Sarah: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities.
I'm Sarah Hexem Hubbard with the Pennsylvania Nursing Workforce Coalition and the executive Director of the National Nurse-Led Care Consortium. This is part two of a special maternal health series. If you haven't heard part one, we recommend that you listen to that episode first. You'll hear from Miyah Davis about how she became a doula after being a client with the Philadelphia Nurse-Family Partnership here at NNCC.
On this episode, we're going to speak with my colleague Dr. Erin Graham about the doula training program that Miyah participated in and about broader related support from maternal health. Erin is NNCC’s deputy executive director and has dedicated her career to community nursing. She is a family nurse practitioner, leads a variety of healthcare integration projects, and brings a wealth of experience as a Nurse-Family Partnership home visitor.
She has a deep commitment to public health and a strategic vision for expanding access to opportunities for the communities we serve, including the vision for the project that inspired this interview today.
Erin, welcome to At the Core of Care.
Erin: Thank you.
Sarah: So actually we have had you here before, back in 2019 on our second episode. You joined us to talk about breastfeeding support at Philadelphia Nurse-Family Partnership. And now, six years later, we're going to be talking about a cohort of former nurse home visiting clients that have now become doulas. So, lots to talk about here. But first, we always love asking guests to tell us their story about how they chose healthcare as a profession.
So can you share your experience about what led you to become a nurse?
Erin: My journey into nursing really began with a love of public health. When I got into college, I really wasn't sure if I wanted to be a pediatrician, an optometrist, a physical therapist. I really was all over the place, but I knew I wanted to go into healthcare. And so all of those fields had the same prerequisites. So I started there. I started just taking some prerequisites and I ended up in a public health class. And that class just opened my eyes and changed everything. I learned about primary prevention and social determinants of health. And it just clicked. And I remember learning about all of these diseases that were preventable. And it made me think about how something like access, something that we might take for granted, could literally mean the difference between life and death. And in my experience with my grandparents, I connected with that deeply.
Three out of my four grandparents died before I turned nine years old, and they all died from very treatable conditions. And, you know, I really didn't realize how much of an impact that had on me until I had public health classes. So that's what led me to pursuing a degree in public health. So after that one class in public health, I ended up having internships, and those internships exposed me to these amazing nurses. Shout out to Neva White and Nancy Rothman. They both were these like amazing nurses in public health, and they showed me what it meant to be a nurse in public health.
So after I graduated with a degree in public health, I ended up pursuing a nursing degree and it was there that I was introduced to the Nurse-Family Partnership program, which partners a nurse with a first-time pregnant person who's interested in learning about having a healthy pregnancy, a healthy child, and a healthy family. So it was like a no-brainer once I finished school, I knew I was going into Nurse-Family Partnership, and there happened to be an opening right when I graduated, and I got a job, and it felt like home. And I've been connected to the program ever since.
Sarah: And that wasn't the end of your nursing education, right?
So. What made you go back to nursing school?
Erin: So I went back to nursing school because I started off as a home visiting nurse. I also was a postpartum doula, and then I transitioned into becoming a supervisor. And as you move up in leadership there, you have a little less one-to-one direct contact with families, and I really missed that.
And I also, you know, at home seeing, having an aging parent and remembering again, like taking it back to my grandparents, remembering them passing at such young ages, I wanted to increase my clinical skills so that I could really be there to not only support people in my community, but like my direct community, my family, my father. You know, I really wanted to be a good healthcare provider in that way.
So that's a big part of what led me back to becoming a family nurse practitioner.
Sarah: And obviously you were exposed to Nurse-Family Partnership in your education. Clearly that's a maternal child health program. But what has kept you here in this field really, in the space around maternal and family healthcare in particular?
Erin: I think the family element, like I love children. Anyone at our organization can tell you whenever we have an event, I'm the first one to say where are the babies? I need to be in the community. I think that's why I went back to nursing school, so that I can continue to have opportunities and explore opportunities where I really get to engage with the community and make systems change.
So yeah, the family is what keeps me connected to the work. Being able to not only work with the babies, but to work with the parents and to work with the community. Because it takes a village, and I just see how they're all interdependent and none of those things can operate on their own. We can't operate on our own. We need every part of the family to be healthy, successful individuals in life.
Sarah: And you had even mentioned your own experience as a postpartum doula. Clearly, there is a direct connection to the work of maternal child health, to nurse home visiting. How did the idea for the doula training program take shape?
And of course, it actually has two components, right? So there's the piece that was, directly expanding access to doula services and partnership with Pettaway. And then we had this ability to also train clients. So how did those different components come into play and where did this idea even come from?
Erin: I feel like this idea came from our, really came from our nursing staff and from our clients. At NNCC, we do an annual client survey, and in that annual survey we found that 40% of our clients had expressed an interest in newborn care and self-care for mom. And about 30% of those clients also expressed wanting extra labor and birth support. And so when we were thinking about innovations for programming, doula support came to mind.
And then we thought, how cool would it be to train former graduates of our programs to become doulas. And we knew that clients were asking for additional supports, and we knew that nurses from the data were referring to doula supports.
Sarah: And that was also really reflecting what we were hearing from the nurse home visitors at that time, right?
Erin: Yes. We always are listening to nursing staff and I just love that the nursing staff really do pay attention to our clients. And you know how you talk about the nurse being the voice of the client. It's nice to see that when we started doing these client surveys that almost all of the things that nurses were reporting were consistent with what clients were reporting.
So that's always nice 'cause you know in research or data you have a concern - are we projecting? Are we only thinking what we think the client wants? But it's like, no, it's, yeah. Perceived versus real. Like what's the real need and the perceived need. And it's nice that both perceived needs match up, and that's not always the case.
Sarah: And that's a lot of how this programming is structured. We try to use a parallel process. So the client is the expert on their own life. The nurse home visitors, the expert on that relationship, the supervisor, the expert on the nurse, how to support the nurse, so and so on and so forth. So I remember even seeing those survey results and thinking like, we're getting something right in that we're hearing from nurse home visitors. This would be a really helpful resource, and we're hearing from clients, this is something that we really wanna see.
And that's also not surprising because in the broader environment, we certainly weren't the only people talking about doulas. And clearly there are a lot of stakeholders that are invested in maternal health, and trying to find innovation.
Erin: And that's where the Black Maternal Health Caucus was really instrumental in securing funding for maternal health initiatives. We were fortunate enough to be able to do our programming because of those funds.
Sarah: So let's sketch out a little bit the components of the program.
Erin: So the two components of the program are, we have doula services. So we were able to partner with an organization called Pettaway Pursuit Foundation.
And the other arm of the project is we were able to train five graduates of our home visiting programs to pursue training to become certified doulas.
Sarah: And why did you choose the partners that you worked with?
Erin: We partnered with Maternity Care Coalition because they just had this phenomenal community health worker program. One of our staff had participated in the program and we thought that would be a nice element for that person to be a peer mentor to clients who ended up pursuing the training to become perinatal community health workers.
So they had this longstanding program, lots of success with the program. They offer mentorship, professional development opportunities, beyond the doula training program. And they also offer this opportunity for those doulas to become part of a larger network of doulas. And then for Pettaway Pursuit Foundation (PPF), at that time, they were really the only agency that I was familiar with that did birth doulas and postpartum doula services to the population that was most similar to our population.
Sarah: And so what was it about these two components? Why look at services and training at the same time?
Erin: So I think it was really exciting for us to be able to offer training to former graduates of our programs because these were people who had firsthand experience of what it meant to have this type of support during pregnancy. So they had this nurse home visitor, someone in their home who was providing emotional support, offering education.
And we also knew that if we were able to invest in them, that we were also investing in increasing diversity in the workforce for perinatal care.
Sarah: And it also aligns with a lot of the model elements in home visiting related to self-efficacy. And I know that this has been an area that you've been developing as well. What kinds of supports are helpful to clients, and where do you see opportunities for workforce development?
Erin: Yeah, I'm really excited about workforce development because we serve a low-income population, and we know that if you have gainful employment that you have better health outcomes. You can provide better financially for your family. So I'm really excited about all these different types of workforce initiatives and opportunities to not only build people's skills, but also to have them gain employment.
Sarah: Can you clarify a little bit about the difference between a nurse home visitor and a doula, and a perinatal community health worker?
So let's break this down really simply. What is a nurse home visitor?
Erin: A nurse home visitor is able to go out to the home, provide education, provide emotional support.
And also provide clinical support, meaning they can check blood pressure, they can support with doing assessments.
And doulas or perinatal supports that are non-licensed staff are also there to do some very similar things. With the birth doulas. Our nurses, as an example, really don't have the capacity to be able to attend births at the same time of serving a caseload of 20 families.
So it's really nice for the nurses and doulas, you know, the partnership to exist because we can refer to doula services so that those doulas are able to, really, provide individualized care for the family, at a level that the nurse may not be able to do. So it allows the nurse to really focus on those more medical needs, whether it's diabetes education or vaccine education.
Sarah: And that's another data piece that we saw to support as well, that nurse home visitors were making a lot of referrals to doula services. So, yet again, trying to establish, you know, what are the needs and how can we design something to address them. And so often the case our clients have the answers. And to clarify, what is a doula?
Erin: So a doula provides perinatal support for pregnant or expecting parents. And that type of support can look like education, it can look like physical support during labor. So things like comfort measures, breathing techniques, and emotional support.
Sarah: And you talked before about a birthing doula and a postpartum doula. Can you clarify the difference there?
Erin: So a birthing doula helps a mom through labor and birth. And then the postpartum doula really supports a mom after birth. But they can also visit moms, obviously, before birth so that they can get to know the mom, know the family, know what their needs are to really be able to individualize care for the family. And after the baby is born, the postpartum doula can tend to meet self-care needs for mom.
Sarah: And you shared that you had been a postpartum doula.
Erin: So some of the benefits of being a postpartum doula for the mother is that Moms feel more supported. It increases mom's mental wellbeing. It decreases risk of postpartum depression. It's just really nice to have someone present who's nonjudgmental, who can, you know, listen to you during a very vulnerable time. Which is right after delivering a newborn. And forget it if it's your first newborn, that makes it an even more challenging time. And when you don't have additional supports, having someone listening to you really helps make you feel good. And just really being able to focus on taking care of yourself and taking care of your baby.
Sarah: And I think there's also a need for more research in this area because as we look at maternal mortality, morbidity, we look at infant mortality and morbidity, that postpartum period is a really challenging time.
We know from the research that it actually extends well beyond what we had been defining as the postpartum period. So trying to think about how to recreate those supports in different ways. Doula care being one of them. The ecosystem of home visiting programs being another one. But to try to think about adding layers of support when, as you say, people are their most vulnerable and where unfortunately we see that reflected in health outcomes as well.
We're talking about different types of perinatal health workers. nurse home visitors and other home visiting programs. Talking about doula care. And you've mentioned this term now, perinatal community health worker. It's been interesting to see how this field has evolved and the ways in which non-licensed professionals are increasingly able to access the benefits of being part of a healthcare system.
And most recently, doula care has been identified as something that can be reimbursed by managed care organizations. This is in the state of Pennsylvania, we're seeing many states take similar actions. This idea of the perinatal community health worker is yet another way that we are able to support care professionals that are not licensed in a particular healthcare field, but are proven to support health outcomes related to the perinatal period.
So what are some other career paths that seem to resonate with the client population that we're serving?
Erin: So a lot of the careers that our client population is interested in is healthcare. Jobs in medical coding and billing, jobs as certified nursing assistants, medical assistants, EMT. Some are interested in early childhood education.
Sarah: And it, it comes back to what you were saying about public health and even primary prevention to think about how all of these things are related. And I often am talking to healthcare leaders and nurses that are talking about the workforce and talking about the pipeline.
And so to see this entire client population of first-time parents who, maybe with additional support, can start to pursue some of these opportunities. And this was a, while a small project, it was only those five clients, those five clients are now contributing, right, to that perinatal workforce that we've been talking about.
Erin: Right. And the other benefit is, you know, I talked a little bit about our client population. I remember talking about PPF and why we were interested in pursuing that connection because PPF was familiar with the population of clients that we serve, and we know that culturally concordant care improves maternal health outcomes, especially in the black population.
And in Nurse-Family Partnership and our other programs, we predominantly serve black and African American communities and Hispanic communities. So if we're basically training former graduates of our programs who are then going to provide services to our families, then we know that we are more likely to improve maternal health outcomes because we're increasing that diversity in the workforce.
Sarah: And we heard that from Miyah Davis in the first interview: how important it was to her, also, to find a doula that reflected her background and how she sees part of her role in diversifying the perinatal workforce.
How do we make those experiences more accessible? How do we connect more people to doula care?
Erin: I think it's having access to opportunities like the one that we were able to do. So if we can show and demonstrate that our clients are interested in pursuing these opportunities and being successful in the workforce, then it's going to create space and opportunity for more initiatives like this to happen.
So I think it's, yeah, just being aware of the opportunities and then sharing them. So that's why having this podcast is so great because we get to share with listeners, other organizations, about how they might want to pursue initiatives like this one.
Sarah: Before we end our conversation, are there any final thoughts you'd like to share with our listeners?
Erin: Yes. If you're a healthcare provider or a leader in a healthcare organization, I would really encourage you to collaborate with community-based organizations to really partner on shared goals.
I'm very proud of the work that we were able to do with Maternity Care Coalition and Pettaway Pursuit Foundation because we were able to, you know in a small way, really have an impact on improving maternal outcomes through providing doula services and training these former clients.
So, I love integration, and I think it's important for organizations to continue to come together so that we are making deep and meaningful impacts.
Sarah: Thank you so much, Erin, for joining us.
Erin: Thank you for having me.
Sarah: Special thanks to Erin Graham for joining us. You can find our most current and past episodes of At the Core of Care, wherever you get your podcasts or at panursingworkforce.org.
For more information on upcoming webinars and trainings for nurses to obtain continuing education credits, log on to panursingworkforce.org on social media. You can stay up to date with us through our handle @nurseledcare and @PANursingWorkforce. At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Nursing Workforce Coalition and the National Nurse-Led Care Consortium. Thanks for joining us.
