Integrating Doulas Into Maternal Mental Healthcare, Care Teams

December 15, 2023 - As part of its overall mission to improve health equity, NewYork-Presbyterian is host to a program aimed at improving maternal mental health and, in particular, closing race-based disparities in maternal mental health.

According to the Centers for Disease Control and Prevention (CDC), one in eight women experience postpartum depression, and only around half of them get access to treatment. This problem is more pervasive for people of color, with Black and Hispanic families being unable to access care or access healthcare coverage for care.

NYP’s Postpartum Doula Program seeks to change that by creating an interdisciplinary care team to provide holistic care to pregnant people in their third trimester and into the weeks postpartum.

In this week’s episode of Healthcare Strategies, Davina Prabhu, vice president of the Ambulatory Care Network at NewYork-Presbyterian, discusses that program and the organizaton’s overarching efforts to promote equity in birthing outcomes.

Sara Heath: Hi, and welcome to Healthcare Strategies. I'm Sara Heath, managing editor at Xtelligent Healthcare Media and the lead editor on PatientEngagementHIT. Today, we're hitting on a topic that I'm personally very passionate about, and I know has long ignited a fire in a lot of healthcare professionals too, and that's the maternal healthcare crisis. The United States is knee-deep in this maternal health crisis with poor outcomes being wide-reaching, but far more likely to affect Black, and American Indian and Alaska Native individuals. But it's not just the physical outcomes that ail America, the nation is also staring down a maternal mental health crisis hallmarked by increasing rates of postpartum depression and postpartum anxiety. The facts have spoken for themselves at this point, and with greater amplification of public health research, and data and more media involvement, the push to improve maternal mental health outcomes has gotten stronger than ever. Hospitals and public health agencies nationwide are in the throes of developing key interventions to ensure nobody falls through the cracks. And although many of these efforts are just getting their recognition, they show a lot of promise to hopefully end this crisis.

And here to discuss one such program is Davina Prabhu, the vice president of the ambulatory care network at New York-Presbyterian, where she says maternal mental health is a very high priority. So, thank you so much for joining us today, Davina.

Davina Prabhu: Thanks for having me.

Sara Heath: Yeah. I guess maybe to lay our groundwork, if you could begin by just describing this crisis around maternal mental health. What are some of the figures that we're looking at? Where are there racial or other health disparities that we're seeing in this area?

Davina Prabhu: Disparities in maternal and early childhood health really have been pervasive and deep-rooted in the United States for some time, but were exacerbated during COVID in 2020. The inequities related to not only disparities in health outcomes, but specifically around the social factors that impact health or social determinants of health, really were highlighted. And I think that's why there's so much focus and attention now on addressing the health disparities around maternal mental health, but just maternal mental health in general.

The statistic from the CDC is that one in eight women experience postpartum depression, and only maybe 50% of those get treatment. And specifically within Black and Hispanic families, we note that they don't have, especially in low-income communities, don't have access to care, or don't have the ability to be able to get to care or the insurance coverage to be able to have the care. There [are] so many factors that really limit those in low-income communities to be able to access this care. And so, there's really a call for a more integrated approach, an approach that's more approachable, well, to communities so that we can meet communities where they are and have access to this care that is much needed so that we can really impact not only this generation, but generations to come.

Sara Heath: Yeah, of course. I know you just described a lot about access to care and other social determinants. I was wondering if you could expand on some of those or describe some of the other forces that might be behind this maternal mental health crisis.

Davina Prabhu: Sure. Those who, not only lack the income to be able to get access to whether it's care or beyond delivery of the child in the early childhood phases, child care, there's job stress, which can lead to toxic stress, which can then, that said, when you're carrying a baby and you face all of this toxic stress, it actually impacts the baby. And then therefore, after birth, and the first critical time period of the child, the first 1,000 days, we say, it impacts the child. And those health factors start to seep in. And if there's delayed treatment to care or no treatment, then again, it's pervasive and it continues in a cycle, generationally. Some factors, social factors really are around food, housing, transportation, and just being able to make sure that there is that connection. And with COVID, we saw that social isolation was a big issue.

Sara Heath: Yeah, absolutely.

Davina Prabhu: That really contributed to the worsening of these conditions.

Sara Heath: I know that this is clearly a nationwide issue. I know you've mentioned CDC had statistics on this, which kind of illustrates the nationwide nature of all of this. But what prompted you all at New York Presbyterian, in particular, to begin designing programs to address maternal mental health? And beyond that, what went into program planning and design? Who was involved? What kind of decisions were you guys prioritizing?

Davina Prabhu: Well, it starts from the leader, our board, our chief executive officer. Our strategic pillar at NYP is around being a pioneer in health justice. And so we've established the New York-Presbyterian Dalio Center for Health Justice, where we focus on "how do we achieve health justice by way of really achieving health equity?" And it starts with making it a strategic focus area.

But then also when we look at our service lines, and what's always been a priority here at NYP is really maternal and child health programming because, again, these quality outcomes are not new to us. They're things that we've known. It's just that, again, COVID exacerbated this. And especially as we noted, what had been happening from 2020 and beyond, we had been providing more and more supports in the way of food, in the way of being able to make sure that our communities, and therefore also our employees who are part of our communities, are taken care of. That's what really prompted us.

We also do a comprehensive Community Health Needs Assessment every three years. And with that Community Health Needs Assessment, it also further, through data, showed us that in the communities that we serve where our hospitals exist, maternal and child health, especially behavioral health, really needed to be a focus area. And so, when we were looking at what we currently have and what we provide, we have primary care centers. We provide state-of-the-art, world-class care from world-class physicians to be able to provide that episodic care when people need treatment.

But what we realized was necessary was an interdisciplinary team model. A model where we're not taking the patient to have to go to the OB [obstetrician], to have to go to a pediatrician, to have to go to a mental health provider. We wanted to bring the care to the patient, and so this is a very patient-centered model where we connect the OB with a pediatrician, with a psychologist or psychiatrist to meet weekly about patients who were referred and need this care. And we look at from a range of low-risk, to medium-risk, to high-risk, and figure out a tailored plan of care for these patients that are eligible.

Sara Heath: And that's a very perfect segue. I really wanted to hear more specifically about the NYP Post Partum Doula Program. And if you could just describe that program a little bit more in-depth for our audience?

Davina Prabhu: Sure. In 2020, as part of the work we've been doing around maternal-child health and an integrated mental health program, we recognized that we wanted to create a comprehensive suite of services, and that was really to prepare mothers in their last trimester, but then going into postpartum, six to eight weeks, to be able to continue to engage in their care, because we know that mothers tend to focus on the child once the child is born, and everything is about the child and the moms are forgotten. And so, the purpose here is for doulas to be the advocate, to help mothers really advocate for themselves, to engage in care, but then also to create a sense of calm. When we talk about toxic stress and what impacts everyone, having that additional support is so instrumental and helpful in these, really what are pivotal moments of, not only the mother giving birth to the child, but the child's early phase of their life.

Sara Heath: Yeah, absolutely. We're going to talk about doulas in particular in a little bit, because I feel like that's just such an emerging provider type, but I wanted to talk a lot about that interdisciplinary team that you mentioned. I think that, especially as healthcare has been embracing patient-centered care and health happens outside the four walls of the hospital and clinic and all of that stuff, we're really recognizing the fact that it's not just an MD, or an NP, or an RN, but it's really all these people who are experts in different aspects of care. So I was wondering why you guys find that to be so important to delivering good outcomes, but then additionally, how you coordinate care across all of these different types of providers.

Davina Prabhu: You're exactly right. There's physicians, nurse practitioners, psychologists, psychiatrists. We talked about the doulas. And one thing that I didn't mention about the importance of how we really leverage these important care team members like, doulas, really the collaborations that we have with community-based organizations in the local communities where our patients are coming from. Because the hallmark of this is really building trust. And in order to build trust, you really need to truly understand the community dynamics, the aspects of various cultures, all the nuances there. And other members of the care team are community health workers. We have nurses, we have social workers, really to care for the social needs, medical assistants. And again, the main premise of this in order to create holistic service for patients, is shaping what we're calling a two-generational model, where we're caring for the mom and we're caring for the child. It's going from while the child is in the last trimester of pregnancy and then into the first six to eight weeks--but then, really, we're talking about the first 1000 days that are so critical. The services not only from these various different care team members also span the period of obstetrics, then the period of pediatrics, but then, all-encompassing is the behavioral health psychologist or psychiatrist that stays constant there.

Sara Heath: Are there any technology systems that you guys use to help link care across these different providers?

Davina Prabhu: Yes. I'm so glad you asked. We utilize an electronic health record that is able to collect all of our data centrally, and using that electronic health record, we're able to share information across all these integrated care team members. We communicate using data on a weekly basis, so we're able to pull data on, "Here's what's happening with this patient. Here's the comprehensive look on what's happening with this patient. These are the interventions that we recommend doing next." And we started doing that weekly just so we could get the hang of it. Now we're getting to a place where utilizing this electronic health record, the chat functions and communications, there's always referrals, and work queues, and things that go between the various different providers and the various different touches. We're able to get to a place that where we started in 2020--where we were really hands-on and looking at that data on a weekly basis--we've been able to parse that out because we're really getting the hang of the systems and how we can communicate one another through this centralized repository, if you will, of data on our patients and the various aspects of care, depending whether it's around obstetrics care, pediatric care, or psychological or psychiatric care.

Sara Heath: Yeah, absolutely. And I wanted to zoom in on doulas in particular. Could you talk a bit about the role that they play in this particular Postpartum Doula Program, and what do they bring to the care encounter that's unique that can support better outcomes?

Davina Prabhu: Doulas really are--the vision has been for them to be the advocates for a mother, for someone who is in their prenatal phase, and into their postpartum phase, and really support, not only the mother, but families in infant feeding the emotional aspects, the physical recovery from delivering a child, being able to soothe the infant, any kind of coping skills for new parents, and really support from labor into birth, and then into postpartum care.

Sara Heath: Yeah, absolutely. And I wanted to talk a little bit about almost the public perception of doula care because rewind, 10 or 15 years ago, people either haven't heard of doulas, or they think it's some woo type of care, but it really isn't. So I wanted to hear a little bit about how you see, maybe those public perceptions changing, and in what ways you may or may not be still facing an uphill battle in helping the public understand what doulas really do in improving maternal health outcomes?

Davina Prabhu: Traditionally, women supporting other women during labor and birth, we've seen that historically. And then, as I guess, we could say, countries became more industrialized, and evolved, and then more medicalized, you start to see that grow apart over time. And we're really understanding how important that support is, especially going through such huge milestones in a person, a family, or community's health, that it's integral to birth outcomes to better quality outcomes, and therefore really should be thought of as part of a patient's care team. The good news is we see the perceptions changing and that people are becoming more aware of the positive impacts of having a doula as a part of the care team on patient outcomes, which is really exciting for this doula movement. But there's still a lot of work that needs to be done, I think, especially as traditional medicine, or medical care, and clinicians, and how they see doulas as part of the patient care team. And I think that movement is happening, but I think there is still a way to go.

Sara Heath: Yeah, that makes a lot of sense. What other programs do you all have at New York Presbyterian that you guys are implementing to improve maternal mental health outcomes?

Davina Prabhu: As we're, again, really aiming towards developing this two-generational approach to care, understanding the needs of the community, especially after things were exacerbated through COVID, we recognized that targeting social isolation through group care was a program that we really needed to implement. And so, there is a nationally recognized program, so it's nothing that is specific to NYP, but that we've embraced the tools and the guiding principles from called "centering pregnancy." And that's where we bring either first-time mothers to a group setting where they actually get their clinical care together and they're able to bond together. And this creates this mechanism of, "You're not alone in this," and they can ask each other questions, they build those bonds, and it actually has shown favorable outcomes in being able to carry babies full-term and decreasing preterm births and low weight rate babies. Other programming also includes what we've done, again, on the child front from zero to five, we work with Healthy Steps, which is another nationally recognized program. So we're not here to reinvent the wheel, but we're here to really integrate various things that we know are proven to give good outcomes, but make sure that they're made available and, again, are patient-centered so that our patients have access to this. With Healthy Steps, again, we're able to follow the mother [from] final trimester into postpartum, but further into the child's life where we connect more with pediatrics and are able to incorporate the behavioral health aspects of care for children.

Sara Heath: And I guess, maybe to weave this all together, and I feel like it's been a common thread throughout this entire conversation, but just, how do you guys ensure that all of these different programs are also driving health equity? I think we've really hit on the fact that these issues can affect anyone, but they disproportionately affect different populations. So what kind of goes into making sure that health equity is baked into everything that we've discussed?

Davina Prabhu: It's really looking at the data just to make sure of it. We already know that the patient population that we serve is predominantly women of color, and in our communities, that's who we serve. So we know the demographics of, as I mentioned, the community health needs assessment through publicly available data, whether it's the US Census Bureau data, et cetera. We're able to know, this is our community, and this is what is the socioeconomic status of the community and what the health needs of the community are. And so as a result of that, we know who we're serving, and as we employ all of these programs, put them into place, we know we're also using evidence-based programming. Being able to provide access to that, and then being able to assess the data, when you first start out a program like this, you're looking at, "okay, how many people did I engage and what do those outcomes look like?" But over time, you start to see the trends in quality outcomes. Did we decrease preterm births and did we improve the health literacy and engagement around prenatal care? Those types of outcomes. That's what we start to--but we can disaggregate data, so you can disaggregate it by race, by ethnicity, by language, by payer, just to really understand who did we serve, right? And who was impacted by these outcomes? And that's why it's been so important for us to partner with the NYP Dalio Center for Health Justice, where we really have been able to get better data through campaigns of making sure that we're collecting all the demographic information so that it's accurate, and also be able to disaggregate the data in the ways that we need to study where the continuous improvements that we need to make in the programming that we provide.

Sara Heath: Thank you so much for joining us today. This was a really great conversation, so I'm glad that we were able to connect.

Davina Prabhu: Thank you, Sara. I loved the discussion.

Sara Heath: And to all of our listeners, thanks for joining us. If you're interested in learning more about this topic, check out our site dedicated to patient engagement called PatientEngagementHIT. If you have thoughts on this topic or if you have any healthcare-related stories that you'd like us to consider for coverage, you can reach out to me at sheath@TechTarget.com. That's S-H-E-A-T-H (Heath like the candy bar) @TechTarget.com. Follow us on Spotify to get more of these conversations and let us know what you think by rating or reviewing the show. See you next time.