Birthing a Peer Doula Program

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Birthing A Peer Doula Program For Immigrant Women
In Montreal

• Rivka Cymbalist
• Montreal Birth Companions

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Funding Acknowledgments

• La Maison Bleue Projet Doula
• Montreal Birth Companions

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• Id also like to thank Isabelle Brabant for her
  contribution to this project.

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Introducing Montreal Birth Companions

• Montreal Birth Companions is a registered charity
  that has provided free doula services for women
  in need since 2004.

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• The MBC doulas range greatly in experience,
  background and training. The MBC program supports
  mentoring and apprenticeship.

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• In October 2010, MBC membership consisted of four
  professional doulas, eleven volunteer doulas, and
  five active peer doulas. There are about ten
  inactive doulas who may return in the future as
  volunteers.

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Referrals

• MBC is referred clients by
• La Maison Bleue
• Montreal Diet Dispensary
• CLSCs
• Alternative Naissance
• Other agencies

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Outcomes

• In 2009 our clients had an average c-section rate
  of 40.

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• This rate can be compared with the rate for a
  professional doula-assisted population for whom
  natural birth is the goal. In my private doula
  practice the c-section rate is an average of 6 .
  

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• The inflated rate for MBC clients may reflect
  some of the difficulties these women face
  physical and emotional trauma, poor nutrition,
  and poor or very late prenatal care.

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• So far for 2010, the MBC c-section rate is 23.

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Possible Causes for Decrease

• In 2010 MBC started to assign peer doulas to
  accompany experienced doulas to births.

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• We have also taken care that each client is
  paired with two doulas, to ensure support.

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• MBC doulas accompanied a greater volume of Maison
  Bleue clients than women referred by other
  agencies. These clients generally have more
  continuity of care.

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Our Clientele

• MBC doulas accompany an average of 55 women a
  year.

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• Most of the women we assist are refugees, recent
  immigrants and asylum seekers. Many of them are
  alone and many have experienced sexual abuse and
  violence.

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• These women are often isolated during their
  pregnancy and birth. Many women have children
  they have left with their families in their
  country of origin. Their isolation increases
  during our harsh winters when women from warmer
  climates may be unable or unwilling to go outside.

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• Many of our clients come from the African
  continent. We have also had clients from Central
  and South America, China, South Asia, Eastern
  Europe, the Middle East, the Caribbean and Canada.

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Languages Spoken

• In 2010, just over half of these women spoke
  English and about a third spoke French. However,
  these languages were not their mother tongues.
  Some of the MBC clients are Spanish speaking and
  occasionally we are referred clients who do not
  speak any of these three languages.

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The Peer Doula Program

• In 2009, MBC and the Maison Bleue teamed up to
  provide peer doula training for women from the
  communities we serve.

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Teachers

• The program facilitators were Isabelle Brabant,
  midwife at the Maison Bleue, and myself. I have
  been training doulas for seven years, using a
  training program that consisted of 84 hours of
  class time, an integrated apprenticeship and
  self-directed study.

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Students

• To date, 13 women from nine different countries
  have been involved in the program. The women
  speak a total of eleven different languages.

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• Of these women, three were trained midwives,
  three had college degrees and the rest had up to
  high school or less education.

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• The students ranged in age from 19 to 55.

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The Training

• The training consisted of 24 hours of class time.
  The students were then expected to attend three
  volunteer births. Two of the students have
  completed this requirement. Five are working on
  achieving it.

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The Classes

• We taught two courses. The first was in English
  and we used a simplified version of the
  professional doula training program. This first
  program was definitely a learning experience for
  the teachers.

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• The second course was in French and we used
  visual aids, physical props, games, and skits.
• The dynamic changed and students and teachers
  were more involved and interactive. My
  difficulties in French helped to create a more
  democratic feeling in the class.

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• It became clear during the initial trainings that
  we needed to deconstruct the modern understanding
  of the professional doula and go back to Klaus
  original understanding of the doula as a
  continual female presence.

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• In Klaus early paper he describes the students
  mistake that led to his work on doula support.
• Klaus, Marshall H. Touching during and after
  childbirth. In Field, TM (Ed), Touch in early
  development (pp 19-33). Mahwah, NJ, Lawrence
  Erlbaum.

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Challenges

• Of the 13 students, three did not attend any
  births, and a further four dropped out of the
  program after attending one or two births.

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• Attendance and concentration were affected by the
  womens financial situations, child care,
  fulltime work, and emotional stresses.

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• The midwives had difficulty unlearning their
  skill sets.
• The way we approach women differs across borders,
  but more importantly, the doula is not a
  medically trained person so a midwife or nurse
  needs to forget her clinical training when she
  is working as a doula.

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• Because many of these clients will have long
  labors, or will be back and forth from the
  hospital several times in early labor, it is more
  difficult for the students to be on call.
  Financial considerations meant that the peer
  doulas could not take taxis to and from the
  hospital, or could not arrange or afford child
  care.

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• Occasionally a woman will not want to be
  accompanied by someone from her community. There
  may be a stigma attached or she may worry that
  her birth story will circulate.
• There may be class or caste issues that we are
  not aware of.

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Achievements

• The students who overcame their significant
  hurdles and attended births were excellent
  support providers.

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• Clients were happy with the support, and the
  students sense of satisfaction was significant.

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The Benefits of a Doula

• Research and observation has consistently shown
  that the presence of a doula can reduce labor
  time and lowers the rate of epidurals and
  cesarean sections.
• The most frequently quoted source is of course
  Klaus and Kennells study from 1991
• (Kennell JH, Klaus MH, McGrath SK, Robertson S,
  Hinkley C. Continuous emotional support during
  labor in a US hospital a randomized controlled
  trial, JAMA, 2652197- 2201, 1991)

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• But more importantly, the presence of a doula
  favorably affects the womans perception of her
  birth experience, no matter what the outcome. If
  a woman feels supported and in control, to the
  extent that she is part of the choices made about
  her care, then she will be more likely to look
  back on her childbirth experience with a sense of
  accomplishment.

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The Doula and Post Partum Depression

• A small study (594 women) done in 2004 showed
  that factors predictive of depressive
  symptomatology at 1-week postpartum included
  immigration within the last 5 years, history of
  depression independent of childbirth, diagnosis
  of pregnancy-induced hypertension, vulnerable
  personality style, stressful life events, lack of
  perceived support, lack of readiness for hospital
  discharge and dissatisfaction with infant feeding
  method.

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• The presence of a doula, especially one who
  understands the womans cultural background, can
  help reduce the effect of these risk factors.

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• "Pour la première fois, je vois un meilleur
  avenir pour nous deux pour mon enfant et pour
  mois-même. Je nai plus peur. Jai le certitude
  que mon bébé recevra de lamour et des soins.
  Avec votre aide, dautres femmes pourraient
  recevoir le même soutien. Merci! " S.K., 27

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Why Peer Doulas?

• Professional doulas move on to private practice
  as that demand increases.

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• Most private practice doulas are white, middle
  class ladies. Their work with this client base,
  while generous and appreciated, enforces the
  stereotype of helper and victim.

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• The peer doula approach serves to empower both
  the client and her peer doula.

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• Peer doulas can provide the same support and
  often are better equipped to provide simple doula
  care.

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• With funding available, peer doulas can receive a
  stipend for the births they attend.
• Subsidized peer doula trainings can create
  employment for these women.

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• The peer doula concept can be extended to other
  marginalized groups women on the street drug
  users and women in recovery teenage mothers
  incarcerated women.

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Money Talks

• A decrease in cesarean section, epidural rates,
  labor duration saves money and bed space for
  hospitals and provincial health care systems.

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• There is also a decrease in PPD and associated
  costs, if a doula has been involved in care.

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• The cost of a peer doula training program and
  subsequent funding for stipends compares
  favorably to the cost of cesarean section and
  increased hospital stays.

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• It is possible that these savings extend well
  into the life of the child, as the mother is
  better equipped to deal with the challenges of
  parenting if she has been empowered by her birth
  experience.

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• Thank you