The laboring mom was determined to have a natural birth, and her nurse-midwife, Anastasia Hallisey, was determined to help her do it.
But at the same time, Hallisey had another patient in labor, who also required her attention. Moving back and forth between the two delivery rooms, Hallisey might not have been able to give that first patient the full attention she needed as she pushed ahead toward a natural birth.
Luckily, there was another woman in the room who could help her get there: a doula. A doula (the word comes from the Greek, and means "a woman who serves") is a support person for women in labor. While a doula does not provide hands-on medical care, she can offer the kind of emotional and physical support that, generations ago, before the medicalization of birth, laboring women received from their sisters, friends, neighbors.
In this case, Hallisey said, the doula was able to help the mother with pain management—helping her into a relaxing shower, applying hot compresses on her back. She was also able to help relieve some of the pressure felt by the mom's partner, who, like many partners, wasn't exactly sure what he could do to help. "He was left to do what the dad or the birth partner does: just love her," Hallisey said.
Studies show multiple benefits to doula-assisted births, from shorter labor times to emotional benefits to the mom; research also finds that these benefits result in lower related medical costs. Despite these benefits, though, doulas are still relatively rare in the delivery room. According to a 2002 survey, only about 5 percent of births in the U.S. were attended by doulas. While that number is increasing, one significant barrier stands in the way for many families: a doula's attendance can cost anywhere from several hundred dollars to as much as $1,000 (depending on the services offered, among other factors), and insurance companies uniformly don't cover it.
"Our clientele are not a clientele who can spend two, three, four hundred dollars for a doula," said Hallisey, whose practice—Baystate Midwifery and Women's Health, in Springfield—serves a large number of low-income women, teen moms and recent immigrants.
Luckily, they don't have to. Last year, the hospital and the Green River Doula Network established an on-call doula program staffed by local volunteers who attend births when requested by the mother. That, along with a program that provides doula services to at-risk pregnant women in Franklin County, is part of GRDN's effort to offer community-based support to new moms, especially to those who need it the most.
Nancy Madru became interested in doulas while doing graduate studies work with HIV-positive pregnant women at Baystate. During pregnancy, she said, the women received a good deal of support to help them deliver healthy babies. But once the babies were born, all that attention was focused on the infant, with very little left for the new mother—despite her on-going need both for physical and psychological support and for help bonding with her child.
In our culture, that's true for all new moms, Madru said: "Mothers get put to the side after the baby's born. We forget that there's a mother/child dyad. When the mom does well, the baby does well."
For instance, by the end of her pregnancy, a woman is likely scheduled for weekly medical appointments; once the baby is born, however, she typically gets one more final checkup, six weeks post-partum. "That's a crucial time of transition for the mother—physically, psychologically," Madru said. For moms with extra challenges—poor health, emotional issues, a lack of resources or family support—it's even more crucial that they don't slip between the cracks.
Inspired by that experience, Madru went on to get her certification as both a birth and a post-partum doula. She also coordinates the community doula projects for the Green River Doula Network, an all-volunteer non-profit (www.greenriverdoulas.org). Earlier this year, GRDN received a $10,000 grant from the March of Dimes to provide doula services to at-risk pregnant women through Pioneer Women's Health, a midwifery practice affiliated with Baystate Franklin Medical Center.
To qualify for the program, women need to be low-income, be age 20 or younger, or have a history of depression, pre-term labor, smoking, alcohol abuse or illicit drug use. Participants meet with their doulas at least five times during their pregnancy and three times after the birth; the doulas also attend the birth. In addition to their direct support during labor, the doulas help clients develop birth plans, answer questions about childbirth, breastfeeding and newborn care, and help connect them to local resources such as WIC (the federal Women, Infants and Children program), local parent centers or programs for young mothers.
"That's a primary goal," said Madru. Being a new mother can be tough even for women who have support and resources. "For moms who don't have resources, they're very much on the edge. Their maternal/child relationship is at risk."
The March of Dimes grant will cover 15 women in the program, which began in March; so far, Madru said, nine have enrolled. For their work, the doulas are paid $500.
"They're working definitely above and beyond what they're getting paid for," said Deborah Billings, a certified nurse-midwife with Pioneer Women's Health. "This is a calling."
Many of the women she sees have social and economic needs that a medical practice alone can't meet, Billings said. "It's really wonderful to have a doula that can come and work with them, and help them find out about resources available in the area, as well as do a great deal of teaching about pregnancy and labor, and stay with them throughout the labor," she said. "It meets a number of needs."
At Baystate Midwifery in Springfield, GRDN's program is, by necessity, more modest—it's unfunded, and depends solely on volunteers.
The program began last year, when the midwifery practice asked GRDN to submit a proposal for an on-call doula program. Volunteers (who must have a certificate of completion from a doula training program and complete a Baystate program for hospital volunteers) sign up to be on call during certain shifts at the hospital, to be available for any laboring mother who asks for a doula. While the program doesn't have the same eligibility criteria as the Franklin program, Madru said, the great majority of women who use it are low-income. The practice also serves a large number of teen moms as well as new immigrants, such as Somali women who have come to Springfield as part of a resettlement program.
While the doulas and their clients meet in the delivery room and don't have the benefit of building a relationship over the course of the pregnancy—"There's a very quick getting-to-know-you," Madru said—response to the program has been very positive, both she and Hallisey report. Labor doulas can help partners and other relatives find ways to support a mom—getting her a drink, rubbing her back or just holding her hand. They can assist midwives and nurses, help the mother with relaxation techniques, and help make sure she understands and agrees with the sometimes rapid, confusing decisions made during labor.
"We don't take over in any way," Madru explained. "We don't answer medical questions. But we can help [women] get answers to their questions.
"[The medical staff may] say, 'We're going to give you Pitocin and in an hour check back.' Then they leave the room. We say, 'Do you understand that? Do you have any questions?'" Doulas might also remind women of their rights to refuse medical interventions, or to simply ask for more time to decide what they want to do, Madru said.
"They're a very passionate group of people," Hallisey said of the volunteer doulas she's worked with. "That's why most of us get involved in the crazy work of midwifery, because we feel really passionate about it. And, frankly, it's really hard to maintain that in a hospital setting. It's inspiring to me as a midwife to have [doulas] there to try to remember how we can bring a bit of sacredness, a bit of heart into the birth process."
While midwives care deeply about meeting the emotional needs of the women they work with, she added, "the reality of our job is, we can't always be the person to provide that." Doulas, however, can fill that gap.
Madru would love to see the Springfield doula program develop into a program like the one in Franklin County, where doulas have time to develop relationships with the women they work with and help connect them to community resources—and get paid for their work.
But in the current economic climate, financial support, either from private foundations or from hospitals, can be hard to find; indeed, there's no guarantee the Franklin program will find continued funding after its March of Dimes grant expires. The GRDN recently incorporated as a 501c3 nonprofit, which makes it eligible for more charitable funding. The group also hopes to begin working collaboratively with like-minded groups in the area, like the Pioneer Valley Breastfeeding Task Force and MotherWoman, Madru said.