The Champion Dyad Initiative (CDI) is a quality improvement initiative that was co-developed by two San Francisco nonprofit organizations, SisterWeb and Expecting Justice, to address the issue of disparities and inequities experienced by Black and Brown people during pregnancy and birth. The reasons for these disparities are multi-faceted, and include economic, social, and healthcare factors – with structural and systemic racism at their core. These can include limited access to quality prenatal care, as well as a poorer quality of care in birthing centers and hospitals, sometimes leading to deadly consequences (Centers for Disease Control, 2023).
The United States (U.S.) has the highest rate of maternal deaths among high-income countries (Figure 1), with women* of color the most affected (World Health Organization, 2016). Black women are 3-4 times more likely than white women to die during labor and pregnancy (California Preterm Birth Initiative (n.d.). These racial disparities persist across all levels of income, age and education (California Preterm Birth Initiative (n.d.). Tragically, most of these deaths from pregnancy-related complications are preventable (Winny & Bervell, 2023). The numbers point to a national crisis of maternal deaths (California Preterm Birth Initiative (n.d.). The implicit bias and discrimination within the healthcare system that Black women and other populations of color face urgently needs to be addressed. This is where the CDI comes in.
The CDI works to combat these inequities by partnering one or two “champions” at hospitals and birth centers with SisterWeb community doulas. These collaborations foster close working relationships, and act as a quality improvement tool to ensure that all Black and Brown women receive fair and equitable treatment during their births and pregnancies.
The CDI currently has five participating hospitals and birth centers in San Francisco
(Zuckerberg San Francisco General (ZSFG), California Pacific Medical Center (CPMC), UCSF, Kaiser Permanente & the San Francisco Birth Center). Of the five sites, ZSFG has the highest percentage of referrals, and also shares the highest number of clients/patients with SisterWeb. CDI champions at each site provide logistical and administrative support, coordinate Doula/Nurse activities, provide a communication channel, and act as a point person when SisterWeb doulas are supporting patients at each hospital / birthing center. SisterWeb doulas focus on cultural competency, helping to educate hospital staff about culturally congruent support while tending to and advocating for the well-being of their clients. Professional development sessions, panels, networking events and other opportunities help build community between doulas and hospital staff. Bi-directional feedback provided via forms between doulas and providers creates a framework for monthly discussions at in-person meetings.
According to data from the 2022-2023 SisterWeb Shines Fiscal Year Impact Report, there
were 39 CDI meetings held between medical representatives and SisterWeb over the year, and 252 referrals in total made from all CDI sites to SisterWeb. Eighty-eight percent (88%) of SisterWeb clients felt supported, heard, and respected by their medical providers during pregnancy, birth, and postpartum with Doula support. In turn, SisterWeb doulas reported an 86% average level of respect from nursing staff. Seventy-one percent (71%) of doulas gave feedback directly to medical staff in the hospital when they did not feel respected, or felt that their client was not receiving respectful care.
SisterWeb staff contributed to a research paper published in June 2023, which evaluated healthcare providers’ experiences with doulas. According to Reed et al (2023), two themes emerged around how providers perceive the effects of birthing clients having a doula on pregnancy-related care.
Firstly, providers described doulas fostering accountability on the part of the providers; at times, this was able to mitigate racism and implicit bias in clinical settings. The odds of respectful care have been seen to increase when there is a doula present; among respondents insured by Medicaid, the odds of respectful care were 80% higher among women with a doula present, compared to those without. As one OB/GYN in the study stated, “I know that there is somebody here who has expertise in respectful, equitable care who is watching me…and so when a doula is present, I actually feel an extra layer of pressure to be my best self.”
Secondly, providers perceived that doulas bridge gaps in care by providing services that clinicians themselves are unable to provide, such as continuous labor support. As one midwife stated, “The doula knows the patients better than I do most of the time. And so it allows me to kind of give the information and have them have somebody that they can work through that with, with someone that they already trust and have that established relationship with. And so it definitely makes my job easier.”
A key component of the CDI is that it provides an opportunity for bi-directional feedback in the healthcare setting. This is a useful mechanism for change in a system where hierarchies and power dynamics often prevent the reception of this type of feedback. Creating a channel for feedback helps to increase provider and institutional level accountability and encourages participants to provide more equitable and high-quality care (Reed et al., 2023). Instances of racial bias can be escalated within the institution, elevating the voices of communities most impacted by racism and providing a path towards change (Association of Maternal and Child Health Programs (n.d.). Performance measures are collected throughout the year and summarized in each SisterWeb Fiscal Year Impact Report. These measures establish the CDI as an evolving practice, while ongoing data collection and evaluation ensures that it continues to improve, focusing on action steps and systemic improvements (Association of Maternal and Child Health Programs (n.d.). SisterWeb also holds biannual All CDI Site meetings, where SisterWeb staff and CDI site champions discuss successes, challenges, and improvements.
Here are four main takeaways of the CDI:
The CDI harnesses the power of a long-term partnership between SisterWeb and medical sites to advocate for systemic changes.
SisterWeb is actively working to address inequities and systemic racism and hold clinical sites accountable through the CDI.
The Champion Dyad Initiative is an emerging and evolving practice.
The Champion Dyad Initiative is a practice that can be adopted by other organizations to implement.
The Champion Dyad Initiative is making a difference. It was selected by the Association of Maternal and Child Health Programs as an Emerging Practice and was highlighted in their database of Maternal and Child Health innovations. We’re proud of this accomplishment!
The CDI is charting a path forward in providing high-quality, equitable, respectful, and joyful care in hospital and birth center settings. It is essential to provide long-term, sustainable funding to community doula organizations in order for them to continue collaborating closely with hospitals and birth centers to dismantle systemic and structural racism.
Resources:
To learn more about maternal mortality, click here. To learn more about the CDI, click here.
References:
Association of Maternal and Child Health Programs (n.d.). MCH Innovations Database – Practice Summary and Implementation Guidance. https://amchp.org/wp-content/uploads/2023/10/Emerging-Champion-Dyad-Initiative.pdf
California Preterm Birth Initiative (n.d.). Doula Care. https://pretermbirthca.ucsf.edu/doula-care
Centers for Disease Control (2023). Working Together to Reduce Black Maternal Mortality. https://www.cdc.gov/healthequity/features/maternal-mortality/index.html
Hoyert, D. (2021). Maternal Mortality Rates in the United States, 2021. Centers for Disease Control. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm
Reed, R., Nguyen, A., Armstead, M., Cuentos, A., Mystic, M., Arcara, J., Jackson, A., Marshall, C., & Gomez, A.M. (2023). “An extra layer of pressure to be my best self”: Healthcare provider perspectives on how doulas foster accountability and bridge gaps in pregnancy-related care. ScienceDirect. https://doi.org/10.1016/j.ssmqr.2023.100259
Taylor, J., Bernstein, A., Waldrop, T., & Smith-Ramakrishnan, V. (2022). The Worsening U.S. Maternal Health Crisis in Three Graphs. The Century Foundation. https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/?gclid=CjwKCAiA-bmsBhAGEiwAoaQNmoPhWyVgE_3GF9qMcEtfCb0jHiZiexz7NOZNCrnhCM8MzEclcQiSgRoClqQQAvD_BwE
Winny, A., & Bervell, R. (2023). How can we solve the Black Maternal Health Crisis? Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2023/solving-the-black-maternal-health-crisis#:~:text=Black%20birthing%20people%20are%20also,birth%20and%20low%20birth%20weight.
World Health Organization. (2016). Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. https://iris.who.int/bitstream/handle/10665/249155/9789241511216-eng.pdf?sequence=1%0Ahttp://www.who.int/iris/handle/10665/249155
* We understand that in addition to or instead of “woman” and “women” some people choose to use “birthing person” to describe their experiences with pregnancy and birth. We recognize that using “woman” and “women” in this blog may not capture the full diversity of lived experiences that includes all birthing persons (cis women, trans folks, and gender expansive individuals).
This blog post was written by Roxane Scherek, Intern for the SisterWeb Evaluations Department and Master of Public Health (MPH) Candidate at University of San Francisco with support and guidance from Sofía Carbone, SisterWeb's Communications Coordinator and Alli Cuentos, SisterWeb's Evaluations Director. Thank you for former SisterWeb Evaluations Interns, Alyana Almenar and Meka Hicks for all their contributions to CDI data and evaluations.