A volunteer doula, one of 70 on the call schedule for UNC Birth Partners, sits in the lobby of the postpartum floor at N.C. Women’s Hospital, rubbing her eyes and palming a cup of coffee. Her shift was over hours ago, when she’d seen a new mother through a healthy – if long and difficult – birth on the labor-and-delivery unit just one floor below. Other volunteer doulas are on call now, and the sun is up, so she could go home. But, in her lap is a small brown bag that holds a tiny, hand-knitted, baby-blue cap. To this doula, the shift isn’t over until she’s seen Mom in her new room and put this gift – crafted by doulas and other volunteers and given to each mother who uses the hospital’s doula service – in her hands.
Doulas are trained professionals who provide continuous physical, emotional and informational support to a mother before, during and shortly after childbirth. In the Triangle area, the number of expectant mothers hiring doulas to attend their births is on the rise. A 2017 research review published in the Cochrane Database of Systematic Reviews evaluated the births of more than 15,000 women and found a clear connection between doula-supported births and a reduced risk for cesarean birth, better pain management and high satisfaction scores. With research that links doula support to improved outcomes and experiences for both moms and babies, hiring one begins to feel like a necessity. But, it’s not accessible for everyone. A private doula can cost as much as $500 to $1,000.
At N.C. Women’s Hospital, School of Nursing faculty Rhonda Lanning, DNP, CNM, IBCLC, LCCE has developed a revolutionary program that provides access to doula care to laboring women at no cost. Volunteer doulas from UNC Birth Partners attended more than 200 births in 2017 and are trending toward at least 300 in 2018. With nearly 3,500 births per year at N.C. Women’s Hospital, UNC Birth Partners are coming close to seeing 10 percent of the mothers who give birth there.
Most insurance companies don’t reimburse for doulas, and most hospitals – especially a public one like UNC’s – wouldn’t be able to absorb the costs. UNC Birth Partners volunteer their time in two 12-hour shifts per month, often in addition to being full-time graduate or undergraduate students or working full-time jobs.
“It is a powerful thing to work with a woman on her childbirth, to walk her and her partner through the steps of labor and support them through what they need – more information about a stage of labor, a back massage, help getting in the tub, strategies for getting through contractions – because it makes an incredible impact on how they feel about their experience,” she said. “But, it’s more than that. It’s an evidence-based practice that has been shown to improve birth outcomes. Offering this service in a major medical center is an extraordinary thing.”
Bringing the Best of Birthing
The word doula has Greek origins and means “a woman who serves.” Throughout history and in many cultures, women have traditionally surrounded other women in labor, providing emotional and physical support before, during and after birth. Bringing doulas into a tertiary medical center like UNC’s takes a process that can feel very medical and helps shape it into the phenomenal experience it is – a personal life even unlike any other.
That all this, Lanning says, is possible within a maternity care center that ranges from low-risk to the most high-risk deliveries is a truly unique opportunity to bring the best of birthing to the Triangle. In bridging those worlds, Lanning has positioned doulas in a once unexpected place: the operating room.
A cesarean section comes with powerful pain management and obstetrical surgeons working behind a drape to safely – and quickly – deliver a child. Many mothers might wonder, why would you need a doula to help manage a birth experience that is already so well managed? Whether a woman has a scheduled cesarean section, or she finds herself rushed from the delivery room to an operating room, Lanning says a doula presence offers a tremendous benefit to a surgical birth.
“In fact, these are some women who need us the most,” says Lanning. “Being in the operating room with a mother as the physician follows his process, we can be there to help this mother experience her baby’s delivery as more than a surgery, but an amazing life event.”
Lanning spent the fall of 2017, in the final year of her doctor of nursing program at Duke University, piloting a doula program for the operating room to measure outcomes and satisfaction rates. Doulas attended the cesarean births of more than 60 women over a period of 12 weeks, and the results were overwhelmingly positive.
Nearly 100 percent of those women were able to experience skin-to-skin contact with the newborn in the operating room, which helps regulate the baby’s body temperature and begin the bonding process, and both patient and nurse evaluations showed the families and practitioners in the room were highly satisfied with the process. Often the OR nurse would be the one to assist the mother with what are known as ‘gentle cesarean’ practices, such as offering a clear drape to feel more connected to the birth or initiating skin-to-skin after delivery. In an emergency situation, a doula presence frees the nurse to assist with the delivery.
“What we found is that a doula is a really necessary addition to an operating room. It’s a high-stakes situation. It’s not as comforting as a delivery room. By attending these births, the physicians and nurses can concentrate on delivering the baby and keeping mom safe, and the doula can help make the experience feel less like a surgical process and more like a birth.”
For Lanning, maternal health is not only an issue of safety, but one of women’s rights. So many negative birth experiences relate to a perceived loss of autonomy, she says, and a feeling that you aren’t able to advocate for yourself amid a room full of experts. She believes every mother deserves a positive birth experience where they feel empowered to have a say in how they receive care.
“In the rush of the medical part of childbirth, it’s easy for a mother to feel like she’s lost her voice, that it is something that is happening to her, rather than a life-changing experience. Doulas honor that,” she says.
Birth trauma is not uncommon, says Lanning, and families can feel continued distress when a birth doesn’t go as planned, even if both the mother and baby are ultimately healthy. For instance, she says, if the baby needs to go to the neonatal intensive care unit for observation, the parents are left in the room trying to process the situation. And, once mom and baby are stable, they may still be left with questions.
“When a family has an unexpected outcome, a doula is there to provide support and helps them make sense of everything that happened. Even positive outcomes begin with difficult situations, and we want the mother to feel like we’re there to help her process and preserve the birth experience,” says Lanning. “Her voice is important, so we want to know what questions she has, and we want to help her stay calm, breathe, and take a minute so she can clarify her needs. It’s not about the doula determining her needs – it’s about creating room for her to express them so together you can figure out how to make even an unexpected birth experience a truly wonderful one.”
Lanning’s own anecdotal observation is that doula support can help a mother avoid or lessen the severity of postpartum depression that may be borne from a traumatic birth. “It’s important for the mother to be able to speak up and begin processing it with someone who knows about labor and birth, and who can also remind her of her strength and the amazing things she accomplished during that birth.”
Building a Self Through Service
Lanning’s work is making a mark on the culture of labor-and-delivery, earning her the 2018 UNC Medical Center Nursing Faculty of the Year. With particular concern for women who might be laboring alone or in difficult circumstances, Lanning has dedicated resources to specially train doulas to serve incarcerated women delivering at N.C. Women’s Hospital as well as women in the UNC Horizons Program, a treatment program for pregnant women who live with substance use disorders.
“I always had this feeling that I wanted to help people and do some good in the world. Early on, I knew I was passionate about women’s rights when it comes to their health care,” said Lanning.
Now holding a doctorate, Lanning started out as a non-traditional student, dropping out of high school at age 16, just one year after she’d found herself completely on her own, to complete a GED. A heart for serving others grounded her and gave her a sense of self-worth, and she filled her time with volunteer activities, longing to do more even as she doubted her academic potential.
A friend suggested Lanning apply to college, but like many first-generation college students, she had no idea where to begin. But once she started, she didn’t stop. She attended Earlham College in Indiana on a Pell grant and graduated with a degree in biology, which she followed with both a bachelor’s and a master’s degree of nursing at the University of Pennsylvania. Lanning practiced as a certified nurse midwife for several years before joining UNC’s School of Nursing faculty, where she teaches several courses including Supporting the Childbearing Family, an interprofessional APPLES service-learning course which she created. The innovative class, for which Lanning earned the 2016 Office of the Provost Engaged Scholarship Award for Teaching, brings students and volunteer doulas together for a hands-on, patient-centered learning experience.
“What I’ve found is that students who engage in service come away with such powerful experiences and such an incredible perspective on all they can do as an individual,” she said. “It’s a fantastic opportunity to feel empowered to do this kind of work.”
Nurses are trained to advocate for their patients, Lanning says, and bringing voice to the voiceless – on the patient floor or in a classroom – is central to her practice as a nurse and an educator. This year she is serving as a faculty mentor for the Lookout Scholars program, which guides first generation college students through their years at Carolina. She wants these students to see their own potential, and not hold themselves back from transformative experiences on a campus where they still might not believe they belong.
It’s an important new role for her on a campus where her impact and influence on the lives of others continues to grow, always rooted in amplifying the voices and needs of others. It is far beyond what she’d long-ago imagined – what she’d never even allowed herself to imagine – she could do.
It is a gift not lost on her.
“I want to be that faculty member for our students who can help them see their potential,” she said. “We need them. They are important. I want them to know they have a voice.”