September 13, 2022
Funding and Reimbursement
- Can you please tell us how much the Birth Sisters are compensated? They are compensated an hourly rate plus a bonus, but we are moving toward a flat rate per home visit and flat rate per birth to mirror the new MassHealth (Medicaid) reimbursement proposal.
- How are Birth Sister doulas funded? Currently they are funded through philanthropy
- Can you speak to how payment/reimbursement for doula services work within your Birth Sisters program at Boston Medical? See #1
- I was/am a doula, but do not practice anymore mainly because it is nearly impossible to make a living. I would love to hear more about your recommendations for living wage payments for doulas. This is an important topic. There are two different payment models that have been used in our program over the years. The flat rate includes prenatal visits, birth and postpartum visits. The hourly rate is ideal for those who want benefits, as well. The key here is to have a payment that compensates not just the time with the client, but also travel time, administrative time and any ongoing training.
- Are the birth sisters employed by the hospital or a separate organization? They are employed by the hospital.
Training and Educational Requirements
- Can I sign up on your website for doula training? We don’t provide training for the public but there are many other trainings available both on-line and in-person. You can find a training that is right for you by asking other doulas in your community about training programs. Different programs focus on different client needs, so be sure to compare options.
- What is the training protocol for attending births? After the initial ‘classroom’ training, new Birth Sisters shadow experienced Birth Sisters with 2-3 clients before working on their own.
- Are there apprenticeship or shadowing opportunities? We do not offer apprenticeships for people who are not hired as Birth Sisters at our hospital.
- Do you have any research on the training of community-based doulas? How did the Birth Sisters Program train their doulas? I’m not aware of research on training outcomes for community- based doulas. Birth Sisters follow a basic curriculum that includes attendance at a childbirth education series, workshops on home visiting, community resource navigation, breastfeeding support, labor support, special circumstances (trauma, DV, substance use disorder for example), effective communication, professionalism, racism in healthcare and hospital-specific information. Ongoing training on relevant topics occurs throughout the year.
- Do you have requirements for the doulas related to education/certification? No, we only require new employees to attend the Birth Sister training and shadowing. Generally Birth Sisters who are hired are required to have some experience working in the community. Some already have doula training.
Program Implementation
- In your research study, did the birth person get to choose their doula or were they assigned? No, they did not choose their doula but they could request a change in doula if the match was not right.
- Did any of the pregnant women have a preference of a doula being black or white? We try and match doulas to clients by their language and racial/ethnic background. The client can make specific requests, as well.
- What specific traits do you focus on selecting a doula for a patient? Language, racial/ethnic congruence, personality, specific needs and requests.
- You mentioned many of your 12 birth sisters were bilingual. How do you determine who is on call in this aspect? The doulas are matched to a client by language and culture. They are on-call to come in for their own client. If they are not available, a back-up Birth Sister is also assigned and ideally is also culturally/racially/linguistically congruent with the client.
- What has been the ideal doula to client ratio? How many clients is each doula seeing? Birth Sisters who do not have other work/family responsibilities generally have 4-5 clients due in a month. Others do more part-time doula work and may have 1-2 clients per month.
- Has your team/BMC considered expanding the Birthing Sisters model to other care facilities? Since our program is funded by hospital philanthropy it currently only serves our health care facility.
- Do you have any plan to extend this service to Asian immigrants or international students? We do offer this service to Asian immigrants. In our population, they are primarily from Vietnam and are served by our Vietnamese Birth Sisters. We do not generally have many international students who give birth at our hospital who would also meet the eligibility requirements for the program (low-income people with social stressors).
- Do you provide doula services in prison? We do not currently offer doulas to incarcerated pregnant women.
- Can you please say more about the scope of practice for doulas and how that might impact the associated outcomes for doula support? Community doulas provide the services we reviewed in the slides that I believe will be publicly available. We do not understand entirely the mechanism by which doula support improves outcomes. One hypothesis is that reduction in stress resulting from social support promotes a healthy physiologic response to pregnancy and birth. Another hypothesis is that the advocate at the bedside during labor influences the behavior and decision-making of the clinical team.
- Do you have any data on doula experience and patient outcomes? We do not have data on doula experience and the relationship to outcomes.
- Where can we find more information on your research findings? They are submitted for publication and, with luck, will be available in the medical sciences research databases soon.
- Do you find that there is often a misunderstanding of the role of a doula? If so, have you educated the Black community on the role and importance of doula support for those who don’t already know? Yes, the pregnant woman's midwife or doctor describes the services of the Birth Sister. We have not yet done a large-scale public education campaign due to lack of resources to serve all people who would want a Birth Sister.
- How do you navigate additional needs and resources to the pregnant and birthing people you support? Birth Sisters make referrals to other programs, community-based organizations and, when helpful, may accompany them on their visits, as well. Sometimes the Birth Sister may reach out to the clinical provider for additional support.
Program Sustainability
- Birthing Sisters Program is in BMC with a lot of resources. Would you please talk about the sustainability/opportunity of doula services in areas that may be lack for resources, such as rural areas? Rural areas definitely need doulas, too. Here is a link to the federal government’s Rural Health Information Hub publication on rural doulas: https://www.ruralhealthinfo.org/rural-monitor/doulas/
- What does the sustainability of your doula program look like? My understanding is that most Medicaid and private payors do not cover doula services, so when you can't bill for this how do you sustain this program? See ‘Funding and Reimbursement’ section, question 2.
Research Implications
- Dr. Mottl- Santiago's last comment regarding "exacerbating" disparities rather than mitigating them. How might that occur? If requirements for workforce entry and practice do not reflect the realities of community doula needs, the workforce will not represent communities most in need of doula support. This will perpetuate issues of implicit and explicit bias in maternal health care, as well as socio-economic immobility for birth workers of color.
- We are also working with community-based domestic violence programs to fund doulas to work with their clients. Are you hearing success with other CBOs (non-medical programs) hosting doula programs? That is wonderful! Yes, healthy start programs have some evaluation data on their doula programs, and much of the literature on doula services come from community-based organizations.
- I'm curious to hear more of the presenters' thoughts about integrating medical systems perspectives with more care- and community-based perspectives. For example the move towards precision home visiting and precision doula approaches. Do providers resonate with that kind of language (e.g., precision)? Integration of community health and medical system perspectives is critical for improving public health. There are many incentives for and barriers to this work. However, the tailoring of services/treatments to meet the unique individual needs of clients/patients is well understood in both realms. The concepts behind precision home-visiting is not unlike (and perhaps even borrowed from) precision-medicine.
- Is anyone considering how to offer health insurance coverage to independent/community doulas and midwives. I was essentially forced out of the field because I have no way to treat my own chronic conditions while being self-employed and with sky-high costs for premiums/deductibles. The cost of health care is a major concern in this country. I am not aware of any work specifically focused on providing health insurance coverage to self-employed doulas or midwives.
- How do you reconcile research on racial concordance of OB/GYN providers with the benefit of doulas? For example, some harms can be related to racial discordance with OB/GYNs vs access to a doula whose benefit might be related to the perception that they are 'outside' of the healthcare establishment? Shared racial/cultural/lived experience between doulas and their clients is valued by both clients and community doulas. In order for doulas to be welcomed into the health care setting, clinical staff must be educated about the role of the doula, as well as about implicit bias in health care.
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