Doulas: A Strategy to Address Maternal and Infant Health

00;00;01;12 - 00;00;39;25
Tom Haedrle
American Medicine has been a world leader in many aspects of health care, pioneering new procedures and developing life saving drugs. So it will come as a big surprise to many - maybe shock is more like it - that the U.S. has fallen alarmingly behind many countries in a basic measure of progress: maternal health. Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;40;05 - 00;01;20;18
Tom Haedrle
I'm Tom Haederle, with AHA communications. In this conversation, the AHA's Crysta Meekins, program manager at the Institute for Diversity in Health Equity, and Ogechi Emechebe, senior communication specialist at IFDHE, focus on ways to address disparities within maternal and infant health by involving doulas in prenatal and postpartum care. They are joined by Sauleiha Akangbe, birth equity manager at Swedish Hospital, and Gwen Kiehne, lead Doula at Swedish Hospital, who explain the role that doulas serve in prenatal and postpartum care and how physicians and doulas can work together to address the growing maternal health crisis.

00;01;21;12 - 00;01;42;24
Crysta Meekins
Welcome, Sauleiha and Gwen. Thank you very much for taking time to speak with us today about this very pressing topic. So I'm sure you've seen the recent data release from the CDC on the worsening maternal health crisis in the United States. According to the Centers for Disease Control and Prevention, there was a 40% increase in maternal deaths from 2020 to 2021.

00;01;43;06 - 00;02;10;12
Crysta Meekins
The U.S. rate for 2021 was 32.9 maternal deaths per 100,000 live births, more than ten times the rates of other developed nations. This report also detailed an even more disheartening reality. The maternal death rate for black Americans was 69.9 per 100,000, which is a little over double the rate for white women. So I really want to gear this conversation towards strategies to address maternal and infant health disparities.

00;02;10;22 - 00;02;22;16
Crysta Meekins
And I believe a great opportunity is to implement doula services into maternity care. Can you explain the role of a doula and the purpose they serve in prenatal labor and delivery and postpartum care?

00;02;23;07 - 00;02;50;11
Gwen Kiehne
Yeah, I guess I'll start. I'm going to introduce myself. I am the lead doula for the Swedish doula program here in Seattle, Washington. And we have been around since about 2016. That's when we started. The role of the doula is kind of a unique role in the health care environment. We are there to provide physical and emotional support to the birthing person in their family.

00;02;50;22 - 00;03;19;26
Gwen Kiehne
So specifically, the doula is like a companion or coach or an advocate who is wholly focused on the experience of the birthing person, their comfort, their emotional well-being and their wishes for their birth experience. So in general, the doula is consider birth like as a natural physiological process that if we can help somebody feel safe and comfortable, that that can unfold for them more easily.

00;03;20;19 - 00;03;27;06
Gwen Kiehne
So we're there to kind of ease their way in the hospital environment specifically, but also at home and in birthing centers as well.

00;03;27;28 - 00;04;04;08
Sauleiha Akangbe
Yeah, And I'm just going to kind of ping in. My name is Sauleiha Akangbe and I am the birth equity manager with Providence Swedish. I run the Justice Unity Support Trust Network over there, and I work a lot with Gwen in our doula program as well. So when I whenever I look at anything, I can't really separate the fact that I am a black woman and me going into the space, whether that's as a birth doula, to postpartum doula, someone who's supporting with fertility or anything like that, I am coming from that lens.

00;04;04;19 - 00;04;29;23
Sauleiha Akangbe
So when we look at a lot of the reasons why doula work and the birth postpartum labor delivery, all of these things need to be implemented into birth overall. For me, I'm looking at it as so where it is that we began and why the movement needed to go in the direction in which it did. And I call it a movement because it feels like that.

00;04;29;23 - 00;04;55;17
Sauleiha Akangbe
It feels like we're really, like literally moving into this space of like we're taking action and it's happening regardless, like keep up or go somewhere. And I feel like a lot of that is because for especially the black communities, I'm African-American events like this, that and so within our communities here in America specifically, we start where we have all we have is each other.

00;04;56;01 - 00;05;19;28
Sauleiha Akangbe
We went through and we built this community together because it's what we were handed when we were taken and brought over here to to work and build this country. And what we took with that is really building community with one another. And so we took all these different people from different tribes and different dialects and different spaces and people, they saw us and they just see black people.

00;05;20;01 - 00;05;41;03
Sauleiha Akangbe
You're all the same. But we understood we were different, but we still were able to merge and create what we consider the African-American culture over here. And when after slavery was abolished, you know, we come into the fact that black people still support it. The whites support it. The black women who were giving birth in these spaces.

00;05;41;03 - 00;06;10;27
Sauleiha Akangbe
And we also had that family support. I believe the doula movement movement came in to really say, you still can have someone who looks like you, who knows about this work. I know your aunt or your mama can't fly across the country, but you absolutely can have someone who can support you in this space, in this room during your birth, during your pregnancy, when you're like sitting there just throwing up because you're in the beginning stages of pregnancy and you don't have anyone to go to.

00;06;11;17 - 00;06;23;26
Sauleiha Akangbe
Guess what? I can come to your home and I can absolutely give you what you need. You need someone to rub your feet. I got you. You need someone postpartum who's gonna, like, help you heal and bring your body back together. I got you.

00;06;24;07 - 00;06;25;03
Crysta Meekins
Absolutely.

00;06;25;24 - 00;07;04;19
Gwen Kiehne
I would be remiss my my first and and and true doula love is postpartum work. And so I would be remiss not to specifically call out the important role of doulas during the postpartum period as well, because I think we get very focused on birth outcomes in the hospital. But then there's this huge gap in health care when people leave the hospital in their home with their babies and they're not going to see their doctor for six weeks or even longer, depending on the traumas that people had in the hospital, how comfortable and safe they feel with their doctor, etc..

00;07;05;09 - 00;07;31;16
Gwen Kiehne
Sometimes people are missing health care for long periods of time postpartum. And so having that doula care, that wraparound care when people are home with their babies is so critical in helping make sure people have the care that they need and eyes and ears on whatever they might be experiencing, especially if they're complications postpartum. So when we think about outcomes, I think that's a really critical piece to talk about.

00;07;31;28 - 00;07;43;10
Ogechi Emechebe
 Well, that actually, Gwen leads into my question right now. So can you please tell us a little bit more on how does can prevent adverse maternal and infant outcomes in maternity care? And then as as a follow up question, do you mind giving us some more information on the critical need for focusing also on postpartum care?

00;07;50;25 - 00;08;14;05
Gwen Kiehne
Yeah, absolutely. I feel like Suli and I will come at this from two kind of different angles that overlap quite a bit. So as a doula, I really think about birth and kind of the process that we go through during pregnancy, during birth and then postpartum as a physiological and natural physiological process that our body goes through, right?

00;08;14;05 - 00;08;49;16
Gwen Kiehne
And that process is heavily influenced by our hormone regulation, our emotional well-being. Right? So when we feel comfortable, we feel safe. We feel connected during our experience, we feel held. That process can unfold much more easily. Whenever somebody has a history of trauma, whenever somebody is feeling unheard, unsafe, you know, when things are rushed, when they're feeling tension in their body, it makes that physiological process a lot more difficult.

00;08;49;22 - 00;09;16;28
Gwen Kiehne
And those are the kinds of things that can influence the escalation of interventions that we think about happening to folks in the hospital. So it's sort of like a feedback loop that can happen in the body where when somebody is feeling afraid, you know, it's harder for their body to relax into this birth experience. So sometimes it's a matter of getting the system out of the way of this birth, being able to unfold the way that it needs to.

00;09;16;28 - 00;09;45;04
Gwen Kiehne
And of course, those medical supports are needed. But how supportive somebody feels in their experience, how heard they feel, how centered they feel in their health care can make such a difference in how safe they feel with the unexpected happening and those medical interventions needing to happen. It's something that I think we often overlook in the medical environment is just that the simple fact of centering somebody in their own experience.

00;09;45;12 - 00;10;19;16
Gwen Kiehne
And that's what a doula does, right? They help that person feel centered in their experience because their role is 100% completely focused on this person and their experience. And so having that person, having that doula or even a family member sometimes can play that role, be an advocate for them. And to be a respected member of the care team can kind of like translate, act as a translator in a sense between this person and their needs and the health care system that they're trying to birth in.

00;10;19;26 - 00;10;58;06
Gwen Kiehne
You know, and at Swedish. It's been really interesting over the last seven years with this new program. We are increasingly integrated into the care team in pretty meaningful ways. We're able to go into the O.R. and be present for somebody when they're having a cesarean birth and to still protect their wishes and their experience, even through a highly medicalized birth where, you know, working with anesthesiologists, we're working on accountability pathways within the hospital environment to address some of these issues that I'm sure Solly will we'll talk about.

00;10;59;06 - 00;11;29;29
Sauleiha Akangbe
Yeah, it's extremely apparent, right, where everything that Gwen is saying is absolutely correct, right? Like as to why it's, like, important that we're there. But the reality is, once again, I'm a black woman. I'm always gonna come from that point of view. We're so displaced because of the racism within health care that we can't even get there as black women and people giving birth.

00;11;30;29 - 00;11;55;05
Sauleiha Akangbe
It's so apparent. And then on the other side of it, you know something personal about me. I just I'm a believer that doulas aren't the fix because we have to first address the racism within health care. And if we don't, you know, we have one side of it where if we don't and if we continue to say, okay, well, we see the statistics that doula support and doula does X, Y and Z, let's keep putting us in there.

00;11;55;28 - 00;12;18;22
Sauleiha Akangbe
And so we are trying to keep ahead. We're trying to keep ahead. We see our our patients experiencing trauma and it's emotionally triggering. I believe that we are absolutely we can be what one is speaking about. But we got to first hit this other piece where it's like, give us the basic human decency to come and give birth as a person.

00;12;18;29 - 00;12;34;20
Sauleiha Akangbe
Trust that I know my body. However, I have also witnessed where we have been able to address these things and our doulas are able to integrate well and culturally affirming care is so important.

00;12;35;26 - 00;12;57;08
Crysta Meekins
He brought really great points in that. The thing that I heard the most, and I know that you've seen it. I've seen it when, you know, we see these articles in the headlines of women dying, we know that a high percentage of the deaths are preventable. But we also know that when women are going into these spaces, that they're not being heard.

00;12;57;20 - 00;13;11;03
Crysta Meekins
And so I think you brought up the great point that that's kind of where a doula can come in to give them that, you know, that empowerment to really push for the things that that they want to be heard about. So I really love that point.

00;13;11;24 - 00;13;28;03
Gwen Kiehne
Yeah, I agree, Sully. I think you brought up a lot of great points. I think the biggest thing that I heard is racism is not being addressed in health care. So, you know, if a lot of women are entering these hospitals and they're pushing and pushing to be heard, but racism has that kind of big cloud over them that they're just not being heard.

00;13;28;11 - 00;13;31;02
Gwen Kiehne
We're still going to keep on seeing these maternal health outcomes.

00;13;31;27 - 00;13;52;16
Crysta Meekins
So, Gwen, you you spoke to this a little bit already, but can you describe the importance of doulas, physician nurses, so that interdisciplinary team, what does that relationship look like? And then how can that team be a beneficial factor in improving outcomes for moms and babies?

00;13;53;05 - 00;14;22;17
Gwen Kiehne
Yeah, I love this question because I feel like that mutual respect and collaboration is really key to this working. We have to start from a place of really recognizing the the role of the doula and, you know, respecting that and respecting the experience of the birthing person. If we can start from that place, the collaboration I think, can flow pretty pretty easily and pretty well.

00;14;22;17 - 00;14;47;28
Gwen Kiehne
And when that works, you know, even when the unexpected happens, even when medical interventions are needed, we can have, you know, a birthing outcome and a birthing experience without trauma. And that's really like that is the ultimate goal, right? Is to birth without trauma. When everybody knows what their role is, and we can come from a place of mutual respect, I think that that can work really well.

00;14;48;06 - 00;15;34;06
Gwen Kiehne
At Swedish, it's been it's been really interesting. We over the last couple of years especially, we've began being able to participate in the emergency simulations that happen in the hospital. So we've done one on hemorrhage, we've done one on shoulder dystocia where the doula actually gets to come in and play the role of the doula in these simulations and be focused on the experience of the birthing person and to kind of demonstrate for the other nurses and providers in the simulation, you know, the importance of our role and how that even in an emergency situation where things are very fast paced and very medicalized and, you know, still we can bring in and we can

00;15;34;06 - 00;16;02;05
Gwen Kiehne
center this person's experience. And that's been really powerful, I think, just to show like how we can be integrated and how that integration can go really, really well and really smoothly, we can all learn from each other and value each other's expertise and, you know, come from a place of, again, centering this person in their experience. We've been in the process of implementing a program called Teen Birth at Swedish.

00;16;02;25 - 00;16;25;29
Gwen Kiehne
I know they're doing this in other places around the country, but the idea is that we put the patient at the center and everybody else is there. You know, everybody is their team. And this person and their birth experience is on the team to get to make their decisions, to be informed, to be a part of every conversation that's happening about their care.

00;16;26;08 - 00;16;48;14
Gwen Kiehne
And at Swedish, doulas have been a part of that conversation and a part of that roll out, which has been really cool. It's been really neat to be at the table deciding like, how does this work and what do we need to think about and how do we center the patient. And having the doula voice valued at that kind of institutional level has been amazing.

00;16;48;18 - 00;17;01;16
Gwen Kiehne
I think it speaks volumes to the level of integration that doulas can have in the hospital and what's possible once we start to allow that voice to be present in the system.

00;17;03;07 - 00;17;35;04
Sauleiha Akangbe
Yeah, and I want to follow up with a little bit of your question with Gwen, because we've been doing a lot of what we call culture work, at Providence Swedish, where we are really looking at the culture that is upheld within each of our units, within each of these professions. And looking at medical hierarchy. You know, when a doctor is in the space, why they even feel like what they say matters most.

00;17;35;04 - 00;17;55;15
Sauleiha Akangbe
And that's when we start having that conversation of recentering the patients like one set and making sure that we're doing the work beforehand. So the just work network specifically is what's trying to address that piece as well as the other culture work that's happening within our hospitals of like, you know, how do we bring you back down to earth?

00;17;55;28 - 00;18;30;17
Sauleiha Akangbe
So realize that you're walking into this patient space and that they actually care a lot more about what's going to happen with them and their baby and trust that process. I know it's hard, but trust that process. So we've we've been attempting to really dig into that and work with each person as an individual to be able to see it all in a sense, or to at least step back and be corrected in the moments when it needs to happen and when it's most important for each person who's giving birth.

00;18;30;29 - 00;18;53;00
Crysta Meekins
I love that. I absolutely love that. Love the idea of really centering the patient because that's what matters at the end of the day, the patient and then, of course, the other patient, the baby. So I've really enjoyed this conversation. This has been so, so good. So what would you say is the call to action for hospitals to produce equitable health outcomes for mothers and babies?

00;18;53;24 - 00;19;13;29
Gwen Kiehne
I think we keep saying it over and over again. We call it the call to action really is to send to figure out ways to center the patient, because when we're really listening, when we're really centering their needs, it's hard to go wrong writing it like and that can look in lots that can look lots of different ways in the hospital environment.

00;19;13;29 - 00;19;35;25
Gwen Kiehne
At Swedish, it's teen birth. It's, you know, respecting the role of the doula, it's respecting family members and different cultural needs of people when they're coming and the different spiritual needs that people have in their birthing. That's the call to action as to pay attention and center the center of the patient.

00;19;36;16 - 00;20;10;28
Crysta Meekins
Absolutely. So I really just wanted to thank you all so, so much. This was such an enriching conversation. Thank you for sharing with us about your your perspectives into, you know, implementing doulas into care in the patient centered experience and what that should look like. And I just really appreciate you all. Thank you so, so much.