By Theresa Hogue
When Evie Steiling’s best friend became a doula, Steiling wasn’t sure what the term even meant. She vaguely knew it had something to do with childbirth, so she decided to invite her along when she went into labor. She figured the midwives present would be doing all the hard work, but it wouldn’t hurt to have an extra set of hands.
But when her labor suddenly and inexplicably became intensely painful, and Steiling found herself thrashing in the birthing tub trying to escape the pain, it was her doula who leaned over, studied her body language, and gently suggested a way to shift her body as she contracted. Suddenly, the pain and pressure lifted, and with the next push, her baby was out.
“A lot of people are under the impression that your OB or your midwife are going to be present with you the entire time you’re in labor,” says Steiling, now a practicing doula in the Albany, Oregon, area. “But they don’t realize that they may have other moms in labor they’re going between. They’re not there to hold your hand, witness your changing body language and see the way you’re moving and how the baby might be coming down. The doula is there to say, ‘You’ve got this.’ She is giving you support the entire time, telling you that you’re not alone.”
A doula is a birth partner who provides physical comfort, patient advocacy and psychosocial support to a mother leading up to and during the birth process (and sometimes after). The doula does not provide clinical or medical support but is there more to follow the mother’s preestablished birth plan. The doula can act as a negotiator between the mother and the doctor or midwife attending the birth and, in general, tries to help the process work as the mother wants it to.
Melissa Cheyney is an Oregon State University associate professor of anthropology as well as a practicing midwife and doula. She knows firsthand the important role a doula can play during pregnancy, labor and the postpartum period. As the head of the Community Doula Program, she is helping to seek out and train Oregon women from all walks of life to become doulas in Linn, Benton and Lincoln counties. The pilot program offers free training to women interested in becoming doulas. It pairs them with a number of targeted populations, including those who have limited English, who are racially and ethnically diverse, are experiencing homelessness or housing insecurity, are medically high-risk, under age 21 and have limited or no family support.
The doulas serve women on the Oregon Health Plan, and the program is sponsored by the InterCommunity Health Network CCO, which gave Cheyney $187,000 to study whether matching doulas to clients with similar backgrounds will improve birth outcomes, such as a reduced rate of Caesarean section and sustaining breastfeeding.
“Our program was developed after researching successful community doula programs and doing a deep dive into the constraints on doula practice in Oregon,” says Cheyney. “It’s really new in Oregon to think about providing doula care to Medicaid-eligible clients. One of the reasons the project has been so successful is because it was oriented to getting over those hurdles.”
Those hurdles include cost, difficulty navigating social services and a state requirement that doulas-in-training attend three births that are not eligible for Medicaid reimbursement before they can become registered. Becoming registered allows them to receive payment for their services.
“Doulas struggle to find access to training, and it’s really expensive,” Cheyney says. “Our program has spent $40,000 training 80 doulas. And when you ask them, the reason they didn’t become doulas earlier was because the training was cost-prohibitive.”
Training for Service
And the program goes above and beyond basic doula training.
“To provide services to the clients we want to care for, there’s some additional training you need to have in place, including interprofessional communication and collaboration, trauma-informed care and safety in home visiting,” Cheyney explains. “Our doulas need to be really well-educated about what other social services are available in the three counties we serve and how to connect clients to those services. Cultural competency and cultural humility classes are particularly difficult to come by.”
Once they receive training, the program also pays the participants for their time attending the required births and then helps them navigate the paperwork involved in getting on the state’s doula registry.
Evie Steiling, who is now a mother to five children, has become a doula herself since her first eye-opening experiences during labor. She is also leading an Albany-based program that links teen mothers with doulas trained in Cheyney’s program. As a former teen mom and a survivor of childhood trauma, she knows that having a doula with a similar background can make a huge difference to the process.
“I’m very passionate about it. I knew instantly I was born to do this work,” she says. She is especially focused on helping the mother know what her choices are and empowering her that there’s no “wrong” way to give birth, whether it’s natural or with medical assistance. She emphasizes that having a birth plan — and then putting it aside if circumstances change — is perfectly acceptable. Steiling serves on the program’s board of directors.
“Let the mom lead” is Steiling’s mantra, and as a doula she hopes to help mothers put aside self-judgment and false notions about pregnancy that prevent them from having a good labor and birth.
Doulas as Professionals
Being able to receive doula care via the Oregon Health Plan has opened the door to many women who would previously never have been able to benefit from the specialized care. “Being a doula is a profession, and there’s a charge associated with it. In practice, only about 3% of women in the U.S. have been able to afford a doula, so the vast majority who have received doula care have been white, middle-class women who can afford it,” says Cheyney.
Analuz Torres just became a certified doula through the Community Doula Program. Torres, who is a community health care worker in Albany, first heard the term doula at a community health conference. When she learned about the services they provide, she says she wished that she had had doula services during the births of her two children.
“We don’t have a lot of family here, so it was just my husband and me,” she says. “It would have been great to have a doula.”
Torres was interested in becoming a doula but found the training to be cost prohibitive. So when she heard about the Community
“The idea of having another woman there during labor, supporting you just by being there, it was something that I thought was so good for the whole family,” she says. Torres admits that the first time she served as a doula, she was scared and felt a little out of place.
“(The client’s) husband was there, and some of her extended family, and at times I felt like, ‘What am I doing here?’” she recalls. “But afterward I realized that I was offering a different type of support than the family could provide. It was an amazing birth, and afterward I thought, ‘I wish I would have had a birth like that.’ I put all of my training into practice during that birth, and it was amazing.”
So far, Torres has attended seven births as a doula, five as the primary doula and two as a backup to help out another doula from the program. Because she is serving a Spanish-speaking population, she discovered that her role is bigger than just providing birth support. She is also frequently expected to be an interpreter between her client and the medical providers, even though she is not a trained interpreter.
“Knowing that you were there in that moment when someone needed you the most is incredibly rewarding,” Torres says. “Especially women from a different culture. They may be scared, because in their home countries, they had horrible birth experiences. To walk them through the process is amazing.”
Torres hopes the doula training program can be extended, because she sees a great need in her community for more bilingual doulas. But she recognizes that even with that support, being able to pursue doula certification is difficult for some, especially recognizing that the pay is not high, and the schedule is unpredictable.
“I’m very fortunate in that I have an amazing husband who is very supportive of me, and he firmly believes in the work I do. But I’m not sure that other women have that support or a flexible job that allows them to take time off to serve as a doula.”
Birth Outcomes Matter
An essential aspect of the pilot program is research, something that Cheyney is especially keen to do. Funding is tied to metrics — specifically birth outcomes in this case — and the more doulas involved and birth information gathered, the better they’re able to push for further funding.
“It’s really great to get this pilot funding, but how do we sustain it?” Cheyney asks. “We’ve been really lucky that our assessment has been built in quarterly. So we have had outcome data from the very first report and been able to leverage up those research findings to continue the flow of funding into the project. It’s a really great collaboration between a grassroots, community-based organization that’s really focused on birth justice. And Oregon State University as a research institution brings the expertise to make sure the amazing work they’re doing gets leveraged up, so it can continue to be funded.”
Although the funding has provided the doulas with a lot of support, financial constraints are still limiting what’s possible within the program. Because of this, the doulas in the program have started identifying gaps in the support and finding creative ways to fill them. When one doula noticed there was no training for pregnancy-specific massage, she came up with her own training and shared it with others. Another noticed that there was no training specific to serving women with obesity and came up with programming related to that issue. Her work was so useful that it’s now being presented at a statewide conference in the spring.
“To see them take ownership and share that with the community has been one of the most wonderful parts of the program,” Cheyney says. “It’s helped with the sustainability of the program, because it’s really hard to fund all the different aspects.” It also reinforces the program’s open-access emphasis.
“We’re documenting our entire program and linking each part to deliverables so we can democratize the knowledge. The program website will eventually host a narrative of our program, so when we produce trainings, they’ll be linked online. It’s very much open source/open access. We are excited about that, so people can take those materials and freely modify them to fit into their own communities,” says Cheyney.
The research is already showing that clients in the program have a dramatically lower C-section rate than other populations (13% as opposed to 30% in Medicaid populations). A high rate of C-sections is linked to poor maternal and child-health outcomes, longer recovery periods for mothers, as well as higher costs.
“That’s shockingly low, actually, lower than we were anticipating,” Cheyney says. “We’ve also had 100% breast feeding initiation, which is also a big surprise.”
Now they need to figure out why that’s the case. They’re interviewing the doulas themselves to learn more about their experiences providing care and how well-prepared training made them, as well as what impact becoming a doula had in their lives. From a research perspective, this will help Cheyney understand the mechanism by which doulas are able to create positive birth outcomes.
The next step is to interview clients and ask them, “What is your experience of receiving care in this way? What is it like having an advocate for you when you go to give birth?” Additionally, they’ll be talking to other members of the care team, including nurses, midwives and doctors about their experiences working with the doulas.
“What is it about her presence? Is it a calming effect that leads to lower rates of epidural use, so you don’t have the snowball effect spiraling into medical intervention? Help us figure it out,” says Cheyney.
The current grant runs out in December, but Cheyney says they have received $75,000 in additional funds to continue the program, with an invitation to apply for another $150,000. Additionally, they received $5,000 to help fund the Oregon Doula summit, which was held at OSU’s Corvallis campus in October. Meanwhile, Cheyney is already witnessing how the doula program is creating a ripple effect in the communities they’re serving.
“When a doula and a client meet and connect, it’s been really powerful for the client to feel they are being cared for by someone who understands their daily experience. I think that’s a real asset to the program,” Cheyney says. “Doulas are having impacts far beyond birth for the people they’re caring for.”