Master's Project Title:

An Assessment of Doula Care in North Dakota

MCH Student:

Leah Mahoney

Date of Defense:

April 1, 2016


Executive Summary


Research on the efficacy of doulas as a public health intervention has gained notice in recent years as disparities in birth outcomes continue to be a major issue in the Nation’s minority populations and here in North Dakota. Studies have suggested that continuous support during labor and delivery improves obstetric outcomes at birth and decreases obstetric interventions (Kozhimannil et. al., 2014). In a review of 22 studies related to one-on-one continuous labor and delivery support they found that women were more likely to have a spontaneous vaginal birth, less likely to have intrapartum analgesia, less likely to report dissatisfaction, and reported shorter labors (Hodnett, Gates, Hofmeyr, & Sakala, 2013). Another study found that women who had doula support at birth had a breastfeeding initiation rate of 97.9% compared to 80.8% in a general Medicaid population (Kozhimannil, Attanasio, Hardeman, & O’Brien, 2013).

The 2015 North Dakota March of Dimes prematurity report card reports that 12.1% of live births to Native American woman were premature compared to 8.3% of live births for a White woman and 8.1% live births premature for a Hispanic woman. For this report premature birth is defined as a birth less than 37 weeks gestation (March of Dimes [MOD], 2015). The infant mortality rate is also not equally distributed. In 2010-2012 the infant mortality rate for Whites was 5.1 per 1,000 live births and for Native Americans it was 17.6 per 1,000 live births. In 2010, 39.8% of the Native American population lived below poverty level compared to 13.0% living below poverty level for the state of North Dakota (North Dakota Department of Health [NDDoH], 2014). The disparity seen in birth outcomes and socioeconomic status impacts a person’s quality of life, overall health status, and ability to access health care services.

Improving and preventing poor birth outcomes is important because it reflects the overall health of a community. The health of our mothers and children today effects the health outcomes of future generations. Addressing poor birth outcomes requires interventions designed to target social determinants of health and access to care in a manner that is culturally appropriate. A community-based doula program would be a beneficial public health intervention to address birth disparities because it utilizes a multifaceted approach that can adapt to different cultural preferences of the target population.


The first learning objective was to explore and apply methods of working effectively with communities or special populations within the community. I achieved this objective by networking with hospitals and community organizations with the goal of finding an interested partner for a doula program in North Dakota. I also met with community doulas to identify doula usage and appropriateness among the Native American population. The second objective was to participate in establishing and evaluating MCH programs. I completed this objective by performing literature reviews and networking with local organizations and community members. Through evaluating the current state of doula care in North Dakota I was able to assess the need and interest in developing a community-based doula program that would be culturally appropriate for the Native American population. This led me to work with the American Indian Public Health Resource Center at North Dakota State University in organizing and facilitating a statewide Healthy Native Families Maternal and Child Health symposium.

My third objective was to be involved in professional development activities. I achieved this objective through participating in March of Dimes trainings and attending Collaboration for Innovation and Improvement Network webinars. I also acted as a liaison for the Tobacco Prevention and Control Committee writing reports to the March of Dimes North Dakota State Program Director, and contacting local community advocates regarding upcoming policy initiatives. The fourth learning objective was to practice epidemiologic knowledge of data collection and analysis in a practice based setting. I achieved this objective by receiving data from North Dakota Vital Statistics and reviewing the finding with the North Dakota MCH epidemiologist.


March of Dimes is a non-profit organization that is dedicated to maternal and child health issues specifically related to premature birth, addressing health inequities, preventing birth defects, and infant mortality. The March of Dimes has 51 chapters across the United States, including the District of Columbia and Puerto Rico. March of Dimes provides educational resources on a variety of applicable topics including preconception care, pregnancy, and infant health. They also provide educational resources to health professionals which can be completed to obtain continuing nursing education credits. The March of Dimes also provides support to families affected by prematurity and birth defects through the NICU Family Support Program (MOD, 2016). The community-based doula program fit well in to the organizations mission because the objective was to improve birth outcomes in an underserved community.

Lessons Learned

Through the extensive networking it required to gather necessary information for the success of this program I learned that public speaking, though it still makes me feel anxious, is not quite as terrifying as I had thought. I have a lot of experience working and communicating in small groups but, before my field experience I had little experience speaking to large groups. I also learned to be extremely patient because I was asking people to take on an additional tasks to their already busy work schedules. I met with many identified stakeholders and potential contributors but collaborating with the American Indian Public Health Resource Center elevated the promotion of the project through the Healthy Native Families Maternal and Child Health symposium. This allowed us the opportunity to network with organizations across the state and provide information on how they could complete a grant proposal to implement a community-based doula program in their communities.


I would recommend that a student continue to work with the March of Dimes in implementing a community-based doula program in North Dakota. Currently, the March of Dimes is waiting for a grant proposal from the Standing Rock Reservation to receive funding to train local women as doulas to provide services in the community. This is just the first step in creating a comprehensive, culturally appropriate community-based doula model but with further support I believe that this project could be seen through to completion.


A community-based doula model has been identified as a possible public health intervention to improve birth outcomes. After completing an assessment of the current availability and usage of doulas I worked with the American Indian Public Health Resource Center to implement a Maternal and Child Health symposium that would provide the opportunity to network with potential collaborators. The Standing Rock Reservation is currently completing a grant proposal to train local women as doulas to provide culturally appropriate birth support services in the community.


  1. Hodnett, E., Gates, S., Hofmeyr, G., Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database System Rev. 7:15:7:CD003766.
  2. Kozhimannil, K.B., Attanasio, L.B., Hardeman, R.R., O’Brien, M. (2013). Doula care supports near-universal breastfeeding initiation among diverse, low-income women. Journal of Midwifery and Women’s Health, 58 (4), 378-382. doi:10.1111/jmwh.12065
  3. Kozhimannil, K., Attanasio, L., Jou, J., Joarnt, L., Johnson, P., & Gjerdingen, D. (2014). Potential benefits of increased access to doula support during childbirth.American Journal of Managed Care, 20(8), e340–e352.
  4. March of Dimes. (2016). Retrieved from
  5. March of Dimes. (2015). North dakota 2015 premature report card. Retrieved from
  6. North Dakota Department of Health. (2014). Infant mortality data summary report for north dakota. Retrieved from