The Case for Holistic Care

When Philly couple Alexis and Tony Gonzalez were planning their first pregnancy, they—like any other family—thought about factors like their physical and mental well-being, their baby’s health, their birth plan and more. While any pregnant person might experience fears, Alexis knew her pregnancy could carry additional risks. Race can play a role in jeopardizing a patient’s medical care, and those inequities are especially poignant in maternal healthcare.

“I was nervous because I am a Black woman in America,” says Alexis.

According to a 2023 study published in JAMA, Black women suffer maternal mortality at a rate that’s 2 to 4 times higher than their white counterparts. That makes maternal health a particularly concerning issue for Black women, but maternal morbidity isn’t contained to a singular demographic. In the United States, maternal mortality rates have been increasing for the last 2 decades.

That alarming data naturally raises the stakes for pregnant people in today’s landscape, and as Black parents, Alexis and Tony were especially motivated to secure the best care possible (and ensure the best outcome). Seeking that safety and confidence, the couple decided to find a midwife and doula to assist during their pregnancy, delivery and journey into parenthood.

“Midwives and doulas have always been a part of the conversation for me,” says Alexis. Alexis’s mother was delivered by a midwife, and Alexis and Tony have friends who work as doulas, so the couple knew not only of these resources, but of how valuable they could be.

The involvement of midwives and doulas in maternal medicine shows better outcomes for mothers, babies and families. Cochrane studies from 2016 and 2017 show that women who give birth under the care of midwives experience lower rates of Cesarean sections, inductions, preterm births, miscarriages and neonatal deaths, and according to March of Dimes, the support of doulas improves communication between patients and providers.

But how exactly are those better outcomes achieved? According to Melissa Patti, a trained birth doula and the director of Maternal and Infant Health Initiatives at March of Dimes, the answer is multi-factorial. But, she notes, it’s important to clarify that doulas and midwives provide entirely different forms of care. Both fields take a holistic approach to pregnancy and birth, but doula support is non-clinical, while midwives are medical providers.

Here’s a deeper look at the specific differences that doulas and midwives can respectively make in patient experiences and outcomes, and how that impact can transform birth care more broadly.

Tony and Alexis Gonzalez

Doula Care

For Alexis and Tony, having a doula meant having a constant support system and being confident and educated regarding their resources for birth and parenthood—and those are just some of the benefits doulas are trained to offer.

“Doulas help prevent birth trauma by offering continuous support and by providing education so that folks have clearer and more informed expectations about their pregnancy, their care and their birth,” Patti explains. A doula can also be a key player in the birthing room—whether it’s a home birth or at a birthing center or hospital—to support parents, whether that’s emotional support, bridging language barriers between patients and providers, or communicating any specific needs the family may have.

“I worked with a mom who was in recovery, and we built a relationship before birth to establish that she was not open to getting any opiates in labor,” says MaryNissi Lemon, the doula of LemonLife Doula & Birthing Services and the community program manager for Philly’s community doula support program. Because that birth was in a hospital setting, Lemon’s role was to advocate for the pregnant person to ensure that her preference to go without medications during labor was respected.

It’s through that pre-established personal relationship that a doula can understand what a family’s needs are and support them accordingly. And within that relationship, according to Patti, a doula can take on many different roles. Doulas can come into a family’s life as early as the first trimester of pregnancy to help mothers prepare their bodies for birth and point to resources like Lamaze classes and affordable car seats and diapers. Some doulas remain actively involved in the family’s life for the first year postpartum, and some make connections that last for years as the family grows.

For Alexis and Tony, that connection with their doula, Loren Jenkins, has lasted even as their child recently celebrated his first birthday—and they hope that relationship will continue as they grow their family. “She’s like family to us,” Alexis says.

Midwifery

Like a doula, a midwife approaches patients holistically—but does so as a provider who actually delivers the baby. Certified Nurse Midwives and Certified Professional Midwives earn board certifications through rigorous educational programs to care for patients not only during pregnancy and postpartum, but to provide general gynecologic care including contraceptive management, preconception counseling, infertility care, menopause support and more. Because they do all of these from a holistic approach, a midwife’s relationship to a family is often deep and continuous, and the same midwife might deliver multiple babies as a family expands.

As compared to the more clinical structure of traditional OB-GYN providers, midwifery

(also a certified clinical practice) centers education and building connections—and that integrated method shows improved care and outcomes for maternal and infant health, especially for Black and brown families. Part of that improvement comes from the way midwives can empower their patients to trust their bodies and make informed decisions about their health.

“Listening to the testimonies of people who have been impacted by the care of midwives, some of the common themes that I hear are empowerment, love, self-advocacy, education, just being heard, felt, and validated all while receiving stellar care,” says Michele LaMarr-Suggs, a certified nurse-midwife at Penn OBGYN and Midwifery Care at Pennsylvania Hospital and the founder of Royal Generation Inc, an organization that serves Black birthing people in Philly. It’s those themes, along with the fact that midwives can create safer birth environments for Black families, that drove Alexis and Tony to seek care from LaMarr-Suggs.

With care from both LaMarr-Suggs and a doula, the Gonzalez family had an especially harmonious birth experience—and that’s the case for many families who choose to work with both a midwife and a doula. In and before the birthing room, doulas and midwives can work together on a shared foundation of prioritizing the patient’s body and wishes.

“Birth is a team sport,” Lemon explains. “The midwife and I speak a similar language of trusting the birthing person’s body. We’re all in sync.”

For Alexis and Tony, the environment of trust and synergy led to a successful birth and transition into parenthood. Still, the couple has friends who didn’t use doulas or midwives (and wish they had), and there are many situations in which holistic care isn’t accessible. According to Patti, some families, like those who live in rural areas or don’t have medical insurance, are often limited in pregnancy and birth care options—and that’s why March of Dimes is working on legislation to expand the impact doulas and midwives can make.

Legislative Goals

One of those initiatives is doula integration efforts, which would enhance doulas’ partnerships with health systems to make sure they can be included in birthing rooms in hospitals. But according to Patti, those efforts largely depend on the specifics of a health system and patient population, and that’s why removing the financial barriers from holistic care is crucial. For example, March of Dimes advocates for Medicaid reimbursement for doula care so that more people can access it, especially those who might need it most.

“Having Medicaid reimbursement for doulas allows folks who are often the most vulnerable and at the highest risk to be able to access more comprehensive, supportive care,” explains Patti.

Reducing the obstacles that stand between patients and holistic care is one half of the equation to achieving a more equitable health system—and making sure that the positive outcome of Alexis and Tony’s story becomes the norm for more families across the country. The other is creating more opportunities for people to join the birth care field.

“We have a lack of diversity in midwives in Pennsylvania and across the nation,” says Patti. According to the American Midwifery Certification Board’s 2023 demographic report, over 83 percent of midwives are white, and only around 8 percent are Black. To address and remedy that lack, March of Dimes supports initiatives like loan forgiveness for midwifery students and pathways to midwifery licensure that don’t require a background in nursing school.

An increase in diversity means that families of color can access care from midwives and doulas of color. “One of the things that I’m working on is partnerships with education and especially with historically Black colleges and universities, to develop midwifery education programs, and personally mentoring black midwifery and nursing students and empowering them to serve in marginalized communities where the maternal mortality crises are more acute,” says LaMarr-Suggs.

With a greater number of people in the field and a greater recognition of the value of doulas and midwives, a greater difference can be made for families across the country.