Share ThisIn 2019, the Allegheny Health Network (AHN) Center for Inclusion Health launched an Immigrant Health Doula program, funded in part by the Jewish Healthcare Foundation. The program trains immigrants to provide doula services to immigrants and refugees during and after pregnancy, with a special focus on Latinx, Bhutanese/Nepali and Arabic-speaking communities. As part of their certification, doulas received training through AHN's STAR Center, the Midwife Center, and Birth Partners of Pittsburgh.
Doula support and advocacy in helping to achieve a successful, personally satisfying pregnancy can be especially valuable for immigrants and refugees who may not speak English, aren’t accustomed to the U.S. health care system, and may be dealing with effects of isolation and, in some cases, trauma.
I spoke with project coordinator and doula Katie Hyre, LCCE, about the role of a doula, the benefits of this program, and the important connections between doulas and the individuals they serve.
Katie Hyre, LCCE, doula and project coordinator for the AHN Immigrant Health Doula program.
Emily Laubham: To start, what does the role of being a doula encompass?
Katie Hyre: A doula provides physical, emotional, and informational labor support. This could include breathing techniques, different labor positions, massage, and support for partners or other labor support people. Birth is a big time in people’s lives, so part of the role is validating that experience for everyone — holding that space and advocating for them.
It’s easy for people in labor to default to whatever a doctor says and not ask questions. As doulas, we’re good at asking for five minutes alone to talk things over before making a decision. That way, you can slow down and think about what you’re being told, what the options and risks are. This is even more important with immigrants and refugees who may not be familiar with the language or our health care system.
Emily Laubham: Is that something you’ve seen — a sort of lack of autonomy due to fear?
Katie Hyre: In the case of the people we serve, it is very often their first hospital experience in the U.S. Even for non-immigrants, pregnancy might be the first big hospital trip in someone’s life. It can all be overwhelming — the doctors and nurses, the beeping machines. You have no idea what you’re doing and often think, well, these people will just tell me. This is true — and, after all, they’re very educated and highly skilled. However, they also have their process, certain preferred methods and options, and that’s not always what a patient might see as the best experience. That’s where doulas can be beneficial.
Emily Laubham: Does having a doula lessen the chances of needing some sort of medical intervention like a C-section?
Katie Hyre: Researchers have found that people who have continuous labor support from a doula have a 39% decrease in risk of Cesarean and a 31% decrease in the risk of being dissatisfied with the birth experience. That’s a good thing for the individual, and avoiding unnecessary Cesarean procedures also helps reduce the total cost of health care.
Doulas talk about reducing C-section rates and reliance on medication, and that’s true, but I think it’s really about showing people how strong they are. I’m not creating strength in anyone — they had that to begin with, but we can help people tap into it and trust it.
Emily Laubham: Is it fair to say that doulas make the birthing experience more personal — for immigrants and non-immigrants alike?
Katie Hyre: Definitely. I have seen us compared to Sherpas on Mount Everest or golf caddies. We’re not the ones who are actually playing the game, but we know the game and can make suggestions about what you might do to get a better result. We know the lay of the land.
Emily Laubham: Are there any misconceptions about doulas that you’d like to clear up?
Katie Hyre: Doulas get confused with midwives. We hear people say, oh, you deliver babies? First of all — babies are not pizzas, they’re born, not delivered. Midwives sometimes say they “catch” babies. But the main distinction is that doulas don’t do the medical side of pregnancy and birth. We don’t check your blood pressure or the baby’s heart rate. We’re not doing examinations. After many births we may learn what some of that information can mean, and some doulas do have medical training, but it’s not our role.
Emily Laubham: How are doulas in AHN’s Immigrant Health Doula program different from the average doula?
Katie Hyre: They did all the standard doula training, but beyond that, they’re also doing a lot of work identifying social determinants of health and connecting people with social services. They’re looking for where people need additional support. We’ve connected people with housing resources, different shelters and food resources, and helped them find gear for their babies. We also make appointments and accompany them if they need us.
Emily Laubham: When doctors don’t look like the patient or speak the same language, there can be a level of disconnect. Do immigrant doulas serve as a kind of bridge in that respect?
Katie Hyre: Studies are finding that diversity in health care is vital to increasing trust and comfort levels, and representation may also play a big factor in improving medical outcomes. Something that we have noticed anecdotally is that when we match a doula with a client from their own community, the level of trust often starts out much higher than with someone from outside of that community. Clients want doulas who look like them, who communicate in their native language, and who understand their culture and religious beliefs. It relieves some of the burden of feeling that they need to educate this new person. There is an immediate sense that in many ways, this doula already knows what this client’s life is like, what they have been through, what their struggles might be, how their wishes for birth may differ from the status quo. There is less concern about being judged. When we establish that sort of trust, we begin to hear things that their medical team may not and we are able to encourage them to seek care or help them find resources.
We also want to make sure our clients don’t feel terribly alone. Going into any hospital can be a scary experience. For some families, there’s the added fear of getting reported if they don’t have proper documentation. Having someone there who speaks your language and can tell you that you’re OK is huge. Some clients are just excited to have someone be there, especially someone who knows their culture and speaks their language.
Emily Laubham: How has coronavirus affected the program?
Katie Hyre: We’ve been working through it, but it absolutely had an impact. Hospital support person restrictions meant that there were several months when our doulas could not attend births unless they were the only support person present. During that time, we offered virtual doula support for labor and birth. We also began completing all of our prenatal and postpartum visits by phone or video call instead of in-person. As things begin to improve, we have started to offer in-person home visits again, but we are ultimately still leaving that up to the family.
Emily Laubham: With virtual visits, do you feel like you still make those vital personal connections?
Katie Hyre: It’s been a challenge for sure. It takes more time to establish that level of trust, and this is especially true with our clients.
With the political climate, there are heightened fears — will they be able to stay, what happens to their baby if they get deported, what if they get separated from their partner? These are common concerns that we work through with them. That also means that when we call them and ask whether they’d like a free doula, we have to do it carefully. These folks need support, but at the same time, they feel an understandable sense of distrust.
Doulas in the AHN Immigrant and Refugee Health program also help identify and address challenges that involve social determinants of health, such as food insecurity and transportation issues.
Emily Laubham: What are some cultural differences you’ve seen in regard to the birthing experience?
Katie Hyre: Postpartum care is often a much bigger deal in other countries. Here, when you have a baby, you may get visitors, but they’re coming to see the baby, and you’re sort of expected to entertain them. In many other cultures, there is a period of time after having a baby when you’re expected to do nothing besides feed and take care of your baby. The community and your family come to you and do everything else — they cook for you, clean for you. Here, if you’re employed you might get six weeks’ leave, then you’re back to work, and in the meantime, you’re still expected to do the cooking, cleaning, and laundry. This pressure to return to “normal” so quickly is a huge culture shock for many immigrants and refugees.
Emily Laubham: What kind of support are the doulas providing postpartum?
Katie Hyre: Typically, we check in by phone a couple days after the birth. Pre-COVID, we would set up the first postpartum visit within a couple of weeks so everyone had time to get settled. We’re mostly looking to see how they’ve adjusted. If they’re breast feeding, is that going well? Do they need extra support from a lactation consultant? Does the baby need a safe place to sleep? If there are challenges, we can help them solve those.
Also, how is everyone’s mood? We’ve had a couple clients deal with postpartum depression. The good thing is that this condition is treatable, but a lot of people struggle to identify it. Our visits, typically around two weeks, four weeks, and six weeks, are a way to potentially identify any issues. In many cases, you might not see your doctor until six weeks postpartum, so if we see signs of a mood disorder, we can recommend they talk to their doctor sooner.
Emily Laubham: It seems to me that doulas must build meaningful connections. Do you have an example of what that looks like over time?
Katie Hyre: One of our first clients is a good example: We followed her from early on in the pregnancy to about six months after she had the baby. Her first birth, in her home country, had been pretty traumatic. Her baby also had some medical problems, which was why they came to Pittsburgh in the first place. She had her second baby here, and it was definitely a better experience, but there were still challenges. Her partner was working a lot, her first child ended up in the hospital at the same time she gave birth, and she had postpartum anxiety. There was a lot going on, and it really showed our doulas that it’s more than going to the birth, seeing a baby be born, and rubbing mom’s back a bit. We were there through this whole process and became like family. It was hard for our doulas to end that case.
Emily Laubham: Are there plans to expand in the future and bring in more doulas?
Katie Hyre: It’s on the table. We would love to expand within the communities we’re already serving, and expand into other underserved communities as well — both immigrant and non-immigrant. I can’t say when this growth would happen, but ultimately, that’s the goal.
Katie Hyre joined Allegheny Health Network in 2019 as the project coordinator for the Immigrant Health Doula Program at the Center for Inclusion Health. She has worked in the Pittsburgh area as a private birth doula and continues to support families as a childbirth educator and child passenger safety technician. In her current role, she coordinates a team of doulas who provide prenatal, labor/birth, and postpartum support to local immigrant and refugee families at no cost and regardless of insurance or immigration status.
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