ACOG Releases New Guidance for Ob-Gyns on Partnering with Doulas

Washington, D.C.-Stronger partnerships between clinicians and doulas can lead to better patient outcomes, according to new guidance released today by the American College of Obstetricians & Gynecologists (ACOG).

The committee statement, "Partnering with Doulas in Clinical Settings," was authored by both ob-gyns and practicing doulas and offers recommendations on how ob-gyns can help foster this essential relationship with the goal of creating health systems that can improve patient experiences and outcomes.

Doulas are nonmedical professionals who have historically provided emotional, physical, and educational support and advocacy. Although there are different types of doulas, such as end-of-life or abortion doulas, most of the available data on the benefits of doulas refer to birth doulas.

There is strong evidence that doula support can lower the length of labor, decrease cesarean deliveries, improve rates of breastfeeding initiation, and increase feelings of birth satisfaction. When a patient is laboring, doulas can provide counterpressure; encourage movement; and provide physical comfort, reassurance, and encouragement.

"While ob-gyns are used to collaborating with a variety of maternity care professionals, medical education rarely includes collaboration with doulas," said Adetola Louis-Jacques, MD, FACOG, guidance coauthor. "We have more data on the benefits of doulas today than we did even a decade ago, but still more research is needed, especially in the postpartum period. This guidance aims to help fill some of the knowledge gap by explaining the role of doulas and why it's critical for ob-gyns to partner with doulas as an integral part of the care team."

With U.S. maternal mortality rates still unacceptably high, the incorporation of doulas has proven to be an evidence-based and cost-effective model to address the social drivers of health inequities that have persisted despite other concerted efforts and interventions. For that reason, many strategies to improve maternal health outcomes have increasingly included doulas.

"Doulas can help pregnant patients navigate what can be an intimidating health care system," said Rolel Mbaidjol-Kabra, MD, FACOG, coauthor of the guidance. "Pregnant patients who have historically been marginalized, including those from certain racial and ethnic groups and those who are low-income, incarcerated, or suffer from substance use disorders can benefit from having a doula that can help them feel more empowered, improve communication with their clinician, and support self-advocacy."

Today, doula services, which have typically been paid for out of pocket, are covered by Medicaid in nearly half of states with varying rates, processes, and certification requirements. Because there is not a single certifying body for doulas, core competencies can vary. Implementation also remains challenging due to a complicated reimbursement process and low reimbursement rates.

"The absence of a single national certifying standard can be a barrier to care for the patients who need it most, especially where institutions and health systems require credentialing to reimburse," said Lauren Graves, PHR, SHRM-CP, IPMA-CP, certified doula and coauthor of the guidance. "Standardization should set a floor but not be a single narrow gate. Accessibility is neither negotiable nor optional, because I've seen firsthand how much patients benefit from compassionate, respectful care when paired with medically necessary clinical interventions."

Doula coverage by private insurers is less common, though more states are attempting to change that by making it a requirement. ACOG does not have a position regarding payment for doulas; however, the guidance states that doula reimbursement should not be part of the direct payment from insurers to ob-gyns.

Despite efforts to increase coverage, there are still many patients who are either unaware of the benefits of doulas or simply can't afford one. The guidance highlights that it's important for ob-gyns to educate their patients about doulas and local resources that may be available to them to help with the cost.

"This guidance brings attention to the fact that doulas and ob-gyns have a shared goal of making sure each patient has a safe and dignified birth," said Dr. Louis-Jacques. "Doulas offer the kind of emotional and physical support that might not always be possible for clinicians when they need to be focused on their patients' medical needs. We should all strive to provide this type of team-based care because it is an important part of improving patient outcomes and because ob-gyns are uniquely positioned to champion this partnership for themselves and for their patients."

"Partnering with Doulas in Clinical Settings" was endorsed by DONA International, Doula Trainings International, the National Black Doulas Association, and the National Health Law Program. Read the full guidance.