Jail doulas make childbirth less laborious

It is well known in the correctional community that female detainees are visited less often than their male counterparts. That sense of isolation is magnified for detainees who give birth while incarcerated. For them, labor and delivery is lonely experience, one devoid of support and often framed against a backdrop of guards, shackles and judgment. It’s been like this as long as women have been jailed. At the Cook County Department of Corrections, however, an innovative program is changing the birth experience for pregnant Cook County Jail detainees.
In March 2001, staff at the Cook County Bureau of Health Services introduced a doula program to support pregnant detainees during labor and delivery. A doula is a woman trained to provide continuous emotional, physical and informational support to a woman before, during and immediately after childbirth. The program is staffed by five volunteers employed by the CCBHS (comprised of Cook County Hospital and Cermak Health Services of Cook County, located at the Department of Corrections). One of the five has been a practicing, certified doula for more than seven years; the other four are in varying stages of achieving doula certification through Doulas of North America, a 3,350-member not-for-profit that has trained and certified doulas since 1992.
“The doula program is one of the finest examples of a program that epitomizes our mission of providing care with dignity and respect,” says Ruth Rothstein, chief of the CCBHS.

Identifying the Need

Nearly a year elapsed between the time the doula concept first surfaced at the Bureau of Health Services and its implementation at Cermak.
Among the issues to be resolved: with what population to implement it and how, since most doulas are privately trained and individually certified, says Martha Gottlieb, coordinator of maternal and infant services for the CCBHS.
Gottlieb is one of three Cook County Hospital doulas. The others are Bertha Condes, a breast feeding clinician, and Toishia Jamison, abreast feeding care counselor. Representing Cermak Health Services are nurse clinician Agnes Jones-Perry, BSN, CCHP, and Shawn Withers, BSN, CCHP, who manages the nursing continuous quality improvement program.
“We looked at what population within the Bureau might be at highest need for doula services,” Gottlieb says. Cook County Jail detainees rose to the top of the list.
Woman make up nearly 10% of the jail’s population of 10,500, and each year, 40 to 50 of them give birth. All of the women have one visiting day per week and are closely monitored. No family members or friends can be with them while they are in labor. A guard sits outside the labor and delivery room, and postpartum women are shackled and kept under 24-hour guard. After the birth, they are returned to Cermak and separated from their baby, who is taken by family members or becomes a ward of the state. “These women don’t have anyone else with them. How terrifying that must be! We felt that this population would benefit,” says Gottlieb.
Joclede Benn, superintendent of the jail’s women’s division, agrees. “These women don’t have the support that we have. They don’t have husband there, or a mother or sister or close friend. They didn’t get to go to Lamaze class. So just to have someone there to give them support is important.”
In fact, Benn is so enthused about the program that she has decided to pursue doula training after her retirement this year.

Building Buy-In

Implementing the program required more than a desire to assist pregnant detainees; it required considerable education and coordination among all the entities involved in an inmate’s care.
“As much as I was excited about this opportunity, I did recognize that there would be some barriers,” says Mary Muse, BSN, CCHP, director of nursing at CHSCC. “Not in terms of acceptance of the doula concept, but we’d have to educate and get buy-in from the Department of Corrections and from our own staff. We’d have to organize systems, communicate with our partners and develop support structures.”
The good news, adds Muse, is that the relationship between the health care team and county DOC is very positive. “It was a matter of sitting down and reaching out to the right people and telling them what we wanted to do any why, and what we saw as the benefits.”
A series of meetings followed with Bureau of Health Services senior management, the DOC, the Cemak Health Services general operation department and hospital administrators. Getting buy-in from the correctional officers, whose inmate custodial duties extend to the labor and delivery room, proved the biggest hurdle. The key, Muse says, was getting the officers’ leaders on board.
“When you talked to some of the officers, the question was, ‘Douls? What is that? Why are you doing that?” she says. “To smooth some of that out, we agreed to write up a summary of the purpose that the correctional leadership could share with their staff. And they really did embrace it. They had meetings with their correctional officers and shared the information, and some of us were present to talk about what we wanted to do. So the correctional officers heard the support.”
The easiest part of the program was introducing it to the women. The doulas, joined by superintendent Benn, corrections staff and Muse, presented the program at the pregnant detainees’ housing. “We had an open discussion to explain what the program was about and how we could service them,” says Jones-Perry. Condes, a doula for eight years, demonstrated some of the massage therapy interventions. The women’s enthusiastic response “verified what we believed anyway-that there is a need among women to have that support,” adds Muse.

Birth Plan

Each pregnant detainee completes a birth plan that Condes designed. In addition to general information-due date, other deliveries and health background-it asks the patient to describe what’s important to her during her birth experience, how she would like to be supported or comforted, what kinds of comfort and pain relief measures to try, and what she’d like after the baby is born. The doulas meet monthly to discuss the birth plans.
When a detainee goes into labor, Cermak staff pages Gottlieb before the woman is transferred to Cook County Hospital. Gottlieb then pages the detainee’s doula, who will spend the next eight hours at the detainee’s bedside. “After eight hours another doula comes to relieve me, but it’s like I never left because the doulas are all on the same wavelength,” Jones-Perry says.
“It is important for a doula to be present for the entire labor and delivery,” Gottlieb says. “We spend an average 12 hours of labor and delivery time per patient. Plus we visit them every day in the hospital postpartum.”
And they are doing it in addition to their regular jobs. Gottlieb commends the Bureau of Health Services and the Department of Corrections for being “very flexible and supportive, adjusting schedules.”

Positive Outcomes

As in all new programs, the first doula-assisted birth at Cook County Hospital was not without its challenges. Cermak’s Withers was the pioneer. “That was real difficult, being the first and going to the hospital. They kept asking, ‘Who are you? Why are you here?’ I had more support from the doctors, who said, ‘OK, she’s a doula, let her in.’”
The corrections officers challenged her presence, as well, she says, “but once you got over those barriers, it was OK. I was the icebreaker and had more resistance than the ladies who followed after me.”
Today, the doula program is more favorably received the hospital and corrections staff. Physicians have noticed that doula-assisted births improve patient outcomes: fewer cesarean sections and less use of medications. Of the 22 doula-assisted births, none of the women had cesarean section, nine delivered without anesthesia and less than half received epidurals. This tracks with data collected by Doulas of North America showing dramatic decreases in the rate of cesarean sections and anesthesia use among women who deliver with a doula present.
“We find that patients given better support in labor did better and had more successful outcomes,” says Dr. Maureen Ruder, an attending physician in the hospital’s obstetrics/gynecology department. She also notes another benefit: “Any time there is a support person with a woman in labor, it tends to help the staff be more attentive. It keeps everyone on their toes.”
Ruder welcomes the program and believes the doula’s presence tends to blunt the somberness of births to incarcerated patients. “It is a lonely experience because they are not allowed visitors. The guards are always close by and they converse back and forth, putting a damper on the experience. Having a doula is good and helpful.”
Another true believer is Leonard Bersky, CHSCC’s chief operating offices. “This program is win-win for all concerned because it’s a partnership. The biggest winner is the patient, who has support at a time when she really needs it. This arrangement benefits both mother and child. We hope that when other large urban jails hear of this program, they will consider making similar arrangements.”
One year after its inception, the program’s managers are conducting an evaluation to assess outcomes; program satisfaction among patients, providers and doulas; and the time commitment. The results will help them determine how to expand the program to other women delivering within the Cook County Bureau of Health Services system.

What Doulas Do
Collectively, the five doulas at the Cook County Bureau of Health Services have supported 22 women in labor and delivery.
They’ve also made more than 40 antepartum and more than 70 postpartum visits.
Importantly, doulas do not replace clinical caregivers nor do they make decisions for the mother. Rather, they stay by the mother’s side throughout labor and delivery, using a variety of therapies to provide support.
“It’s the little things that provide comfort,” says Toishia Jamison. “The women we work with are so isolated that often things are disregarded that could comfort them.”
Therapies can include praise, reassurance, aromatherapy and improving the physical comfort of the mother, as well as physical contact such as rubbing the mother’s back, massage and holding her hands. The doula also provides information to the laboring woman, explaining what is going on during labor and delivery.
According to Bertha Condes, it’s essential for doulas to possess qualities such as “spirituality, endurance, being nonjudgmental and possessing strong belief in what you’re doing.”

This article was written for the Cook County Bureau of Health Services by Cynthia Val Chapman, a professional writer based in Chicago. For more inforamtion about Cook County Bureau of Health Services doula program contact Martha GotliebMartha Gotlieb, coordinator of maternal infant services, at (312) 633 – 3839