*Y.C.* Community Maternal Health Doulas

DOULAS FOR COMMUNITY MATERNAL HEALTH

Childbirth and parenting education is one of the oldest and most effective ways to promote lifelong good health. Prospective parents who work one-on-one with an educator for information and support learn more about the processes of labor and birth, communicate better with their developing infant, change unhealthy lifestyle practices to facilitate a healthy family, and learn to trust their own wisdom as parents. This principle has been proven true in areas of the world where women traditionally receive a high level of medical care, as well as more personalized support; it follows, therefore, that one-on-one support and childbirth and parenting education would be even more valuable for women who live in the developing world and lack a similar standard of medical care.

Over the past several years, one resource available for members of these populations increasingly has been birth and postpartum doulas, women who offer emotional support, encouragement and wisdom throughout labor and birth process, and support women and families through the transition of building a family. Doula care is based on three core beliefs: that birth is normal, not pathological, that labor and birth constitute not merely a physiologic process, but a psychosocial one as well; and that healthy mothers and babies are the basis for a healthy community.

Until now, however, doulas have traditionally participated either solely during the birth process, or afterwards, particularly to provide breastfeeding support. Additionally, they have shared their supporting role with other non-medical maternal healthcare workers such as childbirth educators. Making the process even less efficient is the lack of a uniform international training program for doulas, or a central clearinghouse through which to share critical information and best practices.

With this in mind, it is my honor to present a proposal for the establishment of Doulas for Community Maternal Health (DCMH), a project designed both to streamline the training of new doulas, and to provide a central informational and educational resource to support them. Drawing on my own extensive experience, as a birth and postpartum doula, childbirth educator, lactation counselor, and committed advocate for maternal healthcare, I hope to create a model for doula training and support that will be a catalyst for healthier mothers and babies in the communities where it will have the most impact.

This unique and innovative program will draw on the key roles and activities of a variety of maternal health and wellness workers (e.g. childbirth and breastfeeding educators, as well as pre- and postpartum doulas) to create a new type of comprehensive maternal health caregiver, the Community Doula. This individual will perform several formerly discrete functions and provide integral, ongoing support for the expectant mother and her family throughout the course of the pregnancy and extending beyond childbirth. DCMH will also act as a repository for knowledge acquired by its field doulas, and a resource for sharing best practices across disparate communities internationally.

It is the objective of DCMH to create a tipping point in overall health improvements and community wellness in villages and remote areas around the world through both the doula model of care and community building efforts.

In order to accomplish this, DCMH will identify women in at-risk, resource-poor communities who have the potential and desire to be advocates in maternal healthcare and enroll them in a training program inspired by, and in accordance with, the “International MotherBaby Childbirth Initiative 10 Steps To Optimal Mother Baby Maternity Services” (http://www.imbci.org/ShowPage.asp?id=209). Students will learn a variety of skills, including the foundations of maternal and child health; birth and postpartum doula practices; and breastfeeding advocacy and support. A pilot program will train local women over the course of two months, initially through group trainings, followed up with an apprentice-style model of education. Educational materials will be picture-based so that women who are unable to read can still be of service.

Once trained by DCMH, Community Doulas will be prepared to supply education to their own and neighboring communities. They will be qualified to provide pregnant women and their families with vital non-medical support, such as offering information relating to pregnancy nutrition; what to expect during labor and birth; where to give birth; breastfeeding; infant care; and family planning. Furthermore, DCMH’s trained Community Doulas will encourage and help women get to a staffed birthing facility once in labor, if needed, and remain with them during labor. In order to accomplish this, it is recommended that Community Doulas be provided with mobile phones and dedicated transportation.

Following birth, Community Doulas will visit families during the first two postpartum months to assess the mother's physical and emotional health and follow up with breastfeeding assistance, if necessary. Eventually, a group of three to four Community Doulas will support a community by taking turns teaching group classes, doing home visits, liaising with local clinics and hospitals, attending births, and providing breastfeeding follow-up support.

The model on which DCMH intends to base its training and mission is supported by extensive research* worldwide demonstrating that continuous female companionship during labor and birth has a profound effect on both the medical outcomes of the mother and baby. It also creates a positive impact on the woman’s feelings about the birth experience and herself, while enhancing her ability to bond with, care for, and breastfeed her newborn. The medical benefits of continuous female companionship during birth include shorter labors; a reduction in cesarean rates, assisted deliveries, labor medications and postpartum depression; an increase in breastfeeding and maternal-infant bonding; and an overall reduction in medical costs.

These benefits are particularly significant in resource-poor settings, where medical assistance is often scarce and the risks for negative birth outcomes and experiences all too common. In such circumstances, the physical, emotional, and educational support available to a pregnant woman is paramount for her postpartum recovery, as well as to improve her overall health and wellbeing and that of her newborn. While they do not perform any clinical tasks such as heart rate monitoring or vaginal exams, doulas are trained to attend to the emotional and physical needs of laboring women. A doula meets each woman during pregnancy to review birth expectations; assess her knowledge of labor, birth, and pain management; provide supplementary instruction on breastfeeding and newborn care and development; and develop a plan for participation in labor and the postpartum period.

It is no secret that internally displaced persons camps (of which women and children constitute 80 percent), refugee camps, and many clinics and hospitals in the developing world are understaffed. Beyond that, for various reasons, many women choose not to birth in hospitals or clinics, but instead stay in their village aided by only family members or a traditional birth attendant whose experience and skill vary from village to village. Although traditional birth attendants offer a unique and important form of support to the women they serve, the best model of care is one that includes midwives and doctors when available. In addition to offering education and emotional support throughout the pregnancy and birth, Community Doulas will encourage and help women to find appropriate medical care, thereby reducing the risks associated with births not attended by medically trained professionals.

By training Community Doulas, DCMH will not only create new jobs in resource-poor communities, but also inspire community health partnerships and collaborations aimed at changing the lives of women, babies, families and communities.

FOOTNOTE
*Pediatrician John Kennell, MD, and neonatologist Marshall Klaus, MD, conducted the first large randomized study of labor support in Guatemala during the 1980s. The results of this study showed that the introduction of support during labor was associated with a reduced prevalence of perinatal complications within a population of poor women who routinely underwent labor alone in a crowded ward. Furthermore, the acclaimed Cochrane Library published a systematic review of the effects of continuous labor support in July 2003. The review includes 15 studies summarizing the experiences of a total of 12,791 women in Australia, Belgium, Botswana, Canada, Finland, France, Greece, Guatemala, Mexico, South Africa, and the United States. At least four of the studies in each category, involving a total of at least 1,000 women, demonstrated that the medical benefits of labor support listed above were greater when continuous support was provided by a caregiver who was not an employee of the hospital, and were members of the local community. These women supporters shared values and were able to communicate with the laboring women more effectively.

Furthermore, research has significantly shown that, at six weeks postpartum, doula-attended women were more likely to be exclusively breastfeeding successfully, managing well with their babies, and finding it easier to be a mother. The level of support a woman receives during her birth experience and for the first six weeks postpartum, has been shown to be the most significant indicator of whether she will breastfeed and for how long. This research supports the premise that a Community Doula, who can take the time to fully support a new mother as she embarks on the task of breastfeeding, will be critical in creating healthy mother/child bonds and a healthy community.