After COVID-19 began to spread across the United States, New York State (NYS) quickly became one of the country’s epicenters. Consequently, NYS and its health facilities took drastic measures to reduce the spread of the virus. Within hospital-based maternity care, there were significant changes, namely limiting the presence of additional physical support, including doulas. These mandates took place amid my dissertation research on Black and brown community-based doulas (CBDs) in Syracuse, New York. I was able to gain insights into the rapid accommodations doulas needed to make to maintain their work with clients and the greater community during the crisis. In facing the pandemic, doulas began to implement virtual options for care and maternal health social media campaigns. For the doulas with whom I work, it was apparent that ensuring their work remained accessible was vital to moving forward during this unprecedented time; however, they needed to also consider public health mandates, hospital policies, and the needs and safety of their clients.
Doulas are non-medical support persons who provide various comfort measures, prenatal education, postpartum care, breastfeeding support, and more. Research has shown the benefits of doulas not only for birth outcomes but also for their communities, especially for women of color. The CBD organizations I with whom I work in Syracuse, Doula 4 a Queen (D4Q) and Village Birth International (VBI), offer four educational prenatal meetings, birth plan counseling, continuous labor support, and postpartum visits. While doulas practice in hospitals, home births, and birthing centers, VBI and D4Q doulas almost exclusively attend births in the hospital setting because of the lack of homebirth midwives in central New York. I have worked alongside VBI and D4Q since 2018. During this time, I have attended and assisted in teaching childbirth education classes, and I have observed client meetings with doulas, doulas’ support of labouring parents, and clients’ births.
Doula work for VBI and D4Q does not end at birth. It is a continued practice to ensure a safe and healthy environment. The organizations explicitly state their intent to improve Black maternal health outcomes and experiences. In doing this work, both VBI and D4Q have remained autonomous, relying on grant funding, but they demand livable compensation from NYS that goes beyond the Medicaid-reimbursement bill put forth last year. VBI and D4Q have been consistently vocal about the state’s failure to properly fund and support doula care. Following the onset of COVID-19, the doulas remained critical of how both state and specific hospital maternal health policies influenced their ability to care for their clients. In developing particular NYS policies for maternal health, the state did not consider the role of doulas, including their significant physical role during labor. Initially, only a single support person was allowed in the maternity room. The doulas shared their concern that COVID would negatively influence maternal health outcomes for Black, brown, and other marginalized people. I attended collective meetings where many doulas mentioned concern for “increased medical intervention,” “more C-sections,” and “lack of postpartum care.” Overall, the doulas’ concern was that even though Black women already faced abuse and discrimination in healthcare settings, hospital mandates now placed an even more significant amount of power in the hands of medical staff. The organizations slowly began to roll out virtual options for doula support, including virtual prenatal appointments, as they adapted their practice for COVID-19.
The doulas knew that without authorization or assistance from the state or hospitals to continue in-person doula care, they would need to engage with their communities and expectant parents virtually. Their collective response was to begin an online social media campaign to educate about pregnancy, childbirth, and postpartum and to provide free virtual doula support. This virtual doula support could be as simple as answering questions, or as comprehensive as full coaching support during labor and delivery. During this time, VBI hosted free virtual doula training for any doula trained through their organization. On an Instagram post advertising the Zoom-based training, VBI highlighted the importance of continuing their doula work online. The caption stated, “We must ensure that the values of birth justice and human rights in childbirth are upheld and respected in the way pregnant people and their families are treated during this pandemic…Perinatal health disparities that impact the Black community do not disappear during a pandemic. They are further illuminated.” During the Zoom-based event, the roughly fifteen doulas were trained to translate their in-person doula work into virtual doula work. The training centered Black mothers and families.
In addition to this training, the doulas held a Zoom panel discussion entitled “Protecting Birth Justice during COVID-19,” which also centered on Black mothers and doulas’ experiences. This discussion was part of VBI and D4Q’s virtual Black Maternal Health Week, a collaboration with Black Mamas Matter Alliance and other partners. Throughout much of the discussion, emphasis was placed on the need to guarantee that women could continue to have the ability to have a physically present support person. Many stated their concern once more for maternal health experiences, especially for Black women, if there were no in-person support doulas. Furthermore, the doulas discussed their desire for healthcare professionals to facilitate the use of a virtual doula when requested by laboring parents.
As of April 2020, the policy limiting in-person support has changed in NYS. However, the guidance for doulas is still unclear. The governor created a task force to provide insight and recommendations for maternal health. One of these recommendations was to allow doulas into the birthing room in addition to a support person, describing them as essential. While this was an improvement, the policy still raised concerns for the doulas because hospitals made the final decision. The doulas explicitly pointed to the wording of the recommendation, “Exceptions should be made only in limited circumstances and based on clinical guidance, such as availability of PPE.” Many of the doulas view this as concerning because “decisions were in the hands of hospitals, not families.” In other words, individual hospitals could have significant power in allowing doula care to continue for specific patients. Due to all the changes in policies, shortly after the statewide policy change, the VBI directors contacted a local nurse by video-conference to answer all questions about assisting in a hospital setting. The Zoom discussion included about ten local doulas and allowed them to ask various questions about what this experience is like for a labor and delivery nurse and how their doula work could continue to support laboring mothers.
During this meeting, many of the doulas pointed out the duality of the new mandate allowing doulas in labor units. On the one hand, it clearly stated that “doulas are considered an essential part of the support care team.” On the other hand, there was no discussion about guaranteeing their admittance into hospitals or ensuring PPE. For the doulas, this was not unusual, as they had long seen interest but no real commitment from local or state governments. Additionally, the decision to allow doulas remains specific to individual hospitals, and it depends upon their ability to provide proper PPE. Unfortunately, due to the limited amount of PPE at most hospitals, the doulas do not feel they can safely offer in-person care. Asteir, a founding VBI doula, summarized the doulas’ perspective, saying “There is so much more that needs to get done if you are going to make statements like doulas are essential.” Her words demonstrate the lack of structural support in NYS for doulas.
The CBDs from VBI and D4Q knew that they must continue their work but that they must also protect themselves and their clients. Consequently, the interruption of in-person interaction did not hinder the motivation of the D4Q or VBI doulas. Instead, they moved their work online and continued providing virtual services, including monthly childbirth classes, starting in May. As cases continue to trend downward in NYS, CBDs may decide to re-start doula services; however, the trajectory of the virus and the local hospital and state responses to doula care will ultimately weigh on the final decisions to continue in-person doula work. Until then, VBI and D4Q will continue to reach their community and clients safely and through a virtual context.
Mariel Rivera is a PhD candidate at Syracuse University in the Department of Anthropology. Her research interests are within medical anthropology with a specific focus on reproductive health. She is interested in how race and gender influence reproductive and maternal health experiences. For her doctoral research, she is focusing on the use of community-based doulas in Syracuse, New York, who specifically work with Black women and other women of color.