Could Tele-Doulas and Care Navigators Transform Maternal Health Equity

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As Black History Month comes to a close, it’s important that the insights that came to broader awareness continue to have an impact on social change.

At NourishedRx, we make high-quality, culturally appropriate, nutritious food accessible to the people who need it most. A pregnancy program we helped run in Minnesota in 2021 and 2022 increased our awareness of the deep health inequity factors affecting maternity care, especially for Black and immigrant women. It also might provide learnings that can help transform maternal health equity going forward.

The Black Experience of Pregnancy

Black women are three times more likely to die during pregnancy than white women, and that death rate increased in 2020 and 2021 during the height of the COVID pandemic. Two-thirds of all pregnancy-related deaths in the U.S. are considered avoidable but Black mothers face   particular challenges rooted in systemic racism. As a recent National Bureau of Economic Research study out of California showed, for every 100,000 babies born:

The racist history of maternity in the U.S. has become clearer in the past few years. As modern historians have illuminated, enslaved Black women were forced to have as many babies as possible to grow the numbers of enslaved workers. Even America’s “father of gynecology”, J. Marion Sims, is now known to have conducted brutal experiments on enslaved women.

Many of the factors impacting Black maternal and newborn health today are rooted in that history. Because of socio-economic barriers, pregnant Black women are more likely to suffer from chronic illnesses, chronic stress, poor environmental conditions, food insecurity, and lack of access to affordable care. Even when seen by a doctor, Black mothers are treated differently than white mothers and given different interventions. When a Black doctor is involved, Black newborns and infants are more likely to survive.

The Role of Doulas in Closing the Gap

Historically, Black midwives, known as Granny midwives, played a prominent role in delivering babies. As maternal healthcare became hospital-based, mortality and disease rates actually rose until regulators implemented rules around hygiene and care. That death rate began climbing again in the late 1990s as health inequities increased. According to a 2018 CMMI (Center for Medicare and Medicaid Innovations) study, the health of newborns improves when those births take place in birth centers operated by midwives.

Doulas are also increasingly important in improving birth outcomes. A doula is meant to provide support to pregnant women and their families, before, during, and after delivery. A 2013 CDC study revealed that doula-assisted births were four times less likely to lead to complications.

Community-based doulas have proven effective in providing advocacy and support for minority or immigrant populations. Sweden recently implemented a program for African immigrants, using doulas from that community as translators, advocates and birth coaches, helping pregnant women navigate the Swedish healthcare system. Such programs are gaining ground here.

Delivering Nutritious Food to Pregnant Mothers

Nutrition is a significant health equity driver for pregnant women, and Black mothers are more likely to develop gestational diabetes while pregnant. In 2021, NourishedRx launched a program with Blue Cross ® and Blue Shield® of Minnesota to assist pregnant BIPOC women at high risk of developing gestational diabetes, preeclampsia and elevated glucose levels.

Blue Cross flagged at-risk pregnant members for outreach, and we delivered prepared meal kits and groceries to them before and after they gave birth, to improve their health outcomes and reduce their food insecurity, isolation, and stress.

In St. Cloud, Minnesota, our wellness associate was a woman named Saadia Ali who’d worked as a midwife and doula in Somalia and Saudi Arabia before immigrating to the U.S. Saadia’s skill as a doula, and her personal experience as a member of the local Somali community, made her particularly effective.

Providing outreach by phone, Saadia was able to connect to pregnant Somali women at risk, gain their trust and meet their nutrition needs. She was also able to flag other social care needs, facilitate referrals, and provide education and support in navigating our healthcare system.

For pregnant women and new mothers who may not speak English and who may find the American healthcare system overwhelming, Saadia was a lifeline. And her own satisfaction in being able to provide that support is palpable. As she puts it, “When we deliver food to a woman who is pregnant and cannot do much for herself, she is always so grateful. And when her sugar and stress levels go down, we feel like we did something very good.”

A Better Future for Maternal Care

The program was highly effective in meeting an array of important needs related to health equity and health outcomes, even though that support was provided largely by phone.

The COVID pandemic put a spotlight on health equity and the way it impacts quality of life and health outcomes.

Yet, the pandemic also illustrated how effective digital technology can be in enhancing access. My take-away from Black History Month is that we can continue to make important progress in the maternal health space by making community-based tele-doulas and care navigators available to all who need that support.

So, let’s do it.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.