As doulas and anthropologists, we have anxiously followed North American hospital policies that limit the number of support people who may accompany a birthing person to the hospital. We’ve wondered what these shifting policies mean for doulas – birth workers who provide continuous emotional, physical, and informational support to pregnant and laboring people – and those they accompany during labor. The COVID-19 pandemic comes on the heels of increasing attention to a maternal health crisis that disproportionately impacts people of color and the poor. Doulas, long seen as serving upper middle class white women, are increasingly becoming a valuable source of advocacy in the face of birth disparities. In data collected from 450 qualitative surveys, we address how US and Canadian doulas adapted to the constraints posed by virtual support, how this then shifted their perceptions of care, and how virtual doula work exposes existing inequalities.
Just as hospitals began experiencing a large influx of patients with COVID-19, they also announced new policies impacting birth. These new guidelines spanned from allowing only certified doulas, often with their own personal protective equipment (PPE) and on pre-approved hospital lists, to forcing pregnant people to choose only one support person, and in extreme cases, to banning any labor support– whether partner or doula.
I am now working with clients who are fearful rather than excited. All of them are afraid. I am spending a lot more time helping them process a rapidly changing birth landscape. (New York)
Doulas detailed shifting hospital, local, state or provincial policies, and described how difficult these have made the provision of in-person support.
My city now has mandatory shelter-in-place and it’s questionable whether doula care is an exception. Penalties for being out include a $5000 fine and up to 90 days in jail. But my client is a lawyer, so she drafted a memo on her firm’s letterhead with her interpretation of the law. I plan to carry a copy of that letter and the signed doula contract in case I get stopped by the police on my way over to her house when she goes into labor. (Maryland)
In all locations, doulas are working with uncertain hospital protocols. A doula in Ontario reported, “Currently, all hospitals have limited policies to one support for a laboring person (though that continues to feel precarious). There have been several changes – from originally no change [to doula support], to unclear change to significant changes.” Doulas responded to these uncertainties with frustration. One doula in Alberta said, “There is a sense of powerlessness all around, since this policy change came from ‘on high’ without consultation of clients or doulas or even looking at possible solutions that would allow for both safety of medical care providers and the support that clients need in birth and postpartum.”
An outcome of changing policies forces women to choose between a partner or a doula. For some birthing people, especially when attempting aVBAC or birthing as a sexual assault survivor, a doula can provide more experience with comfort techniques and is better skilled at navigating the hospital space and personnel than a novice partner. A doula from Utah wrote, “One hospital treats doulas as members of their staff so long as they pass a health test and can verify they are a professional doulas, not just a family friend sneaking in. The other hospital will only allow a doula if the partner agrees to miss the birth of his child.” Another doula in Alabama explained, “I have one client (first baby) who wants me there instead of her husband because she wants an unmedicated birth. An unthinkable choice.” Although we heard a few examples of successful changes to doula hospital policies, overall the resounding response to COVID-19 from doulas across the US and Canada has involved transforming the ordinarily intimate and hands-on forms of care they provide into virtual support services. Many felt online support restricted their ability to protect birthing families. Some doulas saw the impact of restrictive policies as trauma on vulnerable bodies, “I’m seeing responses to birth, in pregnant people, to these new policies that I usually only see in assault survivors who are giving birth. So, it has affected my work in every way” (Texas).
As doulas, we’ve had to grieve the loss of support we know we can offer. In many ways, even though we are all long-time experienced doulas, we’re back to the discomfort of being “new” doulas as we learn a new way of doing this work. (Alberta)
Doulas described investing in new microphones and lighting to use with such platforms as Zoom, Loom, Facetime, WhatsApp, Slack, Marco Polo, Skype, BlueJeans, GoToMeeting, and Hangouts. New services have included creating relaxation scripts, virtual meditations, comfort measure videos, online perinatal education, and facilitating chat groups for moms.
Doulas also wrote about collaborative on-line efforts with other doulas, for example, launching “a 24/7 virtual hotline” in New York City, a new Facebook group called “Calm During COVID (CDC)” in Houston, and online weekly ‘new moms meet-ups’ in Toronto. Houston-area doulas described their virtual efforts this way: “We keep it up to date with verified information about changing medical practices and visitor guidelines. We post educational articles. We do self-care posts. We create space for all of the feelings.” Even while collaborating with other doulas, the majority focused their efforts on supporting partners. A doula from Ohio shared, “My focus has changed from affirming my continuous support role to empowering, even more than ever, the partner to be responsible for practicing coping tools and understanding how to navigate the hospital maternity care system on their own.” Some doulas expressed their concerns that women’s partners were “very unprepared for being the only support person” (Missouri). In response, some worked to resolve this issue by creating new virtual options like “doula skills for dad’s webinars” (Yukon).
There is a lack of personal contact I would normally be allowed to provide. Basic human rights are being taken away and women are afraid. I work with young moms who are being talked into procedures they previously did not want. (Washington)
Just as there have been critiques of doula services catering to affluent white cisgender populations, the new reliance on virtual care further exacerbates structural vulnerability and worsens existing inequities. Who has access to virtual doulas, which hospitals have sufficient network bandwidth, and how do care providers determine who is worthy of virtual doula care?
From rural to urban spaces, some doulas described a digital divide based on race and class inequalities. In Rhode Island, a doula wrote, “I primarily serve in the Black community, so it’s hard for me to hold space when my clients don’t have Internet and have a limited cell phone plan.” To add, without access to high speed Internet, doulas were unable to offer women their “continuous presence,” which is the hallmark characteristic of doula care.
Doula virtual support foregrounds ongoing hospital anxieties about privacy in recording births. From Ontario we heard, “Virtual support [is] not accepted, as local doctors think this will just ‘stress’ the birthing person.” Limiting access to labor support exacerbates inequitable maternal healthcare. A California doula described, “When my first client began pushing, her provider demanded they close the laptop. I soon received frantic text messages from the father saying they were alone and scared and didn’t know what to do. But we were told my virtual presence wasn’t allowed.” Another Ontario doula described the impact of these restrictions, “My clients are living in a level of fear and uncertainty that no practitioner can undo – and while I try to soften the edges, I’m aware that they are not receiving the full breadth of care they deserve.” In these instances, how are laboring bodies read for worthiness by care providers and what can doulas do when their virtual window closes?
Pandemics are useful mirrors revealing both societies’ “flaws and their commitments.” Attention to what happens to birth during a pandemic offers opportunities to better understand the problems and potentialities of reproduction. Doulas are a resource for families and communities, and they provide better patient outcomes as well as personalized care. Critical analysis of doulas as they both encounter and redefine boundaries of care entails a corresponding focus on shifting hospital policies and their impact on birthing families. Will we see an increase in home births, self-directed births, midwives and doulas? Will we see a rise in obstetric violence, postpartum post-traumatic stress disorder or postpartum depression? Doulas offer us a window onto the shifting landscapes of care impacting our maternal health system during COVID-19.
Julie Johnson Searcy is an Instructor at Butler University in the History and Anthropology Department. Her research in South Africa compares experiences of birthing women across clinical settings, and her research in the U.S. focuses on doulas, the politics of reproduction and birth culture.
Angela N. Castañeda is Professor of Anthropology at DePauw University. Her research explores the intimate labor of doulas; unpacking the social and cultural meanings of attending to women during the transition to motherhood.