Association Between Doula Use on a Digital Health Platform and Birth Outcomes

Abstract

OBJECTIVE: To examine the association between the use of virtual doula appointments on a comprehensive digital health platform and users' mode of birth and their birth experiences, among all platform users and Black platform users. METHODS: Data for this retrospective cohort study were extracted from individuals who enrolled in a comprehensive digital health platform, between January 1, 2020, and April 22, 2023. Multivariable logistic regression models were used to estimate the association between number of virtual doula appointments completed on the digital health platform and odds of cesarean birth and user-reported birth experience outcomes, which included help deciding a birth preference, receiving a high level of support during pregnancy, learning medically accurate information about pregnancy complications and warning signs, and managing mental health during pregnancy, stratified by parity. The interaction of doula utilization by race for each outcome was also tested. RESULTS: Overall 8,989 platform users were included. The completion of at least two appointments with a virtual doula on the digital health platform was associated with a reduction in odds of cesarean birth among all users (adjusted odds ratio [aOR] 0.80, 95% CI, 0.65–0.99) and among Black users (aOR 0.32, 95% CI, 0.14–0.72). Among platform users with a history of cesarean birth, completion of any number of doula visits was associated with a reduction in odds of repeat cesarean birth (one visit: aOR 0.35, 95% CI, 0.17–0.72; two or more visits: aOR 0.37, 95% CI, 0.17–0.83). Analyses among all users indicated dose–response associations between increased virtual doula use and greater odds of users reporting support in deciding a birth preference (one visit: aOR 2.35, 95% CI, 2.02–2.74; two or more visits: aOR 3.67, 95% CI, 3.03–4.44), receiving a high level of emotional support during pregnancy (one visit: aOR 1.99, 95% CI, 1.74–2.28; two or more visits: aOR 3.26, 95% CI, 2.70–3.94), learning medically accurate information about pregnancy complications and warning signs (one visit: aOR 1.26, 95% CI, 1.10–1.44; two or more visits: aOR 1.55, 95% CI, 1.29–1.88), and help managing mental health during pregnancy (one visit: aOR 1.28, 95% CI, 1.05–1.56; two or more visits: aOR 1.78, 95% CI, 1.40–2.26). CONCLUSION: This analysis demonstrates that virtual doula support on a digital health platform is associated with lower odds of cesarean birth and an improved birth experience. Positive findings among Black users and users with vaginal birth after cesarean suggest that doula support is critical for patient advocacy, and that digital health may play a meaningful role in increasing health equity in birth outcomes.