I’ve been doing some soul searching the past few months in regard to birth, and the transition into a new year has brought the feelings and intention for change welling up inside me so much that I need to express them. So here I go. Those who are involved in the birth community of Hampton Roads as birthing families or birth workers, are aware that right before the pandemic hit our country full force, a beloved labor and delivery unit which included a midwife staffed birth center, closed its doors. This was a huge loss for our birthing community, one that was felt acutely by countless people locally but also spanned the globe as previous birthing families had moved away. After all, it had been in operation for over 25 years, and with our highly mobile military presence, their influence on birth and the beginning of parenting has spread far and wide. The Midwifery Center had tubs for laboring and birthing, which were a huge draw for many families. But more importantly, those who were intended to birth in the Center were met with openness. Their midwives listened and gave options, and trusted in the birthing woman and the innate safety of birth. And since there is always the potential for risk, the collaboration between midwives, OBs, and pediatricians, and nurses created the best of both worlds. As risk factors developed the elevated level of medical support was available. However, by and large, birth was safe and low risk, creating the opportunity for women to welcome their babies with minimal intervention. Options like intermittent monitoring, eating in labor to their comfort, laboring and birthing in a variety of positions, and even the option of laboring and giving birth in a tub were the norm. 

The pandemic hit like a tidal wave right as so many were adjusting to ache of such a loss. The OB practice reestablished itself in a different facility, and with change come growing pains. To be frank, there was some resistance from staff in part due to lack of information or understanding, but also because the expectations of birthing women were significantly different than the status quo of birthing the staff had grown familiar with. Women who had come to expect a certain sort of care from their providers, were having to conform their wishes to the hospital rules and protocols, all while navigating the fear and panic brought on by COVID-19. To be fair, the pandemic affected the labor and delivery units of all of our hospitals. They struggled to balance safety and choice, all while incurring the additional responsibilities like COVID tests, enforcing mask wearing, and a higher level of PPE for the safety of all. However, many thought some of the COVID protocols were extreme with the risks and benefits balance questionable. Doulas were excluded from the birth space physically, relegated to virtual support at all hospitals, except one. Only one support person was allowed, leaving laboring women to make difficult choices about who would attend them. Babies were separated from moms with positive COVID tests, and masks were required by laboring women until a negative COVID result was confirmed. Women who tested positive would be required to mask up for the duration of their births. Many families chose to give birth at home where they still had a sense of agency in who would be present and how they would birth. This was a very good thing for our homebirth midwives as well as the families served, for it gave them a higher level of recognition and appreciation, while shining the light on birth as a natural process. Our homebirth midwives had more work than they could handle. And many in the birth community were very excited about it.

Yet here we are nearly 10 months later, still adjusting to this new normal. Some restrictions have been lifted, like virtual doulas and separation of moms and babies, with others in place to maintain a reasonable level of protection from transmission of the virus. But it is possible to normalize, embrace and accept low intervention birth even in the midst of the pandemic. It does not require a huge overhaul in policy, except perhaps the addition of birthing tubs. The change would involve a change in thinking. The time has come. ESPECIALLY in light of the pandemic. Birth is the same as it always was. The way we approach it has changed. At a time when fear for our health and safety has overhauled so many of our daily routines, we need to remember that birth for most continues to be normal and safe. 

Collaborative care, evidence-based practices, and listening to birthing families, really hearing them out and having a dialogue with them, are what it will take to change the mindset of staff. And above all, trusting the birth process is absolutely essential. Childbirth education, in-depth thorough education about the process of birth brings a confidence to women—confidence in their bodies and their ability to tune in to it. And they also feel more comfortable laboring longer at home. But education and trusting the process must also happen from the hospital side. Childbirth education that goes beyond a standard medicalized birth is just as important for the hospital providers and staff serving laboring women. Yes, the interventions are there if needed or requested, but they should also learn how to serve a woman who does not desire those things.  The care is quite different. Education is crucial to change mindset. For example, when a woman arrives at the hospital in labor, why not trust that they are actually in labor and skip the triage room? Triage brings with it the assumption that a woman might not be in labor, as if she must prove she is in labor before soiling a room. Why not assume she’s right and commit by admitting her to a room? If she has prepared for her birth with an in-depth childbirth education class series, she is much more likely to present in active labor. Education is a win-win scenario.

Things like dimming the lights, while seeming superficial, can do a lot to allow a woman to follow to her instincts and limit distractions. Music can also have a wonderful effect on the birthing environment and the temperament of the laboring woman and her support team. Aromatherapy is another way to do this, creating strong emotional responses that can relax and empower the birthing woman during key points in labor. As she nears delivery, that is not the time for lights to be switched on, a crowd to gather, and lots of rushing about. Late second stage is precisely when a minimal number of necessary support people enter quietly (without loud side conversations!) and take their places. This will better enable the woman to continue to birth in the way she had been up to that point, with limited distractions and the support of her core team. Only a nursery nurse is necessary unless elevated risk requires the presence of a pediatrician. All others are extraneous and very distracting.

After baby is born, and the baby is transitioning well—this does not have to involve aggressive rubbing of the baby for many minutes—the initial birth cry and subsequent movements and color changes are indicators that baby is transitioning. Evidence shows that babies transition best against mom’s skin. Mom can rub the bottoms of the feet to keep baby crying and alert just as well as a stranger can. The trained medical staff can glean a lot by looking and listening to baby. Intervene if necessary, but in most cases it’s not. Covering baby with a towel against mom skin-to-skin is the best way to maintain baby’s body heat. Rubbing the wetness off (and the valuable vernix!) doesn’t amount to much. Keep that towel still on baby she they can remain warm against mother’s skin and also benefit from the microbiome being established in part by that vernix.

And when it comes to breastfeeding, the first hour, deemed the magic hour in birthing vernacular, is for mom and baby to explore each other. It is not the time to rob a mother of her power by grabbing her breast and the baby’s head and show her how to feed her baby. There is plenty of time for that. Remember, one sustained feed in the first 24 hours is a normal expectation, even after presenting the breast every 2-3 hours during the day, and 3-4 hours overnight. Keep the lights dim to encourage baby to open eyes and take in mom, and try to limit lots of extraneous noise and side conversation. This hour is magical, remember. And it is made more magical by empowering mom and baby to learn and discover hunger cues and smells. The help is there if they need or ask for it. But don’t jump to intervene at the slightest delay of a latch.

I would love for women to have the option of laboring and birthing in tubs again. The evidence shows that it is safe and an excellent comfort measure for women in the most active part of labor. It’s a shame that it feels a bit elusive right now, but I know it can happen again with proper planning and exploring resources. Birthing families want options and that is an option in high demand but very limited availability.

I have seen midwives and OBs work side-by-side to insure the best outcomes for mom and baby. But I have also seen these same providers trust birth and trust a mother’s instincts when conditions are right and all is well, to birth how she wishes. I have been welcomed and respected as a member of the birth team, working alongside the medical staff and my clients as a valuable part. I have watched women feel strong, empowered, and trusted to know the best decisions to make for themselves and their babies. And I have seen women move forward into motherhood with the best possible start because of such agency in their birth and the respectful support received. Let’s come together to create normalcy in birth for options, less intervention, and trusting moms, and most of all for trusting birth. It can revolutionize not only the way birth looks, but the way birth feels, and the way mothering begins.

In an effort to facilitate contacting hospital administrators to return doulas to the birth space, I have written a blanket letter for the intention of distributing as you see fit. Please copy and paste it and mail or email to those in leadership at the facility in which you have chosen to give birth. Feel free to make any changes you see fit. DONA International has also drafted a letter than can be forwarded on concurrently or separately. Whether you use my letter, DONA’s, or your own doesn’t matter. The more letters the better! Just reach out.  If you are looking for more evidence, visit my previous blog post for links.

To Whom it May Concern:

First and foremost, I want to express my appreciation for your diligence in keeping your staff and patients safe during the COVID-19 pandemic. It is no small task, and as with any unprecedented outbreak, evidence and information is constantly being weighed to assess potential risks to your staff and patient population. However, my request to you addresses the safety of your patients and has evidence to back up the benefits to their experience in your facility. I am writing this letter to ask you to please reintegrate doulas into the birth space by acknowledging them as a member of the labor and birth team, not as a visitor subject to the hospital restrictions. At the time of this writing, several Hampton Roads hospitals permit doulas to be physically present in the labor and delivery room. Sentara Leigh and Riverside Regional have opened back up to doulas and Sentara Williamsburg never restricted them. Please consider following their lead to insure your patients receive the support they expect.

The Centers for Disease Control and Prevention’s guidelines on caring for a mother with COVID-19 recommend healthcare facilities follow, “infection control guidance on managing visitor access, including essential support persons for women in labor” (Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, February 2020). They go on to state, “If restriction of all visitors is implemented, facilities can consider exceptions based on end-of- life situations or when a visitor is essential for the patient’s emotional well-being and care.” Surely, labor and birth should be considered an experience in which a doula’s presence is essential for the patient’s emotional well-being.

The evidence is overwhelmingly in favor of the presence of a doula during birth, showing a significant improvement in birth outcomes for both mom and baby. A 2017 Cochrane review of 26 trials of continuous labor support and doula care involving over 15,000 women in 17 different countries in high and middle-income settings found many improved incomes for women and infants including: “increased spontaneous vaginal birth, shorter duration of labor, and decreased cesarean birth and instrumental vaginal birth, as well as a lower incidence of the use of any analgesia or regional analgesia, less likelihood of a low five-minute Apgar score and fewer negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support.”(Continuous Support for Women in Childbirth, Cochrane Database Syst. Rev, July 6, 2020).

 In an effort to improve outcomes and lower the rate of the primary cesarean, both ACOG and SMFM came together with a list of guidelines to that end. Using the evidence collected by the Cochrane review quoted above, they encourage the continuous presence of support personnel, such as a doula, due to evidence showing improved outcomes, including a lower rate for cesarean delivery. (Safe Prevention of the Primary Cesarean Delivery, American Journey of Obstetrics and Gynecology, March 2014).

And in a timely response to the Coronavirus, both DONA International and AWHONN made public statements in March 2020 about the vital role of the doula and how the doula should not be a visitor relegated to hospital restrictions, but rather considered an essential member of the birth team. (AWHONN Position Statement: Continuous Labor Support for Every Woman, Journal of Obstetric Gynecological and Neonatal Nursing, 47, 73-74; 2018). Nurses are not able to spend as much time with their patients as the doula can. And it is specifically that constant one-on-one presence that provides the benefits demonstrated by the numerous studies. In fact, with heightened vigilance and increased task load in response to COVID-19, nurses are busier than ever. Laboring women are also dealing with heightened fears and concerns giving birth in the pandemic. Their need for emotional support and attention is greater than average. Clearly the doula is more beneficial than ever, and more essential for every member of the birth team. The evidence in favor of a doula’s presence cannot be ignored. 

It also bears mentioning that I have hired my doula to be present with me during my birth. She is contractually secured as part of my birth team. She is certified and has a skill set that she brings to the birth space, skills different and separate from those of the nurse, and skills that cannot be expressed the same virtually. The benefits conveyed by her steady one-on-one presence may be compromised in the virtual setting. 

For all of these reasons, I respectfully urge you to reconsider integrating doulas into the birth space. With the benefits clearly stated in evidence and the strong desire by your patients for doula support, with adherence to personal responsibility and safety through PPE, frequent and thorough hand washing and sanitizing, I am confident you can see to it that doulas return to the labor and delivery room. 

Thank you for your time and attention to this matter,

(Your name)

Our community was thrown off kilter mid-March with the official arrival and acknowledgement of COVID-19 as a global threat in the United States. It was upon us and as with any stressful event, many birthworkers, myself included, walked through the stages of grief in regards to the pandemic. First there was denial. Surely this wasn’t really a thing, was it? Then anger. I felt this acutely as a doula. The restrictions on birth support hit me in the gut and I’m not ashamed to admit that initially I took it as a personal attack on doulas. Of course, I have since come to my senses and understand that at the heart of the decision by hospital administration was to keep everyone safe, including doulas, which brings me to the third stage, bargaining. Birthworkers explored how to continue to offer birth support, even if virtual, and they pivoted to accommodate the needs of their clients through FaceTime, Zoom, text, and phone. Depression, stage four, was in there too, and lingers today for many of us. As doulas, we yearn to be with our clients, sharing their birth space and offering physical support in their presence. It pains many of us when we are separated from our clients during birth. It’s truly a struggle that hits a doula right in the heart. And finally, we encountered acceptance. COVID-19 would remain in our midst for awhile and would have far-reaching implications on how births would look for the foreseeable future. It was our new, indefinite normal, restrictions, masks, hand sanitizer, and all.

Now it’s time to act. We’ve had our six months of processing, doulas and birthing families alike. But the last stage of acceptance is unacceptable, especially when it comes to restricting doulas from physically attending births in the hospital setting. It’s time to push more aggressively to reintegrate doulas in-person at birth. If you are a birthing parent, I implore you to advocate for your doula, and for all doulas, to return to the hospital. Doulas should be permitted to attend in person because it is the right of every laboring woman to have support, but also because the research is extensive proving that the continuous labor support doulas provide improves birth outcomes. Doulas help everyone, including the staff and care providers! In fact, reputable birthing organizations made statements early on defending doulas as essential members of the birth team, and encouraging them to be permitted to continue to serve in person DURING the pandemic. On March 12, 2020, DONA’s statement for including doulas as an essential member of the support team was compelling, as was AWHONN’s pro-doula statement from March 11, 2020.

So what are we to do to affect change in hospital policies? There needs to be a push from the patients to hospital leadership. Contact the manager of the labor and delivery unit, and the administrator of the hospital. Make a phone call. It’s harder to ignore a voice on the line. Follow up your phone call with an email and a letter. Paper trails are also hard to dismiss. DONA has made this easier by drafting a letter to hospital administrators. They have already done the work for you. You can find that letter here. Simply print it and send it along. Furthermore, if there are other hospitals who have allowed doulas to return, be sure to mention them as well. In Hampton Roads at the time of this writing the only hospitals permitting doulas to attend births alongside the primary birth partner are: Sentara Leigh, Sentara Obici, and Sentara Williamsburg. And don’t forget to express your wishes with your provider. Not just one, but to each doctor and/or midwife at every single appointment. 

This push needs to come from the birthing families, not the doulas. The amount of research in favor of the presence of a doula is dizzying. And the number of statements by various obstetric, nursing, and birth organizations is compelling. The evidence is there and the need for one-on-one labor support is higher than ever. What’s lacking is the advocacy for the presence of doulas during the pandemic. I have compiled some links in an effort to cut down on your need to research data. You will find them at the end of this post. Feel free to use any or all that you see fit. And write those letters, send those emails, and make those phone calls. The change must begin with the birthing women. Not the doulas. We believe in you and we support you. You can do this! (Sound familiar?) Thank you so much for trusting us to serve you and for fighting for that right…for all of us.

Below are some links to incorporate into your letters/emails/calls campaigning for the reintegration of doulas to attend births in-person. Please don’t forget the links embedded a couple of paragraphs above to statements by both DONA International and AWHONN for having doulas attend births in-person DURING the pandemic. They are particularly timely and relevant since the statements were made in March 2020, right as the pandemic was taking hold in the US.

Cochrane Database Evidence that continuous labor support may improve outcomes for mom and baby

 AWHONN Position Statement for Continuous Labor Support for Every Woman

 ACOG (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine’s joint document on the Safe Prevention of the Primary Cesarean Delivery

 ACOG Approaches to Limit Intervention During Labor and Birth

 March of Dimes Position Statement on Doulas and Birth Outcomes, January 30, 2019

 Evidence Based Birth: The Evidence on Doulas, Updated May 4, 2019

These are unprecedented times. Have you heard? Of course you have. And you have probably
said that same thing yourself. We are throwing this phrase about so much with the COVID-19
pandemic that it is becoming alarmingly normal to be living in unprecedented times. Everyone
has been impacted by the adjustments that have been made to preserve health and safety. And
right about now, if it hasn’t already, it’s become a struggle. I’ve got to be honest, when I first
learned of the restrictions at our local hospitals, I was angry. I was upset that the women who
had chosen to have doulas at their birth would be forced to decide between having their
partner present or their doula. But when I took some time to reflect on the severity of the
situation, my heart was settled knowing that the restrictions were made for the health and
safety of everyone, including me. So I changed my thinking and jumped on board with my doula
sisters in being creative and inventive during the pandemic.

At the heart of the matter, my work as a doula is the same as it always has been. We have our
prenatal visit and our postpartum visit, only now it occurs virtually using Facetime or Zoom. It’s
important more than ever that we connect and discuss fears and worries about the upcoming
birth. It’s coming together as a team, and an opportunity for me to reassure and encourage
during what is such an uncertain and to some, scary time to have a baby. I am present for my
clients, offering reassurance and nonjudgmental support. And then postpartum, when stay in
place mandates have limited or eliminated the option of postpartum help from family and
friends, it’s critical that I check-in with my clients to see how they are doing and to answer any
questions or give any encouragement I can. It’s easy to feel isolated after giving birth in
ordinary times. In a pandemic, it’s pretty much a guarantee.

While the current situation has made it so I am not physically present in their birth space, I’m
still a presence at their birth. Let me elaborate. Some clients have chosen to have steady
support by way of video, using Facetime or Zoom. We are in touch in early labor same as
always, by phone or text. Then when their labor intensifies to the point that they would
summon me to join them, we setup the video connection and I am there. The words are the
same, the questions are those I would ask in person, and the recommendations are as the
situation warrants (cold cloth, position changes, comfort measures). Sometimes I am quiet,
assessing, watching and listening, ready to help when the need arises. But we know that
women are made to birth and as such staying silent is as important or more so, than speaking.
Some clients have preferred steady connection the whole way through with text and phone
calls and so I have honored that preference too.

I have been so very pleased with the reception I have received as a virtual doula in our area
hospitals as well. The nurses are working so hard to take care of their patients with the added
stress that comes with working in the medical field during a pandemic. And they have
graciously welcomed me to the birth space virtually. They have helped to incorporate me by
moving the laptop when the partner has forgotten, so I have a better view of my client. I have had conversations with the nurse, midwife, or doctor when there is reason to talk about options and to encourage the birthing woman as a team. We are all still connected, still have the same goal, and still have a job to do.

While the current situation has its challenges, I am grateful to still have the opportunity to
serve my clients. There is more need for doula support more than ever, with such a feeling of
uncertainty day by day, and the fear about bringing new life into a world that feels so unsafe.
As doulas we can still do what we do best—support our clients, offer reassurance and
encouragement, and to be a lifeline when they feel disconnected from the world. Hopefully, we
can return to being a physical presence sooner rather than later. But for now, this will work. We
have a job to do. And our clients are counting on us.