Michele DeMeo

Birth Justice~SOSC 2020

Summer Trimester

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Service Learning Project for the

Toledo-Lucas County Health Department

• Doula Program to reduce infant mortality

Service Learning Project

Purpose: birth justice in action

Focus: infant mortality

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Action taken to find a service learning project in my area:

I knew that Healthy Start had a postpartum doula program, and their intention was to help reduce infant mortality and racial disparities within Lucas County.

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I reached out Shynell Jones MSN, RN

the Maternal and Child Health Supervisor and the Healthy Start Program Director with the Toledo-Lucas County Health Department

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Photo credit: https://www.lucascountyhealth.com/

Tiana Taylor

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Birth and Postpartum Doula

• What led to your passion for maternal and infant care? What are some guiding principles in your work as a postpartum doula?
• Bias is embedded within the healthcare system, POC are treated with bias. Can you tell me ways that you have seen this played out while in your role as a Doula?
• How do you confront bias in maternal healthcare? How does doing this work in Lucas County present its own challenges?
• How many black doulas are there in this area?
• People reflect on how much their work has impacted others, but how has your work affected you?
• Do you think there is a place for white allies in reducing infant mortality and racial disparities, and how can they be most supportive of your efforts?

Links to Tiana’s answers (shared with permission): https://drive.google.com/open?id=14ftNqHMdPH

scEMZ7nvkaIAzn4iWIGxGV

https://drive.google.com/open?id=1VV5pPXQJ_hyUkOO2A6SRMaGKG7QcV0sX

Description of how this project helps to advance birth justice agendas

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Overview:

Reducing infant mortality is one of the five priority areas in Healthy Lucas County’s Health Improvement Plan.

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Infant mortality especially is a concern for African American infants, who are dying at more than twice the rate as white babies statewide in Ohio (Getting to 1, 2017).

The Ohio Department of Medicaid has invested $3.23 million investment for the “Getting to 1” coalition. This is the largest amount that any Ohio community is receiving to combat infant mortality.

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“Getting to 1”

According to the Ohio Department of Health statistics (Getting to 1, 2017) In 2012, Lucas County had an infant mortality rate of 7.05 infant deaths per 1,000 live births for whites and 13.52 infant deaths per 1,000 live births for African Americans.

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The state then allocated $26.8 million over two years to support community-driven proposals to combat infant mortality and enhance care coordination among various agencies that provide care for women and infants who are at risk (Getting to 1, 2017).

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“Getting to 1”

My contribution:

Assist with research needed for re submission of Medicaid funding, specifically within the doula program.

My focus: create a list to include the benefits of doulas, how they help reduce maternal and infant mortality, and reduce racial disparities.

Intention: Combat erosion in funding and underinvestment in family support and healthcare programs in order to connect with more low-income women who are or could become pregnant to the medical care and social services they need to have healthy babies.

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Photo Credit: Evidence Based Birth, 2019

Why a doula program?

Photo Source: Kaiser Family Foundation analysis of data from OECD (2017), "OECD Health Data: Health status: Health status indicators", OECD Health Statistics database . (Accessed on July 5, 2017) Get the data PNG

Medicaid program touch points

• Expand Medicaid funding to cover additional support for doula care, and connect with more low-income women who are or could become pregnant to the medical care and social services they need to have healthy babies.

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Photo Credit: https://www.healthylucascounty.org/getting-to-1/

2. Medicaid doula program will offer free doula services to identified areas of risk; for example, low-income people in Black and Latino neighborhoods (Thomas et al. 2017).

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Medicaid program touch points

People of color experience higher rates of poor birth outcomes, including higher rates of Cesarean, preterm birth, low birth weight, and infant death (Thomas, Ammann, Brazier, Noyes, Maybank, 2017).

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3. Promote equity and improve outcomes in maternal and infant health outcomes within at-risk populations by offering continual doula presence and support.

4. Reduce/eliminate ethnic and economic disparities, and end preventable mortality and morbidity.

5. Reduce health disparities and ensure that pregnant people and new parents have reliable access to community resources and high-quality care.

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Medicaid program touch points

Address the numerous health factors that can lead to the pregnancy-related death of a mother and infant.

• Individual, institutional, and generational stress related to racism and inequality. increased stress can negatively impact pregnancy outcomes (Giscombé and Lobel, 2005).
• Implicit bias and unconscious bias exists in health care that contributes to health disparities, and inappropriate, unjust, unethical care towards people of color (Hall et al. 2015).

Medicaid program touch points

Studies show that mortality rates and racial disparities exist even after accounting for factors like the pregnant person’s income, education, marital status, tobacco/alcohol use, and insurance coverage (Evidence-Based Birth, 2019, Thomas et al. 2017).

Medicaid program touch points

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6. Identify ways doulas contribute to reducing maternal mortality, infant mortality, and racial disparities.

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Medicaid program touch points

Medicaid program touch points

Doula support may help disrupt negative social determinants of health by offering the following: continual support which assists with sense of agency and empowerment in one’s own care, positive feelings of personal security, respect and autonomy in decision-making, knowledge about the pregnancy,birth process, and newborn care, increased knowledge and understanding of related testing and procedures, feeling of connectedness and shared experience particularly with someone who shares their culture and background (Kozhimannil, Vogelsang, Hardeman, Prasad, 2016).

Medicaid program touch points

Doulas have been shown to increase positive health outcomes, including reducing birth complications for the birthing person and the baby including lower rates of cesarean section and preterm birth, higher rates of breastfeeding initiation, and increased satisfaction with the birth experience (Thomas et al. 2017).

Identifiable barriers for doula program within Lucas County

• Not enough doulas in our area
• There is one postpartum doula currently in a service contract with Lucas County.
• Lack of funding for programs that provide doula services to the community.
• Lack of funding to pay for training and service contracts with doulas.
• Not enough education for community awareness about what doulas offer and how they can help reduce maternal and infant mortality and racial disparities.

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Identifiable issues for Lucas County area:

• Lack of community education about what doulas do
• Doulas have been shown to increase positive health outcomes, including reducing birth complications for the birthing person and the baby including lower rates of cesarean section and preterm birth, higher rates of breastfeeding initiation, and increased satisfaction with the birth experience (Thomas et al. 2017).

Identifiable issues for Lucas County area:

2. What are the benefits of having a doula

• Prenatal
• Perinatal
• Postpartum

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Identifiable issues for Lucas County area:

3. Who do they serve: the birthing person, babies, families, communities

4. Misconceptions about what doulas do...

5. Not enough doulas to hire, specifically doulas of color.

6. Medicaid funded programs requiring doula certification or licensure may be cost-prohibitive for doulas if the fee is not covered through the training program.

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Possible solutions:

• Local paid training or scholarships to become a doula could be made available
• Identify the need for diversity in doulas serving the same or different cultures.
• Offer an incentive to cover the cost of certification which would be a requirement through the funded program.
• Have fair and appropriate pay for doula contracts funded through the Medicaid program.
• Work with local groups to make sure doulas and the community are aware of the program and how to secure services.

Problems identified in other Medicaid doula programs

• Not enough Doulas signing up to be in the program
• The low reimbursement fee set for doulas:
• New York’s program pays doulas $600.00 -includes four prenatal visits at $30 each, plus labor and delivery at $360, and four postpartum visits each at $30.00. That equals $23 an hour, $7 above the state’s minimum wage.
• Minnesota’s program pays doulas $400 per clients and includes up to six doula visits, plus assistance at the birth.
• Medicaid requires all doulas to be licensed or certified which is cost-prohibitive.
• Low reimbursement rates deterring more experienced doulas from offering services.

What I learned from this project:

What and where?

Infant mortality is calculated as the number of infants who die before reaching a first birthday per 1,000 live births.

As mentioned previously, Lucas County had an infant mortality rate of: 7.05 infant deaths per 1,000 live births for white infants and 13.52 infant deaths per 1,000 live births for African American infants.

This was only the second time since the state started recording these statistics in the 1930’s that fewer than 1,000 Ohio babies died (the first time was in 2014).

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What has changed?

As of 2017 there were 42 fewer infant deaths documented compared to the previous year (Ohio Department of Health, 2017) but this was mostly among white infants…

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Photo credit: https://www.lucascountyhealth.com/

What I learned from this project:

What and where?

Note: the unevenness of the gains across racial groups.

Fewer white babies died in 2017, but among black families there was an increase of 15 more deaths (Ohio Department of Health, 2017).

“The national infant mortality rate (in 2016) was 5.8 infant deaths per 1,000 live births. Nationally the black-white racial disparity is about 2.4 and may be growing.” (Ohio Department of Health, 2017).

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What has changed?

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What I learned from this project:

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How to be an ally

My ally-ship is always going to be about me in some respects…. because I want to use my identity/privilege to seek equality for those who don’t or cannot identify the same way.

Where it shouldn’t be about me is in the “why””

Photo credit: https://catchingsomethinginvisible.com/what-i-am-learning-about-how-to-be-a-white-ally/

It can be difficult to know what to do or how to go about being an ally.. Putting yourself out there takes courage.

Works Cited

Dowling-Ketant, T. (2019). Why Every Black Woman Deserves a Doula. Intelligencer. Retrieved from: http://nymag.com/intelligencer/amp/2019/03/new-yorks-medicaid-reimbursement-plan-for-doulas.html

Evidence Based Birth® (2019). Evidence on: Doulas. Retrieved from: http://evidencebasedbirth.com/the-evidence-for-doulas/

Healthy Lucas County (2017). Getting to 1. Retrieved from: http://www.healthylucascounty.org/getting-to-1/

Giscombé, C. L., and Lobel, M. (2005). Explaining Disproportionately High Rates of Adverse Birth Outcomes Among African Americans: The Impact of Stress, Racism, and Related Factors in Pregnancy. Psychological Bulletin, 131, 5, pp. 662–683, doi:10.1037/0033-2909.131.5.662

Governor Andrew M. Cuomo (2018). Governor Cuomo Announces Comprehensive Initiative to Target Maternal Mortality and Reduce Racial Disparities in Outcomes. Retrieved from: https:// www.governor.ny.gov/news/governor-cuomo-announces-comprehensive-initiative-target-maternal-mortality-and-reduce-racial#_blank

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Works Cited

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., … Coyne-Beasley, T. (2015). “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” American Journal of Public Health, 105, 12, pp. 2588–2588, doi:10.2105/ajph.2015.302903a

Kozhimannil, K. B., Vogelsang, C. A., Hardeman, R.R., Prasad, S. (2016). Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. The Journal of the American Board of Family Medicine, 29, 3, pp. 308–317, doi:10.3122/jabfm.2016.03.150300

Thomas, M., Ammann, G., Brazier, E., Noyes P., Maybank, A. (2017). Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Maternal and Child Health Journal, 21, S1, pp. 59–64, doi:10.1007/s10995-017-2402-0

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