Nurse-midwives and educators from three prominent research universities have teamed up to improve pregnancy outcomes in Black communities by providing specialized training for doulas, persons who support birthing mothers and families through the entire process of childbirth.
The Alliance of Black Doulas for Black Mamas is led by Vanderbilt University School of Nursing Associate Professor Stephanie DeVane-Johnson, PhD, CNM, FACNM, Duke University School of Nursing Assistant Clinical Professor Jacquelyn McMillian-Bohler, PhD, CNM—both graduates of Vanderbilt’s nationally-recognized Nurse-Midwifery program—and University of North Carolina School of Medicine Assistant Professor Venus Standard, MSN, CNM, FACNM. The project leaders are Black, certified nurse-midwives with a combined 60+ years of midwifery experience.
Doulas offer emotional and informational support for pregnant persons and their families. Unlike nurse-midwives, they are not medically trained; however, their help with things like breastfeeding, acupressure, birth plans and postpartum issues can be critically needed, as can their presence as an advocate for the mother.
The three researchers are addressing the U.S.’s Black maternal health crisis. The U.S. has the highest maternal mortality rate among developed countries—and the crisis is even more pronounced for Black mothers. Centers for Disease Control and Prevention statistics reveal disparities between pregnancy complications and risks across different racial groups. Black women are approximately twice as likely to have a moderately low birthweight child and three times as likely to have a very low birthweight child than white or Hispanic women (https://www.cdc.gov/nchs/products/databriefs/db306.htm). Black women are also more likely than white or Hispanic women to die from pregnancy complications—almost 67 percent of which are preventable.
Having a trained and trusted professional who can help parents-to-be make healthy decisions and choose proper prenatal care can make a difference in maternal health and birth outcomes.
DeVane-Johnson, McMillian-Bohler and Standard worked together to write and fine-tune a plan to train and provide Black doulas to help Black families, with hopes of mitigating the high Black maternal and infant mortality rate. In 2020, the doula project was funded by a $75,000 award from UNC, the Harvey C. Felix Award to Advance Institutional Priorities and the group trained its first 20 doulas. In 2021, they received a $545,000 Duke Endowment grant, which will fund the program for three years beginning in May 2022.
Nurse-midwives Jacquelyn McMillian-Bohler, Venus Standard and Stephanie DeVane-Johnson.
The main program goals are to: decrease Black maternal mortality and morbidity; improve patient experiences; provide doulas for free to families; and help those interested in becoming doulas build critical skills and later use those skills to earn wages. The program’s goals align with the 2021 Black Maternal Health Momnibus Act, which “directs multi-agency efforts to improve maternal health, particularly among racial and ethnic minority groups, veterans, and other vulnerable populations,” states congress.gov (https://www.congress.gov/bill/117th-congress/house-bill/959).
“The training is more than about labor and birth,” said McMillian-Bohler, who teaches the mindfulness curriculum. “We also introduce the doula to general stress-reduction techniques such as mindfulness and acupressure. Although evidence suggests these techniques are helpful, they are often not accessible to the Black community.”
DeVane-Johnson works remotely as the community engagement liaison for the program, which is housed at UNC Family Medicine in Chapel Hill, but the doulas will be serving families in Durham, Wake and Orange counties in North Carolina. Devane-Johnson hopes to receive funding to expand this program to Black pregnant persons in Nashville, TN.
“The strength of the program is the expertise of the entire team and the integration of the expertise,” said Standard, who connects families with doulas from the program and is currently teaching the third cohort of Black doulas. “Although each university could independently support the doula program with its hospital system and academic affiliation, a collaboration between the three universities positively impacts the project as a whole.”
Doula training applicants attend information sessions and are screened to make sure they will be successful in the program and that they will enjoy the work.
According to McMillian-Bohler, the program’s doula/family partnerships offer racial concordance, which can increase trust and understanding.
“I think the fact that we are able to come in and talk about some of these health resources and, I hope, remove some of the stigma, opens up a whole area of health care and wellness to people who desperately need it, who maybe didn’t feel like it was for them,” McMillian-Bohler said.
The doulas recognize that birthing parents have the right and need to speak up for their own bodies and health, and help them build the confidence and ability to do so.
To receive help from a doula in the program, a person must be Black, pregnant and planning to deliver at a University of North Carolina-affiliated hospital.
“By having a culturally concordant doula, the patient has a personal advocate, educator and support person to help guide and navigate the system as a Black person, whose needs are often dismissed or ignored,” Standard explained.
“Our hope is that by selecting doulas, who are gatekeepers into various aspects of the Black community, and by giving them tools to share with families, we create a community project that helps birthing families and doulas, said McMillian-Bohler”
The program offers doula training that is expanded to accommodate the specific needs of Black women, covering topics like reproductive justice and the “superwoman schema,” which says that many Black women care for others at their own expense, increasing stress during a pregnancy.
“The goal is to help mitigate Black maternal and infant mortality rates,” DeVane-Johnson said. “Doulas stand in the gap. Sometimes, Black women bring things up to their health care providers and are not taken seriously, or the provider does not talk at a level that the patient and family can understand. The doula is there to bridge that gap and potentially interpret information.”
DeVane-Johnson also serves as the facilitator for breastfeeding lectures. She studies the history of breastfeeding and presents lectures to doula-trainees to help them understand the hurdles faced by those they are trained to help. The doulas use this training to support Black women who want to breastfeed and connect them with lactation consultants, as research indicates that breastfeeding decreases cancer risks in mothers and improves health outcomes for babies.
“Black women have the lowest breastfeeding rate out of any race,” DeVane-Johnson said. “When variables such as socioeconomic status, education and marital status are controlled for, similar positioned white women still tend to breastfeed at higher rates.”
Doulas help solve communication issues and offer consistent labor support for those who don’t have it, something that has been shown to decrease time in labor and the need for pain medications.
“We hope to create opportunities for Black women to find their voices and be empowered to ask questions,” McMillian-Bohler said.
“Doulas are there to empower, uplift and elevate birthing families,” she continued. “If something doesn’t feel right, the doulas help them recognize that they need to speak up and keep speaking until their voice is heard.”
The doulas are trained to recognize preterm, term and postpartum warning signs that may otherwise go untreated, leaving parent and baby at risk.
They train over the course of seven weekends. While on-call with patients, they assist with birthing plans, help pack bags for the hospital and even attend appointments, depending on how much support the birthing parent needs. Once trained, a doula is paired with three Black families who receive assistance for free.
DeVane-Johnson says program applicants need to be Black, have a passion for birth work and have a desire to support women in labor. In the past, applicants may not have been financially able to secure training, but thanks to the grants, training is free.
Applicants are screened to make sure they have reliable transportation, a job that’s flexible enough to allow them to leave to attend a birth and are vaccinated against COVID-19.
According to DeVane-Johnson, the most important qualification is “a passion to help support Black families in the community.”
“Being a doula often is different than what many people imagine,” said McMillian-Bohler. “They may have a romanticized notion of what the job is like. Babies come all the time, anytime, and doulas have to be able and willing to drop whatever other things they may be doing to come to a birth.”
The program benefits go beyond those received by the birthing family.
“Doulas are marketable and can hire out their services after they work with their first three families through the program,” DeVane-Johnson said. “This training will help them bring in money for their families and provide an important service.”
The program supports workforce development, DeVane-Johnson said, as the new doulas have sustainable jobs and develop entrepreneurial skills.
With many interested in training and families lining up for the service, the program is poised to make a difference in communities and in Black maternal health—and the leadership team envisions it as something that can go even further.
“Our goal with this program is to create a doula training model that can be tailored for birthing people with disabilities, those in the LGBTQ+ community, making things culturally relevant to whatever specific marginalized population that is birthing, because it’s these marginalized populations that have the worst birth outcomes,” DeVane-Johnson said.
At this time, the program has one year of data and the group looks forward to evaluating the incoming qualitative and quantitative data, something the new Duke Endowment grant will help them do over the course of the next three years.
DeVane-Johnson, McMillian-Bohler and Standard also hope to see the program expand beyond the borders of North Carolina.
“We want to disseminate this program throughout the country,” Standard said. “We want to reach out to other academic hospital-affiliated institutions and integrate this program into their maternal care systems.”
If the program receives additional funding, Standard said they plan to increase compensation to the doulas and faculty, and hire additional staff to support an expansion to help more families.
Changes in the status of women’s reproductive health and protections have been at the forefront of new headlines in recent weeks. The leaked Supreme Court documents indicating that the justices are on the precipice of turning over 50 years worth of reproductive health precedent has a lot of people pausing to consider the implications of losing something they have largely taken for granted. Many women are recognizing that if Roe v. Wade is overturned, they will have less bodily autonomy than corpses often have in their home states.
Of course, for many women – particularly minority women in deeply conservative states – these rights were slipping away long before this. In many of these states, the number of reproductive health clinics is extremely limited and causes undue burdens on women trying to access them. Multiple studies on the topic have shown that minority women, especially those from poorer backgrounds, are the most likely to face difficulties accessing any sort of reproductive healthcare than their more affluent, white peers.
Regardless of where our personal beliefs related to abortion rights fall, we can all agree that women having better access to reproductive healthcare is a valuable endeavor. For many nurses out there, this means striving to break down barriers that limit healthcare access. It also means becoming an advocate for health equity. But how does one become an advocate within their own community?
Many of the inequalities that nurses see every day aren’t easy ones to just address and deal with. Rather, they are ingrained, pervasive community and cultural issues that will take years to fully unpack and start to address in a positive manner. However, there are things that nurses can do to help address some of the healthcare inequalities that minority women face regularly.
Perhaps one of the most powerful things nurses can do to help address health disparities is to recognize and empathize with the differences. Minority nurses with a background in minority communities are in the position to play a unique and powerful role here. Who better to build a bridge of understanding and trust than someone who already has an understanding of the social, cultural, and economic factors that may be influencing healthcare choices.
Immediately addressing any form of blatant discrimination.
Advocating for policies that promote human rights and equity.
Working with numerous professionals across disciplines to ensure patients are receiving holistic healthcare.
Encouraging medical trials that are inclusive and address the concerns of minorities.
Seeking out and promoting other professionals that are striving to address equity issues in their communities.
When working directly with patients there are a few things that can be done to help decrease health disparities. Arguably the most important is building trust in the community, which most certainly will not happen overnight. Small steps to start can include things like doing preventative health education out in the community, finding strategies that can help with payment for medical services, and being available for health-related questions without requiring an appointment.
Unfortunately, minority women are typically at greater risk for developing a number of diseases. For instance, African American women are twice as likely to develop breast cancer. Likewise, African American women are more likely to develop high blood pressure earlier in life than white women. There are many factors that influence this, but ultimately detection is one of the best forms of prevention.
Women can benefit from regular health screenings, but many are reluctant to do so. Going to the doctor’s office is uncomfortable, time-consuming, and potentially expensive. Helping women, especially minority women, understand the value of preventative health screenings over the long term is a vital role that nurses can play. Promoting more screenings can be one straightforward way to catch and treat issues before they become life-altering health problems.
Soft Skills Matter
Minority women, particularly women of color, are more likely to face negative health outcomes than other groups. Ingrained inequalities and cultural perceptions of the healthcare system play a major role in this. As nurses work to address these health disparities it becomes apparent that not only is a deep knowledge of nursing and healthcare important, but so are the soft skills that help convey the message.
For example, soft skills such as empathy are critical to understanding and adequately responding to the difficulties that some patients are facing. Empathy can lead to better, more realistic health prescriptions and outcomes. Patients are also more inclined to trust and listen to someone that shows an understanding and compassion for the information they are providing about themselves and their health.
Communication is another important factor. Even the best messages can be lost if they are not delivered in an understandable and relatable way. Patients do not like to feel talked down to and many very deeply want to understand the healthcare system before they have to make major decisions within it. Clear communication about procedures, health factors, costs, and outcomes are also imperative for building trust and making patients feel comfortable about their health choices.
Healthcare inequalities are significant for some demographics of the population, particularly minority women seeking reproductive healthcare. Nurses can make a real difference in starting to address some of these disparities by becoming advocates for their patients. It involves building trust, showing empathy, and encouraging positive health choices. None of it is easy, but it can add up to make a powerful difference in local communities.
We interviewed Moore, who is also Assistant Professor/Director of the Women’s Health Gender-Related Nurse Practitioner Program at Thomas Jefferson University College of Nursing, to find out what this means to her and her plans for the future.
Shawana Moore, DNP, MSN, CRNP, WHNP-BC
What drew you to wanting to take a leadership position like this? When did you first become involved in NPWH?
My desire to impact diverse communities and amplify the voices of historically marginalized women and gender-related populations. I became involved in NPWH as a Program Director in 2014. NPWH provided the opportunity for individuals leading Women’s Health Nurse Practitioner/Women’s Health Gender-Related Nurse Practitioner programs throughout the nation to collaborate and share knowledge.
Being the first Black Chair in the organization’s 41-year history has to mean a great deal to you and other nurses of color. How did this make you feel? What do you think this says to nurses who are BIPOC?
I am honored and humbled to serve as the first African American Chair of NPWH. I hope to pave a pathway for other nurses from the BIPOC community to be elected or appointed to leadership positions within national organizations. This historical milestone within NPWH history displays to other nurse’s from BIPOC populations that they have the opportunity and capabilities to lead in high-level positions within the profession of nursing.
What are you bringing to the organization that past Chair/Presidents who were not BIPOC couldn’t have?
Each Chair/President brings their perspectives, life experiences, and expertise to lead in this position. Those who have come before me have led the organizations to new heights. As I embark on this new role, my uniqueness as a Black woman brings a different viewpoint. I hope to use my perspectives, experiences, and expertise to facilitate and promote clinical practice, policy, community engagement, education, and research with a lens of equity.
What are your biggest challenges in this position? What do you think some of the greatest rewards are?
Being the first at anything comes with the challenge of not being seen or done before in the position. However, it serves as an opportunity to set the stage and create a pathway for others to build upon. The most significant rewards will be the opportunity to amplify historically silenced or unheard communities of women and gender-related populations, collaborate with other national organizations, and lead change within the profession using a lens of equity.
What advice would you give to nurses who are BIPOC about taking leadership roles?
I would advise nurses who are BIPOC to seek leadership roles in all facets of our profession. Their voices, perspectives, expertise, and experiences are valuable to society and can make meaningful and sustainable changes for communities of people.
While maternal outcomes have improved over the years, a considerable number of women in the United States die from or continue to experience a number of pregnancy-related complications. According to the National Center for Chronic Disease Prevention and Health Promotion [NCCDPHP], each year approximately 700 women die of pregnancy related causes while 50,000 women experience severe pregnancy complications. Women living with chronic conditions such as hypertension, diabetes, heart disease, and obesity are at a higher risk for complications during pregnancy, childbirth, and the postpartum period. In particular, African American women are more likely to die from pregnancy-related complications when compared to their white counterparts. Notably, maternal mortality is higher in the United States than in any other developed nation.
Severe maternal mortality is due to severe pregnancy complications. According to the NCCDPHP, these rates have doubled from 2000–2010 and have affected more than 50,000 women in the United States. Some contributing factors include: maternal age, persisting chronic conditions, complications during delivery, and pre-pregnancy obesity. Researchers note that approximately half of pregnancy-related deaths are preventable and point to implications for reducing maternal mortality.
Efforts to reverse these disturbing statistics will require a multifaceted and comprehensive approach. Interventions must include a focus on better data collection, quality improvement measures, provider and patient education, earlier identification and intervention targeting high-risk women, proactive preconception health approaches, and improved obstetrical and maternal care services. Many hospitals and health systems across the country are addressing the mortality death rates and have designed programs, which include some of the aforementioned strategies.
The rise in maternal morbidity and mortality has stimulated discussion and action among nongovernmental and governmental agencies, advocacy, and professional groups and the United States Congress. Groups such as the American College of Obstetricians and Gynecologists, Black Women’s Health Imperative, and the Alliance for Innovation on Maternal Health (AIM), to name a few, are speaking out for legislative action. The table below provides a brief snapshot of legislative proposals introduced at the federal level during 2018, the second half of the 115th Congressional Session. These and other initiatives are a critical first step to reversing the poor maternal health outcomes for women.
Nurses are encouraged to stay abreast of this issue by identifying the state of maternal health in their respective communities. Nurses wishing to improve maternal outcomes can do so by helping to identify high-risk populations and working with their respective institutions to develop educational programs, outreach initiatives, and quality standards for maternal care. As health care providers, nurses are well-suited to work with multidisciplinary teams to disseminate best practices as well as advocate for sound public policies focused on alleviating poor maternal outcomes.
Additionally, nurses can look to professional/specialty organizations to identify what organizations are doing to address maternal mortality. For example, the Association of Women’s Health, Obstetric and Neonatal Nurses, one of nursing’s leading organizations devoted to women’s health and newborns, has a number of resources on this issue and advocates for work that expands the work of state-based Maternal Mortality Review Committees. Maternal Mortality Review Committees are critical to collecting, reviewing, and monitoring data on pregnancy-related deaths.
Maternal Health: Proposed Legislation
Mothers and Offspring Mortality and Morbidity Awareness Act (MOMMA’s Act)
Rep. Robin Kelly (D-IL)
· Establishes an expert federal review committee to help enforce national obstetric emergency protocol
· Establishes best practices between providers and hospital systems
· Improves access to culturally competent care training and workforce practices
· Standardizes data collection to collect uniform data
· Expands Medicaid coverage to cover the full postpartum period
Ending Maternal Mortality Act of 2018
Rep. Raja Krishnamoorth (D-IL)
Amends the Public Health Service Act to require Department of Health and Human Services to publish every two years a national plan to reduce maternal deaths occurring during or within 12 months of pregnancy
H.R. 5457 / S. 2637
Quality Care for Moms and Babies Act
Rep. Eliot Engel (R-NY) / Sen. Debbie Stabenow (D-MI)
Amends Title XI of the Social Security Act to improve the quality, health outcomes, and value of maternity care by developing maternity care quality measures and supporting maternity care quality collaboratives
H. Resolution. 818 / S. Resolution. 459
Black Maternal Health Week
Rep. Alma Adams (D-NC) / Sen. Kamala Harris
Creates awareness about the maternal health care crisis in the black community and the urgency to reduce maternal and morbidity among black women
Health is defined as the state of being free from illness or injury. Health is what keeps all individuals in a state of harmony and balance because when our health is good, we are good. However, the state of being free from illness or injury is not equal across all spectrums of the human species. Some of you may deal with health related issues on a daily basis, occasionally, or rarely. Despite your frequency, it’s doubtful time allows you to look up interesting facts and figures on this topic. For instance, did you know that black women have a shorter life expectancy than White women by 5 years, 50% higher all-cause mortality rates, and death rates from major causes such as heart disease, cerebrovascular diseases, and diabetes that are often 2 to 3 times higher than those for Caucasian women? Knowledge is power, so here are a few interesting facts and figures about the health of minority women that make you go hmmm.
Caucasian women are more likely to develop breast cancer than African American women. But African Ameri- can women are more likely to die of this cancer because their cancers are often diagnosed later and at an advanced stage when they are harder to treat and cure. There is also some question about whether African American women have more aggressive tumors.
African American women between the ages of 35-44, have an increased breast cancer death rate of more than twice the rate of White women in the same age group—20.02 deaths per 100,000 com- pared to 10.2 deaths per 100,000.
Black women develop high blood pressure earlier in life and have higher average blood pressures compared with white women. About 37 percent of black women have high blood pressure.
About 5.8% of all white women, 7.6% of black women, and 5.6% of Mexican American women have coronary heart disease.
A 2011 Journal of Women’s study indicated that 57 percent of Latina women, 40 percent of African American women, and 32 percent of white women had three or more risk factors for having a heart attack.
According to the article published by the Diabetes Sisters, the prevalence of diabetes is at least 2-4 times higher among African American, Hispanic/Latino, American Indian, and Asian/Pacific Islander women than among white women.
One in four African American women over 55 years of age has diabetes.