URGENT! Federal Funding Opportunity for Community-Based Doula Programs

U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau, Division of Healthy Start and Perinatal Services

The Community-Based Doula Program Initiative

Announcement Type: New & Competitive

Announcement Number: HRSA-10-036

Catalog of Federal Domestic Assistance (CFDA) No. 93.110

FUNDING OPPORTUNITY ANNOUNCEMENT Fiscal Year 2010 Application Due Date: July 1, 2010

Angela Hayes-Toliver, MBA, Public Health Analyst, Division of Healthy Start and Perinatal Service

Telephone No: 301.443.0543 Fax: (501) 594-0186

I. FUNDING OPPORTUNITY DESCRIPTION

In fiscal year 2010, Congress allotted $1.4 million to the Community-based Doula Program to fund urban and rural community-based organizations to support community-based Doulas. Three (3) urban, three (3) rural grants and one (1) technical assistance grant will be awarded.

This funding opportunity announcement solicits applications for The Community-based Doula Program grant program. This program will provide grants to urban and rural community-based organizations to support community-based Doulas. This approach identifies and trains indigenous community workers to mentor pregnant women during the months of pregnancy, birth and at least six (6) months post-partum, (optimally one year post-partum). In addition, an award will be made to an organization with expertise in replicating community-based Doula programs, to offer outreach, training, technical assistance and evaluation services to Doula grantees in order to maximize project effectiveness and care quality across all projects.

Applicants applying for the grant must provide a program which identifies and trains indigenous community workers to mentor pregnant women during the months of pregnancy, birth and at least 6 months post-partum, (optimally one year post-partum). Programs are expected to focus on the best ways of delivering supportive services both before and after the birth of the child. Breastfeeding initiation and retention should also be emphasized in both rural and urban. In addition, funding is provided to an organization with expertise in replicating community-based Doula programs, to offer outreach, training, technical assistance and evaluation services to Doula grantees in order to maximize project effectiveness and quality care across all projects.

Background

Overview of Community-based Doula Program

The Community-based Doula Program was funded in 2008 by Congress as part of a demonstration program. The purpose of this program was to provide grants to urban and rural communities to support community-based doulas. Doulas, having specialized knowledge and experience in perinatal care and support, are utilized by pregnant/postpartum women to provide continuous physical, emotional and informational support during the prenatal, childbirth, and/or postpartum periods. Doulas spend numerous hours with the families they serve providing pregnancy and childbirth education; early linkages to appropriate healthcare and other services; encouraging parental attachment; breastfeeding promotion counseling; and parenting education. In addition to grants awarded to communities, the legislation provided for a grant award to an organization with expertise in replicating community-based doula programs, to offer outreach, training, technical assistance and evaluation services to doula grantees in order to maximize project effectiveness and quality care across all projects.

Through a competitive grant application process, six (6) communities were initially awarded funding to support community-based doulas. Three (3) were provided in urban communities located in Illinois, Missouri and Georgia. Three (3) were provided in rural communities located in Minnesota, New Mexico and Texas. A technical assistance center was funded through the same competitive process and is located in Illinois. These grants were awarded funding for a two year period starting September 1, 2008 and ending August 31, 2010.

Overview of Community-based Doulas

The Community-based Doula program identifies and trains indigenous community workers to mentor pregnant women during the months of pregnancy, birth and the immediate post-partum period. Doulas provide culturally sensitive pregnancy and childbirth education, early linkage to health care and social services, labor coaching, breastfeeding education and counseling and parenting skills while fostering parental attachment. Doulas are required to follow ethical standards and provide the highest quality labor support to birthing women and their families.

What is a Doula: The word “doula” comes from the ancient Greek and refers to a trained and experienced woman who provides continuous physical, emotional, and informational support to a woman before, during, and immediately following childbirth. With a doula, a woman is never left alone during labor and birth (Doulas of North America, 2002).

History: Enormous improvements in the safety of childbirth have taken place and now efforts to improve psychosocial outcomes are receiving greater attention. The birth of each baby has a long lasting impact on the physical and mental health of mother, baby and family. The doula is emerging as a positive contribution to the care of women in labor. By attending to the woman’s emotional needs, some obstetric outcomes are improved. Just as importantly, the early mother-infant relationships and breastfeeding are enhanced. Women’s satisfaction with their birth experiences and even their self-esteem appears to improve when a doula has assisted them through childbirth. Providing guidance and encouragement to laboring mothers and families and encouraging communication between patient and Care Provider is the most evident and definable part of what a doula does (JOGNN, 2002).

The maternity care team in the United States has expanded in the last decade with the addition of doulas, which represent a growing group of paraprofessionals. In the broadest sense of the role, a doula is a community health worker who provides skilled and intimate continuity of care throughout the childbearing years. The use of doulas is an innovative option to address complex health problems during pregnancy (e.g., preterm labor, low birth weight, and postpartum depression) that have multiple contributing etiologies beyond biological factors (Low Lisa, Moffat, & Brennan, 2006).

In the 1970s Klaus and Kennell unintentionally discovered the effects of a supportive woman accompanying a mother during labor while doing a breastfeeding study in Guatemala (JOGNN, 2002). Later research found that women who had labor support by doulas had lower rates of cesarean section, lower requests for pain medication, fewer epidurals and narcotic, and shorter labors than women who were not supported in labor (Kennell, Klaus, McGrath, Robertson, & Urrutia, 1980). In the 1980s, manuals of many childbirth education organizations, such as the International Childbirth Education Association, encouraged their instructors to attend births when possible (Doulas of North America, 1987). After attending the births of their students informally, they then attended births of their students professionally (Haaf, 1992). Also during this 1980s there was a growing consumer awareness of the rapid rise in the American cesarean birth rate. Women who wanted to avoid cesareans where encouraged to have a labor advocate (Doula) whose purpose at the time was to help avoid routine procedures that could lead to cesarean surgery (JOGNN, 2002).

Research results have shown that those new parents who have support and feel secure and cared for during this time are more successful in adapting than those who do not. Cultures in which women are cared for by others for a defined period of days or weeks and are expected only to nurture themselves and their babies during that time have superior outcomes in postpartum adjustment. Women who experience support from their family members, care providers, counselors and peer groups have greater breastfeeding success, greater self-confidence, less postpartum depression and a lower incidence of abuse than those who do not (Doulas of North America, 2002).

Evidence indicates that timely referrals to competent, appropriate professionals, and support groups can have a significant positive outcome for the family. Research states that support for and from the partner can have a significant impact on their partner’s own experience as well as the emotional adjustment of the mother (Doulas of North America, 2002; Abramson, Breedlove, & Isaacs, 2006).

Role of the Doula: The doula’s main role is to provide physical and emotional support and assistance in gathering information for women and their partners during labor and birth and offers help and advice on comfort measures such as breathing, relaxation movement, and positioning. She also assists the woman and her partner to become informed about the course of their labor and their options and enhances early mother-infant relationships and breastfeeding. The most important role of the doula is providing continuous emotional reassurance and comfort. The role of the birth doula encompasses the non-clinical aspects of care during childbirth. Doulas specialize in non-medical skills and do not perform clinical tasks, such as vaginal exams or fetal heart rate monitoring. Doulas do not diagnose medical conditions, offer second opinions, or give medical advice (Doulas of North America, 2002).

Doulas often serve in mediation and advocacy roles — Doulas assist families in their navigation of the health care system. A multi-lingual Doula (or one who knows sign language) can serve as a woman’s interpreter and facilitate communication with her caregivers (Center for the Childbearing Years, 2008). For fathers who want an active role in the birth process, the doula assists and guides them in effective ways to help their loved ones through labor (Doulas of North America, 2002). The role of the doula is never to take the place of the husband or partner in labor, but to compliment and enhance their experience. Today, many husbands are taking a more active role in the birth process. With a doula as a part of the birth team, a father can do whatever he feels comfortable with at each moment. Doulas can encourage the father to use comfort measures and can step in when he needs a break (Childbirth Connection, http://www.childbirthconnection.org).

The doula’s goal is to help the woman have a safe and satisfying childbirth as the woman defines it. Doulas can help maximize the benefits of pain medications while minimizing their unwanted side effects (Doulas of North America, 2002). Women cared for during labor by a birth doula, compared to those receiving usual care were 26% less likely to give birth by cesarean section, 41% less likely to give birth with a vacuum extractor of forceps, 28% less likely to use any analgesia or anesthesia, and 33% less likely to be dissatisfied or negatively rate their birth experience (Hodnett, Gates, Hofmeyr, & Sakala, 2003). A link between the pregnant mother’s emotional state and her infant’s subsequent emotional well-being and behavior implies that intervention by doulas during the pregnancies of vulnerable women may have positive outcomes for their children’s development (Abramson, Breedlove, & Isaacs, 2006).

The community-based doula will help social support, home-visiting, medical and nursing care programs; find innovative ways to address the needs of birthing families, and relate to the culture, values, and language of mothers who face difficult challenges (Abramson, Breedlove, & Isaacs, 2006).

Overview of Community-based Doula Program Requirements

Priority 1 and 2: Urban and Rural Community-based Doula Service Requirements:

Under these priority areas, funding is provided to urban and rural community-based organizations to support community-based doula activities to improve infant health, strengthen families and provide support to ensure family success. The community-based doula program identifies and supports training of indigenous community workers to mentor first time pregnant women during the months of pregnancy, birth and at least six months (approximately 26 weeks) post-partum period, (optimally one year post-partum). All applicants must demonstrate how doulas will provide culturally sensitive pregnancy and childbirth education, early linkage to health care and social services; labor coaching, breastfeeding education and counseling and parenting skills while fostering parental attachment. Data in support of these activities must be cited. All applicants are also required to partner with the Community-Based Doula Leadership Institute funded under Priority 3 for initial and ongoing training of the doulas, technical assistance, and quality improvement. Applicants must also agree to coordinate their evaluation activities with the Community-Based Doula Leadership Institute and contribute information to the cross-sited evaluation of this demonstration program.

The target audience for the doula service is first time mothers-particularly young women, women with language barriers and women from low-income backgrounds-who have a higher risk of prematurity, infant mortality, low birth weight and poor maternal outcomes. These women may also be dealing with higher rates of substance abuse, child abuse and neglect and difficulty with maternal attachment. The community-based doula program should engage first time mothers as early in pregnancy as possible, and continue services through at least 6 months (approximately 26 weeks) postpartum (optimally one year postpartum).

Women are eligible for doula training without prior experience in mothering or pregnancy and delivery. They should also possess a capacity to form strong trusting relationships, and have the ability to listen and respond to a mother’s needs. While traditionally candidates may not have needed prior work experience in home visiting or family support to be eligible to be doulas, to facilitate this demonstration program, they should already be trained as community outreach workers with skills in home visiting and family support

All applicants must demonstrate how doulas will provide culturally sensitive pregnancy and childbirth education, early linkage to health care and social services, labor coaching, breastfeeding education and counseling and parenting skills while fostering parental attachment.

Doulas must be:

  • Paid full time employees to the extent possible.
  • Trusted women recruited from the same community as the women who will be receiving doula services.
  • Committed to helping women have healthy and satisfying births.
  • Trained as a community outreach worker with skills in home visiting and family support.

All applicants are also required to partner with the Community-Based Doula Leadership Institute funded under Priority 3 for initial and ongoing training of the doulas, technical assistance, and quality improvement. Applicants must also agree to coordinate their evaluation activities with the Community-Based Doula Leadership Institute and contribute information to the cross-sited evaluation of this demonstration program.

Responsibilities of the Doula Grantee

Program Orientation

  • Establish an Advisory Group.
  • Develop and implement a program orientation.

Program Implementation

  • Plan logistics for program implementation (including but not limited to doula training, employee policies, transportation, etc.).
  • Conduct doula recruitment, interviewing and hiring.
  • Formalize relationships with health care providers and institutions.
  • Approve data collection/documentation forms.

Doula Training and Initial Service Provision

  • Conduct the doula training with on-site visits from the Doula Leadership Institute. There will be approximately two visits.
  • Facilitate experiential learning using popular education techniques and the Doula Leadership Institute training curriculum.
  • Provide trainees with access to and support for obtaining clinical observations.
  • Evaluate trainees’ progress.
  • Formalize policies and protocols.

Initial Project Evaluation and Maintenance

  • Refine outcome evaluation issues.
  • Identify emerging program issues of concern.
  • Develop written action plans for the first project year to address program evaluation and financial issues.
  • Report on milestones achieved, obstacles confronted, cost of implementation and outcome data where applicable.

Priority 3: Community-based Doula Leadership Institute Requirements:

The Community-Based Doula Leadership Institute shall provide outreach, training, technical assistance, quality improvement, and cross-sited evaluation services to Urban and Rural Community-based Doula programs funded under this announcement. Training and technical assistance must include culturally sensitive pregnancy and childbirth education; skill development to provide early linkage to health care and social services; labor coaching; breastfeeding education and counseling; and parenting skills development including fostering parental attachment. Site visits will be required to each Doula grantee. The purpose of the visits may be combined to accomplish the requirements.

Training provided to doulas by the Leadership Institute should also include information on the following topics:

Pregnancy Education to include information on home visiting; what to expect during labor/delivery; depression education and screening; and preparing the family for baby’s arrival.

Birth Education to include information on culturally sensitive support to mothers; emotional support; advocacy on behalf of expecting mothers; tracking birth data; attendance at birth (one-on-one labor support); and providing information and encouragement to clients. Educational information regarding preventing complications such as pre-term labor, low birth weight, and postpartum depression should be discussed.

Postpartum Education to include breastfeeding training, depression training (signs and symptoms, process for referral), transitioning client to medical home (health care with physician), home visits, community resources, newborn care information for mom.

Responsibilities of the Leadership Institute

Program Implementation

  • Provide a program implementation plan which must include an overview of program components. These components should complement national doula perspectives as stated by DONA International. This plan must also respond to the listed Responsibilities of the Leadership Institute.
  • Provide technical assistance and support for planning doula training.
  • Provide consultation concerning interviewing and selection of screened doula applicants.
  • Offer an on-site training/workshop for both direct service staff, and clinical supervisors and coordinators.
  • Provide templates for data collection/documentation forms.

Program Planning

  • Provide technical assistance during program planning.
  • Provide templates and materials useful for resource development.

Program Orientation and Training of Trainers

  • Conduct an intensive program orientation and Training of Trainers (not to exceed a total of three days).
  • Provide technical assistance to administrators, supervisors and trainers.

Doula Training and Initial Service Provision

  • Offer two site visits during doula training for mentoring of training team.
  • Provide technical assistance for development of policies and procedures.

Project Evaluation and Maintenance

  • Conduct cross-sited evaluation.
  • Conduct data collection.
  • Facilitate one site visit meeting during program assessment and planning to determine next steps.

Programs/Services to Link Community-based Doula Program:

For this program, all applicants must receive support from and be linked to the appropriate system’s goal of promoting a healthy birth. Of particular importance are close collaboration and coordination linkages with Title V MCH, Local/State Health Professional Organizations, Patient Navigator Systems and other community stakeholders such as (but not limited to):

  • Healthy Start
  • Medicaid
  • Children Health Insurance Program (CHIP)
  • Family Planning (Title X)
  • Early Head Start
  • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
  • Center for Substance Abuse Prevention Services’ Grant Program for Pregnant and Postpartum Women (with a substance abuse addiction)
  • State Subsidized Child Care Program
  • Community Based Child Abuse Prevention Programs (CBCAP)
  • Abandoned Infants Assistance: Comprehensive Support Services for Families Affected by Substance Abuse and /or AIDS
  • Preventing Abuse and Neglect through Nurse Home Visitation