The Doula’s Role in a COVID-19 Birthing World
“Yes, but doulas like to touch patients.
They don’t need to be there.”
— A Central IL OBGYN
Photograph by Wild Heart Photo and Film; Jacksonville, Florida 2020
In July I attended an appointment for a tubal consult. It’s been on my heart so I thought I would explore options. I asked for several different recommendations on who to see. Who was going to give me the best odds at never conceiving again and also not acquiring an infection in hospital as I have some immune system dysfunction.
We got on the topic of how hospital culture has changed, especially in L+D units. I am not sure she was aware I was a doula or not. I am not confident she really knew who I was at all. But doctors see a lot of people, so that didn’t really strike me. And honestly if she did know who I am and what I do, kind of just made the whole thing about eleven times more cringe-worthy.
It struck me how our conversation evolved to her obvious need for control in a birthing room. Here we were establishing a philosophical hierarchy in an hypothetical labor room. I stated I wished our area was more flexible about doula attendance, that doulas are willing to follow all the same precautions as other healthcare employees if meant being able to be bedside with families. She just dismissed me. This highly respected OBGYN said she “loved” not having doulas present, because they like to touch mothers. And no one really needs to touch a laboring person right now. Doulas don’t need to be present.
A laboring person does not need someone to hold their hand, to give a hip squeeze or counter pressure, to stroke hair out of their face, to massage the tension of their shoulders. A laboring person doesn’t need a physical reassurance that she is safe, that she is heard, that her pain is real but she is coping. Non-essential. A mother’s physical comfort in labor is non-essential. A mother’s ability to cope through changes both seen and unforeseen— non-essential. I didn’t seek follow up care with this OBGYN, because her complete lack of compassion was grossly evident… and it scared me.
Photograph by Lisa Phillips Photography, Leesburg, VA 2020
Recently a hospital in Central IL has rescinded their policy to allow professional doula support in the birth space in addition to a birthing partner. Rising COVID-19 positivity rates were cited as the need for this change. And while I do strongly support the need to mitigate our circumstances, I firmly believe this is not the area we can afford to do it in.
Doulas are often seen as luxury care. Non-essential. Unnecessary. Accessory. Inconvenience. Just a status symbol for wealthy white women who seek homeopathy as a hobby. They are often not viewed as part of the birth team or professionals, but a hinderance to OBGYNs from practicing as they desire: unquestioningly unencumbered. Historically though, women have been attended and supported by other women during labor. Since the middle of the 20th century, in many countries as the majority of women gave birth in hospital rather than at home, “continuous support” during labor has become the exception rather than the routine. Concerns about dehumanization of women’s birth experiences have led to calls for a return to continuous, one-to-one support by women for women during labor. Common elements of this care include emotional support (continuous presence, reassurance and praise), information about labor progress and advice regarding coping techniques, comfort measures (such as comforting touch, massage, warm baths/showers, promoting adequate fluid intake and output) and advocacy (helping the woman articulate her wishes to others). These elements are the foundation of doula work. This. Is. What. We. Do.
“During labor, women may be uniquely vulnerable to environmental influences; modern obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, lack of privacy and other conditions that may be experienced as harsh. These conditions may have an adverse effect on the progress of labor and on the development of feelings of competence and confidence; this may in turn impair adjustment to parenthood and establishment of breastfeeding, and increase the risk of depression.Studies of the relationships among fear and anxiety, the stress response and pregnancy complications have shown that anxiety during labor is associated with high levels of the stress hormone epinephrine in the blood, which may in turn lead to abnormal fetal heart rate patterns in labor, decreased uterine contractility, a longer active labor phase with regular well-established contractions and low Apgar scores.”-Continuous support for women during childbirth, Cochrane StudyEmotional support, information and advice, comfort measures and advocacy reduce anxiety and fear and associated adverse effects during labor. Let me say that again. Doulas reduce the occurrences of adverse events in birth. Doulas lower the use of interventions. Doulas lower the likelihood of “non reassuring fetal heart tones”. Doulas keep labor going and lessen the use of Pitocin to augment labor. Pitocin can cause fetal distress, uncontrolled high blood pressure in birthing people, hypercontraction of the uterus, increase likelihood of hemorrhage and uterine rupture and more. Doulas give confidence to birthing people. Doulas decrease risk of perinatal depression. Doulas. help. babies. have. better. Apgar. scores. Babies born unto labors with doula attendance statistically show better tone, better reflexes, better color, better heart rates and better BREATHING.
Nurses and midwives do not have the availability to assist birthing people at the bedside. For example, nurses and midwives often have simultaneous responsibility for more than one laboring woman, spend a large proportion of time managing technology and charting, and begin or end work shifts in the middle of labors. They may lack labor support skills or may work in short-staffed environments. I don’t know if you’ve heard, but COVID-19 among healthcare workers is at an all time high, creating strained work environments and bare boned staffing in many units.
But why can’t dads just be enough? Companions from a birthing person’s social network, such as husbands/partners and female relatives, usually have little experience in providing labor support and are themselves in need of support when with a loved one during labor and birth. They don’t know enough about birth. They don’t have enough time to learn. And they have no opportunities to gain experience by attending a multitude of births. And so it becomes the burden of a birthing person to choose in a COVID-19 birthing world… between having her child’s parent attend the birth and having adequate support to help ensure best practices and positive outcomes, as doulas are seen as unnecessary and non-essential.
Let me ask you: how essential are the following events in birth?
Reduced use of augmented labor with synthetic oxytocin.
Shortened active labor periods.
Reduced use of epidural and narcotic analgesics.
Reduced risk of abnormal fetal heart rates.
Reduced risk of instrumentation delivery.
Reduced risk of serious perineal trauma.
Reduced risk of caesarean section.
Reduced risk of low Apgar scores.
Reduced risk of admission to the special care nursery.
Higher rates of breastfeeding at birth and even 8 weeks postpartum.
Reduced risk of PTSD in events of adverse outcomes.
Reduced risk of postpartum depression.
There have been no identified negative outcomes of doula attendance in any published studies I have reviewed in writing this. Not one. Anecdotally, there are doulas who may take patient advocacy to an extreme and challenge the plan of care created by care providers. Doulas will challenge providers to seek out evidence based information and not make judgments or medical decisions in perceived habit or fear. Doulas will challenge hospitals to monitor mothers with the latest, evidence based information from the World Health Organization, the CDC, even the American College of Obstetricians and Gynecologists — the very board that certifies the providers and surgeons which care for birthing people. Doulas help to create a system of checks and balances in a an institutionalized, sometimes outdated, and highly intervention-based birthing environment. And, most importantly of all, doulas only attend an average of 3%-6% of hospital births in North America. By limiting professional, trained, doula support, we only restrict 3-6 births in 100 from having a second support person. Yet nearly 100 in 100 births are attended by multiple physicians, midwives, nurses, patient care techs, housekeeping personnel, food service personnel, pediatric hospitalists, lactation consultants, contracted luxury baby photographers such as BellaBaby, in addition to paramedic students, nursing students, residents and administrators asking, “How was your stay?”
It seems to me, that especially in a COVID-19 world, we need a little less unfamiliar personnel leading to the dehumanization of birthing people’s experiences, and quite a bit more doula support to help contribute to the health and safety of a family in the hospital setting. In fact, hospitals around the country are recognizing this and rescinding their policies to disallow second support persons in the form of doula support. Even in Chicago, multiple hospital systems are allowing doula support in addition to a support person despite rising positivity. These systems recognize the need for professional, continuous care and work with doulas to create policy that focuses on balance between safety and experience. If Chicago can, amidst their dire circumstances, why can’t we?
The Association of Women’s Health, Obstetric and Neonatal (AWHONN) released the following statement in regard to doulas and COVID-19: “AWHONN recognizes that doula services contribute to the woman’s preparation for and support during childbirth and opposes hospital policies that restrict the presence of a doula during a woman’s active labor. “Doulas are not visitors and should not be blocked from caring for patients in the antepartum, intrapartum and postpartum period. Most doulas have been contracted by patients weeks to months ahead of time and have established provider relationships. They are recognized by AWHONN and ACOG as essential personnel and part of the maternity care team,” AWHONN supports doulas as partners in care and acknowledges their ability to provide physical, emotional, and partner support to women. AWHONN opposes hospital policies that restrict the presence of a doula in the inpatient setting during an infectious disease outbreak. Read more about AWHONN’s position on continuous labor support for every woman here.”— AWHONN member Nancy Travis, MS, BSN, RN, BC, CPN, CBC, Florida Section Chair.