BEL-HEALTH PROMOTION 2

Reducing Maternal Mortality and Severe Morbidity via Culturally Tailored Doula Integration 1

Reducing Maternal Mortality and Severe Morbidity via Culturally Tailored Doula Integration

 TOPIC: Category 1: Perinatal Care & Maternal Health – Reducing Maternal Mortality and Severe Morbidity via Culturally Tailored Doula Integration.

Student’s name: Belkis Palacio

Instructor: Dr. Nora Hernandez Pupo

Institution: Florida National University

Course: Health Promotion & Role Development in Adv. Nursing Practice-DAX-DL01

Date: September 22, 2026

Reducing Maternal Mortality and Severe Morbidity via Culturally Tailored Doula Integration

The concerns about maternal mortality rates and health risks associated with the mother returning back to society are major ones in the United States of America, particularly for Non-Hispanic Black women who have higher risks of death during pregnancy than any other racial group. According to Hoyert, (2026), in 2024, there were 44.8 maternal deaths out of every 100,000 live births in the population of Non-Hispanic Blacks, while Non-Hispanic Whites had 14.2 deaths and Hispanics had 12.1 maternal deaths per 100,000 live births. This health promotion program focuses on culturally adapted postpartum doula care with home blood pressure monitoring and mHealth communication to help alleviate this issue in terms of low-income, uninsured, and Medicaid-insured postpartum Non-Hispanic Black women living in Miami-Dade County. The objectives are to take at least 80% of blood pressure measurements at home according to the guidelines, to complete 90% of all planned doula visits and to follow up at least 90% of abnormal BP readings in the first 6 weeks postpartum within 30 minutes.

Vulnerable Population

The target population will include non-Hispanic Black postpartum women living in Miami-Dade County who are poor, uninsured, or Medicaid-insured and who have an elevated risk of developing hypertensive complications and challenges accessing continued postpartum care services. Being vulnerable depends on an interplay of multiple different factors, and race is not the only one. Insufficient financial resources, unstable health insurance, problems with transportation, inability to visit follow-up visits, taking care of children, and previous negative experiences with healthcare services can interfere with timely detection and management of the complications. The postpartum period can be especially vulnerable because patients have fewer contacts with healthcare providers after birth despite the fact that serious complications can persist. Remote monitoring can help to deal with this issue and provide doctors with BP readings without visiting the clinic for all check-ups. It has been established that remote monitoring of BP is effective in the case of Medicaid-insured and mainly Black populations (Zhang et al., 2024). Also, cultural competency and racial concordance can be important aspects of supporting perinatal women (Falade,et al., 2023).

Evidence-Based Interventions

Current low-bandwidth sensor monitoring is one component of an evidence-based measure being proposed as an intervention. Mujic et al. (2024) demonstrated in a safety-net hospital environment that it is feasible to use connected technology to gather postpartum BP readings and implemented a cellular-enabled remote BP monitoring program in the postpartum period. Likewise, Zhang et al. (2024) investigated the usefulness of remote BP monitoring in a predominantly Black, rural, Medicaid population and discovered that it is a viable tool for detection and management of maternal hypertension. In addition, these studies echo the models of connected BP devices, supporting the benefit of connected devices for patients to share readings anywhere; getting to the office may not be necessary. The drawback is that simply supplying them with the equipment doesn't rule out social barriers or ensure that the patients use them on a regular basis. These issues of access to technology, digital skills, cell phone connectivity, and timely clinical action on alerts need to be tackled.

Research indicates that providing care with support from a doula has been linked to better M-I outcomes, higher patient satisfaction, and that it may help to reduce racial disparities (Ramey-Collier et al., 2023). In an analysis of propensity score-matched doula programs in three states, Falconi and colleagues (2022) drew links between doula care and positive maternal health outcomes. While the volume of evidence is mixed and depends on population, program design, and outcome measured, the findings of more recent studies continue to support the benefits of community-based programs such as doula care.

One component of proposed intervention is remote BP monitoring, which is evidence-based. During the postpartum period, a safety-net hospital that was unable to use standardized, automated methods for BP collection implemented a cell phone-based remote BP monitoring program and showed that cell phone-based monitoring with connected devices can provide postpartum measurements of BP. However, connected devices can be used to monitor postpartum BP in a safety-net hospital that had been unable to apply standardized, automated approaches, as demonstrated by Mujic et al. (2024), who checked the feasibility of remote BP monitoring in a predominantly hermetic, rural, and Medicaid population and identified that it was feasible to detect and do care management of maternal hypertension. The findings of these studies provide evidence that connected BP devices should be used since they allow the patient to provide readings from home without relying on transportation and on traditional office visits. The downside is that remote monitoring will not remove social barriers or ensure that patients will use the equipment regularly.

Mothers and babies, when supported by a doula, showed a variety of outcomes and higher levels of satisfaction (Ramey-Collier et al., 2023). A few findings also indicated some benefits for racial disparities, among the other potential benefits (Ramey-Collier et al., 2023). Falconi et al. (2022) examined the impact of doula services in 3 states (propensity score matching). Results showed associations between doula care and better maternal health outcomes. There is still further evidence in more recent studies to support doula care as a valuable community-based intervention, but evidence is not consistent across populations, program design, and outcomes measured (Lemon et al., 2025). One of the great things about doula care is that it is people-based care that is not possible through technological means. This is due to training and scope of practice, reimbursement, and integration with healthcare systems. Therefore, doulas should be used in synergy with, rather than at the expense of, APRNs, obstetric clinicians and/or emergency services.

Program Implementation and Evaluation

This project will involve the use of a structured six-week postpartum pathway to incorporate doulas into the project. This would involve the recruitment of doulas from community organizations, maternal health projects, and local professionals who will be trained on postpartum warnings, BP monitoring procedures, cultural humility, confidentiality, motivational interviewing, and social services. Each participant will be provided with an automatic upper arm BP monitoring system prior to their hospital discharge. On the first home visit, the doula will demonstrate proper position, placement, BP monitoring procedure, and transmission of BP measurements. The doula will make two home visits during the first two weeks and weekly home visits for six weeks.

Escalation criteria will also be set prior to implementing the BP-monitoring pathway. If the woman's BP reaches 140/90 mmHg or higher, then repeat measurements and review of this case will be carried out, whereas readings above 160/110 mmHg will be considered high-range readings and will be addressed according to the clinical escalation process stipulated by the program's obstetric protocol. The APRN or other obstetric clinician will be informed of the BP readings via the remote monitoring platform. The doula will not make a diagnosis or treatment decisions related to hypertension; rather, she will provide additional education, ensure that the woman has understood the escalation protocol, and help with communication. High or persistent readings will necessitate a clinical assessment on the day that these occur; emergency services will be recommended if there are symptoms or BP readings indicating an emergency. The program will have arrangements in place for referral to safety net clinics, FQHCs, and EDs for women who do not have insurance.

Intervention will take place on multiple levels. Individual-level interventions include educating the patient about severe headache, visual changes, chest pain, difficulty breathing, sudden swelling, neurologic symptoms, and high BP; training in the use of the BP machine; and reminders using mHealth. Community-level interventions will involve providing culturally competent care by doulas, connecting the families to transportation, food, housing, insurance, and other social support services. On the healthcare system level, the APRN will serve as the point person and will coordinate all communications between the doulas, obstetricians, primary care providers, and telehealth staff using documentation and escalation protocol. All communications between the doulas and all abnormal BP readings will be documented in the patient’s electronic medical record or other approved platform. Policy-level intervention will focus on advocating for Medicaid reimbursement for the postpartum doula services, BP machines, and remote monitoring.

The evaluation of this program will involve process indicators and clinical outcome indicators. The process indicators will comprise the following: the percentage of anticipated BP measurements done; the percentage of scheduled appointments with the doula; the percentage of abnormal BP results followed up within 30 minutes; and the percentage of participants who stay engaged for six weeks after delivery. Clinical outcome indicators will consist of postpartum emergency room visits and readmissions due to high blood pressure. Patients’ satisfaction with the care provided will be measured with the use of a standardized patient satisfaction survey.

Guiding Theoretical Framework

The Social Ecological Model is an appropriate model for this health promotion program since maternal morbidity is affected by factors at the individual level, interpersonal level, organizational level, community level, and policy level. The Social Ecological Model is closely associated with this intervention in that remote monitoring and education regarding symptoms affect the individual level, while doulas affect the interpersonal and community level; healthcare team integration affects the organizational level, and Medicaid reimbursement affects the policy level.

Using the Social Ecological Model will ensure that the health promotion program does not place blame on the patient. The patient will understand that it is important to monitor her BP, but she might be unable to attend a clinic appointment because of environmental barriers, such as transportation, childcare, lack of insurance, or work-related barriers. In response to these environmental barriers, the proposed program will bring monitoring and culturally tailored support to patients and connect them to resources for healthcare and social services. At the organizational level, escalation pathways between the APRNs and the obstetric teams will be developed in order to ensure that abnormal findings result in action.

References

Falade, E., Cornely, R. M., Ezekwesili, C., Musabeyezu, J., Amutah‐Onukagha, N., Ferguson, T., ... & Larson, E. (2023). Perspectives on cultural competency and race concordance from perinatal patients and community‐based doulas. Birth, 50(2), 319-328. https://doi.org/10.1111/birt.12673

Falconi, A. M., Bromfield, S. G., Tang, T., Malloy, D., Blanco, D., Disciglio, R. S., & Chi, R. W. (2022). Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. EClinicalMedicine, 50. https://doi.org/10.1016/j.eclinm.2022.101531

Hoyert, D. L. (2026). Maternal mortality rates in the United States, 2024. National Center for Health Statistics. https://doi.org/10.15620/cdc/174651

Lemon, L. S., Quinn, B., Young, M., Keith, H., Ruscetti, A., & Simhan, H. N. (2025). Quantifying the association between doula care and maternal and neonatal outcomes. American Journal of Obstetrics and Gynecology, 232(4), 387-e1. https://doi.org/10.1016/j.ajog.2024.08.029

Mujic, E., Parker, S. E., Nelson, K. P., O'Brien, M., Chestnut, I. A., Abrams, J., & Yarrington, C. D. (2024). Implementation of a cell‐enabled remote blood pressure monitoring program during the postpartum period at a safety‐net hospital. Journal of the American Heart Association, 13(13), e034031. https://doi.org/10.1161/JAHA.123.034031

Ramey-Collier, K., Jackson, M., Malloy, A., McMillan, C., Scraders-Pyatt, A., & Wheeler, S. M. (2023). Doula care: a review of outcomes and impact on birth experience. Obstetrical & Gynecological Survey, 78(2), 124-127. https://doi.org/10.1097/OGX.0000000000001103

Zhang, Y., Lin, Y. Y., Lal, L., Swint, J. M., Tucker, T., Ivory, D. M., ... & Collier, C. (2024). Feasibility of remote blood pressure monitoring for detection and management of maternal hypertension in a predominantly black, rural and medicaid population in Mississippi. Telemedicine and e-Health, 30(7), e2096-e2102. https://doi.org/10.1089/tmj.2023.0426