A guest posting by Jill Wodnick, MA

Hudson Perinatal Community Doula Valerie Inzinna explains,

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'I first met Tina (not her real name) in January. She was nervous, scared and very much alone. We took Lamaze childbirth education classes together at a federally funded health center; we toured her birthing hospital and discussed everything from car seats and slings to timing contractions. My back-up doula Alison Chiappetta and I were impressed from the beginning with Tina's inner strength, her intelligence and her commitment to breastfeeding her expectant baby, Rose. Our doula time together was more than just educational; it was emotionally intimate. As Tina shared her very real fears and concerns with us, she became more confident in her abilities to not only birth, but parent. At our last meeting together before she gave birth, for the very first time Tina said, 'I can do this,' as she caressed her belly with her hands. We agreed!'

The state of New Jersey is an interesting and complex microcosm of birth and breastfeeding for American women. Some counties are extraordinarily wealthy, while others have some of the highest poverty rates in the nation. From the highest cesarean birth rates (44%-51% c-section rates in Hudson County hospitals) to growing homebirth rates, but with no free-standing birth centers, the state with the highest density of people presents many challenges to the Lamaze evidence based care practices for birth and breastfeeding. Tina's story dramatizes the tremendous power of the community doula model as well as the tremendous difficulties of implementing it effectively.

Tina is a 20 year old woman enrolled in a local community college and living in Jersey City. Her prenatal medical care was supported through a Medicaid managed plan at an FQHC (federally qualified health center); WIC services; and community doula care and childbirth education delivered through HPC (Hudson Perinatal Consortium). This alphabet soup of public health programs would be much more difficult for expectant moms like Tina to navigate without what HPC Community Doulas do: engage, inspire and support their clients.

Founded in the summer of 2010 through an Access to Prenatal Care grant from the New Jersey Department of Health & Senior Services, the Hudson Perinatal Consortium's Community Doula Program offers relationship-based intervention to low-income expectant women. Our clients, who receive free doula care with home visits and breastfeeding support, are enrolled in Medicaid, in WIC, or are without insurance. Our comprehensive doula training and education is free for women wanting to be doulas through Merck's NJ Neighbor of Choice Award. Our doulas get cross trained in many public health topics, among which are the Lamaze Care Practices for a Safe & Healthy Birth. With a 20 hour a week commitment for training, the women entering our fellowship see first-hand how poverty impacts pregnancy and parenting.

HPC Doula Mary Szubiak summarized research on doula care as part of her training with us. In her summary, she states that 'doulas offer value as they work toward providing more positive obstetric outcomes in an attempt to reduce birth disparity among women. Research has shown that black non-Hispanic mothers experience much higher rates of preterm labor, low birth weight, and fetal and maternal mortality (Martin et al. 2006). By providing doula services, we work with many other community health partners to reduce this disparity. A national survey highlighted that the women with the least amount of resources are most likely to benefit from doula care and are least likely to receive it (Lantz, et al., 2005). Furthermore, a focused study in Northern California involving low-income participants concluded that doula care was associated with timely onset of lactogenesis and higher breastfeeding prevalence at 6 weeks postpartum (Nommsen-Rivers et al 2009).'

Just a few days ago, Tina gave birth to Rose, who looks exactly like her mother. It was a natural birth with directed pushing in the supine position after which the baby was routinely separated but then returned to breastfeed.

Unfortunately, some of the most important care practices for safe and healthy birth, like freedom of movement, and non-separation of mother and baby, are not supported by the system mothers like Tina typically birth in.

HPC Doula Alison explained, 'When Valerie and I left Tina and baby Rose, we were thrilled to know that she was committed to exclusive breastfeeding. After her discharge from the hospital, I checked in with Tina by phone to see how things were going. As she was settling into her new role as Rose's mother, she informed me that Rose had been given formula at the hospital on the day following her birth since Tina was told by the nurse that she 'did not have any milk in her breasts and Rose was nursing constantly because she was hungry.' Since they have returned home, Tina has not had success inviting Rose to latch on her breast and has resorted to pumping and offering expressed breastmilk in a bottle. I am amazed at Tina's commitment to feeding her daughter breastmilk, but am also saddened by the misinformation received at the hospital which has had a huge impact on her ability to breastfeed naturally. I found it so frustrating that all the information Tina had heard and digested during her pregnancy had been undermined by what she was told during her hospital stay and it seems that it has had a profound impact on her breastfeeding relationship.'

My role as the HPC Community Doula Fellowship Coordinator blends my passion for social justice beginning with birth and breastfeeding with the clarity that the safe and healthy birth practices I teach are evidence-based thanks to Lamaze International. I encourage all Lamaze International members to learn about community health programs. Nationally, 44% of pregnant women birth through Medicaid. By making an impact in public health programs like Medicaid through the research and resources of Lamaze, we can truly change the culture of birth and breastfeeding for all families.

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Jill Wodnick, M.A., is a Lamaze & Birthing From Within trained childbirth educator; an advanced doula trainer; a prenatal yoga instructor and a mom of 3 boys. She runs the Hudson Perinatal Consortium's CommunityDoulaFellowship. Please visit www.HPCDoulas.com or www.Hudsonperinatal.org

Lantz PM, Kane Low L; Varkey S, Watson R. L. (2005). Doulas as childbirth paraprofessionals: Results from a National Survey. Women's Health Issues. 2005: 15: 109-116.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, and Kirmeyer S. (2006). Births final data for 2004. National Vital Statistics Reports 55(1). Hyattsville, MD: National Center for Health Statistics.www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf

Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. Journal of Obstetrics Gynecology Neonatal Nursing. Mar-Apr;38(2):157-73.

Nommsen-Rivers LA, Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. Obstetrics Gynecology Neonatal Nursing. 2009 Mar-Apr;38(2):157-73.

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