As doulas worldwide prepare for the arrival of coronavirus in their region, many of us are concerned about the ability to support our clients during their birth, postpartum, or need for palliative care. As paraprofessional health care workers, doulas are also worried about contracting the disease or spreading it to their clients. Many of our fears around this virus are fears of the unknown, however experienced doulas already possess a key skill set. Not knowing how things will turn out or what will happen is part of the job. Waiting for the virus to hit is similar to early labor, postpartum or early admittance to hospice. We can help others to maintain calm in uncertainty by using relaxation, distraction, and physical movement. In this post I will list strategies and resources in case you need to advocate for your presence in a health care facility and then some essential information for doulas.
This is a critical time for people with doula careers. It is an opportunity to take a stand for our profession and our professionalism, and the critical nature of the work that we do in preserving maternal, paternal, infant, and family mental health during major life transitions. The way hospital administrators behave and the policies they set will reveal who stands behind patient access to doula support.
Can a hospital or medical facility keep a doula from serving a client in their facility?
The short answer is that facilities can set up whatever policy they wish – however they need to balance their fear of not being able to contain the virus with the reality of serving the needs of their patients. The current U.S. Centers for Disease Control recommendations leave room for facilities to say “yes” to doulas. In their infection control guidelines, you may be asked verbally to report any symptoms. But even patients with active COVID-19 infections are still allowed visitors, as long as visitors use proper hand washing techniques and avoid touching the patient or any surfaces they may have touched. If the medical center does decide to restrict visitors, the guidelines state that “facilities can consider exemptions based on end-of-life situations or when a visitor is essential for the patient’s emotional well-being and care.”
To us, doulas are clearly there for the patient’s emotional well-being. However the medical staff may only be thinking narrowly about virus transmission and not broadly about the holistic well-being of the patient. Multiple hospitals across the country are implementing a one or two visitor policy without allowing any switching out of visitors.
If you need to advocate for your presence, here are some things that can help:
1. Consider organizing with other doulas and approaching them as a group. Consider doing this today or over the weekend, before they post a policy. In New Jersey, a group of doulas wrote a template for YOU to use as the beginning of an open letter to your hospital. In the state of Michigan, the birth doulas there gathered together and the governor issued a proclamation declaring that doulas and partners be present during the pandemic. Thank you to these forward thinking colleagues!
2. Utilize statements of support by existing organizations.
A. Probably the most important is the AWHONN statement supporting the presence of the doula in the labor and delivery process. AWHONNN has gone on record as supporting the doula as an essential part of patient care. Doulas should not be considered in the same category as other visitors, but an irreplaceable part of the patient’s health care team. Many hospitals are following the AWHONN guidelines and are not restricting the presence of birth doulas or community midwives. See March 11, 2020. ACOG has also written an opinion in support of birth doulas, and in this week's practice advisory has not recommended restricting birth doula support during the COVID 19 emergency.
B. DONA International has written a letter of support for ALL doulas to use in communicating with hospital administrators. Even if you are not a DONA member, you can use their letter. It includes their Standards of Practice and Code of Ethics, which many doulas follow.
3. Recognize your own value and self worth; the doula’s role is unique and cannot be fulfilled by a nurse, midwife, or partner. If you need a pep talk about your own power during this crisis, go here.
4. Different arguments will work with different administrators. Here are some options:
A. Research Approach
Use the research on continuous care to show that your clients care about the quality of their birth experience and desire the best possible outcome in their facility. By denying their choice of professional support, they are negating the positive outcomes that doula support brings. DONA International’s Position Paper on Birth Doulas and and Evidence Based Birth's Evidence for Doulas (which I co-authored).
B. Affirm Patient’s Rights Approach
According to Birth Monopoly’s Cristen Pascucci, “It is a human right of the birthing person to decide who attends their birth as well as a federal right to have support” during the experience. By denying their choice of labor support attendant, the hospital is negating their legal rights. Rights for support likely extend to the hospice or dying experience as well. INELDA's position is that end of life doulas should think of themselves first if they are in high risk groups, and adhere to the guidelines of their local organization.
C. Establish Career Credibility
Birth, postpartum, and palliative care (death) doulas are not lay people. They are paraprofessionals as defined by U.S. Labor Law. Paraprofessionals are trained individuals who work alongside professionals or independently after extensive training. Their role is to assist in getting the best possible outcomes for patients. The definition of a “lay person” is someone who is untrained.
D. Show Your Paperwork
Sometimes paperwork equals professionalism in some medical cultures. Bring your training workshop and CE certificates if you aren’t certified; and your certification credentials if you are. Show your list or requirements for certification – be proud! Show them your legal contract or letter of agreement and your signed client confidentiality release form. Bring Your LLC paperwork if you have one. Bring the originals to show, but copies in case they want to keep one. You are a small business, you take yourself and your client’s health seriously. They should take you seriously too.
E. Negative Effect On Partner/Family Approach
A single “visitor” policy in labor and delivery reveals their cultural bias that labor support is not valuable or necessary AND their bias that intimate partners OUGHT to be able to do labor support. In this time of potential health crisis, they are invalidating the experience of the partner, stating that they are not worthy of receiving support, and that they are required to fulfill that cultural role, even if they didn’t want to or don’t feel qualified to do so. This is often why people hire a doula in the first place, because they want the labor and parenting support expertise for both parents.
Nursing literature reveals that most men do not want the sole labor support role, and the vast majority of those that do end up with negative memories of the birth. In turn, these memories affect their feelings of self worth and efficacy as a father. So, by simply acting to protect the potential spread of a virus, these restrictive policies negatively affect later family life.
By denying the presence of the palliative care doula, facilities are stating that the doula’s presence and support are unnecessary rather than essential. Doulas provide practical, emotional and informational support, no matter what their caregiving role. The presence of the hospice doula will likely depend a great deal on the level of risk, according to this CDC document. The Maryland, USA, Department of Health and Human Services has been proactive in outlining essential policies that affect care facilities where hospice patients may be residing.
Things Doulas Should Know:
1. Self Isolate as soon as possible and maintain your isolation status, except for births. If you want to be available, you will want to prove to yourself and others beyond a shadow of a doubt that you are virus-free. Personally I have only seen two other people in the last ten days (I isolated early). You're going to need to state honestly that you have not put yourself in a position to be exposed. If you can prove 14 days of isolation and are symptom-free, you are in a much better position to get in the hospital. Even better would be a recent test to prove your are symptom free, but those are hard to come by in the US and maybe in your country too.
2. Know how your country develops its response policy. In the United States, the federal government is responsible for making sure the disease does not cross our borders. However each state health department is responsible for setting policy and procedures once the infection has been confirmed within their borders. That’s why there are different criteria for who gets tested and different policies at health care facilities. Know what is happening in your state or province.
3. Coronaviruses are spread just like the cold and influenza viruses. People who are communicable cough or sneeze into the air, releasing the virus particles. They land on a surface, which is then touched by another human being. That person then touches their face, allowing the virus to be breathed in through the mouth or nose, and infection follows. That’s why the guidelines for prevention sound so familiar: frequent handwashing, not touching your face, disinfecting surfaces frequently touched by lots of people, avoiding close contact with people who might be infected, or large crowds where personal distance cannot be maintained. We don’t know how long this virus can live on a surface, but most viruses are fragile and can’t live without a host for more than a few hours. Some, like HIV, can’t live on any surface and must be transmitted skin to skin. Transmission can be minimized through the mutual cooperation of human beings. Typically, we're lazy and unmotivated which is why colds and influenza spread like they do.
4. Restriction to two visitors, even if one is a doula, may be devastating for some birthing families. In their culture and family, they expected to be tended to or visited by several people. At one of my last births, 18 people came in a nine hour period to pay their respect to the laboring person. If this was an expectation of a pregnant person, they may need to grieve for this loss. The culture in control, White culture, doesn’t see birth in this way; for many Whites birth is seen as a private, couple’s event. If we are White and doulaing cross culturally, we need to recognize this as a real and tangible loss. We also need to push for open door policies for visitors to return when this crisis is over.
5. Get your technical knowledge and back up supports ready. In case any of us show symptoms, we need to have a back up doula, and a back up for the back up, just in case. If that isn’t possible, you may need to use Face Time, Skype or Zoom to be in video contact with your clients during their labor. Distance doulaing isn’t the same, but when nothing else is possible, it is better than no support at all. Prepare your clients for these possibilities, reassuring that you are still there for them every step of the way.
6. Hospitals are where the germs are and where ill people go. Be just as concerned with carrying germs out of the hospital as you are about carrying them in. Be especially vigilant with cleanliness and preventing any bacteria or viral transmission when doing support activities. Wash your hands when entering a room and anytime you touch your face. Carry unscented hand sanitizer with you. Wear gloves more often to keep you from touching your face or the surfaces in the hospital room if needed. Ask the hospital staff how they are adapting and what they are doing differently. Bring a full set of extra clothes with you and change when leaving the hospital. Wear shoes you can put in the dishwasher or completely disinfect after the birth. Do not wear shoes you wear in the hospital in your car or home.
7. The hospital may allow the doula in as a professional and not use one of the “visitor” slots. However, they may not allow you to switch to a backup doula – even after 24 hours. If this is the case, work with your laboring clients so that you can get quality rest to keep going. Have a virtual/phone back up doula available.
8. With the current level of knowledge shared during the 3-12-20 CDC phone call, stated that most healthy infants who become infected have mild infections. However they can shed the virus in their body secretions for up to 30 days. This has implications for postpartum doulas wanting to make sure that any infant respiratory infection is not COVID 19, so they do not unwittingly spread the virus to other families. Testing guidelines will vary between states and provinces, and also counties or parishes within their borders, depending on the rates of infection.
9. Let your clients know how your care for them will change. Here is a blog post outlining what parents can expect to be different.
10. The most unfortunate person to be affected by all this may be the healthy newborn, born to a person with an confirmed COVID-19 infection. It is recommended that the newborn be isolated in a room by themselves for up to two weeks with only essential cares done by people wearing gowns, gloves, and masks. No skin to skin. No breastfeeding. The limits of our current knowledge lead us to think that the pregnant person with an active infection has not passed the virus to the unborn baby, and it is not present in birth fluids or breastmilk. It is possible for the infant not to get the virus when they are separated. Here are chestfeeding and breastfeeding guidelines for people with suspected or confirmed COVID-19.
However, if the supportive parent has been with the laboring one, they are then exposed. This puts parents in an awful position - either isolate the supportive parent days prior to the birth so they minimize transmission and have that person do newborn care alone; keep both parents together and have a third person take care of their newborn; or do the care themselves and risk the outcome of their child possibly getting the virus. I don't know what is worse - risking the mental health and developmental potential of a new baby against the danger of a respiratory virus. These are the decisions that will be facing pregnant and new parents who do get exposed and their health care providers. Until we know more about its effects, there isn't more helpful information available. What is most helpful is what doulas do best: Help people calmly discover and weigh their options. Forecast and understand these unique dilemmas. Normalize how abnormal these circumstances are. Be present.
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Post updated: March 17, 2020 and March 19, 2020.