Harm reduction doulas want you to ask: What makes a good parent?

Editor’s note: This story was published alongside a photo series as part of a project from journalists Celeste Hamilton Dennis and Florence Middleton about harm-reduction doulas and the parents they work with. It was produced in partnership with the Pulitzer Center.

Livia Perkins couldn’t help but crack jokes during her cesarean section. At one point, she even hit on the anesthesiologist, quipping, “I’m already naked.” 

As she lay on the surgery table, tent-like drape over her big belly, this wasn’t the birth she’d imagined. There were no friends or family, no partner massaging eucalyptus oil on her temples. But there was Ash. 

The night before, Ash Woods, who uses they/them pronouns, Livia’s harm reduction doula, rushed to Swedish First Hill Hospital in Seattle when Perkins learned doctors had moved the surgery up a week because of her and the baby’s plummeting heart rates. 

The what-ifs were overwhelming. What if the baby had respiratory issues because of the alcohol and meth she’d used? What if the epidural paralyzed her and she had to learn how to wipe boogers with her toes? What if the human she created was…ugly? That last one she couldn’t believe she’d said out loud. 

When it came time for labor, all Perkins needed to do was look at Woods, and their signature side braid, for support. 

“I’ll be there for the whole thing. Just focus on me.”

Woods is a co-founder of the Harm Reduction Doula Collective, a loose handful of volunteer doulas in Seattle and Portland fighting against a deeply ingrained belief: doing drugs automatically makes you a bad parent. That work means roles ranging from advocate to confidant to educator, always centering the autonomy and dignity of the parent. 

“So many of the folks I work with have nobody,” said Chelsie Porter, a co-founder of the collective who also works in public health. “To have one person who is checking in with you and caring for you, even if they can’t meet all your needs, makes such a huge difference.”

For many, that one person can mean the difference between life and death.

Overdose and suicide are among the leading causes of maternal mortality, not only in Washington state but nationally, with Black and Indigenous families most impacted. And myths of the crack-cocaine epidemic, when substance-exposed babies were mistakenly thought of as doomed, still haunt maternal care. Parents who use are often labeled as selfish, and with addiction largely seen as a moral failing rather than a health condition, the specters of stigma and shame deter people from seeking help or prenatal care. Those who do face the threat of child protective services (CPS) and in nearly half of the U.S., fines or jail. 

The doulas will say that they haven’t met anyone yet who doesn’t want the best for their baby. They continually, doggedly ask: Doesn’t everyone deserve at least a chance at raising their kids? And what happens when parents who use drugs are supported instead of punished? 

Woods knew what it was like to use drugs and not feel welcomed, and the difference a chosen family could make. Perkins could tell them anything. How she wanted nearly her entire life to be a mother. How guilty she felt about the vodka she drank every day during the first trimester, and the occasional meth use, unhoused and unaware she was pregnant. How afraid she was of not bonding with her baby. 

Now, the moment was here. A flurry of doctors and nurses around her in scrubs, the anesthesiologist she’d hit on now hovering in the back of the room. Perkins sweaty and shaking, the pain from her deteriorating hip numbed. Woods by her side. Both of them laughing despite the unknowns. 

Woods was comfortable in the liminal space. They’ve lost many close friends to overdose and suicide. And they’ve helped many parents bring new life into the world. 

Perkins felt pressure and within minutes, Eleanor arrived. No doctor held her up towards the sky like that scene from The Lion King. She didn’t make a sound. A nurse whisked Eleanor to a scale covered with butterflies and rainbows. Woods held Perkins’ clammy hand, their eyes locked. 

They waited. 

Seven months earlier, on her 41st birthday, Perkins threw the pregnancy pee stick from across the room at Motel 6 with the flourish of a basketball player. “Kobe!” she crowed, after it landed in the sink. 

Perkins longed to tell her mom about the two lines. Perkins’ mom had raised her and her sister alone, warming their home in Edmonds, Wash., with dance parties and dirty jokes. Inspired by her mom, who fed wildlife every morning, Perkins became the first in their family to graduate from college, cum laude, with a degree in environmental science. Yet she struggled with mental health and substance use throughout her life and eventually was diagnosed with borderline personality disorder — characterized by emotional dysregulation, impulsive behaviors, and chronic feelings of emptiness that can lead to self-harm.

A decade ago, her mom found her in a bloodied wedding gown after a suicide attempt. When Perkins woke up in the emergency room, asking if she’d looked pretty, her mom didn’t hesitate. ”You were beautiful, sweetheart.” 

Her mother passed away from breast cancer in late 2019. Perkins had a volatile relationship with alcohol, and her mother’s death was the catalyst for her to start drinking heavily again. Without the anchor of her mom’s love, she eventually floated away on what she calls a “homeless adventure” in the Tacoma area.

She cut ties with everyone, including her dad, packed her polka dot dresses and mini pink leather backpack, and set out solo at the end of summer 2023, falling soon after into an abusive relationship with a man who sold drugs. A flurry of strange faces and uncomfortable floors followed. Flames ignited her tent behind a strip mall Subway. Then suddenly, winter. The cold burrowed into her bones. Her hip hurt, her heart hurt. Vodka eased the pain. Meth numbed it further. 

Woods, meanwhile, was volunteering with the Harm Reduction Doula Collective. As a former nanny, they’d worked with families–those with money, those without, those with housing, those without–and saw how time and resources could help parents shift out of survival mode. The collective was a way for them to provide that privilege for others. 

It started in 2019  when a trio of doulas–Woods, Porter, and Carra Wetzel Chubb–began doing mobile outreach at homeless encampments around Seattle, building relationships. Now it’s referral-based, with Medicaid reimbursements. Guided by a harm reduction ethos of what the person needs instead of the doula’s agenda, the work remains largely pro bono, often blurring traditional boundaries between doulas and their parents.

There’s no turning off the phone at 5 pm. The doulas will drive parents to appointments, buy baby supplies with their own money, and help navigate food, housing, and legal systems. They will encourage parents to speak up, but will step in if they aren’t heard. They de-escalate sticky situations and soothe in times of loss. And they’ll follow a parent’s lead about substance use–whether ensuring Naloxone, an overdose-reversal medication known as Narcan, is available; establishing safer use plans; or connecting people with treatment, which in Washington is seen as beneficial if CPS is involved. 

Sometimes, blaring Nelly’s “Hot in Herre” in the car is exactly what a parent needs. Other times, it’s birthday cupcakes and baby showers. 

That pee stick from the dollar store changed everything for Perkins.

“The party is over,” she said to herself at the motel. Nothing mattered to her more than the life growing inside her. 

Except the same couldn’t be said for her partner, who left, or the stranger who stole her phone. Soon, she was barely sleeping on a wooden pallet in a concrete underpass with a man named Tooth. She’d eat frozen Marie Callender meals with her bare hands and pee in a Big Gulp cup. 

Abrupt withdrawal from alcohol, widely recognized as the most dangerous commonly used substance for a pregnancy, could put both her and the baby at risk of serious complications. She knew this, so she drank enough vodka to prevent seizures or worse, death.

It was like she was watching a horror movie of herself, except she couldn’t recognize the lead character. Time melted, the rumbling trucks were relentless. The meth spoke to her through ghost-like forms by the charred makeshift fire pit. The only respite was the sound of her own voice. Every day she sang, hand over belly. “I kept waking up expecting to have lost her,” Perkins said.

“I finally had a reason to live.”

Thirty miles away, another prospective mother had long had a reason to live. Destiny met Nathaniel at a potato chip factory, where she drove a forklift. She swooned over his intelligence and vice versa. Theirs was a whirlwind romance of beach walks and effortless conversations.

On the first night he wanted to see her apartment, Destiny hesitated. All of her income went to an active fentanyl addiction. She had no furniture save for a cot, survived on chips, barely showered. But instead of running away, Nathaniel offered to help. Nobody had ever responded that way to her before. 

Destiny, who’s using her first name out of privacy concerns for her son, first tried heroin as a teen. An abusive relationship with a man twice her age who sold drugs prompted a six-year heroin addiction. She discontinued use with the help of Suboxone, a medication that treats opioid use disorder, but returned to use with fentanyl. She had no idea what it even was, or how addictive it could be — 50 times stronger than heroin with an overdose death rate four times as high — until she smoked the blue pills. 

“It hugged me from the inside out,” she says.

Destiny never thought dinosaur onesies would be in her future — as a kid, she told her mom she wanted a hysterectomy. To her surprise, she was overjoyed when she found out she was pregnant. She imagined showering her son with an “annoying” amount of hugs and kisses, and decorating the tree with him and her husband at Christmas. Piercing the fantasy, however, were Destiny’s agonizing fears about the health of the baby and whether or not they’d be separated. 

“Who are we gonna have to fight? What are we gonna have to prove?” she said. “What do I need to do to ensure that our son is coming home with us?” 

She knew that in Washington state, high-potency opioids like fentanyl had become more scrutinized — authorities could seek a court order to remove children without notifying parents if there was alleged immediate danger, for example, and exposure to fentanyl was a big factor in assessing risk. She was familiar with CPS, having witnessed its impacts on her fractured family while growing up. 

Destiny wanted to stop using for her son. Detoxing from opioids like fentanyl without medication in pregnancy can increase the chance of returning to use and overdose, so she gradually introduced methadone. At the opioid clinic, she was asked to give monthly urine samples to make sure nothing else was in her system, which could be used if CPS decided to open an investigation. 

She tried a couple of inpatient treatment programs but they were isolating. It was only when she got to the Substance Using Pregnant People (SUPP) program, a voluntary 26-day inpatient stay at Swedish’s Ballard Hospital, that her fentanyl cravings were extinguished. She could call Nathaniel. And the staff was warm, sitting down next to her on the bed as they encouraged her progress.

Still, she wondered: Would it be enough?

Without a doula yet, without her mother, without a partner, Perkins had to save herself. After a couple of weeks, and with her hip still painful, she army-crawled out from the claustrophobic underpass. She landed at a 7-Eleven, alone, sleeping on a grass patch in a dirtied dress. It was spring, and the sun seared her legs. The doctors at the hospital she ended up at gave her nothing for the pain and eyed her with disgust. 

“You can’t hate me more than I hate myself right now,” she remembers thinking. “All I’m doing is begging you for help.” 

Perkins knew she too had to get to SUPP, where she imagined clean sheets and quinoa on the menu. Except there was a two-week wait for a bed. She had no choice but to go back to the grass, with nothing but a peeling leather backpack and a prayer.

Harm reduction in the perinatal space, including doulas, exists in scattered pockets across the country. Groups like the Academy of Perinatal Harm Reduction, which started in 2015, have helped chip away at the stigma through education and training. Yet abstinence remains the dominant approach. 

In Washington, SUPP is only one of three programs in the state where perinatal addiction doctors like Collin Schenk, who practices harm reduction, will say to pregnant patients, “you’re already so strong, I’m just here to give you a boost,” and flyers with locations of Naloxone vending machines are plastered in the bathroom. 

Schenk had overlapped with Woods when they were working for a needle exchange and he was doing mobile medical outreach in Seattle. Now, in his day-to-day as SUPP’s medical director, he collaborates closely with harm reduction doulas as they facilitate conversations with medical providers or help parents advocate for what they need to feel well, like pain management. 

Less trauma, more agency. Autonomy. Dignity. “Whatever is best for the parent is best for the baby,” Schenk says. 

That could look like stabilizing a parent on buprenorphine, an effective medication for opioid use disorder, or assuring a parent that their child will have every chance to be healthy, smart, successful, and kind. What’s important is the environment they grow up in. Ensuring children avoid harmful experiences that can lead to a slew of health conditions is the ultimate shared goal.

Schenk’s experience with addiction in his family shaped his understanding. What drew him to the work was seeing the rapid transformation that can occur when people have access to medications and encouragement. What kept him there was the relationships. 

The hard part is supporting parents who can’t be with their baby after birth due to active use or intimate partner violence. Then there are the parents who leave early — who aren’t ready, who are too isolated in withdrawal, who are worried about their partner, animals, or belongings. Schenk does his best to mitigate the compounding traumas.

Perkins was ready. When she arrived at SUPP, she was delighted to find quinoa on the menu. She heard Eleanor’s heartbeat for the first time and swallowed an Ativan to ease alcohol withdrawal. At a group class, she met Woods, who also worked as a doula on Swedish First Hill Hospital’s labor and delivery floor and described themselves as a “bulldog.” 

Perkins knew she needed them. After SUPP, she spent six pregnant months at a residential recovery facility, just one of five programs in the state and after the program reconnected with Woods, who felt like an old friend. Their hobby tracking wildlife made Perkins’ nature-nerd heart flutter.

In the operating room, Eleanor’s silence lasted three minutes before she let out a piercing cry–the best sound Perkins ever heard. “See, she’s not ugly,” Woods said. Perkins agreed. “She’s beautiful.”  

With Perkins still woozy from the sedation and stitches and hooked up to an IV, Woods helped cradle Eleanor against her breast to feed, and held her cheek-to-cheek for bonding. An hour later, Woods wheeled Perkins’ bed into her hospital room, bought her a Starbucks latte, and placed a vase of pink flowers on the table. Perkins finally had somebody and for the first time in months, she had hope. 

During pregnancy, Destiny connected with FIRST Legal Clinic, whose goal is to prevent children from winding up in foster care and the trauma that results from separating families. When Destiny said she wanted a doula two months before her due date but couldn’t afford one, her parent ally, who worked at the clinic and had lived experience like hers, suggested the Harm Reduction Doula Collective. 

At first, Destiny wanted someone who looked like her. Black and Indigenous families experience medical discrimination at higher rates and disproportionately have their children removed. The collective does partner with doulas trained in harm reduction who can offer parents culturally competent care, but Destiny and Chelsie Porter, who is white, just clicked. 

Porter had lived experience with substance use, and had long worked in harm reduction. It was where she found community — some of the most real, kind, and funny people she’d ever met. 

She had volunteered connecting parents with free doula care and saw how life-changing it could be. Pregnant folks who used drugs were often left out, judged even within that community Porter held dear, and she wanted to be that bridge.  

She talked weekly with Destiny. “You have to really love your folks,” Porter says. “And we deeply love them.” 

Porter would allay any concerns Destiny had, like when she texted a photo of her slimy mucus plug, unaware of what it meant. “You’re almost there, mama!” Porter replied. Labor at Tacoma General was a quick three hours, unmedicated. Her son was perfect and looked exactly like Nathaniel. Porter missed the birth by a few minutes, but snapped the first photos of the family Destiny had so desperately wanted. 

Her son temporarily experienced mild neonatal opioid withdrawal symptoms because of the methadone, and was jittery and irritable. It was painful for Destiny to witness, even though studies are inconclusive about its long-term effects.  Normally, the baby would be separated and placed in a pediatric unit or nursery. Destiny stayed with her son in the room, and with Porter’s help, piloted the hospital’s first five-day compassion stay under the “Eat, Sleep, Console” model that prioritizes parent-baby bonding and can reduce the severity of withdrawal due to the parent’s steady presence.

And when Destiny met with the hospital’s social worker, she was confident as he went down the list of things CPS gives weight to when deciding whether to proceed with the child removal process or not. Safe and stable housing. Check. Willingness to enter treatment. Check. Community supports, like a doula. Check. 

After the five days, she took her son home.

But postpartum was lonely. Her hormones were all over the place, and without a human growing inside her, doctors cut her 270mg methadone dose in half, leaving her groggy. Nathaniel changed diapers but seemed distant. Destiny did everything for the baby except breastfeed, the thing she wanted most. It was safe on methadone, but her son had difficulty latching. Porter was either texting or visiting every day, but Destiny’s disappointment in not breastfeeding, coupled with the guilt and shame each time she looked at her son, was overpowering.

With every future milestone, Destiny could foresee herself worrying. Fetal fentanyl syndrome, which physically affects newborns, is emerging but rare. For opioid use disorder — which includes heroin and has been studied for decades — a systematic review that sometimes draws on studies from over 20 years ago points to adverse impacts on motor development, attention, and executive functioning. 

Gathering robust data on pregnancy and addiction has historically been challenging. Poverty, multiple substance use, genetics, and stress can all influence outcomes. Yet for many parents, the weight of not knowing is heavy.

Destiny returned to use. Nathaniel became responsible for soothing and feeding. With the support of past providers, she stopped, last smoking fentanyl on her first Mother’s Day. Destiny didn’t tell Porter, ashamed and afraid of rejection. She didn’t want to disappoint her. 

One day, in tears on the couch, Destiny spilled. Porter reached over and gave her a long hug. “I know it’s hard. I know it hurts,” she said. “Think about your baby. Think about everything you’ve accomplished. Be proud of where you are and accept this space is temporary.” 

Fifteen months later, on that same couch, Porter is proven right–the space was temporary–and the mood is markedly different. After a morning of cooking baby-friendly beef stroganoff and color-coding a toddler summer book list, Destiny catches Porter up. 

“He loves cars, boats, doggies, socks,” says Destiny. “Socks?” replies Porter, laughing. 

Destiny talks about how she’s pursuing her final credit to finish high school, shows Porter the childbirth educator certificate she recently received. Tells her how she’s only on 5 mg of methadone now. The guilt remains, but as her son runs around them in fish shorts, stopping only to giggle when she swoops him upside down in her arms, she can’t help but think, “This side is so much brighter.”

Every morning, Destiny wakes before her son to prepare handouts, with sheet protectors, for the childbirth preparation classes she teaches. She has many dreams — some big, like becoming licensed to provide more classes to parents like herself, and others smaller, like obtaining a wheelie bag for her materials. 

“I guess I should stop being in denial about being a go-getter,” Destiny tells Porter, pretending to pop her collar. 

“Yes, I think you’ve officially made it,” Porter replies. 

There was only one surviving strawberry in Perkins’ garden. She knew it was cheesy but she couldn’t help but identify with it, a fellow redhead. After giving birth, she was back in Graham, Wash., at her dad’s house, lucky and grateful, but in a place where her life first fell apart. The incision from her cesarean caused an abscess that took a month to heal. The surgery date for her hip kept changing, so she used a walker, trapped. And she’d distanced herself from friends who were still using. No matter how lonely she felt, she was determined to be Eleanor’s–now Ellie’s–everything. 

Her mom was omnipresent. On the wall in her bedroom, a poster bore the words “I Love You to the Moon and Back” and a lipstick imprint of her mom’s kiss from before she died. When late November and the anniversary of her death came around, dark thoughts of self-harm returned. 

What encouraged the light: Ellie. Journaling and therapy. Gardening. Woods regularly checking in. “Haven’t heard from you. You having any dance parties yet?” They’d drive an hour south from Seattle to Graham to see Perkins, or accompany her to Ellie’s doctor appointments, where she felt more comfortable advocating for her baby’s needs, knowing Woods would back her.  

“Every time Ash called or came to visit, I felt so good after,” Perkins said. “I felt like I had someone.”

Like Destiny, Perkins had a return to use. The pressure of being a single mom in recovery during postpartum, chasing normalcy under the weight of the guilt she still carried. It was all too much. One mimosa at a ladies-only brunch led to another, her car getting stuck on train tracks, and a night in jail. 

Shame stopped her from telling Woods at first. It was an all-too-familiar feeling she had to fight. When she did open up, deciding to shed the shame, Woods was there with the requisite support–“I’m so proud of how far you’ve come”–and humor–“even your DUI is totally dramatic.”

In spring, first came strawberries and then hip surgery. Woods was at her dad’s house afterward — making exercise lists, folding baby clothes, and blending smoothies while Perkins sang to Ellie on a chair. The walker went back into the shed. One of the first things she did was take Ellie to the library for a “Mommy and Me” storytime, finally able to criss-cross applesauce her legs on the floor. The second thing she did was put a cute bow in her baby’s hair and go grocery shopping. 

Woods continues to show up. On a walk at a nearby lake in summer, the two stroll down a path together with nine-month-old Ellie in a stroller. 

It’s the first time they’ve been able to enjoy nature together, and they wonder at the tittering of the black-capped chickadees, who, Woods notes, are fiercely protective of their babies. Ellie starts to fuss. “Do you want a better view?” asks Woods, who pulls the stroller hood back. Perkins adds another layer of sunscreen on her baby’s legs. Ellie plays with her pacifier, eyes locked on Perkins’ lightly freckled face, babbling the beginnings of the word, “mama.”

In addition to support from the Pulitzer Center, this story was made possible by the support of Sunday Long Read subscribers and publishing partner Ruth Ann Harnisch. Photos by Florence Middleton. Edited by Peter Bailey-Wells. Designed by Anagha Srikanth.