MCH Student:

Kathryn Spray

Date of Defense:

October 5, 2018

Abstract:

Introduction

The goal for this Field Experience was to create a program model for a Hospital Based Doula Program. A doula takes on a non-clinical, supportive role during labor and delivery.¹ The doula has a continuous presence, keeps the patient informed, in lay terms, as to the progress of labor, advocates on behalf of the patient, helps her identify any questions she may have and aids her in communicating those questions with health care staff.¹ The literature shows that the use of a doula during labor and delivery aids in improving both maternal and infant health outcomes including infant mortality, birth weight, and prenatal visit attendance.

In 2016, Hennepin Healthcare System administered a Community Health Needs Assessment (CHNA) which identified three main areas for improvement in patient outcomes. One of the three main areas for improvement was Maternal and Child Health, especially within the African American and American Indian populations in Hennepin County. In 2017, the overall infant mortality rate at HCMC was 17 per 1,000 live births.² However, the infant mortality rate for African American babies was 28 per 1,000 live births.² Additionally, in 2016 the average recorded number of prenatal visits for American Indian women was 6.8, for African American women it was 8.7, compared to all other women with a total of 10.5 prenatal visits.² Due to these findings, as well as known high rates of premature/low birth weight births in both higher risk populations, the MCH workgroup concluded that there was a need to develop a comprehensive group prenatal care program that included the reimplementation and expansion of doula services.² Lastly, due to the fact that  African American and American Indian populations experience some of the worst health disparities it was decided that is was imperative higher-risk mothers were the key focus of the work being done.

Experience

For this field experience I worked with the Hennepin Healthcare System, MCH workgroup to develop a Hospital-Based Doula Program model to address maternal and infant mortality rates in Hennepin County. A 2016, article published by The Journal of Perinatal Education, found that doula care improved many labor and delivery outcomes. Moreover, doula care decreased the use of pain medication by 9%, decreased the use of Pitocin by 31%, increased spontaneous vaginal births by 12% and decreased the length of labor by an average of 40 minutes.³ The desire for a new program model stemmed from the community health needs assessment which identified disparities in African American and American Indian maternal and infant mortality rates. A key intervention identified to address this was the reinstatement of a hospital-based doula program. In 2017, the doula program was cut as part of reduction in force efforts at Hennepin Healthcare. Since then, many individuals from patient care up to executive leadership have stated that cutting the program was a mistake. Thus, with the known improvement in health outcomes, as stated above, experienced when a doula is involved in the care of a mother, the MCH workgroup felt that it was imperative for doula’s to be brought back to the system.

The main goal for this Field Experience was to develop a hospital-based doula program which included the addition of a comprehensive package for high-risk mothers. This comprehensive package will be offered, with priority to African American and American Indian women, but will also be offered to other high-risk women as capacity allows. In addition to intrapartum care, the comprehensive doula package also includes visits with a doula during the antepartum period as well as the postpartum period. The comprehensive package includes a total of 7 visits with the doula including the intrapartum care. At least 2 visits must occur during the antepartum period and 2 visits during the postpartum period, the other 2 visits, for a total of 6 can occur either both in the antepartum period or postpartum period or be split evenly.

At Hennepin Healthcare I worked closely with Anna Mueller, Clinical Director of Family Health, Dr. Tara Gustillo, Chief of Obstetrics and Gynecology, and Jessica Holm, Nurse Midwife Service Director, to develop criteria for a culturally sensitive doula program. Additionally, I worked with community-based doula organizations to work together to develop an agreement for the formation of a community doula collaborative to provide the doula care in this culturally sensitive and relevant model at Hennepin Healthcare.

In conclusion, I created the program design for the doula program, worked with the community organizations to establish partnership agreements, completed a literature review on doula care, met with the HCMC employee benefits team to have doula care added to the employee benefit package, and participated in the overall MCH workgroup to improve maternal and infant health in Hennepin County.

Organization

This Field Experience was conducted at HCMC the hospital system for Hennepin Healthcare System in Minneapolis. HCMC is a “safety net hospital serving a large population of under-served, vulnerable communities”. Additionally, Hennepin Healthcare is a Level 1 Adult and Pediatric Trauma Center. The mission of Hennepin Healthcare is as follows: “We partner with our community, our patients and their families to ensure access to outstanding care for everyone, while improving health and wellness through teaching, patient and community education, and research.”⁴ The MCH work group has three main goals; 1. To improve birth outcomes for African American and American Indian women. 2. Improve awareness/knowledge of available prenatal programs and services in recent refugee and new immigrant populations. 3. Improve provider awareness of culturally relevant programs, services, and resources to improve referrals to these programs.⁵

Lessons Learned

My experience developing the program design for the doula program at Hennepin Healthcare taught me about the opportunities and challenges working to advance maternal and child health outside of local and state public health in a clinical healthcare environment. Firstly, collaboration is so incredibly important in order to move things along and have buy in on the system side. Additionally, the creation of a collaboration with community partners requires individuals on the system side who are invested in doing the ground work to ensure progress continues and the program doesn’t lag and stall. Lastly, working to bring a program back that used to exist, albeit not to the full extent that we have designed for re-implementation, is difficult. We must show that the program has a return on investment (ROI) to operationalize it and protect it from being cut if the system were to experience a reduction in force again.

Recommendations

My recommendations for Hennepin Healthcare’s doula program are as follows: first and foremost, continue to ensure that the voice of the community is integral in program implementation as this will ensure that it has the improvement on outcomes as it was designed to have by addressing the health disparities identified in the CHNA. Secondly, Hennepin Healthcare must ensure that it is fiscally responsible in its implementation of the doula program; the program must be self-sustainable and have a ROI. If this is not done future cuts may be eminent. Lastly, the potential use of a doula training program must be considered to not only increase the doula workforce in the Twin Cities area, but also increase the number of doulas of color to ensure we are representing the patient populations we are serving.

Conclusion

This field experience taught me what it is like to work as a public health professional in maternal and child health in a clinical public health setting. Hennepin Healthcare has a great opportunity to expand its doula services to better serve the community it strives to work so closely alongside. Additionally, Hennepin Healthcare has the opportunity to be a leader in the realm of women’s and infant health in Hennepin County through the innovative work of the MCH work group.

References

1. Ballen, L. E., & Fulcher, A. J. (2006). Nurses and Doulas: Complementary Roles to Provide Optimal Maternity Care. Journal of Obstetric, Gynecologic & Neonatal Nursing,35(2), 304-311. doi:10.1111/j.1552-6909.2006.00041.x
2. Schaffner, P. (2018, September 18). [Maternal and Child Health CHNA Implementation Results 2018]. Unpublished raw data.
3. Strauss, N., Sakala, C., & Corry, M. P. (2016). Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health. The Journal of Perinatal Education,25(3), 145-149. doi:10.1891/1058-1243.25.3.145
4. About Hennepin Healthcare. (2018, March). Retrieved September 17, 2018, from https://www.hennepinhealthcare.org/about-us/
5. Schaffner, P. (2017). 2017-2019 CHNA Maternal Child Health Action Plan [Chart]. In 2017-2019 CHNA Maternal Child Health Action Plan. Minneapolis, MN: Hennepin Healthcare System.