Podcast: Exploring the Role of Doulas in Maternal Mental Health Support

Inside Mental Health Podcast Guest and Host Bio

Asima Ahmad, MD, MPH, is a co-founder and the chief medical officer (CMO) of Carrot Fertility, the leading global fertility care platform. As Carrot’s CMO, Ahmad leads clinical strategy, overseeing the company’s expansive network and telehealth program, which offers access to more than 10,000 reproductive endocrinologists, urologists, adoption experts, mental health experts, OB/GYNs, doulas, and midwives.

In addition to her role at Carrot, Ahmad is a practicing reproductive endocrinologist and infertility specialist. She is double board certified in reproductive endocrinology and infertility and obstetrics and gynecology. Ahmad earned a combined medical and public health degree from the University of Chicago’s Pritzker School of Medicine and the Harvard T.H. Chan School of Public Health in Boston. She completed her residency in OB/GYN at Yale-New Haven Hospital in Connecticut and her fellowship training in reproductive endocrinology and infertility at the University of California, San Francisco. She has worked alongside and received mentorship from former ASRM presidents Dr. Hugh Taylor and Dr. Marcelle Cedars. Ahmad’s work has been published extensively in academic literature and internationally on various topics related to infertility, reproductive and hormonal health, gynecologic malignancies, and patient safety.

Ahmad has been recognized by Entrepreneur magazine and Fierce Healthcare on their Women of Influence lists and named to Business Insider’s 30 under 40 in Healthcare list. She has also spoken at The World Economic Forum and has been featured in The New York Times, the “Today” show, “Good Morning America,” NPR, CNN, USA Today, Women’s Health, and more.

Our host, Gabe Howard, is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without.

To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Episode Transcript

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Thanks for listening, everyone. I’m your host, Gabe Howard. Calling in to the show today, we have Dr. Asima Ahmad. Dr. Asima is the co-founder and chief medical officer of Carrot Fertility and has been featured on the Today Show, Good Morning America, CNN, and is now here with us today. Dr. Asima, welcome to the podcast.

Asima Ahmad, MD, MPH: Gabe, thank you for having me. I’m so excited to be here and to have the opportunity to talk about this very important topic.

Gabe Howard: We are all excited that you are here as well. Now, Dr. Asima, today we’re going to talk about doulas. So just to make sure that everyone is on the same page, can you explain what a doula is and also what training do doulas receive?

Asima Ahmad, MD, MPH: So a doula is an individual who provides non-medical support or care. So they can do this through education, guidance, emotional support, counseling. And then they can be there for that person throughout their pre-pregnancies even before they get pregnant journey. Their pregnancy, postpartum and even like help them prepare on returning to work for some people. And I want to clarify that although doulas traditionally are thought of in the sense of, oh, they’re just there for labor or maybe even pregnancy, doulas can be available to support people through other journeys as well. So infertility. So people who might be going through infertility treatment, or they could also be there to assist individuals when they’ve gone through a pregnancy loss. So in that case they might be called a bereavement doula. Going back to the type of training. So again they’re not a medically trained professional. But there are some certification programs out there that they can receive. And a doula should also have a certain level of experience with whatever type of service they’re providing. So if they are a doula who helps with the birthing process, in many cases they’ll want to have done a certain number of hours being there, supporting individuals who have gone through a vaginal birth or a cesarean birth, for instance.

Gabe Howard: I was really surprised to learn, while I was doing research for this show, that one of the criticisms of doulas is that they’re frankly, just a status symbol for the wealthy. That having a doula is just something for rich women who think they’re better than everyone else because they’re bringing their own personal assistant or employee into the process. What do you think of that criticism?

Asima Ahmad, MD, MPH: I can understand where that might be coming from in that in many cases, traditional insurance might not cover doula services. So people may think that to be able to work with a doula and rates can vary, that it might be too costly, and it might only be someone who is at a higher income level, but doulas can be used for many different populations. It’s not just somebody who is wealthy. I’ll give an example of a study. So there was a study that looked at the Medicaid population and found that for those people who had doula support, it helped reduce the cesarean delivery rate. Now, the Medicaid population is not one that we would categorize as having that, you know, higher level income. And for example, there’s many cases around the US now that are starting to support doula coverage. It’s not just something that somebody who is wealthy might be able to use. And there’s data showing that people who are in those marginalized communities, which again, we can probably dive a little bit more into regarding this, the statistics around that, but can have a very strong benefit from working with a doula to help close some of those gaps that exist in their current medical care and access to medical care and can help improve outcomes for them.

Gabe Howard: The next controversy that came up all over the internet was that the medical establishment feels that this is unnecessary, that these are untrained people sticking their nose where it doesn’t belong. Now, interestingly enough, you’re you’re you’re both someone who has used a doula in your own pregnancy and you’re also a doctor. What’s your thought on that pushback against doulas?

Asima Ahmad, MD, MPH: Again, I understand where that’s coming from. It’s not just, for example, doulas. There will sometimes be cases and having delivered hundreds of babies, I’ve experienced this also. Whereas there’s someone in the room that is trying their best and has great intention to help the person who’s giving birth, but then in the process, then starts to get to a point of wanting to dictate medical care. And I think that’s where that that comment that you mentioned comes from. That’s again, I just wanted to highlight that the doula is not licensed medical professional. They’re there to be the voice to the person’s preferences to support them. And if there is a danger to that person who’s delivering or their baby. And for example, a change needs to be made to the birthing process like it needs to convert from vaginal to C-section delivery, then, yes. You know that that should be carried out and decided between that patient and the medical provider, be that the midwife or the physician who’s doing the actual delivery. So again, they they are there for support and, and guidance. But at the end of the day, the final decision of what are the next steps for medical care should be between the patient and their medical provider.

Gabe Howard: Keeping along the lines of controversies, are there ever any issues that doulas need to resolve in doing their job, so that they can better set the expectations of where they belong, of where doctors belong, where, you know, other support staff belong so that everybody can get along, or are they becoming more widely accepted? And the controversy is sort of fading into the background.

Asima Ahmad, MD, MPH: I think it’s a little bit of both. I think people have been talking more and more about the positive impact that doulas can have for the pregnant person and for the baby. And so people are more open to allow, because there’s some hospitals that don’t even allow them to come into the delivery room. So they’re becoming more and more open to allowing them to be there as a support person during the prenatal care process, the labor and birthing process, for example. And I do think going back to the first thing that you mentioned, that it is important for all individuals to have a very clear and straightforward discussion about what the expectations and roles are for each person in that process, for the pregnant person, for the doula, and for the health care provider, and especially if they’re able to meet even before the day of the the actual birth, that would be even more helpful, because then they’re all aligned and they understand each person’s role. And I think if that discussion takes place, there’s less likely to be any of those instances where one person may feel that the other is stepping on their toes, for instance, or that there’s an obstruction to care. At the end of the day, everyone wants the same thing. They want that journey for that person, the pregnant person, to be very pleasant, happy, and most of all safe, and for the baby. And that the baby is safe, and that the best possible outcomes happen for both.

Gabe Howard: I want the audience to know that you’re not just a doctor who believes in doulas and their potential to improve outcomes, you have firsthand experience. Now, if I understand correctly, you have had five pregnancies and given birth four times, but you only used a doula for one of those births. What made you hire a doula for your last pregnancy versus all of the other ones?

Asima Ahmad, MD, MPH: So, on a personal level, I was lucky in that I had a wonderful support system in place for each of my pregnancies my mother, my husband, my community. They were all available when I needed them, and I don’t think I could have done it without them. But even given that, as you mentioned, I did choose to work with a postpartum doula with my last pregnancy, and I found that it not only helped me, but it also helped my support system with her being there because they were also able to take a break and relax. Because let’s be honest, it’s not just the person who delivers the baby that’s going through a lot. So are all the people that are there helping the person get through this phase of their life. And one thing that I’ve found to be extremely valuable during my postpartum journey with my doula was that, for example, she really listened to my challenges that I had with lactation and understood that me being this. Here I go, type A and overachiever type of personality. I was pushing myself way too hard to reach a goal that for me and my body might be physically unattainable. And because of that, I was placing a lot of blame on myself not being able to produce enough milk for my baby.

Asima Ahmad, MD, MPH: So she recommended two lactation consultants to me specifically, given my background. And both of them were amazing. But one of them really said to me, resonated with me, and really helped me get past that feeling of the blame and the guilt because she said, you are physically and literally doing everything you possibly can and your baby is fine. You need to take care of yourself too, and I think I really just needed to hear that from someone else other than my family and my loved ones, because it really gave me a reality check again. She also helped put my son into a better sleeping schedule so that we that we hadn’t been able to do for any of our other three children at that point in time when they were that age. But this really helped better prepare me for going back to work and feel more rested. And again, I think this is different for everyone, but I really felt that having my postpartum doula helped me this time around.

Gabe Howard: I’m just curious, why is a birthing person’s emotional state during labor so important?

Asima Ahmad, MD, MPH: When you’re going through labor. And again, I’ve gone through it four times and I’ve delivered hundreds of babies. It can be different for everybody, but for people who haven’t gone through it before. So there’s that unexpected feeling sometimes of like, you know, is something bad going to happen to me? Something bad going to happen to the baby and or when someone’s not using pain medication, it can be a lot. It’s a lot to manage both physically and emotionally. And again, I think that’s why it’s important to make sure that you have something in place, whether that’s a support individual through the form of a doula or some family member or friend there with you to help you through the process. Because as much as we also plan for how we want the birthing process to go, there’s a lot of things that are out of our control, and having those support mechanisms in place can help to stabilize the whole process for the a little bit more than it would be otherwise.

Gabe Howard: We’ve been talking about the mental health benefits of using a doula, but largely with a 35,000 foot view about how it can help your mental health. Do you have any hard numbers, any research, any stats that you can share with our listeners?

Sponsor Break

Gabe Howard: And we’re back discussing the mental health benefits of doulas with the chief medical officer of Carrot Fertility, Dr. Asima Ahmad.

​​Asima Ahmad, MD, MPH: There has been a lot of research on doulas and how they can impact deliveries. I think going specifically to the question of like, can they help for, you know, in regards to the mental health, yes, there are studies that have shown that they can help reduce anxiety and stress for the pregnant person. There’s also data that shows that during the birthing process, when they are there and they’re present and their support individual that the person delivering has improved satisfaction with the process. And then when it comes to the other medical stuff around it, like we see a reduced use in pain medication. So like reduced epidural use, we see a reduction in instrumental or operative delivery. So that could be like a vacuum delivery forceps. And some studies show even C-section. And when they’re also a part of the overall pregnancy journey, meaning that they were there during the prenatal care and while the pregnant was while the person was still pregnant, we see a reduction in premature deliveries or babies with low birth rate. So a lot of research has been done around this, and a lot of it has been very supportive of having them be available for pregnant people

Gabe Howard: Up until now, we’ve been focusing on pregnancy or helping someone during delivery, but I understand that doulas can also play a role after delivery. What’s the impact there?

Asima Ahmad, MD, MPH: Excellent question. And actually I’m going to answer that not just in the context of after delivery, but again, going back to the fact that doulas can be available for many different types of journeys. So, for example, I’m going to give you some numbers too, because I think that’ll help kind of help visualize just how much of an impact can take place. So, for example, when you think of the rates of infertility and pregnancy loss, it’s not a small number. 1 in 6 people globally have infertility. This was released by the World Health Organization last year. And again, some studies have shown that one in 7 to 1 in eight women may develop postpartum depression within a year after giving birth. So with approximately about 4 million live births occurring annually in the US, this now equates to for postpartum depression about 5 to 600,000 people who might develop it, and that this number doesn’t even include those people who have pregnancy loss. Some data suggests that 1 in 5 pregnancies may end in loss, and that actual number may even be higher if we consider biochemical losses or very, very early pregnancy losses.

Asima Ahmad, MD, MPH: So there was a study that came out in 2022 is in the Environmental Research and Public Health Journal. There’s a large study on longitudinal morbidity after pregnancy loss and showed that one month after loss of pregnancy, 29% of women revealed symptoms that were suggestive of post-traumatic stress. And also looking at the cost related to that, the cost of untreated perinatal mood and anxiety disorders. And this could be during the period from pregnancy to five years postpartum, can be around 32,000 for each mother child pair affected. And then far worse is the toll that perinatal mental health issues can take on women and their families. Because roughly 20% of maternal deaths after childbirth are from suicide, and in rare cases, women without sufficient access to care and support could potentially harm their children again if they don’t have adequate care in place for themselves. And so I’m just highlighting just how many people could potentially benefit from working with a doula, because, again, doulas provide services for all these types of individuals.

Asima Ahmad, MD, MPH: So going back to the question of postpartum again, given how high the incidence is of postpartum depression, having someone there to be able to support you throughout that journey. And for, you know, for some people it might just be for a couple of weeks, or it could be for a few months. But having someone there to help you heal, to help you, you know, for example, for me, like, my doula helped me, and that was so bad with my other children about this, but helped me put the newborn into a better pattern of sleeping, which helped prepare me for work and reduce my stress levels as I prepare to go back to work. Those types of things can then help to reduce the the feelings of sadness or feelings of hopelessness that sometimes people feel. Because I’m quoting postpartum depression, the the amount of people that have postpartum blues is even higher than that. I can say myself that I’ve had that with, with some of my deliveries where you’re just like, wow, this is a lot. And so having someone there can really help.

Gabe Howard: During my research for this show, Dr. Asima, I saw a suggestion that doulas may reduce the risk of C-sections because having someone witness the entire birthing process gives the the medical personnel less anxiety. They don’t have as much pressure to move things along. They they don’t hold the reins as tight. They understand that the patient is cared for and and things like that. But it made me curious. Do doulas also affect the psychological state or the mental health of the medical personnel? And it sounds like it’s for the better? Is that true, or is this that just something that I found on Google?

Asima Ahmad, MD, MPH: That’s a great question. I think it can go both ways depending on that relationship. Remember we talked about the establishment of like setting the roles and expectations for each person in that room. So in some instances when those conversations don’t take place and maybe for example, the doula may be voicing the preference of the birthing person, that may conflict with what the doctor is recommending at that time. That can actually cause a little bit more friction as opposed to being more helpful. But again, if they understand each other’s roles and are okay with, you know, the doula voicing like, hey, the person’s not ready for a C-section yet, can we try for another 30 minutes? I’ll help her use, you know, using this mechanism to reduce her pain and, you know, help to reduce her anxiety. And maybe that’ll help. Like if that conversation is taking place, then it’s it might actually have the effect that you’re talking about that everyone’s on the same page, we know where everyone’s at. And then the doctor feels like, okay, okay, we’re okay trying for another 30 minutes. But if the baby’s heart rate does something funny and or we think it’s not safe for the pregnant person, then we’re going to just go have and, you know, we’re going to have to do a urgent or emergency section. So I think it can kind of go both ways. Depending on what type of conversations may or may not have taken place between all the people in the room.

Gabe Howard: If we go all the way back to the beginning of the podcast, I shared that you were the co-founder and Chief medical officer of Carrot Fertility. Can you share with our listeners what Carrot Fertility is?

Asima Ahmad, MD, MPH: Absolutely. So, I actually was completing my training as a reproductive endocrinology and infertility specialist when I met my co-founder, Tammy Sun. We met at the American Society for Reproductive Medicine, which is the annual fertility meeting that takes place in the United States. And we were both attending a session on cost effective infertility treatments, and we teamed up. She with her experience as a fertility patient and myself as a provider of fertility care. And that’s how we co-founded the company, which now, several years later, is a leading global fertility and family forming benefits provider for employers, health plans and health systems. And through this, we’re covering and impacting millions of lives globally when it comes to a person’s lifelong hormonal health. So, for example, menopause or low testosterone in men, or even gender affirming care, as well as fertility and family forming journeys like adoption in addition to pregnancy, postpartum and return to work.

Gabe Howard: And the website to learn more is CarrotFertility.com. That’s carrot like the orange vegetable. CarrotFertility.com. Dr. Asima, thank you once again for being here.

Asima Ahmad, MD, MPH: Well, thank you for having me.

Gabe Howard: Oh, you were very welcome and a great big thank you to all of our listeners. My name is Gabe Howard, and I’m an award winning public speaker, and I could be available for your next event. I also wrote the book “Mental Illness Is an Asshole and Other Observations,” which you can get on Amazon. However, you can grab a signed copy with free show swag or learn more about me by heading over to my website, gabehoward.com. Wherever you downloaded this episode, please follow subscribe to the show. It is absolutely free and you don’t want to miss a thing. And hey, can you do me a favor? Recommend the show! Sharing the show with the people you know is how we’re going to grow. I will see everybody next Thursday on Inside Mental Health.

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