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.

"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.

Women 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 a 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.

The good news, adds Muse, is that the relationship between the health care team and the 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 and why, and what we saw as the benefits."

A series of meetings followed with Bureau of Health Services senior management, the DOC, the Cermak Health Services general operations 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, ‘Doula? 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.

"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 by 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 sections, 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 officer. "This program is a 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.

— Editor’s Note: This article was written for the Cook County Bureau of Health Services by Cynthia Val Chapman, a professional writer based in Chicago. For more information about the Cook County Bureau of Health Services doula program, contact Martha Gottlieb, coordinator of maternal infant services, at (312) 633-3839.