Doulas Provide Support for Maternal and Infant Health in Rural Communities

by Allee Mead

A woman incarcerated at the Crow Wing County Jail in central Minnesota gave birth. A doula — an individual trained to provide prenatal, labor, and/or postpartum support — helped the inmate through her pregnancy and labor. After the birth, the baby was sent to live under someone else's care, but the mom was still producing breast milk and wanted it to be sent to her child.

The doula, Shari Olson, advocated for the inmate to be able to pump her milk multiple times a day and get it delivered to the baby. She and the other two doulas in the Minnesota Prison Doula Project worked with administrators at the county jail as well as healthcare providers to facilitate this. When one jailer was concerned about liability if the breast milk would make the baby sick, another staff member met with the county attorney to get his approval.

Kathy Gaalswyk, one of the doulas, said this story "is a lesson about how relationships matter: having the relationships, building trust with the local government officials, being willing to stand up and push and challenge a bit when this is what's best for mom and baby."

She added, "Milk supply is an interesting thing — to keep that up when you're not actually physically with your baby and nursing your baby is a big deal. And so it was a huge commitment on [the inmate's] part and, I'm sure, discouraging at times. It took all of those pieces to make this work and the outcome is something we're really proud of." The doulas were also able to advocate for pregnant and nursing inmates to get additional snacks during the day to support their increased nutritional needs.

Gaalswyk and Elaine Lamon, who own a private practice called Brainerd Lakes Doulas, began contracting with the Minnesota Prison Doula Project in 2017. Project organizers, who began their work in the women's state prison in urban Shakopee, began calling rural midwives and doulas about bringing this project to county jails.

Gaalswyk and Lamon attended conferences to learn more about the prison project and how to set it up at their county jail. Gaalswyk's husband, who used to work in law enforcement, helped them connect with sheriffs in Crow Wing and Cass counties. Minnesota had passed a statute requiring correctional facilities to offer doula services to incarcerated women who are pregnant. Gaalswyk and Lamon told the sheriffs that these services would be paid for through grant funding that the Minnesota Prison Doula Project received.

"How could they say no to that? How often do you bring a local government official the problem and the solution, and they don't have to write a check?" Gaalswyk said.

Benefits of Doula Support

Doulas are not medical professionals and do not deliver babies. Instead, they provide prenatal, labor, and postpartum education and support; make sure their clients' choices are being respected; and refer their clients and families to medical and community resources.

According to a 2017 Cochrane systematic review of 27 studies including 15,858 women in 17 countries, pregnant people who received doula support were 39% less likely to have a cesarean birth and 35% less likely to have a negative birth experience. In addition, the review says, "Among the three types of providers of continuous support [doula, hospital staff, or patient's loved ones], someone in a doula role appears to offer the greatest set of benefits to laboring women."

Katy Backes Kozhimannil, PhD, director of the University of Minnesota Rural Health Research Center, leads research teams studying health equity with the intention of providing evidence to guide policies around equity and health promotion. Her 2013 American Journal of Public Health study — which estimated that state Medicaid programs could cost-effectively improve birth outcomes by covering doula services — informed the passage of a bill in Minnesota to allow Medicaid payments for doula services.

"My research and that of colleagues demonstrate that doulas provide the sought-after 'triple aim' of healthcare: improved patient experience, better population health, and cost savings," Kozhimannil said. She added that people who work with doulas "report more satisfying, positive, and less stressful birthing experiences."

My research and that of colleagues demonstrate that doulas provide the sought-after 'triple aim' of healthcare: improved patient experience, better population health, and cost savings.

She said doulas are especially important in rural communities, where pregnant people have to travel farther to access OB/GYN services, and for Black and Indigenous people, who experience higher rates of pregnancy complications and maternal mortality as well as racism in the healthcare setting. According to the CDC Pregnancy Mortality Surveillance System, from 2014 to 2017, Black and American Indian/Alaska Native women experienced the highest maternal mortality rates of any ethnicity: 41.7 deaths per 100,000 live births for Black women and 28.3 deaths for American Indian/Alaska Native women, compared to 13.4 deaths for White women.

Three programs provide doula support for those facing healthcare access barriers due to stigma, discrimination, or a lack of culturally competent care. A New Mexico program reaches American Indian, Hispanic, and other populations who lack nearby labor/delivery units; a Minnesota program works with moms experiencing incarceration; and a North Dakota program is training postpartum doulas who will care for families impacted by opioid use disorder (OUD) and other substance use.

Doula Services in Home and Jail Settings

The Minnesota Prison Doula Project has three components: Mothering Inside classes offered weekly, peer counseling, and doula services. The doulas provide prenatal and postpartum (up to one year after birth) visits, although Lamon noted that few births occur in the county jail.

The Mothering Inside classes are open to mothers and grandmothers as well as pregnant people. Each class acts as a standalone session, so participants can attend whichever classes they choose. This format works well for this population since people aren't in county jail that long (they tend to have a short sentence or are waiting for a court date), so the attendance changes quite frequently.

For peer counseling, women can sign up for half-hour breaks to sit and talk with Lamon or Gaalswyk. "We're not psychiatrists," Lamon said. "We're not any kind of degreed psychologist or anything like that. We just come as fellow women for them to just talk about whatever." When needed, Lamon and Gaalswyk will refer people to a social worker or other resources.

In Española, New Mexico, the nonprofit Tewa Women United provides full-spectrum doula services across the reproductive spectrum, regardless of pregnancy outcome, in its region as well as doula training across the state. In its Yiya Vi Kagingdi Doula Project, participating families receive three prenatal visits, continuous labor and birth support, three postpartum visits, and two infant feeding visits.

Community care isn't just about making sure that we are able to see a person's spiritual needs or understand some of the historical trauma. It's also making sure that the community members providing that care are able to do it in a way that supports their own health and well-being.

Through grant funding, Yiya Vi Kagingdi pays its doulas a living wage: $1,000 per client. "Community care isn't just about making sure that we are able to see a person's spiritual needs or understand some of the historical trauma. It's also making sure that the community members providing that care are able to do it in a way that supports their own health and well-being," Lujan said.

She added, "I feel like a lot of times doulas are asked to be the answer to all sorts of things like maternal mortality, but then they're being paid peanuts and are often struggling with the very same issues that our families are. So it's got to be a whole systemic shift."

Creating New Programs for an Age-Old Service

The Yiya Vi Kagingdi Doula Project began when the nonprofit completed a community survey in 2005 with the six Tewa-speaking pueblos in its service area. The survey — called the Tewa Birthing Project Maternal Health Survey and published in 2011 — asked 131 women about their reproductive healthcare needs and experiences. Survey results showed that these women wanted more midwifery care and support, like the birthing practices these communities had before colonization.

Jessica Lujan has been a doula with Tewa Women United since 2010 and its Indigenous Women's Health and Reproductive Justice Program Manager since 2015. Lujan said that, at the time of this survey, Indian Health Service (IHS) in the region was closing its obstetric units, so pregnant people could receive prenatal and postpartum care there but had to travel to another hospital to give birth. "And that was causing a lot of challenges for folks around culturally competent support," she said.

Although the term 'doula' is a relatively new term that we use to encompass this type of support, doula care has been around forever, and it has been done by [clients'] sisters and mothers and aunties.

Tewa Women United then created the Yiya Vi Kagingdi Doula Project. "Yiya Vi Kagingdi" is Tewa for "helper of the mother." Lujan said, "Although the term 'doula' is a relatively new term that we use to encompass this type of support, doula care has been around forever, and it has been done by their sisters and mothers and aunties."

A group in North Dakota is also creating a formal project for a service that had been informally provided — this one specifically reaching women who are pregnant, postpartum, and breastfeeding and families living with OUD. Abby Roach-Moore is a project coordinator for the Don't Quit the Quit (DQTQ) program and has completed the first part of her doula training. Maridee Shogren, DNP, the principal investigator for the DQTQ grant, is a certified nurse midwife and lactation counselor.

DQTQ currently serves an eight-county region in North Dakota and just received approval to expand into four additional counties. One of the first programs funded by the Foundation for Opioid Response Efforts (FORE), DQTQ is working to expand access to medication-assisted treatment (MAT), provide community education, and support training for people who wish to provide postpartum doula services to families in their home communities.

"Abby and I are from small towns," Shogren said, "and it's pretty common that in those small towns there'll be somebody that kind of is that community expert, that person that moms call or they ask questions of. In my community, it was an older nurse named Lucy and the moms just knew to call and ask her questions."

…it's pretty common that in those small towns there'll be somebody that kind of is that community expert, that person that moms call or they ask questions of. In my community, it was an older nurse named Lucy and the moms just knew to call and ask her questions.

Roach-Moore said that being a postpartum doula can involve helping parents with breastfeeding, swaddling, and soothing the baby, but it can also involve doing laundry or cooking meals. Doulas also serve as a non-medical resource when new moms aren't sure if they should go to their provider or are worried they'll face stigma or discrimination. A doula, Roach-Moore said, is "somebody to reach out to with a quick question…somebody that you feel comfortable with that is going to be open to whatever you have to ask without any kind of prejudgment."

Recruiting and Training Doulas

Due to the COVID-19 pandemic, the DQTQ doula training had to be offered online instead of in-person. Switching to online training saved the program money on travel expenses, allowing program coordinators to train more people with the same amount of funding. The program has its ninth doula in training.

Shogren said that the grant funding provided by FORE will be used for training, not hands-on work at this time. The DQTQ doulas are being trained through DONA (an international doula-certifying organization) and then receive additional training from the grant team about topics like substance use disorder; access to reproductive services; and a variety of topics related to pregnancy, postpartum, and OUD. At the end of the grant period, the doulas receive a stipend to help them finish their certification and begin offering services in their communities.

At this time, the DQTQ program has doulas in six of its service area's counties. One trainee is already a labor doula, who decided to add postpartum training to her skill set. Two others come from WIC agencies in the state and another is a nurse, who is "hoping to expand maternal/child options for care through her public health department," Shogren said. Other trainees are community health representatives from tribal communities who already make home visits as part of their work. DQTQ hopes to recruit more doulas to provide services in the newly added counties.

Shogren emphasized that trainees do not have to be medical experts, parents, or people in recovery, but they do have to be open-minded to other people's experiences. If, for example, a potential DQTQ trainee said that they didn't believe in medication for opioid use disorder (MOUD), it's an "immediate no for the scope of the grant work that we are doing," Shogren said.

She said that some people believe that women shouldn't take medications while pregnant, to which she'd respond, "Well, if you have diabetes, we would keep you on your insulin during pregnancy, right?" She added, "If we've got mom being cared for and in recovery from opioid use disorder, then we have healthier outcomes [for the baby too]."

…women deserve support, whether they're healthy, they have an opioid use disorder, or they simply have new parent questions.

Roach-Moore echoed the importance of open-mindedness, saying that potential trainees need to acknowledge that "women deserve support, whether they're healthy, they have an opioid use disorder, or they simply have new parent questions."

Creating a Culturally Competent Curriculum

Yiya Vi Kagingdi in New Mexico was originally funded by the Health Resources & Services Administration (HRSA) and focused specifically on first-time mothers in the Indigenous communities. After the three-year grant ended, Tewa Women United expanded their doula work to serve anyone — including non-Indigenous people — in their service area of Rio Arriba County and the Tewa Pueblo Homelands.

In 2015, Tewa Women United began creating its own doula training program. The organization conducted more community surveys and examined different training programs locally and across the country. "And then we began a series of community conversations where we invited in other doulas, parents, elders, doctors, midwives, nurses — anybody that wanted to be part of those conversations," Lujan said.

These conversations helped Tewa Women United create a comprehensive curriculum, and the organization started training its first cohort in 2018. Lujan said that the nonprofit has trained over 100 people using different training organizations and 21 people with its own curriculum. Each session in the seven-month program covers a different topic, such as traditional doula care in the region and worldwide, birth and reproductive justice, or intergenerational trauma. Doulas then complete a two-year certification process.

Doula training fees and certification costs can be cost-prohibitive, preventing low-income community members from becoming doulas. In addition, hiring a doula can be too expensive for low-income families. Yiya Vi Kagingdi addresses both issues by offering the training for free and providing doula services at no to low cost for families.

"We ask for a form of reciprocity where our students give back to the community by providing their certification births for free," Lujan said. Participating families are encouraged to give back as they are able, such as donating baby clothes or volunteering at Tewa Women United.

Tewa Women United completes an interview with people interested in training to "make sure that the [program's] values are aligned with their values," Lujan said. For example, the training discusses how doulas can provide care to someone who's had an abortion. If a hopeful participant is uncomfortable with discussing this issue, program coordinators will recommend that the participant find a training program that better suits them. "We do talk about all of those things in the interview, just so that folks don't feel surprised by it," Lujan said.

Some people on the waitlist are already experienced in doula and other birth services, so program coordinators will direct them to the level-two trainings. One level-two course coming up, Lujan said, will cover lactation after loss: how to care for people who lost their baby (either late in the pregnancy or after birth) but are still producing breast milk and want to donate it.

Helping Parents and Providing Education

According to Tewa Women United's 2020 report Expanding Access to Doula Care: Birth Equity & Economic Justice in New Mexico, preterm births in New Mexico occur at a rate of 10.1% in Hispanic families and 9.7% in American Indian families. Over eight years of data collection, the Yiya Vi Kagingdi Doula Project averaged a preterm birth rate of 2.7% among its clients. The doula project also boasts a 3.5% rate of low birthweight compared to a statewide rate of 9.1% and a cesarean birth rate of 13.3% compared to the state's 24.7%. In addition, all Yiya Vi Kagingdi clients receive preventive care for postpartum depression.

"Sometimes I think we should do a better job of looking at doula services as preventive health care," Shogren from North Dakota said. For example, if a doula suspects that their client has postpartum depression or preeclampsia and directs that client to a healthcare provider, that doula might have prevented the client from experiencing more severe or even fatal health outcomes.

Shogren and Roach-Moore also educate community members about OUD and MAT in an effort to decrease stigma toward people seeking medication-assisted treatment, especially pregnant women. One of DQTQ's first community education webinars addressed this stigma; program coordinators discussed how MAT works and how pregnant women can have a safe, healthy pregnancy while receiving treatment. (The CDC shares more information about OUD treatment before, during, and after pregnancy.) The program's webinar in April featured a mother in recovery who shared her lived experiences.

"We are essentially working to decrease the stigma that perinatal women with OUD often experience," Shogren said, "and we're really hoping to make it easier for them to find those treatment providers and to have those support networks."