Cities Enlist ‘Doulas’ to Reduce Infant Mortality

This article was originally published at Stateline, an initiative of The Pew Charitable Trusts, and was written by Michael Ollove.

BALTIMORE — This city has opened a new front in its effort to give black newborns the same chance of surviving infancy as white babies: training “doulas” to assist expectant mothers during pregnancy, delivery and afterward.

The doula initiative is the latest salvo in the Baltimore City Health Department’s 7-year-old program to combat high infant mortality rates among black newborns.

“The impetus for this program is the huge disparity in infant mortality between blacks and whites born in this city,” said Stacey Tuck, maternal and child health director at the department.

Baltimore is not alone. New York, Chicago and Tampa have also used doula training programs to improve newborn health.

Other cities may follow, according to Dale Kaplan of the MaternityWise Institute, which conducts doula training in Baltimore. A number of other cities, including Denver, San Antonio and San Francisco, have contacted his organization to inquire about starting their own programs.

The U.S. infant mortality rate among African-Americans is more than twice as high as it is for white babies.

‘Woman Who Helps’

“Doula” comes from the Greek, meaning “a woman who helps.” Although doulas are trained to assist expectant mothers through labor, delivery and beyond, they are not medical providers like midwives. Dona International, which calls itself the largest doula-certifying organization in the world, said doulas help mothers achieve “the healthiest, most satisfying experience possible.”

And doulas are good for babies, too. Doula-assisted mothers are less likely to deliver babies with low birth weights or with birth complications and more likely to breast-feed their infants, a 2013 study found. Mothers attended by female caregivers during labor are less likely to have cesarean births, require painkillers, or deliver babies in poor health, as indicated by low scores on the Apgar test, another study found.

“Continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor,” according to the American Congress of Obstetricians and Gynecologists, which cites other benefits such as shortened labor, less need for pain medication and fewer operative deliveries.

Baltimore doulas are a new part of a program that has already racked up some successes. When the city began B’more for Healthy Babies, in 2009, a white newborn was more than three times as likely to survive infancy as a black baby. By 2014, the gap had narrowed to about two-and-a-half times as likely.

African-American Tradition

African-American women have a long history with doulas, particularly during the Jim Crow era when hospitals denied access to pregnant black women, forcing many to deliver their children at home, said Andrea Williams-Salaam, a doula trainer in the Baltimore program. But as legal racial barriers vanished and the medical profession strongly promoted hospital deliveries as the safest option, fewer women practiced as doulas.

A few continued to work in Baltimore, she said, but when the city decided to start training doulas, it followed the example of New York, which started its doula program in 2010. So far New York has trained 68 doulas who have attended 580 births.

Gabriela Ammann, director of the By My Side Birth Support Doula Program, which seeks to reduce infant mortality in Brooklyn, helped start the program. She had been a part-time doula while teaching infant education classes in the Brooklyn Healthy Start Program.

“I noticed when we talked about labor and birth support, participants often said they weren’t sure they’d have someone with them,” she said. “Sometimes they didn’t have someone to support them or that person had to stay home to take care of the other kids.”

As a result, many of the women had to go through labor and delivery with only the help of strangers, adding to the stress of childbirth, she said.

Ammann started connecting some of those expectant mothers with doulas she knew in the community. She convinced the city to formalize the program and to train new doulas.

The program now includes 12 doulas and an annual budget of about $250,000. It operates in the six ZIP codes in Brooklyn with the highest rates of infant mortality.

Like New York, Baltimore wants its doulas to work as independent contractors, rather than as city employees. In addition to advising women about their pregnancies and baby care, Baltimore’s doulas will be trained to connect needy women to housing, transportation, nutrition and employment services.

“The doulas are there to assist, support and empower a woman in whatever way she needs assistance,” Williams-Salaam said. “That could be accompanying the woman to medical visits to help with the terminology used by the caregiver, or helping her obtain proper nutrition, housing or employment.”

It was the idea of empowering other women that induced Keyona Hough to become one of the five doula trainees in Baltimore. Too often, poor, African-American women are treated disrespectfully by the institutions they interact with, she said. She wants not only to advocate for her female clients, but also to “teach them how to advocate for themselves.”

“Like me, a lot of these moms have been subjected to violence and trauma,” she said. “That’s why I want to help them understand what their rights are so they can move through that system without being re-traumatized.”

Training the initial group of Baltimore doulas cost about $5,000, Tuck said. The money came from savings elsewhere in the program. She hopes to find another source of funding and train many more doulas in the city.

For an expectant mother, the cost of hiring a doula varies widely, from as little as $100 to as much as $5,000, according to Ammann. There is generally no insurance reimbursement, public or private, for doula services. Unlike New York, Baltimore will not pay the doulas for their work, so any money they make will have to come from clients.

The architects of the Baltimore program said they warned trainees from the start that they would not be able to make a living from their doula work. Many of their patients cannot afford to pay.

“This is primarily about service and giving back to the community,” Tuck said. “The five women who have enrolled as trainees, their motivation is not compensation, that’s for sure.”