On Saturday I came across this tweet by one of the authors of the award winning ProPublica series on maternal mortality, Lost Mothers.
Very excited to be speaking today at DONA International 2018 Summit to a group of women who have done so much to protect other women from becoming Lost Mothers: doulas.
What have doulas done to prevent maternal mortality? I could find no peer reviewed scientific evidence that doulas have done ANYTHING to reduce maternal mortality.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How can doulas, who have fewer hours of training than some labors, prevent maternal deaths?[/pullquote]
But that hasn’t stopped the ugly effort of doulas to claim they can. And people are listening (although not applying any critical thinking). According to The New York Times:
Gov. Andrew M. Cuomo announced on Sunday a series of initiatives aimed at addressing a disturbingly high rate of maternal mortality among black women, who are four times more likely to die in childbirth than white women in New York State, according to a study released last year.
The plan includes a pilot program that will expand Medicaid coverage for doulas, birth coaches who provide women with physical and emotional support during pregnancy and childbirth.
Studies show the calming presence and supportive reinforcement of doulas can help increase birth outcomes and reduce birth complications for the mother and the baby…
We’re supposed to believe that doulas, who have fewer hours of training than some labors, can prevent maternal deaths?
I’m not exaggerating. Doula training involves only 16 hours of workshops. It is not unusual for the average first labor to last hours longer than that.
The leading causes of maternal mortality are cardiac disease, other chronic pre-existing disease and serious medical complications of pregnancy; how could doulas possibly prevent those? They can’t. It’s an especially puzzling claim when you consider that, as detailed in the Lost Mothers series, many women who die initially received false reassurance that the symptoms of their impending demise were merely variations of normal. Doctors’ chief complaint about doulas is that they offer women false reassurance in the face of high risk status and complications. So how are doulas, who are more likely to offer false reassurance, going to prevent doctors from offering false reassurance? They aren’t.
What’s this really about? Follow the money!
It’s yet another effort by “birth workers” to exploit tragedies to promote themselves. Doulas are desperate to have their high fees covered by insurance and Medicaid; they are expensive and most women can’t afford them. Insurance companies and Medicaid are unlikely to pay doulas to improve women’s birth experiences but they might be willing to pay to reduce deaths, so doulas pretend they can reduce deaths.
This cynical campaign comes from the Ina May Gaskin playbook. Gaskin is the grandmother of America’s homebirth midwives — a second class of midwife different from certified nurse midwives, who fail to meet international midwifery standards and are found no where else in the industrialized world. Gaskin came up with the “Safe Motherhood Quilt” as part of her campaign to receive insurance and Medicaid coverage for this second, inferior class of midwives.
Gaskin represented herself as shocked at the rate of maternal mortality. Yet as far as far as I can tell, homebirth midwives in general and Gaskin in particular have done NOTHING (no research, no education, no fund raising) to reduce the incidence of maternal mortality. They merely exploited the deaths to promote themselves.
Doulas are now doing the same.
But aren’t there studies that show doulas improve outcomes?
I couldn’t find a single peer review scientific study that shows that doulas reduced maternal mortality. There are studies that show that doulas can decrease intervention rates, but that’s a process, not an outcome. Moreover, most studies of doulas are riddled with confounding variables; even when doulas are offered for free, the women who choose doulas differ in important ways from women who don’t choose them and those differences are likely to impact outcomes.
What about the work of midwife Jennie Joseph showing that support improves outcomes?
Jennie Joseph is a British-trained midwife, a women’s health advocate, the founder and executive director of Commonsense Childbirth Inc. and the creator of The JJ Way®. She moved to the United States in 1989 and began a journey that has culminated in the formation of an innovative maternal child healthcare system, markedly improving birth outcomes for women in Central Florida.
What’s the JJ Way?
The key components in our health care delivery are: prenatal bonding through respect, support, education, encouragement and empowerment.
But there’s no evidence that the JJ Way has improved health outcomes for anyone. It’s never been the subject of peer reviewed scientific research. So why does anyone think it works? Because a paid “report” claims it does.
The “report” concludes:
Women who received maternal care The JJ Way® had lower preterm birth rates than women in Orange County and the State of Florida…
Women who received maternal care the JJ Way® had significantly better low birth weight rate percentages than women in Orange County and the State of Florida…
This evaluation of The JJ Way® model of prenatal care showed elimination of health disparities in preterm birth outcomes and reductions in low birth weight babies in at-risk populations.
The report, produced by a sociologist and a mental health counselor, shows nothing of the kind. Why not? Because the authors failed to correct for confounding variables other than race. The women who participated in the program were a self-selected group. As such, they are likely to differ from the average women in the county and the state on demographics like income, pre-existing health conditions, substance abuse, smoking status and a variety of other characteristics.
Unless and until Joseph corrects for those confounding variables, she isn’t entitled to make any claims about her program.
The bottom line is that there is very little evidence that support improves outcomes as opposed to merely reducing interventions. And there’s no evidence that support prevents maternal deaths.
Of course, there’s nothing wrong with doulas; they can be very helpful to women. But there’s something very wrong with them exploiting maternal deaths to promote themselves.
