"Doulas" Help New Moms When Family Support Is Missing

When a family emergency took her husband and small son back to Uganda, a very pregnant Margaret Nalubega felt alone and anxious."I told my midwife 'I don't have anybody to be with me during birth or after -- everybody is busy at work,'" recalled the 29-year-old nurses' aide.The midwife suggested she use a "doula," a Greek word referring to an experienced woman who helps, encourages and accompanies women during pregnancy and labor. Some offer postpartum care, including light housekeeping and guidance on breast-feeding, too.Nalubega took the advice, and many others are doing the same.Doulas have recently gained a certain cachet among highly mobile professionals who may have few family members nearby but enough money to pay for their own doulas. They're not the only ones, though. The services are beginning to reach broader segments of the community.Nalubega's doula, for example, was provided free of charge through one of several community- and hospital-based programs that are making doulas available for those who cannot afford to pay $25 or more an hour for private services.These new programs often target help to specific populations, such as low-income women who are alone, isolated immigrants, substance abusers, or women in prison. And they often offer more after-birth help than doulas usually provide."Ours is one of the only societies in the world that doesn'tsupport women during and after childbirth," said Marshall Klaus, a physician on the faculty of the University of California who has studied the effects of doulas."Doulas who support women during labor are truly effective," he said.Klaus pointed to seven recent studies showing results from using labor doulas: a 50 percent drop in cesarean sections and reduced use of pain medication, such as epidurals.Some hospitals are considering a voluntary early discharge program with a doula and a nurse.A doula and nurse combined could cost about $500 for 20 hours -- half the cost of an extra day in the hospital, said Debra Pascali, executive director of the Center for Perinatal Research and Family Support, one of the collaborating agencies for The Neighborhood Doula Project inThe project provides doulas with up to four weeks of unpaidtraining in childbirth education, newborn care, substance abuse and nutrition, among other topics.Most doula programs targeted to needy populations have been under way for less than five years. They are largely funded by foundations, but project directors are looking to health maintenance organizations for future financial support."I think it could make a lot of sense for HMOs," said Gerald McNair, president and CEO of Americaid Community Care of New Jersey, an HMO for Medicaid patients.Americaid is considering the addition of doula services to its coverage through a subcontract with a community-based doula program. If a pilot program proves cost-effective, it could be expanded to other cities.In New Jersey, the nearly two-year-old Neighborhood Doula Project works with women who are in a treatment program or in recovery for drug addiction.Up to one-third of doulas in this project are in recovery themselves."For many women in the cycle of addiction there is a profound sense of helplessness -- that they're never going to break the cycle," said Pascali. "To have a doula (who is also) in recovery is a real motivator for them."The project funded by the Robert Wood Johnson Foundation isgathering data on the effectiveness of doulas. Findings will be released this fall. Meanwhile, said Pascali, "Prenatal care is where we know we are making an impact on the health of women and babies."In Massachusetts doulas are serving an unusual population of women -- pregnant inmates at Framingham Prison.The women, a number of whom are substance abusers, can choose to have a doula or not. "Many do because, for security reasons, they'll have no one with them in labor except medical personnel," said Debra Brewster, a doula with South Shore Doula Services, funded by the March of Dimes toprovide support for women inmates.The doulas assist the inmates through one postpartum visit. After childbirth, they photograph the mother and infant together. Within a few days the baby is sent to family members or into foster care.The postpartum visit focuses on the mother's physical and emotional health. "We talk with her about the birth and her feelings about the baby," said Brewster.The program plays a humanitarian role and attempts to buildself-esteem, she said: "Often this is one of the few times a lot of these women have been treated with respect."Anecdotal evidence suggests that inmates who have doulas are more likely to enter recovery programs, according to Brewster.On her last visit with Margaret Nalubega and baby Victoria, Ife Bolden of the Cambridge Doula Program, Women Helping New Mothers, took photographs to mark the end of her care before moving on to her next client.That was the plan. But the two women formed a bond that's yet to be broken. "She's like my sister," said Nalubega of Bolden.One month later, the women held a reunion with hugs and flowers. "It's hard to say good-bye," said Bolden. Nalubega agreed.SIDEBAR ONEHELPING NEW MOTHERS HELPS THE CAREGIVERThroughout history, childbirth has largely been a family affair, with many family members -- mothers, grandmothers, sisters and aunts -- pitching in to help the new mother. Today, many women isolated from their families are turning to a new institution -- doulas -- for help."Doula" is a Greek word referring to an experienced woman who helps new mothers during pregnancy, labor and the first weeks after birth.Many doula programs are designed to benefit the caregiver as well as the mother. By recruiting women from the same community as the clients, the programs offer jobs and enhanced self-esteem for unemployed women, including new immigrants. The doulas who formed the Cambridge Doula Program, for example, are from eight countries and speak 12 languages among them."The whole issue of training people in skills they pass on to other members of their community is a way to build community," said Elaine DeRosa, director of the Cambridge Economic Opportunity Committee.Ife Bolden's graduation from Cambridge Hospital's inaugural doula training program this June was a first step toward becoming a midwife."It's a progression from A to B of what I want," said thereceptionist and mother of four. "I don't know whether I'll go on to become a midwife, but for right now being a doula is very satisfying."Many of the women who attended The Neighborhood Doula Project's first doula training in 1995 were unemployed or on welfare. Some have moved on to full-time work as doulas or taken other positions using their doula training."The program isn't just serving one population; both groups are benefiting," said Debra Pascali, director of the Center for Perinatal Research and Family Support in Newark, N.J.Moreover, fewer health care dollars will be spent down the road on moms and babies who get off to a good start, say advocates. This means fewer preterm and low-birth-weight babies."You're going to have a happier family with less stress and less needs," said Lorenza Holt, coordinator of the Cambridge Doula Program "In this managed-care world, this is a very easy, low-cost solution."Molly Colin is a Boston-based free-lance writer. She has reported on social issues for several California newspapers in addition to the New York Times and Newsweek.

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