Advocacy in Birth: Doulas Provide Services to Immigrants and Refugees in Nashville

The U.S. ranks 60th among developed nations in maternal health. Without the help of a trained doula, the medical system can be very difficult to navigate. This difficulty is even more pronounced, however, for women who do not speak the language of their caregivers.

A hospital can be an intimidating place for an expecting mom. Bright lights fill cold hallways as bustling medical personnel talk in medical jargon few can understand. Many mothers don’t meet the caregiver who will deliver their child until they arrive at the hospital already in labor. Though the mother is embarking on her most vulnerable moment, strangers will supervise it, often with limited time to explain the medical procedures she is about to undergo.

The challenge of navigating the hospital system is even more pronounced for those who are not at home in American culture. In Nashville, this is a common occurrence. The number of foreign-born residents in our city has more than doubled over the last decade. Nearly 12 percent of Nashville’s population was born outside of the United States, and nearly half of those individuals are recent immigrants who entered the country since 2000. In 2012, Nashville had the fastest-growing immigrant population of any American city. (1)

Immigrants and refugees approach the birth experience with the associated challenges of being far away from home. The extended family members who would normally support them during this time are often still living in the country they left. The customs, manners, and language of our country are often drastically different from their own. Many foreign-born women report that they received a test, procedure, or even underwent a cesarean surgery without knowing the reason why it was administered. Not only do the women feel isolated and confused in this foreign environment, but the medical staff often lacks the knowledge, patience and humanizing bedside manner to know how to make it a more positive experience for them. Both parties need someone to stand in the middle, a person able to take the time to work through the barriers presented by language and culture.

Chelsea Carver, student in the CBE Certification program at the Institute for G.O.D. Int’l, attended a prenatal appointment with her client during which she received her first ultrasound. The woman is from Sudan and is pregnant with her sixth child. On the day that Chelsea met her, her family was out of food and was unable to get more for over a week. Chelsea’s care for her client has extended beyond the pregnancy itself as she has connected the family to services appropriate for refugees that she was previously unaware of.

Because of this need right in our own city, students enrolled in the Childbirth Education Certification Program at the Institute for G.O.D. Int’l are required to attend at least one immigrant or refugee birth. In addition, all doulas working with NOVA Birth Services are required to give a portion of their doula services to immigrants and refugees free of charge. Tara Garner, Director of the Childbirth Education program, says:

“Serving and supporting expecting mothers of the refugee/immigrant communities is simply doing what the LORD has commanded and expects of us: ‘You shall love the immigrant as yourself,’ (Lev. 19:34) and, ‘Truly I tell you…what you do to the least of these, you do unto me,’ (Matthew 25:45). (2)
If we neglect to humanize the mothers and babies who are in the most need of support right here in our own city, we are failing to fulfill our responsibility to care for our neighbor, and ultimately neglecting to live as fully human ourselves.  We are blessed to have received life-giving information, training, tools and resources, and so freely we also must give. We give ourselves, our love, our prayers, our education, our sweat, our tears, and our time and energies away from our own families (and nursing babies) for an indefinite number of hours (sometimes days) to see that these precious mothers are provided proper maternity care–a basic human right.
The CBE program has proven to be a mutual benefit for both the training students, and the refugee mothers they serve. The student doulas are exposed to the overwhelming needs of the immigrant and refugee community, and they in turn provide these marginalized mothers and babies with an informed, humanizing presence during their pregnancy and birth. In doing so, they help to ensure that this vulnerable stage of life is an energizing experience, rather than a traumatic one.
In the end, after all the hard work and field hours have been put in, we are always the ones that feel most blessed, beyond words, to have the privilege to spend such precious moments alongside of these families. It often seems as if they are the ones humanizing us.”

Kendice Hartnell, student in the CBE program at the Institute, attended a client named Rose (name changed for privacy), a refugee from Malaysia. During Rose’s final prenatal appointment, the doctor told her that she needed to be induced, with no further rationale or explanation. A nurse explained to Hartnell that inductions are almost always scheduled for immigrants and refugees. Many of them come to the appointment thinking it is a normal check-up. When Hartnell explained to Rose that she was going to be induced, she did not know what that meant. Hartnell was able to explain the process along with the risks and benefits, which prepared Rose for the experience. Rose’s induction date was scheduled on a day when her husband and English speaking friends were at work. Fortunately, Hartnell arrived with a list of preferences Rose wanted as part of her birth experience. Hartnell helped Rose compose it ahead of time, and had it translated into English so that the doctors would have easy access to what Rose wanted.

Kendice Hartnell teaches a Childbirth Education class to a group of Burmese refugees. The highest number of refugees that come to the U.S. are from Burma, Bhutan, and Iraq. Burmese and Bhutan refugees have only been given refugee status in the U.S. since 2008 (Pew Research Center). The Burmese community is well-connected in Nashville, and once Rose had received Hartnell’s doula services, she wanted several of her friends to also receive the benefit of prenatal education.

However, when the doctor arrived she promptly told the nurses she was going to break Rose’s amniotic sac. When the nurse began to dial the translator on the phone, the doctor told her not to bother. The doctor then turned to the mother and in one breath said, “Rose, I’m going to break your bag of waters to speed up your labor, okay? Great.” Though Rose could not understand the doctor, they prepared to proceed with the amniotomy.

Hartnell stepped in and introduced herself as Rose’s doula, insisting that she had a right to a translator. The doctor, frustrated, grabbed the phone to report to a translator (via the phone, an option many hospitals have) that she wanted to do something to help Rose’s labor. Hartnell asked the doctor to explain the intervention she wanted to do, along with risks and benefits, and ask for Rose’s consent. Once Rose could understand what was being asked, she refused the intervention. Hartnell then contacted a translator she knew so that they could have someone present in person who spoke Rose’s language.

Hartnell remained with Rose throughout the birth, supporting her as she brought a healthy baby girl into the world. Afterward, she reported the doctor that attempted to manipulate Rose, which resulted in the head of the Maternal Health Department coming to personally apologize for the lack of respect Rose was given. Without Hartnell’s presence at the birth, Rose would have been subject to an unnecessary and unwanted experience that likely would have included more interventions as labor progressed.

Unfortunately, Rose’s story is not unique. There are many immigrants and refugees who do not receive consistent and compassionate care during birth, the most vulnerable experience of their life. Immigrants and refugees like Rose are in dire need of childbirth education and trained birth support teams to help them achieve healthy births in the hospital setting. A doula is typically an added expense that many immigrants and refugees simply cannot afford, or would even know about. Some hospitals, recognizing this, have begun to provide doulas to laboring women free of charge. NOVA’s program offers the benefit of childbirth education prior to labor which allows for the establishment of a relationship of trust between the laboring mother and doula.

Jennifer Sherrod teaches childbirth education to a group of refugees. The immigrants and refugees who receive charitable services from NOVA and the Childbirth Education program often first receive prenatal education, so that they are educated on their legal rights and options before the birth itself. This opportunity also allows for the doulas and mothers to form a bond of trust that can extend from pregnancy, to birth, to lactation counseling, to parenting advice. Our doulas and doulas-in-training provide a comforting and compassionate presence throughout their journey into motherhood, whether it is the first, second, or sixth time they enter it.

Since Garner attended the birth of a Peruvian immigrant in 2008, the importance of offering birth support to immigrants and refugees was a burden she carried. In 2010, the Childbirth Education Program was officially launched at the Institute for G.O.D. Int’l. Since then, NOVA has extended birth support to 33 immigrant and refugee families, with the number increasing each year in combination with the number of doulas trained to provide services.  This has included childbirth classes, informational/emotional support at their prenatal doctor appointments (and transportation to get there), physical and emotional support and advocacy during labor, postpartum visits and support, and breastfeeding counseling–all free of charge. The majority of doulas employed by NOVA have worked overseas with mothers in India, El Salvador, Kenya, Uganda, and the Philippines, and therefore have extensive experience working with pregnant women cross-culturally. Several of our doulas are bilingual, and can offer complete translation services themselves. All of them are trained in cross-cultural sensitivity and care, allowing them to offer the kind of persistent and compassionate assistance that Hartnell extended to Rose.

After years of working with the Nashville immigrant and refugee population, our reputation is spreading. After Hartnell attended Rose’s birth, she had several of Rose’s friends call her, asking for childbirth education. They wanted to know what was happening to their bodies during labor, and what choices they had in the process. In response, Hartnell and classmate Jennifer Sherrod decided to offer a complete five-week childbirth education class to the expecting families (a group of Burmese immigrants). Currently five couples attend, including some who are not yet pregnant! They recognize the value of the education being given, and what a rare opportunity it is. Even mothers who have already had several children attend the class, commenting that they never knew what their “womb” was, or how it worked. The classes cover ways to navigate the U.S. hospital system, and the basics of what happens during pregnancy, labor, postpartum, and lactation. They are also informed of their legal rights as childbearing women. After learning these things, they feel much more confident to make decisions with their care provider and speak up for themselves.

Jesus himself was born away from his parents’ home, in an environment unfit for a laboring woman. Not only were Mary and Joseph forced to travel during her ninth month of pregnancy, but there was no hospitality for them in the “City of Bread” (Bethlehem). Mary didn’t even have adequate supplies to warm her baby after the birth; she had to wrap him in pieces of cloth. We’ve grown accustomed to the idea of the baby Jesus lying in a manger, but in reality, the dank, bacteria-infested feeding trough of cattle is no place any mother would want to lay her newborn baby. No one was there to advocate for the couple and yet, the life of Jesus reveals to us just how much potential every child born into such circumstances possesses (Lk. 2:1-7). As God’s people, we must learn from this story. We can ensure that in their most vulnerable hour, women are cared for properly.

The social and economic disadvantages of families away from their home are plentiful, but these mothers deserve to be loved. Such love takes place when we ensure that they receive the same opportunities that all expecting women deserve, regardless of language, ethnicity or country of origin.

Leviticus 19:34 The immigrant who resides with you shall be to you as the citizen among you; you shall love the immigrant as yourself, for you were immigrants in the land of Egypt: I am the LORD your God.

Written by Cannon Cameron and Laurie Kagay


(1) “New Americans.” Nashville > Mayor’s Office > Priorities > Neighborhoods >. N.p., n.d. Web. 30 July 2014. <>.

(2) Verse 28 reads “And when we saw that we saw you a stranger, and welcomed you,” and later in verse 43, “I was a stranger, and you welcomed me,” including the immigrant or refugee in the list of ‘least of these’ the passage delineates.