'A lifeline': the doulas guiding clients through childbirth – from a distance

Last month, Robin Douthit comforted an anxious client by breathing with her, demonstrating one long inhalation and an equally steady exhalation. The two women then did it together, breathing slowly and intentionally in sync.

Breathwork is one of the tools that Douthit, 56, often reaches for when soothing clients. But this time, instead of sitting in the same room inhaling the same air, the women breathed together on Zoom.

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“It’s devastating, right? I mean, you built this relationship, you fall in love with these people, you get excited about working with them, and then suddenly, you can’t,” she told me.

As Covid-19 changes the way women experience pregnancy, doulas like Douthit are caught between a calling to guide their clients through childbirth and the limitations caused by the pandemic. Many hospitals across the country now limit visitors to just the mother-to-be and her partner in the delivery room, meaning doulas, who are recognized by hospitals only as visitors, are forced to support births virtually or not at all. Some are organizing and pushing back on hospital policies that exclude them from delivery rooms, but therein lies an ethical question: at what point does advocating for recognition and respect outweigh the risks of exposing others to the virus as non-medical visitors in a hospital? It’s a debate saddled with historical tension between doulas and the western obstetrical healthcare system.

For now, doulas are hastily translating their intimate and hands-on work on to impersonal virtual platforms, and preparing their clients for giving birth without them physically present. “We’re trying to scramble to give support in a different way, and learn a new skill set really quickly,” says Raychel Franzen, a New York-based doula. “I think one of the things that a doula brings to their clients is a calm energy. We can still do that with facial expressions on a video call, but the energy exchange is just a little bit different.”

Gwynne Knap, an Atlanta-based doula, is also a faculty member of Childbirth and Postpartum Professional Association (Cappa), one of a few organizations nationwide that certifies doulas. Recently, Knap’s work has revolved around teaching fellow doulas how to shift their offerings to reflect the circumstances – Cappa has developed resources and suggestions for doulas to support their clients virtually, such as having the woman’s partner wear an earbud, the doula coaching through contractions over the phone. But some techniques used by birth workers to calm and comfort women during labor, like hand-holding and eye contact, are impossible to translate. “A labor doula helps the mom a lot with comfort and suggested positions, but she also calms the partner so they can be more emotionally present,” says Knap. “When the doula’s not there, it’s very hard to do that.”

While some doulas have shifted to virtual support, others are pushing back against the new hospital policies and argue that hospitals shouldn’t lump doulas in as regular “visitors”, but rather as critical to ensure the mother’s health. These doulas, along with birth advocacy groups, are organizing virtual town halls to strategize a unified pushback, circulating petitions against individual hospital policies, and distributing scripts for doulas to use when speaking to hospital administrators about the potentially harmful implications of restricting doulas from labor units. In some cases, that advocacy has resulted in hospitals adjusting their visitor policy to allow doulas, in addition to a partner or support person, on the labor floor.

“It’s not a bonus or a luxury for someone to have care that is safe and respectful,” says Cristen Pascucci, founder of Birth Monopoly, an online advocacy organization that focuses on birthing rights. They argue that for some patients, doulas are an essential part of ensuring a healthy, safe birth – especially for marginalized populations like women of color, particularly black women, who bear the brunt of the maternal mortality crisis in America. There is evidence that continuous, one-on-one birthing support, particularly from a doula, reduces the risk of dissatisfying or traumatic birth experiences, unplanned C-sections and low Apgar scores – the method physicians use to assess a newborn’s health immediately after birth.

“There are people who, I feel comfortable saying, have to have a doula to have a safe birth,” Pascucci says. For women of color and low-income women, who statistically face bias from healthcare workers, and who suffer higher maternal mortality rates and worse birth outcomes as a result, a doula can act as a crucial mediator. Many doulas work closely with their clients to inform them about their rights as patients, and talk through the questions they can ask their providers about interventions before they happen.

Some doulas also incorporate trauma-informed practices to mitigate the risk of a traumatic birth for more vulnerable women. “For a rape survivor who doesn’t have a partner [with her], a doula is like a lifeline,” says Pescucci.

She adds: “Doulas have been quietly filling in the gaps of the maternity care system for years and years. Now we have a crisis and the same system that doulas have been making up for, the first chance it got, was like, we still don’t know what you do and we still don’t appreciate you. So all of those gaps that doulas were filling are back.”

In mid-March, the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) released a statement in support of allowing doulas into the delivery room. AWHONN member Shirley Picard, who is both a doula and a nurse in Rhode Island, spearheaded that effort. “I felt it was important as a registered nurse, birth doula and nursing leader that women have their designated labor support companions be at their bedside as planned,” she says. “I also know that it’s been difficult for doulas to advocate for themselves within the hospital infrastructure, hence why I felt it was important for AWHONN to be a leader here.”

For other nurses working on the frontlines, it’s a tough call. One labor and delivery nurse in New Orleans, who asked to remain anonymous out of concern for her job, understands that she can never replace the role of a doula in the delivery room. “Doulas provide an excellent service in that one-on-one care,” she says. “As a nurse, I can’t be in there to get you through every contraction.”

Her hospital’s labor and delivery unit, which previously had minimal restrictions on non-patient visitors, now only allows one support person a patient, and only when they’re actively in labor. (A patient kept overnight for blood pressure monitoring, for example, cannot have any visitors.) She has had to field frantic phone calls from women asking for their doula to be allowed in, only to tell them no. “I think it’s thrown a lot of women – this is their plan, and everything has been thrown off,” she says. “I think about how scary that must be.”

On the other hand, she works in a city besieged by the virus. Every unit of her hospital, which is full, has been overrun with Covid-19 patients (including some in labor and delivery), and the hospital has run out of personal protective equipment for its staff.

“We’re struggling,” she says. “We’re told to reuse our masks. We’re told to wipe down our plastic gowns between uses. It’s a very somber walk into the hospital each day. Because of what I’ve seen, I think the fewer people in the hospital, the better.”