By Rachel Crumpler
Black women are three times more likely to die from a pregnancy-related cause than white women, according to the Centers for Disease Control and Prevention. Additionally, in North Carolina and nationally, Black infants are about two times as likely as white infants to be born low birth weight, according to the National Center for Health Statistics.
“It’s a problem that’s been going on for decades, and we haven’t moved the needle at all,” said Rachel Urrutia, a researcher and instructor in the Department of Obstetrics and Gynecology at the UNC-Chapel Hill medical school.
That’s why, in the fall of 2020, an announcement from the Washington, DC-based Patient-Centered Outcomes Research Institute caught her eye and that of her colleague Jennifer Tang. It was a request for proposed studies to look at reducing disparities in maternal health.
Urrutia partnered with Tang and, together with two community-based doula partners, they designed a study aimed at improving maternal health outcomes, satisfaction and communication, particularly for Black moms.
Their goal: to finally move that needle.
Their study, Accountability for Care through Undoing Racism and Equity for Moms (ACURE4Moms), seeks to decrease pregnancy complications, especially for Black moms, by decreasing institutional racism and bias in health care and improving community-based social support during pregnancy.
The study is specifically looking at the outcome of low birth weight.
“If we can reduce low birth weight, it’s actually showing that we’re making a difference in the underlying factors that caused it,” Tang said. That would come on top of preventing future sickness and deaths among Black mothers.
The study will implement various data accountability methods and doula support at 40 practices providing prenatal care across North Carolina. The research team also said that success of the interventions could chart a new path for maternal care across the state and beyond.
The study’s first type of intervention involves data accountability focused on health care providers and their practices.
To improve accountability, clinics will have access to electronic maternal warning systems that will flag patients who have a risk factor for low birth weight that needs treatment or those who miss an appointment. Clinics will act on the warnings.
To improve transparency, clinics will be shown their pregnancy-related complication data broken down by race every three months via a disparities dashboard. The dashboard will display any racial differences and encourage the clinic to address the gaps in outcomes.The American College of Obstetricians and Gynecologists has voiced support for the use of such a dashboard to monitor process and outcome metrics.
“These tools are really helping us reflect on and be accountable for the caregiving and really helping us not let patients fall through the cracks,” Urrutia said.
Clinic staff will also receive quarterly racial equity training to help them recognize any unconscious biases they may have and learn how racism affects pregnancy care for patients of color.
The data accountability portion of the study is based on prior work by different UNC researchers and the Greensboro Health Disparities Collaboration.
An earlier study called Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) implemented interventions at cancer treatment centers that nearly eliminated disparities in treatment for Black patients with early-stage lung and breast cancers. The interventions consisted of a real-time notification system based on electronic health records showing missed clinical milestones, reporting race-specific treatment rates to clinical teams and using a nurse navigator trained in racial equity to guide patients.
Urrutia believes this study will have a similar effect in closing racial disparities in perinatal outcomes such as low birth weight.
Community-based doula support
The second type of intervention will provide community-based doula support for high-risk patients. Community-based doulas are trained to provide culturally relevant care to patients during pregnancy and up to one year after birth. The doulas attend prenatal visits with patients, help during labor and can set up peer support groups.
Operating with community-based doulas is new for many prenatal practices. Temple Steele, an OB-GYN practicing in the Winston-Salem area at Novant Health WomanCare, admitted her practice is not very familiar with doulas. However, establishing a relationship with doulas in her community is a primary feature that attracted her to participate in the ACURE4Moms study.
Angela Tatum Malloy, a certified doula and the founder of Momma’s Village Fayetteville, will help facilitate training of the doulas needed for this study.
Malloy said she’s seen how doulas have interacted with pregnant women to help them understand their bodies and its changes, connect them to mental health support and facilitate group meetings with other mothers. She also said she’s seen how the non-clinical approach of doulas can be effective in improving maternal outcomes.
Her own daughter is one such example.
Having a doula allowed Malloy’s daughter to make it to about 38.5 weeks in her pregnancy — the longest she had ever gotten. Malloy said her daughter has struggled with pre-term birth in the past and had babies in the four-pound range.
Not only does the study hope to show how doulas can improve patient outcomes, but also the role doulas can play to support OB-GYN practices.
While this is not the first large-scale doula project Malloy and her organization have been approached about, this is the first one she said she felt comfortable accepting. She said she could tell this study is different because it includes those affected by poorer maternal outcomes in the process of finding a solution.
“Being a part of a project that is doing research in a community that I serve and me looking like and representing that community all mattered,” Malloy said.
By the end of June, Tang and Urrutia plan to have finished recruiting and identifying the 40 clinics that will participate in the study. From there, all clinics will be randomized into one of four “arms” of the study: some clinics will provide standard managed care, some will receive the data accountability measures, some clinics will receive community-based doula support and a final group will receive a combination of both data interventions and doula support.
Each practice will receive its intervention for two years, starting this October at the earliest. The study is supported by a $10-million award from the Patient-Centered Outcomes Research Institute.
Steele said she was eager for the three locations of Novant Health WomanCare to participate after she listened to a presentation Tang gave to several OB-GYN providers. Steele saw the promise of the interventions and the statewide scope of the study.
“We can kind of show that these are interventions that number one work, but number two, are easily feasible,” Steele said.
Urrutia believes both types of interventions will improve low birth weight, but thinks both interventions together will show the best improvements. She said the goal is to see a 40 percent decrease in low birth weight for Black women who are at a clinic that received both data interventions and doula support as compared to a clinic that receives no interventions.
“Let’s not have race be a factor in the discrepancies of the outcomes,” Malloy said. “Once we get everyone to a leveled kind of playing field, then we can push more on those outcomes overall.”