O’Malley AS. Provid-
man RR. Medicaid coverage of doula services in ing health care to low-income women: a matter of
Minnesota: findings from the first year. University of trust. Fam Pract 2004;21:484 –91.

doi: 10.3122/jabfm.2016.03.150300 Doula Support during Pregnancy 317