"The impetus for this program is the huge disparity in infant mortality between blacks and whites born in this city," said Stacey Tuck, maternal and child health director at the department.
Baltimore is not alone. New York, Chicago and Tampa have also used doula training programs to improve newborn health.
Other cities may follow, according to Dale Kaplan of the MaternityWise Institute, which conducts doula training in Baltimore. Other cities, including Denver, San Antonio and San Francisco, have contacted his organization to inquire about starting programs.
The U.S. infant mortality rate among African Americans is more than twice as high as it is for white babies.
"Doula" comes from a Greek term meaning "a woman who helps." Although doulas are trained to assist expectant mothers through labor, delivery and beyond, they are not medical providers, as midwives are. Dona International, which calls itself the largest doula-certifying organization in the world, said doulas help mothers achieve "the healthiest, most satisfying experience possible."
A 2013 study found that doula-assisted mothers were less likely to deliver babies with low birth weights or with birth complications than were mothers who opted not to receive such support, and they were more likely to breast-feed their infants. Another study found that mothers attended by female caregivers during labor were less likely than others to have Caesarean births, require painkillers or deliver babies in poor health.
"Continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor," according to the American Congress of Obstetricians and Gynecologists, which cites other benefits, such as shortened labor, less need for pain medication and fewer operative deliveries.
African American women have a long history with doulas, particularly during the Jim Crow era when hospitals denied access to black women, forcing many to deliver their children at home, said Andrea Williams-Salaam, a doula trainer in the Baltimore program. But as race-based legal barriers vanished and the medical profession strongly promoted hospital deliveries as the safest option, fewer women practiced as doulas.
While a few continued to work in Baltimore, she said, the city decided to start training doulas, following the example of New York, which started its doula program in 2010. So far, New York has trained 68 doulas who have attended 580 births.
Gabriela Ammann, director of the By My Side Birth Support Doula Program, which seeks to reduce infant mortality in Brooklyn, helped start the New York program. She had been a part-time doula while teaching infant education classes in the Brooklyn Healthy Start Program.
"I noticed when we talked about labor and birth support, participants often said they weren't sure they'd have someone with them," she said. "Sometimes they didn't have someone to support them, or that person had to stay home to take care of the other kids."
As a result, many of the women had to go through labor and delivery with only the help of strangers, adding to the stress of childbirth, she said.
Ammann started connecting some of those expectant mothers with doulas she knew. She persuaded the city to formalize the program and to train new doulas.
Like New York, Baltimore wants its doulas to work as independent contractors rather than as city employees. In addition to advising women about their pregnancies and baby care, Baltimore's doulas will be trained to connect needy women to housing, transportation, nutrition and employment services.
"The doulas are there to assist, support and empower a woman in whatever way she needs assistance," Williams-Salaam said. "That could be accompanying the woman to medical visits to help with the terminology used by the caregiver or helping her obtain proper nutrition, housing or employment."
It was the idea of empowering other women that induced Keyona Hough to become one of the five doula trainees in Baltimore.
Too often, poor African American women are treated disrespectfully by the institutions they interact with, she said. She wants not only to advocate for her clients but also to "teach them how to advocate for themselves."
"Like me, a lot of these moms have been subjected to violence and trauma," she said. "That's why I want to help them understand what their rights are, so they can move through that system without being re-traumatized."
Training the initial group of Baltimore doulas cost about $5,000, Tuck said. She hopes to find thefunding to train many more.
The cost of hiring a doula varies widely, from as little as $100 to as much as $5,000, according to Ammann. There is generally no insurance reimbursement for doula services. Unlike New York, Baltimore will not pay the doulas for their work, so any money they make will come from clients.
The architects of the Baltimore program said they warned trainees from the start that they would not be able to make a living from their doula work. Many of their patients cannot afford to pay.
"This is primarily about service and giving back to the community," Tuck said. "The five women who have enrolled as trainees, their motivation is not compensation, that's for sure."
Stateline is an initiative of the Pew Charitable Trusts.