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Service Delivery Innovation Profile

Nursing Students Provide Free Doula Care to Underserved Women, Leading to Fewer Preterm Deliveries, Low Birthweight Babies, and Cesarean Sections


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Snapshot

Summary

The Johns Hopkins University School of Nursing Birth Companions Program assigns student doulas (labor assistants who support women throughout the childbirth process) to underserved pregnant women, free of charge. The program trains nursing students to provide emotional, informational, and physical support to women throughout pregnancy and childbirth, including labor. Students also maintain a bilingual patient referral line and deliver prenatal education to groups of women at community-based organizations. The program lowered the risk of preterm delivery and having a low birth weight baby, reduced deliveries by cesarean section, and generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of data on preterm births, low birthweight babies, and cesarean sections for 595 births attended by program doulas between January 1, 1999 and June 30, 2008, compared with Maryland statewide averages for these indicators. It also includes satisfaction survey responses gathered from 405 program participants between 1999 and 2006.
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Developing Organizations

Johns Hopkins University School of Nursing
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Date First Implemented

1997
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Patient Population

Gender > Female; Vulnerable Populations > Womenend pp

Problem Addressed

Preterm births and the delivery of low birthweight babies are significant, growing problems that can lead to serious health problems, particularly among babies born to underserved women. Doulas (labor assistants who support women throughout the childbirth process) can help improve maternal and fetal outcomes, but many women do not have access to their services.
  • A significant health concern: Babies born prematurely (before 37 weeks gestation) face increased risk of a number of serious health problems, including low birth weight, chronic breathing problems, and lifelong nervous system disabilities. In Maryland, prematurity and low birth weight represent the leading causes of death in the first year of life.1
  • Growing prevalence, especially among underserved women: Since the 1980s, the percentage of babies born prematurely and/or with low birth weight has continued to rise across the country. In Maryland, premature births accounted for 13.3 percent of all births in 2005,1 which is above the Healthy People 2020 goal of 11.4 percent as well as the previously published Healthy People 2010 goal for premature births.2 The premature birth rate in Maryland is higher for black (17.1 percent) and Hispanic infants (12.5 percent) than for whites (11.3 percent).1 Pregnant teenagers are also at higher risk, with preterm birth rates across the nation averaging 14.5 percent for women under age 20.3
  • Unrealized potential of doula care: Doula care can reduce the risk of preterm delivery and low birth weights,4 and doula services provided before and during labor can lead to shorter labor, fewer complications during delivery, and fewer cesarean sections.5,6 However, many underserved women do not have access to doulas, either because they do not know that the service exists or because they cannot afford it.

What They Did

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Description of the Innovative Activity

The Birth Companions Program provides free doula care to underserved pregnant women. The program trains nursing students to provide emotional, informational, and physical support to women throughout the pregnancy and birthing process, including labor. Students also maintain a bilingual patient referral line and deliver prenatal education to groups of women at community-based organizations. Key elements of the program include the following:
  • Doula training for nursing students: Nursing students complete a two-credit doula training course offered two or three times each semester. The course includes 16 hours of intensive skill- and theory-based instruction provided by a certified Doulas of North America trainer. Instruction covers patient advocacy, prenatal and postpartum health, infant care, breastfeeding, and use of supportive techniques (such as massage, body positions, breathing methods, and birthing balls) during childbirth. Students also receive an additional 4 hours of instruction from Johns Hopkins School of Nursing faculty that covers how to navigate the health care system and how to connect pregnant women to community resources.
  • Bilingual referral line: Pregnant women sign up for the program via a bilingual (English and Spanish) referral line staffed by nursing students. Each client completes a brief telephone intake with a nursing student, who then enters the client’s deidentified information into a secure and confidential online database. The client is then matched to a student doula, who contacts the client to initiate the relationship. Although there are no eligibility requirements for women to receive doula services, the program makes an effort to target underserved (typically uninsured) women, including low-income women, Hispanics, and teenagers.
  • Free doula services: Each nursing student provides doula care to one or more pregnant women in the greater Baltimore area. Unlike midwives and obstetricians, doulas do not perform any clinical or medical procedures; rather, doulas serve in a capacity that is purely supportive, providing the client with personalized emotional and informational assistance in addition to the medical care the client receives from her providers. Each pregnant woman enrolled in the program receives at least one prenatal visit, one postpartum visit, and labor support from her doula (as described below); many women receive multiple visits, depending on individual needs.
    • Prenatal visit(s): Before labor, the doula meets with each woman to become acquainted, identify any information or resource needs she may have, and explore any fears and concerns about pregnancy or childbirth she may be experiencing. Together, the doula and client develop a personal birth plan, including preferences for pain management and coping techniques.
    • Labor support: During labor, the doula provides the client with emotional support, information, and assistance with physical comfort, including relaxation techniques, massage, and positioning. The doula also advocates for and supports the client’s decisions (such as whether to use pain medication) throughout the childbirth process.
    • Postpartum visit(s): After the baby’s birth, the doula visits the client at home to help her reflect on her childbirth experience, offer additional emotional and practical support, and connect her with any needed community resources, such as lactation consultants, mental health counseling, and public assistance for food or housing. The doula also ensures that followup medical care has been secured for both mother and infant.
  • Community education: Each term, two or three students enrolled in the doula training course serve as community liaisons, maintaining and nurturing the program’s relationships with the more than 30 community agencies to which they refer clients for additional services. Community liaisons provide each organization with informational brochures, handouts, and posters that describe program services, and also conduct educational workshops and presentations for community members on prenatal health care, childbirth, and parenting.

Context of the Innovation

The Johns Hopkins University School of Nursing is one of the top-ranked nursing schools in the country. In the late 1990s, a group of nursing students returning from service in the Peace Corps expressed an interest in learning about and providing doula care. Having worked with pregnant women in developing countries, the students wanted an opportunity to provide hands-on pregnancy and labor support to underserved women in Baltimore. To that end, the students worked with Johns Hopkins faculty to launch the Birth Companions program in 1997.

Did It Work?

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Results

The program lowered the risk of preterm delivery and having a low birthweight baby, reduced deliveries by cesarean section, and generated high levels of patient satisfaction.
  • Fewer preterm births, low birthweight babies: A review of births over a 9-year period found that only 4.2 percent of births among participants occurred before 37 weeks gestation, far less than the Maryland statewide rate of 13.3 percent. Program participants were also much less likely to deliver a low birthweight baby, with only 3.2 percent of participant's babies weighing less than 2,500 grams (compared with 9.4 percent statewide).7
  • Fewer deliveries via cesarean section: Only 22 percent of program participants delivered via cesarean section, compared with 32.2 percent statewide.7 Only 14 percent required episiotomies, and 70 percent used epidural anesthesia.
  • Highly satisfied patients: Among 405 participants completing surveys, 87 percent found the doula services to be a “big help” physically and 80 percent found them to be a “big help” emotionally.8

Evidence Rating (What is this?)

Suggestive: The evidence consists of data on preterm births, low birthweight babies, and cesarean sections for 595 births attended by program doulas between January 1, 1999 and June 30, 2008, compared with Maryland statewide averages for these indicators. It also includes satisfaction survey responses gathered from 405 program participants between 1999 and 2006.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Obtaining leadership buy-in: Nursing students and several School of Nursing faculty members met with Johns Hopkins leaders to provide information on the program and to gain their support for it, including making the training program a credited course within the School of Nursing. Students and faculty presented data illustrating the proven benefits of doula care for women and infants and the need for such services among Baltimore’s underserved women.
  • Hiring doula trainer: The program sought and hired a certified doula trainer through Doulas of North America. This Baltimore area resident works with the program on a contractual basis.
  • Developing course materials: Although the core 16 hours of student doula training are standardized as part of the Doulas of North America structured training curriculum, School of Nursing faculty worked together to develop the remaining 4 hours of instruction, most of which revolve around Baltimore-specific resources and information.
  • Establishing relationships with community agencies: Using existing relationships between Johns Hopkins and the surrounding community, program leaders reached out to local social service and community-based organizations to establish informal partnerships. Creating and maintaining these relationships helps to facilitate client referrals to the program and allows student doulas to provide clients with seamless referrals to resources they may need as they enter parenthood.

Resources Used and Skills Needed

  • Staffing: The program has no dedicated staff. Two School of Nursing faculty members administer the program as a part of their regular job responsibilities. As noted, nursing students provide all program services and an external doula trains these students under contract with the program.
  • Costs: In 2009, program costs totaled $65,000, up from $55,000 the previous year and from $49,000 in 2006-2007. Program costs have generally risen roughly 10 percent per year.
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Funding Sources

Premier Cares; Johns Hopkins University School of Nursing; Johns Hopkins Women’s Board
Birth Companions is funded primarily through the Johns Hopkins University School of Nursing, with additional private funding coming from foundation grants.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Identify a champion: The champion needs to be committed to the program’s mission and willing to be a vocal advocate for that mission, both within the institution and the local community. Ideally, the champion should also be available to students as a source of support and formal or informal mentoring.
  • Build strong community relationships: Creating and nurturing strong connections to community agencies will benefit both the program and its clients. This step helps to ensure that organizations feel comfortable and confident in referring women to the program, and that clients receive accurate and useful information regarding services available to them through external agencies.
  • Maintain relationships with area providers involved in childbirth: To ensure that hospital staff and other providers remain willing to support student doulas in learning about and participating in the childbirth process, keep lines of communication open between program leaders and these providers.

Sustaining This Innovation

  • Plan for student transitions: Because the program relies heavily on students, make sure that an adequate number of nursing students are available to provide program services between semesters and during school breaks.
  • Avoid extending beyond program’s means: Keep staffing and budgetary constraints in mind when accepting new clients and community engagements. Staying within established constraints helps to ensure that the program delivers the best possible service to enrolled clients.

More Information

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Contact the Innovator

Elizabeth Jordan
Co-Director, Birth Companions
Johns Hopkins University School of Nursing
525 N. Wolfe Street
Baltimore, MD 21205
(410) 614-5306
E-mail: bjordan@son.jhmi.edu

References/Related Articles

The Birth Companions Web site is available at: http://www.son.jhmi.edu/areas_of_excellence/local/bc/.

Simpson JC. The New Labor Movement. Johns Hopkins Nursing Magazine. 2004;2(2). Available at: http://magazine.nursing.jhu.edu/2011/08/the-new-labor-movement/.

Jordan ET, Van Zandt SE, Oseroff M. Educating undergraduate nursing students as birth companions. Nursing and Health Care Perspectives. 2001;22(2):89-91.

Footnotes

1 Maryland Family Health Administration. Prematurity Awareness Fact Sheet. Available for download at: http://fha.dhmh.maryland.gov/mch/Documents/Prematurity_awareness.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)
2 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020: Maternal, Infant and Child Health Objectives [Web site]. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26
3 March of Dimes. Teenage Pregnancy Fact Sheet [Web site]. 2009. Available at: http://www.marchofdimes.com/glue/files/teenagepregnancynodate.pdf.
4 Robert Wood Johnson Foundation. Chicago Project Delivers Support to Young Mothers-to-Be. April 2008. Available at: http://www.rwjf.org/reports/grr/029806.htm.
5 Taylor JS. Caregiver support for women during childbirth: does the presence of a labor-support person affect maternal child outcomes? Am Fam Physician. 2002:66(7):1205-6. [PubMed]
6 Van Zandt SE, Edwards L, Jordan ET. Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practice. Complement Ther Clin Pract. 2005:11(3):153-60. [PubMed]
7 National Center for Health Statistics. State Profile: Maryland. 2009.
8 Jordan ET, Van Zandt SE, Wright E. Doula care: nursing students gain additional skills to define their professional practice. J Prof Nurs. 2008:24(2):118-21. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 12, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 31, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 08, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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