How doulas are helping one city lower its high rate of black infant deaths
In the delivery room, preparing to give birth, Natasha Lettner felt intimidated by the on-call OB-GYN. She had spent her pregnancy building a trusting relationship with her own doctor. But when she went into labor a few weeks earlier than expected, her regular doctor was on vacation.
"When it came time to start pushing, I made a little straining sound, and the doctor was like, 'you know, you don't have to make that sound.'"
Fortunately, Lettner was working with a doula, Vanessa Johnson, who was also in that room.
Johnson helped Lettner feel more comfortable by encouraging her to do what her body needed. That included making noises, lowering the lights, getting into more comfortable positions and playing the music she had chosen with her husband. These relaxation techniques were included in the birth plan Johnson and Lettner had developed at prenatal appointments. Johnson's presence at Lettner's baby's birth allowed her to use those techniques without feeling cowed.
Doulas provide physical, emotional and educational support to mothers before, during and after childbirth. Unlike certified midwives, they are not medical professionals.
Johnson and several peers whom she calls her doula sisters serve a community with some of the highest infant mortality rates in the country: low-income African American women in Milwaukee.
In 2017, the black infant mortality rate in Milwaukee was 18.4 infant deaths per 1,000 births. In the 53206 ZIP code, it was 29.1. Compare that to the U.S. infant mortality rate of 4.95 for white babies and 11.1 for African American babies.
Helping moms feel comfortable
As Lettner’s story suggests, a lack of trust in medical professionals is a contributing factor to the high infant-mortality rate in the black community.
"In our community, going to the doctor is a fear," Lettner said. "People feel like they go into the doctor and come out sicker than before because doctors are dismissive of African American people's symptoms."
That lack of trust leads to fewer women getting the medical attention they need during pregnancy.
Johnson understands how feeling uncomfortable can get in the way of getting help.
Two decades ago, she was a teenage mom in Milwaukee. While she had a supportive mother, who was a registered dietitian, and a family of educated women with health backgrounds also supporting her, she still often felt out of place.
Knowing the importance of breastfeeding, Johnson sought out a La Leche League meeting. "Here I am, a 19-year-old single black mom on the east side somewhere trying to get breastfeeding support," Johnson said. "I knew I needed to be there to get the information and support I needed to get, but it was uncomfortable. I was getting funny looks, no one was relatable and no one looked like me."
So she became a breastfeeding educator to support other young black women. She went on to become a registered nurse and, more recently, a doula. “I want to be someone who can bridge the gap,” she said.
Helping moms feel heard
One of doula Tiffany Scaife’s recent clients had two prior pregnancy losses, including a baby who was stillborn. Because of that history, she was monitored more closely and had more doctor appointments than a typical pregnant woman.
Two weeks before the client’s due date, Scaife and infant mental health consultant Kisha Shanks, whom Johnson calls “an honorary doula,” attended a prenatal appointment with her. Both mom and baby were deemed healthy.
But in the exam room, the doctor suggested additional interventions to the pregnant mom, including induction and even a scheduled c-section.
When the women asked why she was recommending these interventions, Shanks said, “the doctor said that when women are overweight, babies tend to die. I saw the terror on the mom’s face, and she just shut down. She wouldn’t say much anymore.”
Scaife recommended a break. "We stepped out of the room and I talked to her about what she wanted to do."
Both Scaife and Shanks asked the doctor if there was a medical reason to be concerned about the baby's health, and the doctor said there wasn't.
To Scaife, that sounded like racial bias. She felt that the doctor's words were based on statistics dealing with overweight African American women, rather than her client's actual history. "I heard that same doctor give a white woman the risk factors for c-sections, but in a totally different tone," she said. "She told her the risks and then reassured her, 'I doubt that will happen.' So, why did you tell my client she has a high risk of her baby dying?"
Helping moms feel supported
Trauma, and the disruptions it causes, has also been identified as contributing to the high black infant mortality rate.
Shanks understands the kind of trauma that some of her clients have experienced. She grew up in a Milwaukee neighborhood where she scrambled onto the floor in the middle of the night when she heard gunshots outside. The support of her grandmother helped her get through those nights.
"She was always my anchor and my safe space. I could talk to her about anything, and sometimes I wouldn't say anything. I'd just lay my head down on her lap, she would rub my hair and I knew everything would be fine," Shanks said. "I've had people who poured into me."
Now much of Shanks’ work with families to build attachment and healthy relationships focuses on helping her clients find those support systems in their own lives.
One client, a single mother of three with one on the way, was evicted from her home two weeks before the new baby was due. The mom had a sister, but she hadn't considered asking her for help because they didn't have the best relationship. The sister had four kids of her own.
Shanks mediated conversations between the two sisters, and the families moved in together temporarily. That gave the client and her family a home during the rest of her pregnancy and the immediate postpartum period. By then, Shanks was able to find housing for the family.
"When she was staying with her sister, it wasn't perfect. There were obviously too many people, but my client did have someone who was willing to help her. She did have support," Shanks said. "A lot of what I do is help people to find the support that exists in their lives. It may not be comfortable, it may not be perfect, but it's there."
Helping moms feel relaxed
A doula works with family members as well as expectant moms.
Johnson included Natasha Lettner's husband, Andrew, in prenatal visits. She educated both about the birthing process, including what procedures to expect during labor and delivery. She never came to the Lettners' house empty-handed. She brought birthing balls to demonstrate comforting laboring positions; dolls to explain a baby's progress through the birth canal; and literature to emphasize the importance of good nutrition.
The Lettners worked with Johnson to develop Natasha's birthing plan. "He was the one who told me to call Vanessa when I went into labor," Natasha Lettner said. "Her being there allowed him to be calm and soothing, to just do things like hold my hand and using encouraging words."
Some people think the relaxation techniques that Johnson teaches her clients are extras or luxuries. But she and her doula sisters say techniques to make pregnant women more comfortable and less stressed are necessities.
Shani Toor observed firsthand the need to support new moms when she was an activities coordinator at Siena House in New York City, a homeless shelter for pregnant women, new moms and their babies.
In her first few weeks there, Toor met a woman whom she described as sweet, kind and perfectly healthy during her pregnancy.
"After she had her baby, something changed," Toor said. "She would refer to the baby as 'that baby,' she would toss her 2-week-old up in the air like he was a toddler, she wasn't engaged with her baby at all."
The woman had postpartum depression and postpartum psychosis. Luckily, the shelter staff recognized the signs and was able to get help for both the mom and baby. The experience left a lasting impression on Toor. She organized more activities for the women that focused on support — prenatal and infant massages, lactation specialists and workshops about self-care. And when she came back to Milwaukee, she became a certified doula who primarily serves women in the 53206 and 53210 ZIP codes.
Toor supports her clients by organizing life celebrations. "We listen to music, we read poetry, I bring a cake that just has her name on it, not the baby's, we'll make an affirmation board," Toor said. "These seem like little things you would do at a 12-year-old's sleepover, but pouring all this love in the mom's direction can reduce rates of depression."
Toor said she sees a tendency for moms to put their children first and neglect their own needs, and that that can especially be true among women who have low incomes. "If you're trying to figure out how to pay the bills and how to get food, clothing and shelter, those thoughts are going to take priority over loving yourself and taking care of your own mental health," she said.
Her life celebrations provide a safe place for the mothers to express their feelings and get their own emotional needs taken care of.
"That's a deficit in the community, and we're trying to gather as many resources together to plug up the hole," Toor said. "Right now, we're fixing the cracks in the foundation, plugging the leaks."
Doulas are catching on
Johnson and her colleagues organized a community baby shower during World Doula Week in March. Expectant moms received gift bags with baby items; stress-relieving massages and yoga classes; and information from doctors, midwives and doulas about pregnancy and childbirth.
In both attendance and donations, the event at Sherman Phoenix was more successful than the doulas had anticipated. Pregnant moms lined up to ask questions of doctors and midwives. Young children walked with their parents sampling smoothies mixed by nutritionists. And the doulas demonstrated how to use birthing balls during labor and slings to carry babies after they're born.
Lettner attended the shower, even though her baby was a few months old by then. "I hadn't realized how high the black infant mortality rate was. I guess I was pretty out of the loop about that," Lettner said. "I already had a lot of respect for Vanessa, but the fact that she's doing all this for the community. I'm just in awe of her now."
At the moment, Johnson and her colleagues are not charging anything for their work in the low-income African American community. Shanks calls it "heart work."
As consensus builds that having a doula improves birth outcomes, funding is starting to follow. The City of Milwaukee recently passed legislation for a pilot program that will provide funding for 100 women in 53206 to receive doula services. Gov. Tony Evers' recommended budget includes a proposal to fund doula services through Medicaid. And the African American Breastfeeding Network recently received a $50,000 grant from the Wisconsin Partnership at the UW School of Medicine and Public Health to help Milwaukee's community doulas work together and educate the community about their services.
"I hope that eventually there will be more funding to help," Johnson said. "But, until then, the work still needs to be done. Black babies are being born right now, and black babies are dying."
Contact Amy Schwabe at (414) 559-2365 or firstname.lastname@example.org. Follow her on Twitter at @WisFamilyJS, Instagram at @wisfamilyjs or Facebook at WisconsinFamily.