Doula Support for Incarcerated Women

“If a doula was a drug, it would be considered unethical not to give it.”
– Dr. John Kennell

Pregnancy and childbirth are events that change a woman forever; the emotional impact of birth is profound and enduring. Birth is a unique opportunity that offers the doula – a trained person who provides continuous emotional, physical, and informational support to the mother before, during, and after birth – a chance to influence women for growth and positive change. In the context of a trusting relationship, the doula can help the mother fulfill her potential.

The Impact of Doula Support

The impact of doula support on a woman’s experience of childbirth and birth outcomes has been well documented. Dr. Kennell and colleagues conducted the first study of the impact of continuous labor support on maternal and infant outcomes in 1980. This research introduced the term ‘doula’, demonstrated their positive impact, and ignited interest in research on the effects of labor support.^[1]

A 2012 review of 22 randomized controlled trials of 15,288 women in the Cochrane Database demonstrated that women with continuous labor support were less likely to:

• Have regional anesthesia
• Have any intrapartum analgesia
• Have an operative delivery
• Have a newborn with a low five-minute Apgar score
• Report dissatisfaction and low levels of control with their experience of childbirth.

Women with continuous labor support were more likely to have a shorter labor and a spontaneous vaginal birth.^[2] Doulas are one of the most effective interventions available for the laboring woman.

In the U.S., the Cesarean Section rate rose from 20.7% in 1996 to 32.9% in 2009, an increase of nearly 60%.^[3] Births by Cesarean Section accounted for 32% of births in 2015.^[4] Doulas can improve medical outcomes and reduce both complications and health care costs. An evaluation of a doula program for women incarcerated at Chicago’s Cook County Jail found lower rates of epidurals and Cesareans for women participating in the program, compared to overall rates for women delivering at Cook County Hospital. In the program’s first year, 50 patients received doula services. The Cesarean section rate was 4% compared to the overall hospital rate of 27%. The epidural rate was 33% compared to the overall hospital rate of ^50%.[5] This represents dramatically better outcomes and significantly reduced costs.

The unfamiliar environment of a hospital is stressful and intimidating.  But for an incarcerated woman, a visit to the hospital to deliver can be an even greater journey to the unknown – a terribly lonely and frightening experience, in part due the presence of unfamiliar and possibly hostile staff, the constant watch of correctional officers, and the lack of privacy and access to support people, visitors, or a phone. The doula can act as a buffer – a nurturing and protecting presence – for the vulnerable mother in such a harsh environment. In my former work as a trainer of community-based doulas who worked with low-income teen mothers, I saw the tremendous impact a doula can have with at-risk women.

Doulas have been shown to be effective in enhancing maternal self-esteem, improving breastfeeding success, and reducing rates of postpartum depression.  Studies have also demonstrated that women supported during childbirth by doulas interact more affectionately with their newborns in the immediate hours after birth. In South Africa, a randomized controlled trial of support by doulas revealed that women in the doula group reported feeling that their baby was their own by 2.9 days after birth compared with 9.8 days for women without doulas in childbirth.^[6] A University of Texas randomized study of mothers’ behavior toward their infants showed that the women who had doulas in labor were more sensitive and responsive to their infants two months after the birth.  It has been speculated that mothers learn how to respond in a more nurturing manner to their infants because they themselves were nurtured during their birth experience.^[7]

An essential component of doula work is ‘mothering the mother. ’ One former doula at the old Cook County Hospital (now called John H. Stroger, Jr. Hospital) shares the profound impact she had on one woman: “I was occasionally able to meet Mothers from Cook County Jail before their babies were born, but more often I was unable to do so. Labor & Delivery would just page me when an incarcerated woman came in. I had not previously met this woman, who had a long, but uneventful birth that she was able to really participate in. After her baby was born she said to me ‘having you with me when my daughter was born let me know what it would have been like if I had had a mother who loved me’”.^[8]

Research suggests that the time immediately following childbirth, during which a new mother experiences a heightened sensitivity, is a critical period in the development of maternal-infant attachment.  The doula assists the new mother in learning her infant’s cues and enhances her ability to respond appropriately and sensitively.  This responsiveness is fundamental to establishing secure attachment of mother and baby, which in turn is vital for the child’s long-term development. The doula mothers the mother, serving as a model for mothers to follow with their infants.  Mothers who have a more positive childbirth experience may feel enhanced competence.^[9]

Doulas for Incarcerated Mothers
Being the recipient of a doula’s nurturing care in labor enables the mother to learn how to nurture her new infant. Unfortunately, except in rare cases, incarcerated mothers have only brief contact with their newborns before they are separated. Only ten states currently have prison nursery programs.^[10] The implications for these vulnerable mothers and infants – and for the broader society – are profound.

In The Psychosocial Impact of Maternal-Infant Separation at Birth for Incarcerated Mothers, Keri Zug wrote about the plight of these mothers: “Incarcerated women experience very complex emotions in response to motherhood and are often fearful and depressed when confronted with the thought of separation from their infants after birth. In retrospect, many consider the loss of their newborn to be the most traumatic aspect of incarceration. Incarcerated new mothers are often more depressed due to altered maternal roles, and need to not only come to terms with losing their infants but also with losing their identity as mothers. Due to the complex reactions women experience, postpartum depression is thought to be under-diagnosed yet overly prevalent in prisons”.^[11] As Carole Schroeder and Janice Bell write, “Within prenatal and parenting groups, doulas help their clients build a system of social support. Doulas can provide support to women who are incarcerated to cope with the anxiety, grief, and depression that result from separation from their infants”.^[12]

The essence of the doula’s work is building a trusting relationship with her client. Being non-judgmental is an underlying principle. Typically, vulnerable women – teen mothers, low-income women of color, incarcerated women – are denigrated and their pregnancies are condemned.  Unlike many in the health care professions and in society at large, where disapproval of pregnancy among women who are incarcerated or opioid-dependent is openly expressed, doulas accept the reality of the women’s pregnancies. As a doula working with low-income pregnant and parenting teens put it, “A lot of them, it’s like their words have been taken away.  Things happen to them, and they become passive.  They don’t see any way out.   I figure if we don’t teach them, then they’re not going to be able to teach their children”.^[13]

Doulas help their clients feel they have someone on their side, which gives them hope and raises their aspirations. Having doulas who believe in their capacity to labor without epidurals, breastfeed their infants, and be loving mothers is empowering.

Doulas are the only support some inmates have.  One woman interviewed about her experience said, “Having someone who believes in me, that’s huge for people who have made so many mistakes that they doubt their own ability to change. Treating inmates with respect… has created a reciprocal environment of mutual respect. It also lends itself to positive changes in perspective, indicated in interviews by key phrases such as ‘hope,’ ‘feeling valued,’ and ‘advocating for yourself” and potentially reduces the likelihood of reoffending”.^[5]

One prison doula project^[12] was evaluated using surveys completed by 40 medical providers and correctional officers who were present at the hospital births. All were positive and indicated that the women appeared satisfied with the doula services. “All interviewees expressed the importance of relationship building.  Those interviewed, who were formerly incarcerated, linked relationship building to successful transition out of prison. As health paraprofessionals, doula services provide an opportunity to intervene by offering support and advocacy, making information available regarding health and recovery resources, as well as aiding in the reintegration into the community with their families.”

Providers and correctional officers shared these observations:

“Excellent support…the doula calmed and encouraged the patient (nurse).Patients need an advocate that is not in uniform . . . I wish all my patients had a doula (physician)”.

“I was present during both of my children’s births and can’t imagine my wife going it alone. The doula project seems to provide tremendous support to women in need (officer)”.

The women’s words also support their positive experiences:

“I would have been absolutely petrified if I had been by myself.”

“It helped me have a positive experience even though I was in custody. There was a guard standing at the door, she let forget he was there.”

“The doula gives steady support and values you. Makes you feel good all over.”

“I would do anything to help support this (doula) program. You need somebody to support you, not just an officer staring at you.”

“I felt like there was somebody on my side.”^[12]

Barbara Hotelling argues that doulas are an intervention that deserves serious consideration. She writes, “With the growing number of incarcerated women who are pregnant, it is important to recognize that failing to provide preventive and curative health care for these women may cost more to society than funding programs that might improve attachment and parenting behaviors, facilitate drug rehabilitation, and reduce recidivism among this population”.^[14]

References

1. Sosa, R., Kennell, J., Klaus, M., Robertson, S., & Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine, 303(11), 597-600.
2. Hodnett, ED et al (2012).  Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. http://www.thecochranelibrary.com
3. NCHS Data Briefs. Recent Trends in Cesarean Delivery in the United States. Number 35, March 2010 http://www.cdc.gov/nchs/data/databriefs/db35.htm
4. Births: Methods of Delivery. CDC Fast Stats. Final Data for 2015. http://www.cdc.gov/nchs/fastats/delivery.htm
5. McAuley, R. and Morris, S. Doula Services for Incarcerated People in State Prison: Positive Outcomes Research Compendium. Evergreen State College: Unpublished manuscript.
6. Kennell, J. H. & Klaus, M. H.  (1997).  The doula:  An essential ingredient of childbirth rediscovered.  Acta Paediatrica, 86, 1034-1036.
7. Gilbert, S.  (1998).  Benefits of assistant for childbirth go far beyond the birthing room.  New York Times, May 19.
8. Mary Fauls, personal communication
9. Hofmeyr GJ, Nikodem VC, Wolman WL, Chalmers BE, Kramer T. Br J Obstet Gynaecol. 1991 Aug; 98(8): 756-64. Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding.
10. Pishko, J. The Rise of Prison Nurseries, Feb. 18, 2015. Pacific Standard.
11. Zug, K. The Psychosocial Impact of Maternal-Infant Separation at Birth for Incarcerated Mothers. http://www.undergraduatelibrary.org/2012/nursing-midwifery/psychosocial-impact-maternal-infant-separation-birth-incarcerated-mothers.
12. Bell, J. & Schroeder, C. (2005).  Doula birth support for incarcerated pregnant women.  Public Health Nursing. 22(1), 53-58.
13. Loretha Weisinger, personal communication.
14. Hotelling, B. A. (2008). Perinatal Needs of Pregnant, Incarcerated Women. Journal Of Perinatal Education, 17(2), 37-44.