When Kendra Nelson was in labor with her second child, small gestures from a doula helped her get through the strongest and most painful contractions.
The woman held Nelson's hand and spoke words of encouragement. She guided Nelson through breathing exercises and pulled her hair back in a scrunchie to keep her comfortable.
"She was there as a form of support and it made my delivery better," said Nelson, 32.
Now Nelson is working to become a doula herself, in hopes of helping other women experience a healthier pregnancy and better delivery. Baltimore health officials hope she will play a role in helping to reduce the city's infant mortality rate.
The city health department has started a pilot program to train Nelson and four other city residents to become doulas — non-medical companions who provide emotional support and comfort to women during delivery.
Doulas can also play a guiding role during pregnancy. They help moms develop birth plans, and can work in conjunction with physicians to make sure expectant mothers have the medical information they need to lead a healthy lifestyle during pregnancy.
After delivery, doulas may help moms adjust to the major life changes that come with a newborn.
"We really saw the need to have an extra advocate for moms," said Stacey Tuck, director of program operations for maternal and child health for the health department. "We felt that we needed an additional person to offer Mom some help that would ease stress levels and also just give extra support."
The pilot program is aimed at low-income moms in the department's B'More Healthy Babies program, which was launched in 2010 to help reduce infant mortality in the city.
The city's infant mortality rate has fallen 38 percent under B'More Healthy Babies, and sleep-related infant deaths have dropped by more than 50 percent. But the city still suffers far more baby deaths than the rest of Maryland. Seventy-three infants died in Baltimore in 2015. Black infants were twice as likely to die as white infants.
The city's infant mortality rate of 8.4 infant deaths per 1,000 live births was 1.3 times greater than that of the rest of the state in 2015. A contributing factor was the number of expectant moms who got limited or no prenatal care. Many of the women to be targeted by the doulas are living in poverty, and face other stresses: financial instability, past emotional or physical trauma, substance abuse, and mental and physical health challenges. Researchers have found that those types of stresses can have a direct impact on the health of a fetus, and can lead to early delivery and low birth weight.
The term doula was coined by the medical anthropologist Dr. Dana Raphael in 1969 from the Greek word female servant. She advocated for the development of doulas to help guide mothers during and after childbirth.
Their use has grown in popularity in recent years. The cost can range from $400 to $1,200 for a delivery and a similar amount for postpartum services. Cost-free, community-based programs such as Baltimore's have made it more accessible to low-income women.
City health officials hope doulas can help alleviate some of the stress on these moms, and make sure they are seeing the doctor, eating right and taking prenatal vitamins.
Andrea Williams-Salaam, one of the doulas involved in coordination of the program, said giving moms support can help reduce health disparities between minority and low-income women and other women.
"It is the intimate conversations and relationship that is built," she said. " We work closely with moms so that they can have a successful pregnancy."
For the first group of doulas, the department is drawing on women from the community it intends to serve, in hopes that they can better relate to the expectant or new moms and the challenges they might face. B'More for Healthy Babies used $5,000 of its own money for the pilot program, Tuck said, but is looking for other funding to keep the program going and expand it in the future.
The five Baltimore women completed a three-day training and now are working on getting certified by the accrediting agency MaternityWise International. The certification process requires them to sit in on a delivery with another doula. They should begin seeing moms in the next couple of months.
Nelson said she was attracted to becoming a doula so she could help other African-American women.
"A beautiful birth experience is not usually the dialogue you hear when having a baby," Nelson said. "It is usually portrayed as traumatic. I want to make it so women don't feel that way."
Keyona Hough, 32, another trainee, was caught off-guard when her son was born premature eight years ago. She wonders if a doula might have better prepared her, or at least provided some support at the time. She wants to help other moms to be better informed about the choices they have during pregnancy and delivery.
Brittany Williams, a recent nursing school graduate, was also chosen to be a doula. She wants women to know they don't have to go through the difficulties of pregnancy on their own.
"Nobody ever knows it all," she said. "There's help out there. You don't have to do it on your own."
Baltimore is joining New York, Philadelphia and other cities in providing community doula services to at-risk women to help drive down infant mortality.
Doulas in the By My Side Doula Support Program, run by Healthy Start Brooklyn, have assisted in 745 pregnancies and 575 births since 2010. It started with four doulas and now has 12 — including some who used the service when they were pregnant.
The program targets the six ZIP codes in Brooklyn with the highest infant mortality rates. Healthy Start Brooklyn director Mary-Powel Thomas said there is anecdotal evidence that they are seeing fewer early births than other parts of Brooklyn.
Gabriela Ammann, community programs manager for By My Side Doula Support Program, said the doulas have addressed some of the social determinants of health, such as financial problems, that have been linked to unhealthy pregnancies.
"These things can lead to chronic stress levels, and there is evidence chronic stress levels lead to low-birth weight and other maternal health issues," Ammann said.
A doula program in Portland, Maine, met some resistance from hospitals concerned about liability, founder Rebecca Goodwin said. But the doulas were allowed into birthing rooms with the permission of the participating women.
Keeping the moms healthy leads to healthy babies, Goodwin said.
"It helps strengthen the foundation of starting the journey of motherhood," she said. "So moms feel like they can make it during labor and that they can succeed at being a mom."