Adrianne Edwards vividly recalls being a scared college sophomore, age 21, in labor at a hospital where the nurses' primary concern seemed to be freeing up her hospital bed.
"I felt like my doctors and nurses were pressuring me to have a C-section," she said. She wanted a medication-free birth but instead received inducing drugs and then an epidural. "If I'd had more information, I would've had a totally different birth."
Now, Edwards, 29, the working mother of an 8-year-old, wants to help change that script for other teen and single moms.
So she joined the North Philadelphia Breastfeeding and Community Doula Program, an initiative to train low-income women to serve as doulas for other low-income women.
The program, run by the Maternity Care Coalition, was the brainchild of staffer Naima Black. She saw it as a way to improve abysmal breast-feeding rates - fewer than half of mothers in North Philadelphia initiate breast-feeding, compared with 60 percent citywide and nearly 80 percent nationally - and create jobs, too.
"The idea was not just to serve women one on one, but to increase the community capacity to support themselves," Black said.
Doulas provide information and emotional support before, during, and after childbirth. The grant-funded program, in its fourth year, has trained 76 of them, and has accepted 545 clients. Each doula receives a stipend for a series of pre- and postnatal visits and to stay with the mother through the duration of labor. It's making a nonmedical service that's often perceived as a luxury - doulas can cost hundreds of dollars, and aren't covered by insurance - free and accessible.
The work could have a sweeping impact on infant health in the community, as doulas have been shown to improve breast-feeding rates, and breast-feeding, in turn, has been linked to reductions in everything from respiratory and gastrointestinal infection to obesity.
And, Black hopes, it could start to transform how women in these communities experience childbirth, as doulas also have been shown to reduce the need for cesarean sections, epidurals, and interventions.
On a Thursday night last fall, 20 women - many juggling their own infants and toddlers - sat in a circle at Maternity Care Coalition's North Philadelphia office, discussing the merits of natural labor inducers, from castor oil to acupuncture to sex.
This is community doula training: 20 evening sessions and one weekend, covering everything from communication skills to pain-management techniques; information on healthy pregnancies to breast-feeding.
The night's guest speaker was Christy Santoro, a certified professional midwife. She played videos of squatting deliveries, and then showed the doulas how to support women using a birthing stool.
But, she noted, at many hospitals, staff resist squatting - or standing, or walking around - during birth because, among other factors, it's more difficult to keep monitors in place. So the conversation centered on how doulas can talk to doctors, making inquiries ("Do you ever delay cord-clamping?") without demanding or confronting.
"Sometimes it can be just thinking of one or two things that can help people feel like they've had a good experience: How they can ask to have epidural reduced, which can help them push more effectively," Santoro said.
"I believe how we give birth matters. It can be this beautiful, transforming, sacred process."
Though the focus is North Philadelphia, the training was open to women from around the city and at any income level. Some doulas have started their own businesses or gone on to train as lactation consultants or even midwives.
Nyra Zaracho, 31, joined because she had doulas for the births of each of her two sons (at a price of $500 apiece, paid in installments). She wanted to offer that to others, but even the cheapest training was out of her financial reach.
Now that she's on the job, she said, "It's fulfilling and disheartening."
One client, a single mother, was given a cesarean section for no reason Zaracho could discern. Another was pressured to take inducing drugs within a half-hour of arriving at the hospital.
"The nurse didn't give a medical reason. She was like, 'Almost all moms get induced,' " Zaracho said.
Zaracho wants to help change the tone around childbirth and help correct a history of trauma.
"One client, who was 19 or 20, her mom told me that when she was a teen mom in Puerto Rico, you weren't allowed to bring anyone into the delivery room. She went in scared and alone, and they gave her a C-section and then a tubal ligation without consent," she said. "That's why I'm doing this. Her mom was like, 'No matter what happens during labor, I'm glad she has you.' "
Recently, she helped a client dance her way through a delivery. She posted a video of it on Facebook, and it went viral.
"I posted it to challenge this fearmongering," she said.
On a Friday night in February, Edwards walked up to a house in Northeast Philadelphia, lugging a birthing ball and a sack of supplies.
She was there for a meeting with Jada Schoolfield, 17, and eight months pregnant, who had learned about the program in school.
Edwards, 29, a case worker for the Department of Public Welfare, has had five clients so far, most of them teens.
Edwards worked her way through a questionnaire, asking Jada about her delivery plans and preferences, and discussing medical and natural pain-management options. "Thinking about what they're going to offer you and whether to accept it will determine a lot of what happens later," she said.
Then she asked about Jada's favorite music for a labor playlist and demonstrated how Jada could use the birthing ball to help widen her pelvis. And she unpacked her gear: heating pads in the form of rice-filled socks, lavender oil, ChapStick, lollipops, scrunchies, and more.
After all, the meeting is about gathering information, but it's also a chance to build the relationship. It's a covert sales pitch - to ensure the mother actually calls the doula when it's time to go into labor.
"Not every mother calls. People lose their phone, change their number, the phones go dead. Sometimes they're referred to us but don't know what a doula does. Or they changed their mind," Black said. "A lot of the families we work with are dealing with many other issues."
Next, Edwards broached the topic of breast-feeding.
Janette, Jada's mother, frowned. She doesn't think Jada's up for it: "She intends to eat healthy, but then sometimes it's Hot Cheetos."
But Edwards is persistent. Sometimes, if the birth goes well, that changes.
One mother she worked with wasn't very interested in breast-feeding initially. But after a successful birth, "I could tell she was really proud of herself. When I visited her 48 hours later, she was breast-feeding. For her to be doing it successfully, it was a confidence exuding from her," Edwards said.
So, she told Jada, "You may surprise yourself."
Edwards folded up her questionnaire.
"We can plan for a lot of this, but when that time comes, go with your heart."