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Appendix C - Additional Tier 4 strategies supported by coalition members

Note: There are no additional Tier 3 Strategies.

Additional Tier 4 Strategies Supported by Members of the Coalition: Ongoing Clinical Interventions

C.  Increase access to midwifery care for all women considered low-risk (medically)


D. Increase access to childbirth and postpartum doula services (Medicaid reimbursement; adding doula care to existing home visiting services)

Strategy 4C: Increase access to midwifery care for all women considered low-risk (medically).

In a recent series of evidence-based papers published in the Lancet, midwifery was identified as a underutilized high quality, high value intervention to help improve maternal and infant health outcomes in the short-, medium-, and long-term.115 A review of the scientific literature associates care provided within the scope of midwifery with reduced maternal and neonatal morbidity and mortality, reduced stillbirth and preterm birth, improved psychosocial health outcomes, and decreased use of unnecessary, and often costly, interventions.115 Increased access to midwifery care can contribute to a paradigm shift from pregnancy being viewed as a pathological event to being viewed and supported as a normal stage in a woman’s physiological development and reproductive life, which necessitates management of complications only when the need arises and when women have been identified as medically high-risk. The profound changes in the US health care delivery system, fueled by the Patient Protection and Affordable Care Act (ACA) passed in 2010, can be leveraged by the increasing delivery of inter- professional collaborative care: a model of care with a track records of excellent outcomes and cost- efficiency.116 In this model, akin to the team –based model known as the patient-centered medical home, midwife/obstetrician/primary care teams can provide seamless access to patients as their health care needs change over the course of their childbearing years.116


The Connecticut Coalition to Improve Birth Outcomes is supportive of programs, policies, and initiatives aimed at increasing the availability and accessibility of midwifery care services for all childbearing women, regardless of socio-economic status and geographic location. We also recommend formally increasing opportunities for seamless inter-professional collaboration for the benefit of childbearing families in our state.

Strategy 4C: Examples from the Ground

Integrated and Collaborative Model at Santa Clara Valley Medical Center

A pilot project funded by the Lucina Health Foundation sought to improve birth outcomes in Los Gatos, CA by supporting a collaborative model of care that integrated midwifery into the standard maternity care team. This model achieved a significantly lower cesarean birth rate (6% vs. the hospital’s average of 16.3% and the national average of 33%). Data also showed no induction, no prematurity, and a patient satisfaction rate of over 98%. Inspired by the success of the Lucina Maternity pilot program at Bay Area Maternity, Valley Medical Center Foundation is bringing this model to Santa Clara Valley Medical Center to improve infant morbidity and mortality rates and reduce costs to public and private payers. This model demonstrated profitability and positive outcomes within six months of implementation.


Coalition for Quality Maternal Care (CQMC)

CQMC advocates for the establishment of national strategies to ensure access to affordable, high quality maternity care for all childbearing women: “It seeks to achieve this goal by removing barriers to optimal maternal health practice, promoting models of care that are evidence-based, improving maternity care choices for women, and reducing disparities in maternal and newborn health outcomes.” The strong focus on advancing midwifery care is evidenced by the steering committee and founding members of CQMC: the American Association of Birth Centers; American College of Nurse-Midwives; Amnesty International USA; Association of Women’s Health, Obstetric and Neonatal Nurses; Black Women’s Health Imperative; Childbirth Connection; International Center for Traditional Childbearing; Midwives Alliance of North America; and the  National Association of Certified Professional Midwives.

Strategy 4D: Increase access to childbirth and postpartum doula services (medicaid reimbursement; adding doula care to existing home visiting services).

Childbirth can be viewed as a critical period in a person’s life, ripe with opportunities for renewal and growth, emotional and physical empowerment, as well as the strengthening of one’s self-confidence and self-efficacy to parent.117 That said, the event of childbirth has joined the ranks of events that can be experienced as traumatic by as many as 4 out of 10 women in the US, and in up to 9% of births give rise to symptoms that meet all qualifying criteria for post-traumatic stress disorder (PTSD).118,119 A history of trauma places women at a higher risk of re-traumatization during childbirth 120, making the quality and continuity of care and supports provided to at-risk women during the perinatal period, a priority from the Coalition’s perspective.

While many low income families in Connecticut can count on the support of home visitors prenatally and postpartum, few can take advantage of continuous informational, physical, and emotional support during labor and delivery, as well as during the immediate early postpartum days, effectively experiencing a break in valuable services during the continuum known as the perinatal period. Studies have shown that such support provided by a trained professional (a.k.a “doula”), who is not affiliated with the birthing hospital, nor a member of the birthing woman’s immediate social support network, can significantly reduce the length of labor, as well as the rate of interventions such as the use of epidurals, forceps, and cesarean surgery.121 Doula support can also significantly increase the woman’s feeling of satisfaction with the birth experience, and improve the odds of successful breastfeeding initiation and duration.122


These outcomes have been observed across different populations, including those impacted by low socio-economic status. In fact, after adjusting for clinical and socio-demographic factors, one prominent study found that the odds of cesarean birth were nearly 41% lower for doula-support births, translating in potential healthcare savings as well as reduced iatrogenic repercussions potentially caused by high intervention labor management practices.123


Members of the Coalition to Improve Birth Outcomes recommend that access to doula support during the perinatal period is expanded to ensure increased equity, reduce the incidence of traumatizing childbirth experiences, and improve overall perinatal health outcomes associated with the critical window of opportunity that comes with providing trauma-informed intrapartum care. Because coordination and integration of services is paramount to improving our perinatal health care system, we do not necessarily recommend that new programs be instituted, but rather that thought be provided into integrating trained doula support into existing home visiting teams, as well as exploring the possibility of making doula care provided by community health workers and other trained doulas more accessible through Medicaid and private insurance reimbursements.

Strategy 4D: Examples from the ground

Doula Training and Certifying Organizations

There are many organizations that train and certify doulas. They generally differ, though not extensively, in terms of certification requirements, fees, philosophy, scope of practice, and extent of support and mentorship provided. In addition to the more mainstream DONA International and CAP P A, there are also other organizations that have become more specialized in training doulas intent on serving families from underserved communities. These include the International Center for Traditional Childbearing and Health Connect One (see below). Other organizations that MCH professionals may want to explore include, but are not limited to: Birthing From Within, To L abo r, and Doula Trainings International.


Health Connect One

Over 6,000 low-income families have received services through the nationally replicated community doula program designed and administered by the Chicago-based organization Health Connect One. Outcome data support the published literature about the benefits of doula care, and add additional data that are of particular interest when serving at-risk populations. These include lower rates of preterm birth, higher birth weight, reduced hospital stays, and increased use of preventative and primary care services.124


ECHN Mentor/Doula Program

In 2002 the Connecticut Chapter of the March of Dimes awarded a one-year grant in the amount of $14,953 to ECHN. The funds were used to develop a Mentor/Doula Program, which to this day, provides supportive services to high-risk women during pregnancy, labor and birth, and in the initial postpartum period. Many women with high-risk pregnancies do not have a stable support system – the volunteer mentor/doula can fill that gap, serving as a role model and advocate, assisting the women so they can receive individualized care based on their circumstances and preferences. Formally trained doulas who complete certification and receive positive evaluations from both patients and staff are then considered for the ECHN Preferred Doula Referral Program, which then allows the more experienced doulas to receive compensation for each supported client. The network of independent doulas who practice at ECHN have the added value of being part of an established group for back-up support and mentoring. For more information contact the Perinatal Education Department at Manchester Memorial Hospital Family Birthing Center.


Young Adult Services (YAS) program

The Connecticut Department of Mental Health and Addiction Services (DMHAS) offers the Young Adult Services (YAS) program to help young adults (ages 18-26) transition successfully from the Department of Children & Families (DCF) to the adult mental health system and to ensure continuity of care as they journey into adulthood. As part of the program, pregnant participants can take advantage of valuable doula care and support prenatally, intrapartum, and during the early postpartum period. Doula care fits well with the YAS model of trauma-informed care, as it understands the intimate and possibly trauma-triggering aspects of clinical care during pregnancy and childbirth. Doulas are professionally trained and can partner with the woman’s clinical team to help alleviate trauma symptoms, while providing emotional, informational, and physical assistance and support to childbearing women with a potential history of neglect and physical and/or sexual abuse. With funding from the CT Department of Public Health, this program has been able to expand its impact to a longer period postpartum (up to age 3 of the child), and to provide additional group- based and in-home parenting support through the use of Parents As Teachers (PAT) curriculum and the relationship-based Circle of Security program that seeks to enhance parent-child attachment.


Medicaid Reimbursement for Doula Care in Oregon and Minnesota

In 2011, the Oregon legislature passed a bill (H.B. 3311) that required the state’s health authority to explore the viability of expanding access to doula care as a means to improving birth outcomes and reducing perinatal health disparities. In 2012, an implementation committee issued a  report recommending that doula care be indeed covered not only by Medicaid, through the CMS waiver program, but also by private insurers in the state, in an effort to reduce disparities and improve birth outcomes for all women in the state of Oregon. Oregon has since implemented said call to action, joining the state of Minnesota, in making doula care more equitably accessible for all childbearing women. Medicaid reimbursement for doula care is permitted under the 2013 CMS ruling allowing states to reimburse for preventive services that have been recommended by a licensed medical provider.

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