A 2019 NM-based pilot research project funded by NIH (Grant # U54 MD004811 – UNM TREE Center) suggests that pregnant patients receiving substance use disorder treatment may greatly benefit from access to experienced doulas providing trauma-informed and addiction-informed support. The results from the pilot also suggest that both doulas and medical providers are eager to facilitate access to doula care for these pregnant individuals

Carrie Murphy

Lawrence Leeman

Micaela Lara Cadena

Pilar M. Sanjuan

Raquel Z. Rivera

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1Providing Doulas as Continuous Labor Support for Pregnant Patients in Substance Use Disorder Treatment Can Help FamiliesRaquel Z. Rivera, PhD (Bold Futures), Pilar M. Sanjuan, PhD (Center on Alcoholism, Substance Abuse, & Addictions, University of New Mexico), Micaela Lara Cadena, MCRP (Bold Futures), Lawrence Leeman, MD (Milagro Program,  Family & Community Medicine, University of New Mexico), Carrie Murphy, MFA, Doula (University of New Mexico Hospital Volunteer Birth Companion Program)2Recent pilot study shows doulas may help pregnant patients in New Mexico receiving addiction treatment. A 2019 NM-based pilot research project funded by NIH (Grant # U54 MD004811 - UNM TREE Center) suggests that pregnant patients receiving substance use disorder treatment may greatly benefit from access to experienced doulas providing trauma-informed and addiction-informed support. The results from the pilot also suggest that both doulas and medical providers are eager to facilitate access to doula care for these pregnant individuals.Nine pregnant patients receiving specialized care at UNM’s Milagro Program for substance-exposed pregnancy participated in the pilot research project. They highly appreciated having doula care prenatally, during labor/delivery, and during the postpartum period. They reported that having a doula 1) was helpful both emotionally and socially, 2) positively impacted pain control and the process of labor, and 3) felt like it made their pregnancies much easier. Overall, they were very satisfied with the support provided by the doulas.3Patient Quotes:“My doula helped me tremendously, emotionally and physically, in the process.”“My doula gave me support in ways my family couldn’t. She was also very helpful with providing information about how depression could affect me after delivery.”Doulas were assigned patients for three consecutive visits (prenatal, labor/birth, postpartum) and they found working with patients enjoyable and satisfying—though they felt that more visits would have been ideal.Doula Quotes:“I enjoyed the connection and the trust-building… I was able to connect in a deep way, where the people that I helped trusted me.”Medical providers were enthusiastic, supportive, and accommodated the doula program. Provider Quotes: “We have found that pregnancy and birth are a really important transformative time for women with opioid use disorder to change their lives—to get sober, become a better parent, and keep their families together. But it can also be a re-traumatizing time, especially for those with childhood or sexual trauma. Having doulas can prevent re-traumatizing by helping women feel in control of the birth process.  We’ve been hoping for years to provide doula services to our patients at no cost.”  -Larry Leeman, MD 4The research team recruited doulas who had received extra training to work with pregnant women with substance use disorders, trauma, and limited resources. Doulas were further required to have a minimum level of prior experience attending births as a doula, and specifically to have experience as a doula for clients who did not have the ability to self-pay. The research team managed the day-to-day aspects of the study informing clinic patients about doulas, matching doulas to interested patients, scheduling all visits, and facilitating access to appointments as well as all research assessments. In effect and over the course of the study, the research team helped patients with situational challenges, such as transportation. The research team also provided a list of vetted community resources to patients, and provided on demand support from a licensed psychologist to doulas as an additional resource for working with patients with complicated mental health needs.If potential funders were to consider providing resources for a doula program, it seems advantageous for the program to have positive inside relations and positioning within medical institutions serving patients, so that institutions are truly invested in providing doulas to patients and to allow for ongoing facilitation of scheduling and patient retention. At the same time, it also seems advantageous that doula programs retain a degree of independence from the medical center in order to foster the critical doula/patient rapport-building process.Doulas improve birth outcomes, especially in the context of socio-economic stressors and health disparities. A doula is a trained, non-medical professional who provides physical, emotional, and informational perinatal support, including continuous in-person support throughout labor, birth, and the immediate postpartum period. Research has demonstrated that doulas have a consistently positive impact on pregnant/laboring people, babies, and entire families.1Research has shown that doulas are especially helpful for people experiencing the greatest health disparities.2 These families often have less resources and experience more stress. Perinatal substance use often occurs in the context of stressors (such as individual and intergenerational trauma, violence, legal problems, family problems, interpersonal problems, low social support) and is associated with high rates of maternal morbidity and mortality. In a prior research project undertaken at UNM’s Milagro Program, 86% of participants screened had experienced at least one traumatic event of the type that can lead to posttraumatic stress disorder (PTSD). In comparison, 60% of the United States population has been estimated to have experienced this type of traumatic event. From 2010 to 2014, 25% of maternal mortality in New Mexico was due to drug overdose.3 5There are a host of negative stereotypes about people with perinatal substance use—one of the most harmful being that they must love drugs more than they love their children. In truth, while some people are able to stop or reduce substance use during pregnancy—many with the help of medication—others are unable to. Attempting to do so without medical care can be dangerous for pregnancies. Many people who do reduce or abstain from use while pregnant later relapse during the postpartum period (a time when overdose risk is high).Doulas can be key in providing necessary physical, emotional, and informational support. Doula support can alleviate stressors that impact mental health, including addiction recovery. However, when economic disparities also are present, pregnant individuals fighting addiction cannot readily access the benefits of doula care.Providing doulas at no cost to pregnant individuals with perinatal substance-use disorders is an investment with great potential to improve health outcomes for New Mexican families.71% of births in New Mexico are to pregnant people who have been determined eligible for pregnancy-related Medicaid (250% of the federal poverty level). In New Mexico, doula services are not Medicaid reimbursable, which means doulas are not currently covered by Medicaid. This creates a behavioral health disparity by which people with low economic status have significantly less access to these supportive services during their pregnancies.Some states do currently have Medicaid coverage for doulas, while several others are in various stages of following suit. The provision of doulas at no cost to low income people—particularly to individuals who have perinatal substance use disorders—will likely reduce health disparities. This will interrupt cycles of stress, halt intergenerational trauma, reduce maternal mortality, and address the lack of support associated with increased symptoms of mental illness including substance use disorders. In turn, investing in experienced and specifically-trained doulas to provide perinatal support for individuals with substance use disorders will decrease parent-child separation, incarceration, and other adversities for struggling families. While Medicaid coverage for doulas will require investment of new resources, research has shown that it is likely both cost-saving and cost-effective for state Medicaid programs to cover doula services. Doula care is associated with improved birth outcomes, including lower preterm and cesarean birth rates, which can lower overall Medicaid expenditures.6Sources1 Meghan A. Bohren, G. Justus Hofmeyr, Carol Sakala, Rieko K. Fukuzawa and Anna Cuthbert, “Continuous Support for Women during Childbirth,” Cochrane Database of Systematic Reviews 7, CD003766 (2017):  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003766.pub6/full.2 Julie Mottl-Santiago et al., “The Birth Sisters Program: A Model of Hospital-Based Doula Support to Promote Health Equity,” Journal of Health Care for the Poor and Underserved 31, no. 1 (2020): 43-55, doi: 10.1353/hpu.2020.0007; Katy Kozhimannil et al., “Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery,” Birth 43, no. 1 (2016): 20–27, https://pubmed.ncbi.nlm.nih.gov/26762249/. 3 Sharon Phelan, “New Mexico Mortality Review Update.” Presented at the New Mexico Perinatal Collaborative Meeting, May 11, 2018. Available at http://nmperinatalcollaborative.com/wp-content/uploads/2018/05/New-Mexico-Maternal-Mortality-Review-Update-5-11-18.pdf.ConclusionPregnant individuals in substance use treatment programs experience profound health disparities; prioritizing their needs is of utmost importance. Doulas have been shown to improve general birth outcomes and, in particular, the birth outcomes of families that experience the most stress and have the least resources. Providing access to doula care for pregnant patients in substance use treatment is a low-cost intervention that stands to significantly improve birthing outcomes for some of New Mexico’s most vulnerable families.

Providing Doulas as Continuous Labor Support for Pregnant Patients in Substance Use Disorder Treatment Can Help Families

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Providing Doulas as Continuous Labor Support for Pregnant Patients in Substance Use Disorder Treatment Can Help Families

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