The Use of Doulas for Inmates in Lahor:

With Outcomes

By Marilyn C. Moses and Roberto Hugh Potter

oula" is a word of Greek origin tbat refers to a. doula provides low-tecb care in a bigb-tecb environment. woman who cares for another woman. Today, this Tbe care is bands-on and may include nonsexual stroking word is used to describe a trained lay birtb atten- and massage, assisting witb relaxation tecbniques, provid- dant wbo advocates for and provides uninterrupted ing continuous encouragement, anticipating and answering D— prebirtb to post-birth — nonmedical support; hands-on questions tbat motbers are likely to present, providing care; information; and encouragement to laboring women. additional instruction on labor techniques, and advocating Doula support for incarcerated women giving birtb is an for the mother when she is feeling overwbelmed by bospital exemplary practice supported by a large and unequivocal staff. body of scientific evidence. More than 20 randomized trials of low-tecb, minimal- Doulas are not nurses, , physician assistants or cost doula support bave yielded positive obstetric out- doctors. Altbough tbey do receive training, doulas do not comes. Doula programs bave been principally implemented bave clinical responsibilities nor do tbey replace tbe roles in tbe general population but also bave been tested witb played by tbe father and otber family members during juvenile and otber bigb-risk populations. Botb prisons and labor and delivery, A doula is a female companion wbo jails bave implemented doula programs and an evaluation befriends tbe laboring motber, providing competent, unin- of one sucb program (described later) has demonstrated terrupted pbysical and emotional care and support. Tbe positive results.

58 — June 2008 Corrections Today Birth is a joyful but stressful time for any woman. during labor with routine care. A published analysis of the Although society has changed, with family members geo- first five studies resulted in positive support for the prac- grapbically dispersed and women having children later in tice; Women with doula support experienced significantly life, the typical woman is still likely to bave tbe father or shorter labors, double tbe rate of spontaneous vaginal some member cf the family providing the crucial support births and a 50 percent reduction in the rate of cesarean needed during delivery. Incarcerated pregnant women, and forceps deliveries."* In 2005, a second review of an addi- however, are not typical women; tbey often bave high-risk tional 15 randomized controlled trials of tbis practice was and are likely to deliver alone in adverse con- published. These studies were conducted between 1986 ditions and without support, uninterrupted or otberwise, and 2002 and involved more than 12,000 women. Again, from anyone. While a doula is intended to augment tbe sup- positive general findings were replicated, including port that the woman is receiving, it is easy to understand reduced rates of cesarean delivery, operative vaginal birtbs why incarcerated laboring women, economically disadvan- and receipt of any anestbesia/analgesia,' Other reported taged women and otber high-risk women laboring alone witb beneficial outcomes include significantly shorter hospital- no support migbt benefit the most from a doula's service.' ized labor time and higher Apgar scores*' of bealtb assess- ment for tbe baby at one and five minutes. Tbe common denominator of these and related studies Vomta la J«U« and Fritoat is the continuous labor support provided to tbe mother. On any given day in 2005, tbere were approximately Wbat varies across studies is who provided the uninter- 98,577 women housed in jails and 111,403 in prisons across rupted support to tbe mother and how much training the the country, Bureau of Justice Statistics data indicated. doula or companion received. Tbe range of training levels Obtaining an accurate count of pregnant women in U.S. cor- across studies included student midwives, hospital rectional settings is not easily accomplisbed. Estimates employees, doulas or other laywomen witb minimal to ranging from 6 percent to 10 percent are found in tbe acad- extensive preparatory training,' emic and advocacy literature.'' And BJS estimated that 5.2 percent of women in U,S, jails were pregnant during 2002. Tbis is likely an underestimate, as it is based on self- Vhy Ooala* Frodaet Po«itiv« OoteoAM reports from women detained long enougb to respond to The clinical trials cited in this article provide sound evi- tbe nationally administered survey. For state and federal dence that continuous supportive care during labor prisons, there are few nationally representative data on tbe produces a number of positive obstetric outcomes. And prevalence of pregnant women on any given day. BJS biomedical researcbers bave an educated guess as to why reported tbat, in 1991, about 6 percent of the approximately it works.^ Recent psycbological research suggests tbat 30,000 women entering state prisons were pregnant. Out of males and females do not respond to stressful circum- 3,2 million arrests of women at midyear 1998, BJS noted stances in the same way. Tbe classic buman response to a tbat 5 percent of female offenders in state prisons were stressful circumstance is "figbt or flight." Researcbers now pregnant upon entry, compared with an estimated 6 per- suggest, based on earlier animal and buman studies, that cent of tbose entering jail. figbt or flight may be more appropriately categorized as a Wbile tbe existing literature allows for rougb estimates male response to stressful situations and tbat females of tbe number and percentage of women wbo enter jails respond differently — they "tend and befriend." That is, and prisons pregnant, knowledge in this area remains rudi- females tend to their cbildren to ensure their safety and mentary. Tbere is no information on the stage of pregn^lncy befriend other females in an effort to manage stressful situ- at which women enter, tbeir histories of prior ations. The female production of '' and opiods'" to and following entry into tbe criminal justice system, or during the tend and befriend response are likely responsi- specific information on birth outcomes of incarcerated ble for the gender-specific response to stressors. women. Therefore, correctional administrators and healtb It is widely accepted tbat women naturally produce cat- care providers must rely on a small number of studies of echolamines (epinepbrine. norepinepbrine and dopamine) tbis population and draw inferences from other studies of wben experiencing pain, anxiety or fear during tbe stress of women in tbe general population wbo sbare the same labor. Increased catecholamine levels during labor results socioeconomic background and behavioral risk factors — in reduced blood flow to the uterus and emd are which often add up to bigh-risk pregnancies with bigber associated witb decreased uterine contractions, slower than average negative outcomes. Therefore, almost any dilation rates and longer labors," It is believed tbat the practice tbat mitigates negative outcomes would be worth- friendly, uninterrupted nature of the motber-doula relation- wbiie and welcome. ship results in the mother's production of oxytocin and opiods, which counteract and reduce tbe catecholamine levels in her bloodstream. Tbis, in turn, facilitates tbe posi- Th« Cvlcl«ae« This Practlet tive obstetric outcomes observed in laboring women witb Rarely is tbere such a long history and sound body of doula companions. positive evidence supporting a practice tban tbere is for using continuous labor support. Studies assessing tbe value of continuous supportive care during labor began in la Gemetioaal S«ttlai« 1980.' To date there have been more tban 20 published ran- In response to tbe unique circumstance and stress experi- domized controlled trials comparing continuous support enced by women who deliver babies during detention,

lune 200H Corrprtions Today — •>*» Seattle's King County Jail experimented with a doula birth use of doulas is in correctional settings, 's and support program. The jail-based progratn was a collaborative state's departments of correction have long- effort among local doulas, jail health care providers, cor- standing programs. rectional staff and local hospital delivery personnel. Prospective doulas were selected and received two ENDNOTES hours of correctional orientation training by the facility and ' Kennell. J,, M. Klaus. S. McGrath, S. Robertson and C. Hinkley. 16 hours of doula-specific training by the Pacific Associa- 1991. Medical intervention — The effect of social support during tion for Labor Support. The doula training involved instruc- labor in a U.S. hospital: A randomized controlled trial. Journal of the American Medical Association. 265(l7):2\97-22l)l. tion on the hospital's delivery routines; an overview of the foster care system; and information on addiction and preg- Klaus, M., J. Kennell. S. Robertson and R. Sosa. 1986. Effects of nancy, labor, past sexual abuse, and other related issues. social support during parturition on maternal and infant morbidi- Pregnant women who would deliver while in detention ty. British MedicaUoumal, 293(6547) :585-587. were recruited for the program. Each woman was assigned a primary and back-up doula whom she met prior to deliv- Sosa, R.. J,H. Kennell, M, Klaus. S. Robertson and J, Urrutia. 1980. ery. Doulas were notified when the women arrived at the The effect of a support companion on perinatal problems, length hospital in labor. Once there, they offered continuous sup- of labor and mother-infant interaction. The New Englond Journal of Medicine, 303(11):597-600. port to the mother throughout labor, birth and up to three days post-birth. Wolman, W., B. Chalmers. G. Hofmeyr and V. Nikodem. 1993. Post- Eighteen offenders, attending nurses and physicians, partum depression and companionship in the clinical birth envi- and correctional officers, were surveyed post-birth. All ronment: A randomized, controlled study. American Journal of expressed a high level of satisfaction with the perception of at\d Gynecotogv, 168(5);1388-1393. the offender response, doula services and the program overall.''^ Comments from the female offenders included: " Centers for Disease Control and Prevention. 2001. Women, injec- tion drug use. and the criminal justice system. Atlanta: U.S. Depart- ment of Health and Human Services. • "1 wouid have been absolutely petrified if I had been by myself." * Campbell, D.A.. M.F. Lake. M, Falk and J.R. Backstrand. 2006. A • "It helped me have a positive experience even though randomized control trial of continuous support in labor by a lay I was in custody. There was a guard standing at the doula. Journal of Obstetric, Gynecologic and Neonatal Nurses, door; she let me forget he was there." 35(4):45&464. • "Nurses were very supportive in their medical way ... ^ Zhang, J., J.W. Bemasko, E. Leybovich, M, Fahs and M.C. Hatch, monitoring, seeing I'm breathing, stimulating the 1996. Continuous labor support from labor attendant for primi- baby's heart beat when it dropped ... where the doula parous women: A meta-analysis. Obstetrics & Gynecology, 88(4):739- was holding my hand, telling me it was going to be 744. OK." • "The doula gives steady support and values you. ^ Hodnett. E.D., S. Gates, G,J, Hofmeyr and C. Sakala. 2003. Continu- Makes you feel good all over." ous support for women during . Cochrane Database of Systematic Revieujs, issue 3, • "A lot of times I had no clue what [hospital staff] were talking about.... The doula was explaining to me *" The Apgar score is a simple and repeatable method of assessing about the epidural; it helped me focus." the health of a newborn immediately after birth. It is determined • "I would do anything to help support this program. by evaluating the newborn on five simple criteria on a scale from You need somebody to support you, not just an offi- zero to two and obtaining the sum of the five values obtained. cer staring at you." • "I felt like there was somebody on my side." ' Campbell et al. 2006, • Ibid. The use of doulas has a very strong evidence base among women in the general population as well as high- Oxytocin is a hormone that acts as a neurotransmitter to the risk women. Doulas have been effectively used in correc- brain. In women it is released in large amounts after the distension tional settings, and a case could be made that incarcerated of the cervix and vagina. In the brain, it is thought to be involved women delivering alone may need this service most. For a with social recognition, bonding, the formation of trust between relatively small investment of $50 for pre- and post-birth individuals and generosity. See Kosfeld, M.. M. Heinrichs, P..I. Zak, U. Fischbacher and E. Fehr. 2005. Oxytocin increases trust in doula visits and a flat fee of $175 for doula support at birth, humans. Nature, 435(7042): 67^76; Zak. P.J,. A.A, Stanton and A, regardless of the length of labor, this practice has demon- Ahmadi, 2007, Oxytocin increases generosity in humans. PLoS ONE, strated improved birth outcomes, as evidenced by study 2(ll);ell28; Stanton, A.A. 2007. Neural substrates of decision-mak- findings. These outcomes could reduce correctional facilities" ing in economic games. Scientific Journals International, 1(1): 1-64, health care expenses through the reduction of cesareans, requests for epidurals. pain , forceps deliveries "^ An opiod is a chemical substance that causes a morphine-like and labor times. While it is now known how widespread the reaction in the body; it acts as a pain killer.

Continued on page 73

60 — fune 2008 Corrections Today The Davidson County Jail for Females " Greenfeld, L,A. and T,L, Snell, 1999.

Continued from page 56 • Murray, J. and D.P, Farrington, 2005. Parental imprisonment: Effects on boys' antisocial fiehaviour and delinquency through the • Centers for Disease Control and Prevention, 2006, STD surveil- life-course. Journal of Child Psychology and Psychiatry, 46(12):1269- lance 2005: Persons entering corrections facilities. Available at 1278, www.cdc,gov/std/stats05/corrections.htm. Kummerow, K,L, 2008. Circumstances of among Maruschak, LM, 2007. HIV m prisons, 2005. Washington. D.C: U,S, women at an urban jail. Poster presented at the Annual Conven- Department of Justice, Bureau of Justice Statistics, tion of the American Medical Student Association. 14 March in Houston, CDCP, 2006, Trends in reportable sexually transmitted diseases in the United States. 2(X)5. Atlanta; CDC. ibid.

CDCP, 2007, HIV/AIDS surveillance report. 2005 edition, vol. 17. Ibid. Atlanta: CDC, • Mumola, CJ, 2000. Incarcerated parents and their children. Wash- ^ Hammett. T.M,, M.P, Harmon and W. Rhodes, 2002. The burden of ington, D,C,: U,S. Department of Justice, Bureau of Justice Statistics, infectious disease among inmates of and releasees from US correc- tional facilities. 1997. American Journal of Public Health, 92(11): 1789-1795. Kristy Kummerow is a second-year medical student at Van- derbilt Medical School. Ruby Joyner. MSSW. is an adminis- '' Ray. R.. K, Stafford, M, Hewett. R Hernandez and N, Williams, 1996. Medical care costs associated with jail incarceration of people with trator at the Davidson County Sheriffs Office Correctional HIV/AIDS, Paper presented at the International Conference on Development Center - Female. AIDS, 7-12 July in Vancouver, British Columbia.

" Greenfeld, LA. and T,L. Snell, 1999,

" Clarke, J.G,, C, Rosengard, J. Rose, M.R. Hebert, M.G, Phipps and M,D. Stein, 2006, Pregnancy attitudes and contraceptive plans among women entering jail. Women and Health. 43(2): 111-130,

The Use of Oouias for Inmates in Labor Zuspan, F.P,, LA, Cibilis and S,V, Pose, 1962. Myometrial and car- diovascular responses to alterations in plasma epinephrine and Continued from page 60 norepinephrine. American Journal of Obstetrics and Gynecology, 84(7):841-851, '' Campbell et al. 2006. ' Schroeder. C, and J, Bell, 2005, Doula birth support for incarcer- Barton, M.D,, A.P, Killam and G, Meschia. 1974, Response of ovine ated pregnant women. Public Health Nursing. 22(l):53-58, uterine blood flow to epinephrine and norepinephrine. Proceeding of [he Society of E.xperimental Biology and Medicine. 145(3):996- Schroeder, C and J, Bell, 2005, Labor support for incarcerated 1003, women: The doula project. The Prison Journal. 85(3):311-!J28,

Lederman, R,P,, E. Lederman, B.A, Work and D.S. McCann, 1985. Anxiety and epinephrine in multiparous women in labor: Relation- Marilyn C Moses is a social science analyst for the National ship to duration of labor and fetal heart rate pattern. American Institute of Justice, chair of ACA's Children's Initiative and Journal of Obstetrics and Gynecology, 153C8):87M77. member of ACA's Exemplary Practices Committee and Lieberman. A.B. 1992, Easing labor pain: The complete guide to a Research Council. Roberto Hugh Potter is a goal team leader more comfortable and rewarding birth. Boston: Harvard Common for healthy institutions at the Centers for Disease Control Press, and Prevention. After August 2008. Potter will be a professor in the Department of Criminal Justice and Legal Studies at Myers. R.E, 1975, Maternal psychological stress and fetal asphyxia: the University of Central Florida Thank you to James Fort, A study in the monkey. American Journal of Obstetrics and Gynecol- cybrarian for the National Criminal Justice Reference Ser- ogy, 122(l):47-59. vice, for his assistance in preparing this article. Simpkin. P, and R, Ancheta. 2000. The labor progress handbook. Maiden, Mass.: Blackwell Sciences.

Wuitchik, M,, D, Bakal and J, Lipshitz, 1989. The clinical signifi- cance of pain and cognitive activity in latent labor. Obstetrics & Gynecology, 73(l):35-42.

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