Bouncing on a pink yoga ball, senior Annel Perez is clearly in labor — alternately crying and shouting — and her impression is so good, you want to ask her how far apart her contractions are.
“AHHHHHHHH!”
“Help me.”
Annel’s acting is over the top, yet her scene partners take their cues from her.
As the nurse, Maya Gomez asks the pregnant person what they need.
Ashley Acuña Grijalva, 18, in the role of doula, wonders if she can help Perez, obviously in pain and scared.
The birth partner stands by, puts a hand on Annel’s shoulder. She shakes it off.
While the high school students work on a labor scenario in the front of the classroom, the stakes are high. They will soon experience the reality of live birth: As student doulas, they must support three births this summer to become certified.
Teachers Shannon Alexander and Joyce Wall nod their heads, circle the room and wonder aloud.
“I want to see what the rest of you remember,” says Alexander, also an advanced certification doula. “What is your ratio for two people doing CPR on an infant? And how many compressions are you getting in within a minute’s time?”
Heads in the classroom go down.
The birth at the front of the room takes a pause.
Students in the doula certification class at Pima JTED continue their work, knowing they have two weeks left until they complete Arizona’s only course to certify high-school age doulas.
A birth doula provides emotional, physical, and informational support before, during, and after labor and birth.
At Pima JTED, students from high schools across the Tucson area have spent the school year in the community health and wellness program. As part of that program, this doula certification class will see 10 students complete the course this week. Because they are 18, six students are eligible to become certified doulas this summer — four others may follow as they reach certification age.
To earn that certification, students must be at least 18 and provide support at three live births, the Arizona Department of Health and Human Services says. Arizona’s $300 licensing fee is covered by JTED.
Some of these students may want a career as a doula or midwife, others are getting a head start as a nurse, social worker or even a dermatologist.
“The students are the ones who show up. And it was quite mind-blowing to see the growth,” Alexander said. “We’ve got future pediatricians and obstetricians and midwives and they’re going to be so much better at their future careers because they’ve learned community health work and they’ve learned doula skills.”
Pioneering a doula program
Pima County’s Joint Technical Education District is a public school district that teaches about 20,000 high school students from across Southern Arizona, often at off hours — think after school and evenings. Students get free career and technical education and can be certified in everything from welding to veterinary and medical tech programs to culinary arts and being a doula.
“While the Arizona Department of Education does not regulate or certify doulas, their Career and Technical Education (CTE) division has formally recognized our doula program as a certification pathway within the community health worker program,” said Beth Francis, a registered nurse and JTED’s healthcare professions manager. “While there are several approved programs statewide, our program is currently the only one operating at the high school level.”
Research indicates doulas can positively impact several maternal and infant health outcomes and experiences, according to the Department of Health and Human Services. Expanding access to doula care improves maternal outcomes for people of color, says a 2024 study from the National Institutes of Health.
About 9,000 people in the United States practice as doulas, typically contracting privately with families and earning $1,500 and up for an experienced doula-assisted birth. Some doula care is covered by insurance, including Medicaid programs in 25 states, of which Arizona is one.
“The birth doula program was the result of nearly a year of planning, research, and collaboration,” Francis said. “During that time, we worked to better understand community needs, identify healthcare workforce gaps, and build strong partnerships (local hospitals and practicing birth doulas) that would help create a meaningful and sustainable program for students. We connected with community organizations, maternal health professionals, and educational partners to ensure the program would provide both high-quality instruction and real-world experiences.”
High school doula certification programs exist in some states including Massachusetts and Arkansas, though they are rare. JTED’s program uses a curriculum developed by Wall and Alexander, who is certified through DONA International, the oldest and largest doula certification program in the world.
JTED’s community health and wellness program also offers a class in community health and wellness. Most of those in the inaugural doula certification class — which started the year with 19 students — were surprised to find themselves there, they said, after not getting into the other class.
“I think these two facets of community health and doula marry up really well because as a birth doula you need to know what community resources are available,” said Wall, who is a registered nurse with 35 years of experience. “And as a birth doula, you’ve got that compassion, that empathy that comes out, which normally the two work hand-in-hand. If you don’t have that empathy, you don’t care for people, then you’re probably not going to be in health care.”
“Where I see my future …”
An aspiring labor and delivery nurse, Ashley Acuña Grijalva joined the community health and wellness program this school year.
The senior at Alta Vista High School had an aunt who used a doula at her birth, but Ashley was unclear about the doula’s role.
“When I got into this program, I learned what birth doula was and community health work and the birth doula really fascinated me,” she said. “I see myself in the future becoming a labor and delivery nurse. Especially because my best friend wants to be a NICU nurse so I feel like that would be the thing.”
Next fall, Ashley will head to the University of Arizona as a first-generation college student. The JTED program helped her see her strengths, she said.
“She’s grown so much,” Alexander said of the soft-spoken Ashley, who found purpose in community health events where she spoke in Spanish about suicide prevention, nutrition and asthma.
“They’ve just made this program really fun. We did our first community health event in Safford,” she said. “That was super interesting to me. We went out to give flyers. And that was the first time I really ever interacted with people. And it felt amazing. That’s where I see my future.”
Like her classmates, Ashley has navigated a class rooted in real-world issues.
“There were definitely conversations about whether students might feel intimidated by the subject matter because maternal health, childbirth, and advocacy can be emotionally sensitive and complex topics,” Francis said. “However, we also believed students would be drawn to the program because it offers something unique, meaningful, and directly connected to helping people during one of the most important moments in their lives.”
Admittedly shy, the hands-on work “felt really good,” Ashley says. Her aptitude surprised her most.
“I feel like the program offered a lot,” she said. “The fact that we’re going to have births, like real life births to do, I’m a little bit nervous.”
Insight and résumé building
If Edwin Moreno Rios felt apprehensive about taking the doula certification class, he hid it from everyone.
The Sunnyside High School senior will finish the program as the only male in the class. Community health and wellness was a focus for him on the path to becoming a dermatologist, he said.
But the doula class?
“I kind of didn’t expect it, but it’s pretty nice because it gives me a better look on my résumé,” Edwin said.
Learning about labor and delivery is also sobering, he says. It’s the other side of a sex-ed class.
“What’s pretty cool is the fact, like a lot of people my age are, how do I say this? Loose? And you know, not protected at all,” he said. “So, it gives a good insight as to what can happen, to be careful.
“When I got here, I felt fearful and I felt like ‘oh God,’” he said. “Obviously, I still kind of do, but swear it off.”
He realizes, he says, that the birthing person doesn’t necessarily relate to him. But, he learned immediately that “everyone has a story and people need help with almost everything,” he said.
“I recognize my community, the Hispanic community, we need help and being a doula can do that.”
Maternal mortality rates among people of color are at crisis levels, according to a 2024 Arizona Department of Health Services report from 2018-19, the most recent data available.
Arizona ranked 11th in maternal mortality rate at 30 deaths per 100,000 live births between 2018-2022, according to the U.S. Centers for Disease Control and Prevention. That’s higher than the national average of 23.2.
Seeing that need here, helped shape JTED’s program, Francis said.
“Maternal health is not only a medical issue,” she said. “It is a community health issue influenced heavily by social determinants of health, access to care, mental wellness, education, socioeconomic status, and cultural support systems.”
Stretch, grow, respect
Connecting with community and imbuing that group with her vibe, is what Desert View senior Sophia Gonzalez says she wants to do as a social worker.
She’s headed to Northern Arizona University next fall as a first-generation student.
“I’ve had social workers in my life. I’ve met them through my school. I’ve met them in my house,” she said. “I’ve been with them in their offices and facilities. I want to do what they do.
“This class has truly helped me with first of all my presentation skills a lot, my communication skills, my being able to work with more people and being a team player and it’s just it’s helped me open up myself more to that like idea of being just a helping hand and collaborating and actually getting my ideas out there,” she said.
As a new teacher, Alexander also learned those new skills and grew this school year too. Although she’s a mother of four and been a doula for about 14 years, leading a classroom forced her to stretch, she said.
“I relate to my students this way, even becoming a doula for the first time,” she said. “Sitting in the discomfort, learning a new skill like teaching and presenting. … It’s life changing and I’m not that kind of person. I never was. And I became that person.”
The “as-if” technique is not a substitute for the real thing. But for now, the students have each other and their roles at the birth in the front of the room.
As the doula in the next scenario, Edwin asks Maya, playing the nurse, to step outside and talks with her softly.
“What does she need? Maybe a translator,” he offers.
The scene stops.
“Did you guys all notice that he called the nurse aside to have a private conversation? That’s very well done,” Alexander says.
“Sometimes you actually need that time to talk to someone and to figure out, OK, what do I need to say, she said. “What language was effective with this? Just show that respect.”
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