2019 report published in Harvard Public Health Magazine leads with a striking title: “America is Failing its Black Mothers.” The article focused on how decades of high rates of maternal mortality and morbidity in the African-American community have contributed to disparities in birth outcomes. It called for policy makers and clinicians to pay more attention to this devastation on birthing persons and their families, regardless of race/culture, education level, geographic location, age, access to healthcare, or other social determinants of health. What is clear is that this disparate impact is not indiscriminate.

This article also profiled Shalon Irving, a 36-year-old pregnant African-American woman, who was a trained Centers for Disease Control and Prevention (CDC) epidemiologist and knowledgeable about her health conditions. Although she advocated for medical interventions and reported troubling symptoms throughout her pregnancy, her outcome was not as fortunate as that of Williams. After telling her healthcare providers about her history of blood clotting, prior cesarean sections (C-sections), high blood pressure, headaches, blurred vision, swollen legs, and rapid weight gain, they suggested that her experience was quite normal and told her to “just wait it out.” Irving died in the hospital after being removed from life support, surrounded by her family, about three weeks after giving birth.

Tragically, these kinds of experiences happen far too often to Black women and expose significant disparities across populations, regardless of the level of resources to which they may have access. America will fail our mothers, especially Black mothers, if this public health crisis in the healthcare ecosystem is not addressed.

Facts about Maternal Mortality and Morbidity

1. Between 700-900 first-time birthing individuals die each year in the US and about 60,000 experience severe maternal morbidity during pregnancy or at the time of delivery. More than 500,000 mothers experience post-partum complications that are considered life threatening. According to the CDC, Black women had more than twice the rate of maternal mortality (or death while pregnant or within 42 days of pregnancy termination) compared to nonblack women in 2021. While maternal mortality tends to increase with age, survival in the US for the birthing parent who is Black is comparable to the survival levels experienced by those in developing countries like Mexico and Uzbekistan where the majority of these populations live in poverty.
2. The US Maternal Mortality Rate in 2019 was 20.1 deaths per 100,000 live births. This rate rose to the shocking level of 32.2 in 2021, the highest rate among industrialized nations. In May 2024, CDC findings from the US Maternal Mortality Review Committees revealed that the major factors that contributed to maternal deaths in 2020 were obesity, mental health conditions, substance use disorders, and discrimination. Eighty percent of these conditions were preventable.
3. Pre-eclampsia is the second leading cause of maternal death, affecting between 2% to 8% of pregnancies worldwide. It is defined as hypertension that develops usually later in pregnancy, along with other evidence of proteinuria or multisystem functioning, after a woman’s 20th week of gestation. This outcome can produce seizures and tends to occur 60% more frequently and severely in Black women compared to their White counterparts.
4. It is important to note the rise in C-sections among Black women who make unscheduled visits (i.e., visits without a pre-specified appointment time) to their pre-natal care provider. These unscheduled visits can be prompted by unexpected utero activity that causes medical concerns or other complications that can lead to poor maternal outcomes, including problems in subsequent pregnancies. Black women with unscheduled visits are 25% more likely to have C-sections than comparable non-Hispanic White women. Also, pre-mature births and C-sections can occur based on the preferences or decisions of the healthcare provider at the time when a patient presents at the healthcare facility.

In sum, multifactorial issues with respect to access to care and/or engagement need to be addressed for Black women who seek maternity services within the healthcare system.

Gaps in Maternal Healthcare

Once a baby is born, care attention shifts from the birthing parent to the evaluation of and services for the newborn(s). However, this is still a critical time for continued post-partum care, mental health assessment, and resources to educate the birthing parent, family, and friends. Over half (52%) of all maternal deaths occur after the day of delivery. The post-partum period is a time of great need for care, resources, and follow-up for the birthing person, offspring, and entire family unit.

The decision-making autonomy of birthing parents during the time of labor and delivery was examined in a 2018 California survey of women’s childbearing experiences by Sakala and colleagues. While birthing persons report different experiences in their treatment and care option decisions (e.g., whether to have a C-section), factors such as insurance coverage, equitable treatment by their healthcare provider, decision-making autonomy, or care management procedures varied (Maternal Mortality in the United States: A Primer).

Maternal mortality and morbidity are multifactorial. Therefore, better understanding and response to policies, systemic barriers, engagement practices, and implicit/explicit biases within the US maternity care systems are paramount. For example, cultural, emotional, financial, and other institutional challenges may impact the care delivery and health status of people who have been marginalized in the decision-making process. Our laser focus must be clear and integrated as we address disparities across groups:

Introducing the BACH Think Tank

The Birthing and Child Health (BACH) Think Tank was formed in 2024 by a coalition of US-based Maternal and Child Health (MCH) thought leaders and practitioners. Their occupations span across disciplines, namely, medical physicians, data scientists, health outcomes researchers, academicians, full-spectrum doulas, lactation specialists, public health practitioners, policy developers, and other experts. Their expressed passion is in addressing gaps in policy, engagement, and access to effective MCH interventions within the healthcare delivery ecosystem. The BACH Think Tank was also formed to discuss and advocate for solutions that accelerate measurable outcomes using digital technologies. The focus is to be intentional in how to think about and operate with the goal of creating greater visibility of proven and effective maternal health interventions, such as doula services (see below). The group intends to raise awareness and propose actions needed to improve care and support throughout the birthing process.

The BACH Think Tank aims to evaluate and recommend various solutions using a specific method or framework that can be integrated and harmonized systematically into the US healthcare system of care. This article illustrates how evidence-based strategies and pragmatic approaches using an operational framework can work to coalesce awareness and solutions that drive action and sustainable change.

Four-Part Framework Proposed by the BACH Think Tank to Operationalize Interventions

The BACH Think Tank has developed a four-part Operational Framework that proposes a consistent approach to the assessment and early intervention of integrated approaches to maternal healthcare. This article provides examples of how this framework can contribute to the body of evidence and pragmatic strategies that raise awareness, present integrated solutions, and drive action for sustainable change in maternal and child healthcare. The framework is designed to:

1. Create evidence to inform policy and access
2. Highlight stakeholder training and education
3. Accelerate community engagement using technology and AI/machine learning
4. Advance sustainability with funded research, output, and building partnerships

BACH Framework Applied to Doula Services

The concept of doula maternity services is not new and dates back to ancient Greece. The Greeks characterized the “doulē,” or female servant, as one who has an established relationship or bond to another. This person would provide care, guidance, comfort, and support services during and after the birthing process to ensure a safe and positive experience for the laboring woman. Doulas have been proven to be trusted companions, and their devotion is maintained even above their own self interests. However, today it is considered a service for hire to assist a family in the reproductive period and afterwards. When this care is provided to a pregnant and/or birthing person, improved maternity and infant outcomes can result.

Background on Doulas: A “Doula Program” or “Full-Service Doulas” refers to both doula care and healthcare navigation activities. A doula has been defined as a trained, nonmedical labor companion who provides comfort, emotional support, companionship, and information during pregnancy and the post-partum period. Doulas are knowledgeable and skilled community health workers who provide nonmedical care that helps to fill service gaps and improve health outcomes of birthing individuals and their children within a healthcare system. The aim of a doula is to ensure that a birthing parent and their family have the support needed to sustain and grow in the pregnancy, deliver in dignity, and thrive in the post-partum recovery period. They are considered to be a valuable “support” to the birthing person, their partner, and the family.

What is the value of having a doula and what do they do? Full-service doulas are often embedded in their local communities and trusted to provide psychosocial, emotional, and educational support during pregnancy, childbirth, and the post-partum period. They are particularly critical during labor and delivery to serve as patient advocates and provide comfort and coaching. Doula programs build on the strong relationships established with the birthing person throughout their engagement to ensure ongoing care and support.

Is there evidence that doulas are worth the costs? Doula services can be costly and less attainable for lower-income families. Overall, about 6% of women in the US reported using a labor doula in 2011-2012, but this varied by race and ethnicity based on the insurance coverage, social service resources, and availability of hospital-based services within their community. The graph below illustrates the support of doulas described in one California study. In this report, Black women respondents expressed great interest in obtaining doula support and an openness to using this service for future births. Specifically, Black women had higher interest than non-Black women in receiving doula support during their maternity care (27% versus 16%) and about the same level of interest in considering doula support as non-Hispanic White women (39% versus 40%). This chart shows the response of Black women and those on Medi-cal pertaining to the support of doula care in one at-risk community.

Doula services may help to address gaps in services and health outcomes, especially in areas with disproportionately high rates of maternal morbidity and infant mortality. However, the availability and applicability of this kind of care can vary from state to state. Comparative effectiveness in outcomes has also not been well-established. Pragmatic alignment and consensus on how these services can be effectively integrated into culturally competent medical models for sustained healthcare delivery is sorely needed.

Why is This so Important now?

The timing is urgent because levels of disparate outcomes, patient dissatisfaction, inconsistent healthcare utilization, and healthcare costs continue to increase. Below, we present a few practical illustrations of how doula care can be maximized using the BACH Think Tank’s Operational Framework to address this crisis in maternal and child health:

• Advocacy and Policy Development: Doulas who operate effectively on health management teams can provide continuous and needed support to birthing parents outside of the medical care setting. Policies and procedures that enable objective, non-clinical insights can assist healthcare providers and other stakeholders to communicate risk factors, provide diagnostic insight, and proactively support early intervention and preventive care. Removal of the barriers presented to at-risk parents using doula care and home health services can facilitate information sharing and decision-making for all players in the birthing process, and particularly for patients in harder-to-reach and rural communities.
• Training and Education: The BACH Think Tank is committed to raising and facilitating conversations through partnerships that promote webinar trainings, podcast communications, training, credentialing standards, and evidence-based approaches pertaining to doula services. In addition, standardized approaches, key performance indicators, and quality metrics for effectiveness pertaining to doula care will help to increase the credibility of doulas who operate in partnership with medical personnel and in community settings. Such targeted training on well-developed approaches and educational support of doula care will also help to build the capability of community lay workers to conduct participatory and translational research that engages patients as partners.
• Accelerating Community Engagement Using Technology and AI/ML: One of the most urgent needs in healthcare is to gather, compile, and synthesize insightful real-world data. Real-world evidence on the use and effectiveness of doula services can be validated and scaled using digital technologies. Artificial intelligence (AI) and machine learning technologies (including natural language processing) can be used to reveal early signals in behaviors, attitudes, and care practices from nonstructured data sources. This can have wide applications for treatment effectiveness, quality control, and reach by uncovering previously unknown insights across a wider network of end users. The presence and leadership of doula representatives at health events, webinars, awareness campaigns, and other promotional activities facilitate efforts to build credible data assets and community-based solutions that foster trust and awareness. The BACH Think Tank is exploring digital technology strategies and solutions involving doula services that can be integrated into electronic data capture systems (or repositories) to support evidence generation for targeted therapeutics and deployment of life-saving medicines within diverse communities.
• Sustained Research, Output, and Partnership: Research design, project implementation, and program evaluation are key areas of development for doula care. The ability to provide a forum and avenue for hypothesis conceptualization, evidence generation, and testing of the success and limitations of doula services will be enabled through sustained partnerships with key stakeholders. Knowledge dissemination at conferences, on podcasts, as authors and subject-matter experts, and as leaders at community forums regarding the impact of doula care is well within our reach.

Implications

The need to make available and implement effective resources and tools that are trusted by birthing individuals, especially those with the greatest needs, is urgent. One study published in The Lancet indicated that birthing persons who receive doula care are less likely to have cesarean deliveries, complications during pregnancy, and other outcomes that incur short- and long-term costs.

One cost-effectiveness analysis of Medicaid coverage in the US Midwest from 2010–2014 showed that coverage reimbursement for doula care produced a cost savings for the state Medicaid programs. Similar analysis of doula care using quality-adjusted life years (QALYs) as an outcome determined that providing these professional services during the first birth prevented 202,538 cesarean births. This resulted in 46 fewer maternal deaths, 99 fewer uterine ruptures, and 26 fewer hysterectomies for the first and subsequent births. Additional analysis revealed that doula services could potentially save up to $884 in costs and produce cost-effective benefits of up to $1,360 per doula.

As the cost of maternity care decreases and quality of life increases due to doula services, birthing parents are better able to benefit from approaches to timely healthcare that meets their reproductive care needs. The inclusion of integrated policies and practices that ensure patient access, standardized training, and partnership with physicians and advocates help to raise the awareness that reaches marginalized communities. Digital technologies can be effective in scaling and disseminating knowledge for sustained outreach, engagement, and a measurable impact on outcomes that lead to cost savings and cost-effectiveness.

Call to Action

This is one example of how the BACH Think Tank Framework can identify gaps, find solutions, and provide excellence across a broader spectrum of the population for impact and sustainability. Our responsibility and call to action as scientists, policy makers, practitioners, advocates, researchers, and users of healthcare services is clear. The tools and resources presented here are not new, but they are facilitators of progress and continuous improvements. Actions such as these can become trusted pathways to achieving sustainable solutions for individuals and families in need, and especially for those who have been disproportionately underserved.

The sixth industrial revolution is well underway, characterized by advances in nanotechnology and use of AI algorithms in quantum computing. When applied within the healthcare ecosystem, this revolution can help to solve our most complex challenges and reduce disparities in health outcomes, but ONLY if it INCLUDES ALL stakeholders in the system. We must effectively leverage new and existing resources and then build better ones to ensure that no one is left behind as we speed into the future. The time to care, listen, include, and act is now!

“When you find people who accept, support, and value you, EVERYTHING else harmonizes together like a Symphony!”