Cross-training Doulas as Promotoras

In 2009, Healthy Family Initiatives (HFI), a Houston, Texas, nonprofit organization, received a three-year Health Resources and Services Administration grant to study and replicate HealthConnect One, an existing community-based doula program. The grant provided financial
support for the doulas in the project to receive certification as community health workers, or promotoras. This cross-training occurred in a community college setting with a curriculum endorsed by the Texas Department of Health. The community-based doula program was created to identify and train community health workers to implement the specialized knowledge and experience of a doula within their local community. These doulas support and mentor first-time, low-income Hispanic women, 23 years of age or younger during their pregnancy, birth, and at least six months post-partum.

Addressing the root causes of poor maternal and child health long-term outcomes as a focus for community response had been an integral component of HFI’s mission. For many years, HFI offered home visitation as its primary activity, ensuring that preventive services were
available to as many overburdened families as possible. Home visitation addresses the root causes, or risks, that result in poor life outcomes for families. HFI’s cornerstone programmatic approach was long-term, intensive, home-based, preventive, holistic, and cost-effective. HFI’s programs fortify families by engaging mothers-to- be and fathers before the birth of a child and committing services to the family for three to five years.

Promotoras, by the very nature of their work, provide clients with significant links to the broader community. Their efforts impact the health and well-being of the clients they serve. The synchronicity of the doula and the promotora approach offers tremendous amplification of community- based maternal and child health services. Doula programs connect underserved women to women in their community who are specially trained to provide support during the critical months of pregnancy, birth, and the early months of parenting. Doulas are trained to identify social risk factors and promote risk reduction to improve overall birth outcomes. Therefore, the cross-training of the HFI doula staff in the promotora model made sense immediately. The benefit was three-fold: expansion of available services in the community, enhanced skill sets for the workers, and greater ability to produce positive results for clients. Characteristics of the Houston Community Doula Program that matched the promotora model:

• Early links to appropriate health care and other services, encouraging parental
  attachment, breastfeeding and parenting education
• In-depth education for young mothers including nutrition, pregnancy and labor,
  breastfeeding, and early child development
• Integration of education and emotional support during the entire perinatal period,
  particularly by way of labor support at the hospital
• Cross-training doulas and mentoring women from the community, these women then
  seek employment as doulas or promotoras. This process creates a multiplier effect as
  these women support each other and remain active in their community.

In keeping with the fundamental objectives of the promotora and the doula models, client recruitment and marketing for the combined program was carried out on a community level. Program information was provided at Community Health Clinics and Women, Infants, and Children sites. Presentations about the program were made to staff at community centers so that they could make appropriate client referrals. Promotoras attended health fairs to engage with potential clients and other agencies who could refer clients.
The program was promoted through public service announcements and interviews on Hispanic radio and television.
The doulas/promotoras were cross-trained to mentor their clients and address the complex health problems that arise during pregnancy such as preterm labor, low birth weight, and postpartum depression.
Goals for the combined program:

• Reduce maternal death rates
• Reduce maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery)
• Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women
• Reduce low birth weight
• Reduce preterm births
• Reduce the occurrence of fetal alcohol syndrome
• Increase the proportion of mothers who breastfeed their babies
• Increase the proportion of pregnant women who attend a series of prepared childbirth classes
• Increase the proportion of mothers who achieve a recommended weight gain during their pregnancies
• Increase the percentage of women giving birth who attend a postpartum care visit with a health worker

Breastfeeding rates in Texas at that time were at 14.2%. Based upon outcome evaluations of 356 participants during the first year on the program, the program registered a 54.6% rate of successful breastfeeding. The cost savings of this activity alone amounted to almost a quarter of a million dollars. The rate of cesarean sections in the program was about a fourth that of the general rate in Texas, saving another quarter of a million dollars. The rate of premature births (defined as less than 37 weeks) in Texas was just over 13%. Premature births from women in the doula/promotora program were only 2%. The total savings inferred from these outcomes amounted to over $1 million in dollars.
Intensive community outreach, education, and the expanded availability of cross-trained doulas/ promotoras, enriched the community’s capacity to deliver maternal and child health services. The parents’ direct relationship with a doula/promotora improved their children’s access to appropriate medical care, nutritious foods, and a healthier life.