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Keeping Doulas at Births in Hospitals During Covid-19

Stages of Grief: Our community was thrown off-kilter mid-March 2020 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 Stage Denial: Surely this wasn’t really a thing, was it?

Second Stage Anger: I felt anger 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.

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.

Fourth Stage Depression: Depression 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.

Fifth Stage Acceptance: COVID-19 will remain in our midst for awhile and have far-reaching implications on how births will look for the foreseeable future. It is our new, indefinite normal, restrictions, masks, hand sanitizer, and all.

Acceptance is unacceptable.

Doulas and birthing families have had six months of processing the restriction of 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 such as The Association of
Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have 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. (

Advocacy: So what are we to do to affect change in hospital policies? There needs to be a push from the birthing parents 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. 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 appointment.

This 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 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. Be an advocate not just for yourself, but for all birthing families.

Below are some links to incorporate into your letters/emails/calls campaigning for the reintegration of doulas to attend births in-person. 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: sensus/Articles/2014/03/Safe%20Prevention%20of%20the%20Primary%20Cesarean%20Delivery

ACOG Approaches to Limit Intervention During Labor and Birth:

March of Dimes Position Statement on Doulas and Birth Outcomes, January 30, 2019: position%20statement%20final%20January%2030%20PM.pdf

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Book Review: Natural Labor and Birth: An Evidence-Based Guide to the Natural Birth Plan by Michelle Aristizabal, MD

I was very pleased with Dr. Aristizabal’s book, “Natural Labor and Birth”, although I must admit I went into it thinking I would just be reading about things I already knew as I’ve attended over 700 births as a doula. That was true in most cases, but I really liked her approach. It was an encouraging book to read because it didn’t come across as judging interventions. While it championed natural birth as a viable and healthy option for women, it also acknowledged the prudent use of interventions. It has been my experience whether in personal interactions or in
books or the media, that one side is so staunchly defended to the detriment of the other. For instance, natural birth is touted as so much of an ideal that anything unnatural is judged inferior. Likewise, when women speak of their plan for a natural birth they are often met with resistance from friends and family, or even their providers or nurses. And that simply isn’t fair, especially since it is the woman’s journey. It has always been important to me that birth be
approached with an open mind from all involved. And I feel Dr. Aristizabal does this.

There is a clear defense of natural birth, as the title describes. But I found it enlightening and interesting when I encountered places in the book where she would use evidence to discourage the presumed correlation between interventions. The most popular one that comes to mind is the often-warned connection between an epidural and the increased likelihood of a c-section. She compares a decent number of studies and couldn’t even draw a correlation between an early epidural versus a late epidural and their impact of having a c-section. It’s just not a cut and dry issue. No labor is. She also goes on to say that the most predictive factor in whether one might be increasing their chance for a c-section is their providers’ philosophy of care. And since the studies to date don’t appear to have evaluated the impact the patient may have on the process, it’s still somewhat murky. But the intervention is not the culprit as much as the people deciding or defending its use. Honestly, that was the point in the book that caught my attention the most. I found her perspective refreshing. And for it to be evidence- based was just icing on the cake.

I also appreciated that she didn’t stop at birth but continued her analysis of studies relating to the postpartum time frame. She addressed the huge deficit in postpartum support that protects the fourth trimester. She also acknowledges how to bolster breastfeeding success. So much can be done to improve what is offered to mothers in the hospital especially, but also at home. She also discussed the importance of postpartum care at home, including pelvic floor and core strengthening exercises, in addition to mental health well-being assessments. I appreciated her holistic, whole-istic and balanced approach by covering every important issue in regard to pregnancy, birth, and postpartum.

In a country where homebirth is just now starting to take hold and grow, it’s important that we present options for a natural birth in the hospital without vilifying the medical system. There needs to be a level of trust to labor well, and finding the balance within the hospital setting for making a natural birth most likely, while still being flexible in case there are changes in the plan, is the best of both worlds. Trusting providers, trusting options, trusting a woman’s intuition, and trusting the process can all be incorporated within the hospital and result in a very high likelihood of a natural birth. And with books like this one, it will only make a natural labor and birth within the hospital a more recognized and realistic option.

*Michelle Aristizabal, MD, FACOG, is a board-certified General Obstetrician and Gynecologist in
Montclair, New Jersey. She runs a busy, private practice with a special focus on supporting women who desire low-intervention, unmedicated births.

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Choosing to Cross Certify as a Doula With BirthWorks International

As I read “Doulas of Love” by Cathy Daub, I was reminded about why I am seeking dual certification as a doula with BirthWorks. As an experienced birth doula, I was familiar with many of the topics since I am a certified Childbirth Educator with BirthWorks. But there was an aspect of the guidebook that was refreshing, and it was admittedly the uniquely BirthWorks part. I think the best way for me to articulate what I learned through my reading would be to
explain what I found to be the most important.

Human Values through the Five Senses is a wonderful goal for my work not only as a doula but also in my life. And taking in the five human values through the five senses illustrates the importance of completely incorporating human values into our daily lives. And I feel I do that. I strive to speak honestly, to encourage and not tear down. I eat (mostly) healthy foods, and exercise my body regularly and support my clients in doing the same. During their births I am constantly helping them to see the positives and the benefits to the hardships that come their way. Labor is hard, but that’s part of the process. To be present with women and help them to see past the difficulty into the learning and transformation that labor brings, is an honor and essential for their positive memories of the birth. I am humble in their strength, and I am calm in their anxiety. I was encouraged to know I already use human values in my doula work.

The second thing that really spoke to me was the explanation of the Three H’s of “Head, Heart, Hands.” The hands should only carry out what is approved by the heart and considered in the mind. The subconscious actions do not consult the heart and manifest as reactions rather than responses. Again, I was encouraged to know that I follow what my heart feels is right and am privileged to work with many providers who do the same. I also found it interesting to consider how sometimes women in labor act from their subconscious, reacting with outbursts
in labor, instead of calm responses. This makes sense though, since a laboring woman, while also feeling with her heart, is less in her frontal cortex, the thinking brain, and far more in the limbic portion of her brain where the subconscious lies. So when a laboring woman acts in this way it can be considered a positive, for it is a sign that she is deep in her labor.

Doulas who practice serving from their hearts, exemplify the BirthWorks Human Values and character training. I have heard doulas and the work we do described as heart work. This is a very intimate job. Our role is very personal and we are present with our clients during vulnerable and intimate moments. It’s of utmost importance that we are respectful and serve unconditionally, meeting our clients where they are. In order to do this truly we must speak
with our hearts and serve that same way. It is not our birth but our clients’ birth. And as such, it’s also important that we respect their decisions even if they wouldn’t be our decisions.

That took me time to learn, but I wholeheartedly believe it now. There is book knowledge about stages of labor and comfort measures. But the true value we bring to a birth is our hearts. The rest will come but if we are not connecting with our clients through our hearts, then all of the techniques and knowledge will fall flat. Incorporating and practicing Human Values goes both ways—the way I serve my clients, and also the way my clients walk their journey of pregnancy, birth, and parenting. Being reminded of the importance of processing my decisions
through not only my brain but also my heart can do so much to encourage my words and actions will help and not do harm.

I also love how the BirthWorks human values approach to doula certification doesn’t stop there. These values are also important to use in life. And these are the parts of my doula work that I find most challenging. Not for me. But when I see providers and nurses acting in ways that don’t respect human values it’s very difficult and it upsets me. As doulas we are caught in the middle. We cannot undermine or oppose providers, for that does not instill
confidence and safety in our clients. My role is to protect the emotions of my client and help her to feel calm and secure. My job is made more difficult when a provider is not using human values in their approach. Thankfully, I rarely encounter this. But I realize there are doulas who are constantly struggling with the cognitive dissonance felt when the providers’ actions don’t reflect human values.

The next thing I found notable in Doulas of Love was being reminded of the deep affect our relationships with our mothers can have on our pregnancy, birth, and mothering. I have a very good relationship with my mother, however I have worked with clients who are not as fortunate. I see how difficult it can be to incorporate their mothers in their birth in a healthy way, and some choose to disengage them for the sake of preserving their experience. We discuss the importance of being selective about one’s support team, but I also remind them it’s critical to communicate feelings even if difficult. It’s all very complicated, that’s for sure. And while it can be hard information to process, and even feel a bit too overblown to me, I don’t recall there being any mention of the mother/daughter relationship in my other trainings.

In helping a woman in labor to relax, I highlighted the line “It is important to remember that the most comfortable position may not be the most effective one.” I agree with this mostly. I see it happen often when a client lies down and finds the contractions ease a bit. Rest has its place in labor, but I know women often prefer it because it is less painful. This is the case in early labor. For we know in active labor it can be more difficult and uncomfortable to lie
down. However, I have served clients for whom when they feel pain, if it’s localized to one area, like on their left or right hip, it may signify a problem and not so much the progress of labor. It could indicate that the baby is in a less than optimal position and thus would require some intentional maternal positioning to encourage baby to move off the one hip. But I agree almost entirely that the less comfortable a position the more productive the position.

I appreciated the reminder of the importance of holistic nutrition as well. Nutrition is not just what we put in our mouths; it is also what comes through our eyes, ears, out of our mouths, and into our minds and hearts. That is profound and illustrates just how extremely influential the messages are that we take into our bodies, not just the food we eat. The messages are all nourishment to us or poison, depending on what it is saying. The section on birthing language really spoke to me. I had not previously given much thought to the significance and underlying meaning behind the word support, not until I heard Michel Odent, MD explaining why the word robs laboring women of their power. It changed my verbiage and now I consciously avoid that word. I have replaced support with serve and I do it now without thinking. It’s so important that we always remember that the woman is the one
birthing her baby, not the partner, not the doula, and not the nurse, nor the provider. As soon as we forget that she is the one birthing, we disengage her from the process and walk the dangerous line of doing things for her or to her, rather than having an open dialogue about what it is she desires and feels is the best course of action. Counsel and explanation of options from the provider is of course welcome and helpful, but the decision should be made by the

If we are to truly believe our clients have the knowledge and ability to birth the way they need to, then we need to avoid considering ourselves an expert. I never want to feel I’m the expert at a client’s birth, although sometimes they paint me out to be just that. The knowledge of comfort measures and labor stages and nuances can easily make us come across as one, as well as the sheer numbers of births attended. But I’m constantly checking myself to
make sure I am respecting the mother as the one who knows best and only offering insight and ideas when relevant or requested for I have never attended her in this particular birth. The only one who is an expert in her birth is her. Knowing and truly believing this, I use my heart to determine whether I should say or do things that are to “help”. I weigh it very carefully before proceeding. And I think BirthWorks’ approach articulates what I feel my doula approach has become.

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Virtual Doula-ing During Covid-19

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.