Where Doulas Calm Nerves and Bridge Cultures During Childbirth

HALMSTAD, Sweden — Maria Hussein, who escaped the war in Syria, was many hours into labor in a Swedish hospital when the midwife realized her fetus was in distress, and called in an obstetrician to help.

The doctor began giving Ms. Hussein instructions and reassurance in Swedish. Oksana Kornienko, who works as a doula culture interpreter for a nonprofit organization serving pregnant immigrant women, listened attentively, leaning over Ms. Hussein’s shoulder and translating the doctor’s words into Arabic.

“This was a typical example where it went well, very much because the doula could explain,” Elisabeth Oskarsson, the midwife who assisted in the delivery, said afterward. “I think it helped her be more courageous that the doula was there.”

In Sweden, midwives deliver babies. Obstetricians and pediatricians are consulted only if there are complications. But doula culture interpreters are a relatively new concept here. They act not only as birth coaches, but also help to bridge the language divide between medical professionals and immigrants during one of the most stressful milestones for women: childbirth.

Last year, 28 percent of the women who gave birth in Sweden had been born in another country. Research shows that immigrants from low-income countries are six times more likely to die of pregnancy-related illnesses or complications than their Sweden-born counterparts and more than twice as likely to have a serious childbirth-related problem — such as shock from hemorrhage or septicemia, heart failure or severe eclampsia.

Sweden ranks high among countries for the quality antenatal care, but it still struggles to ensure equal pregnancy and childbirth care for all. Factors contributing to the higher mortality rate among some immigrants include pre-existing illnesses, such as tuberculosis. But differences in access to treatment in Sweden, inadequate use of interpreters and inadequate care can also contribute to higher death rates, said Annika Esscher, an obstetrician.

“Good communication is listed as one of the best ways to improve outcomes,” Dr. Esscher said.

Midwives at a nonprofit clinic in Gothenburg were the first in the country to start training doula culture interpreters 10 years ago. Since then, almost 200 women have been certified. Their services are offered in a few counties and cities to pregnant women who do not speak Swedish.

Studies show that the support of a trained doula can reduce the risk of complications and interventions during childbirth. Doulas also help women and their partners navigate an unfamiliar medical system and birth routines, and communicate with medical personnel, said Jennie Dalsmark, who started training doula culture interpreters in Halmstad in 2017.

“We know that there are other risks for the woman and the child. Much of this is because the woman can’t communicate with the personnel,” Ms. Dalsmark said. “That is why we are investing in a safer and better care for women who do not speak Swedish.”

Ms. Kornienko massaged Ms. Hussein’s back, brought her a heating pad, walked with her and gave her sips of a liquid to drink. / Elisabeth Ubbe for The New York Times

Ms. Kornienko, a midwife with more than 25 years’ experience in labor units, was in the first doula training class that Ms. Dalsmark started in Halmstad. An immigrant from the Syrian war herself, she arrived on the southwest coast of Sweden in 2014, months before Ms. Hussein.

At first, she faced an uncertain professional future. When she moved to Syria from her native Russia 22 years ago, Ms. Kornienko had learned Arabic, but she did not expect it to be that easy in Sweden. While her three children adjusted quickly to their new country, Ms. Kornienko, 50, dived into mandatory Swedish-language class for immigrants.

Two years later, a classmate told her that the local employment agency was looking for women interested in becoming doula culture interpreters. Foreign languages were a prerequisite. She immediately sent in her application.

Ms. Kornienko is now working toward becoming a nurse, a prerequisite for becoming a midwife in Sweden.

“I can’t just sit at home and study,” she said. “It is hard to start working in Sweden for us newcomers who don’t have the language. But we have experience. We have other languages.”

Ms. Kornienko informing immigrants about the doula service. One important aspect of the doula’s work is to convey a woman’s rights over her own body during labor and delivery. / Elisabeth Ubbe for The New York Times

In Halmstad, about 87 miles south of Gothenburg, deliveries at the regional hospital reached their highest number in 2015, when the influx of immigrants from conflict zones peaked. More than 160,000 refugees and asylum seekers entered the country that year.

“All of a sudden, women showed up in the emergency room,” said Annika Bengtsson, a midwife at Halland Hospital in Halmstad. This left little or no time to take a thorough medical history.

The language barrier was the biggest hurdle, said Nilantika Adin, a midwife in the unit. While city hospitals will bring interpreters into the delivery room, regional hospitals rely mostly on phone interpreters.

“But not all patients are comfortable with a stranger,” Ms. Adin said.

One important aspect of the doula’s work is to convey a woman’s rights over her own body during labor and delivery, said Ulrica Askelof, who trains doulas to serve immigrant women in the Stockholm area.

Many women also don’t expect to be asked what they want, she added.

“In many places, a woman cannot bring anyone with them during delivery,” she said. “They are not allowed to scream. They are told that they will be beaten. That’s hard to hear. When women get scared, the oxytocin that keeps the birth moving forward doesn’t flow.”

On the other hand, when the staff listens and asks the woman what she wants, there is a chance that the outcome will be better, she said.

Once a week, the doula cultural interpreters’ project arrange dance activity for pregnant women. Ms. Kornienko and the other doulas participate in the dance themselves. / Elisabeth Ubbe for The New York Times

“They provide much more support than I can give as a midwife, who goes in and out of the delivery room,” said Magdalena Nilsson, a midwife who has delivered several babies in Halmstad with a doula culture interpreter present. “She is there the whole time.”

When Ms. Hussein delivered her first child, in 2016, she went through an emergency cesarean section in a Swedish hospital with no one but her husband, Abdulhanan Mohamed, to help, she said.

Mr. Mohamed, like Ms. Hussein, had fled Kobani, in northern Syria, when the city was overrun by the Islamic State. The two met and were married in Halmstad, where they share a one-bedroom apartment.

But when she became pregnant with her second child in 2018, she waited for the birth knowing she would have Ms. Kornienko to help her through the process.

On the morning of Nov. 26, when Ms. Hussein’s water broke, she called Ms. Kornienko. They headed to Halmstad Hospital.

In the delivery unit, Ms. Kornienko put on her uniform and went to work. She massaged Ms. Hussein’s back, brought her a heating pad, walked with her and gave her sips of juice. All the while, Mr. Mohamed tended to their 2-year-old son, Dijwar, until he fell asleep in the stroller.

Shortly before lunch, Ms. Oskarsson, the midwife, gave Ms. Hussein an IV drip of oxytocin to get the labor going — and laughing gas. Mr. Mohamed brought back a Kebab Pizza for lunch. The contractions were still too far apart.

“You’ve got a long time left,” Ms. Oskarsson said when she checked on her.

“How long?” wondered Mr. Mohamed, looking a little worried.

At 8:46 p.m. on Nov. 26, Rumaf entered the world at Halmstad Hospital, just shy of six pounds. / Elisabeth Ubbe for The New York Times

A few hours later, the midwife encouraged Ms. Hussein to take an epidural for the pain. Ms. Kornienko interpreted and Ms. Hussein agreed.

At 8:46 p.m., with the obstetrician’s help, Rumaf entered the world, just shy of six pounds. Cries of pain were replaced by peals of laughter. Mr. Mohamed shed tears of joy and relief.

“Thank you. Thank you,” Ms. Hussein told the doctor.

On the second day after the birth of Ms. Hussein’s son, Ms. Kornienko visited the maternity ward at Halmstad Hospital. / Elisabeth Ubbe for The New York Times

Shortly after 10 p.m., a nurse came into the room with a silver tray holding refreshments and a Swedish flag, as is the tradition in all delivery units across the country.

Several days later, Ms. Kornienko followed up with Mr. Mohamed and Ms. Hussein in their apartment. The family was doing well.

Dijwar was wearing a onesie with a holiday motif. Rumaf slept swaddled next to Ms. Hussein on the sofa. Mr. Mohamed brought out coffee with cardamom and cookies. Ms. Hussein nodded happily.

“Mother is happy, then I feel good,” Ms. Kornienko said.

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