Birth Sisters Best Beginnings Evaluation

Racial and income disparities in maternal and perinatal outcomes in the United States are large and persistent. Maternal and infant morbidity and mortality alike are 2-3 times higher in the black population than in the white population. Poor women in general are more likely to have babies born prematurely or with low birth weight compared with women from a higher socio economic strata. Infants born either too early or too small are at risk for a lifetime of disabilities, perpetuating the cycle of poverty and poor health. Low-income and minority populations are also less likely to breastfeed, putting children and mothers at higher risk for a variety of health problems, including obesity, diabetes, and some cancers.

In addition to income and racial disparities, the nation as a whole struggles with inferior maternity care outcomes when compared with other developed countries. This is true despite considerably higher rates of maternity care expenditures. The unnecessarily high rate of cesarean birth is one factor that contributes to both high cost and poor outcomes. The Society of Maternal and Fetal Medicine and the American Congress of Obstetricians and Gynecologists have both called for innovations and strategies to reduce the high rate of cesarean birth.

Community "doulas", or peer support during pregnancy, labor and birth, is one intervention that may both improve outcomes for low-income populations and lower the cost of maternity care. A culturally competent peer who provides caring support during a crucial life transition may lower stress and improve engagement in healthcare, therefore improving health status during pregnancy and lowering the need for costly medical care. Low income and minority women are more likely to desire a doula during labor and less likely to have access to their services.

The Birth Sisters Program One of the few hospital-based community doula programs in the country, Boston Medical Center's Birth Sisters Program has provided multicultural doula support to childbearing women since 1999. The approximately 20 per diem Birth Sisters together speak over 10 languages. Birth Sisters are recruited from the communities served by the BMC maternity service and provide peer support throughout the perinatal period. Prenatal home visits focus on creating a relationship, identifying psychosocial needs and providing childbirth and breastfeeding education. The Birth Sister also assesses whether the woman is lacking in essential resources such as housing, food and baby care items. She then refers her client to social service agencies and helps her navigate those services as needed. During labor, the Birth Sister offers physical and emotional comfort measures, advocacy for the mother, and help with the first breastfeeding. Postpartum home visits provide assistance in the transition to motherhood, help around the house so that the mother can rest, education on breastfeeding, parenting and infant care, and connections to needed medical and social services.

The Birth Sisters Program does not have resources to serve all women who would like a Birth Sister. investigators are currently able to meet approximately 20 percent of the demand. Prenatal providers have traditionally been the primary referral source for the program, with some providers referring often and others rarely referring. This has created inequities in whether women have a chance to receive a Birth Sister. investigators are now changing the referral process to systematically screen all potentially eligible women and allow eligible women to self-refer to the Birth Sister pool. A limited number of Birth Sister assignments are made from this pool each month. Women are informed about the Birth Sister pool through flyers placed in the obstetrical ultrasound unit and, if they would like to be in the pool, they fill out a form with their contact information and place it in the "Birth Sister pool" box. Due to the budget limitations, investigators restrict referrals to women who benefit most, including first time mothers with public insurance.