Best Beginnings for Babies Birth Sister Program 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.

Because investigators only have resources to serve a small portion of women who want a Birth
Sister, investigators have designed an evaluation to provide rigorous evidence about the
health and economic outcomes of our program. Prospective, high-quality data is needed to
inform policy questions about the benefits of billable community doulas for Medicaid
recipients. This is our justification for randomization in a study testing a standard care
program.

Purpose The primary objective of the proposed project is to determine the effectiveness of
the Birth Sisters Program, in reducing cesarean birth rates and cost of care in a safety net
population. The associated objectives are, by the end of the project, to demonstrate
significant reductions in: depressive symptoms, low birth weight and preterm birth; and
significant increases in breastfeeding rates in women accessing enhanced Birth Sisters as
compared to women who are not supported by Birth Sisters. Effective interventions must be
sustainable. Cost of care analyses will evaluate whether the incremental costs of the Birth
Sisters Program services are justified by the savings brought about by lower rates of labor
complications, cesarean sections, emergency room visits and NICU days.

Of note, to improve the ability of the Birth Sisters to address social determinants of
health, this evaluation will add training and consultations for Birth Sisters and their
clients by Medical Legal Partnership (MLP). MLP is a team of legal experts who integrate
legal assistance into the medical setting as a vital component of patient care to ensure that
low-income patients are able to meet legal needs that impact on health. They will provide
trainings for Birth Sisters on key legal issues, such as housing and benefits. They will also
be available for consultation when the mother requires additional resources and information.

Investigators hypothesize that women receiving the BBB intervention will:

1. exhibit lower rates of cesarean sections, low birth weight and preterm birth, and
neonatal intensive care unit days; and

2. exhibit the highest rates of breastfeeding initiation, exclusivity, and continuation;

3. experience reductions in depressive symptoms;

4. incur lower health care costs than incremental program costs, providing evidence for
long-term sustainability.

Inclusion criteria:

- Being a pregnant Woman 16 to 24 gestational age

- First Time Mother

- Singleton

- Public insurance

- No known fetal anomaly

Exclusion criteria

- < 18 years of age

- high risk pregnancy defined by care in the high-risk prenatal clinic