In COVID-19
laboring woman with partner & doula

Photo by Growing Wings Photography

If you wanted to have a doula, a trained health professional who provides continuous one-to-one physical, emotional, and informational support, at your birth, here’s some hope. Some state health regulations allow doulas at births in addition to a partner, family member, or friend. If you live in one of those states, the regs give you a leg up on lobbying to be allowed a doula at your hospital if it isn’t permitted already, and if you don’t, the regulations from states that do may give you leverage in making the request.

Let’s look at which states allow doulas, what their regs say, and why they exempt doulas from the “only one support person” rule. We’ll follow that with your “Take-Away,” a section with practical tips, ideas, and resources.

Which States Allow Doulas and What Do the Regs Say?

These are the states for which I could find official online documents allowing doulas (and a tip of the hat to Jeanna Lurie who put me on to California’s). If anyone knows of any other states with this provision, please send me the link, and I will update this post.

California 

The presence of a partner or support person is essential to the mental health of patients who are in labor and delivery. CDPH [California Department of Public Health] recommends that one support person be allowed to be present with the patient. CDPH also recommends that a doula, if used, be permitted to be present if prior arrangements have been made with the hospital and the doula complies with hospital PPE and infection control guidelines.

New Jersey 

  1. A doula, who is part of the patient’s care team, is essential to patient care throughout labor, delivery, and the entire postpartum hospital stay and shall not count as a support person.
  2. The support person(s) and doula must be asymptomatic for COVID-19. They must not be a suspected of or a confirmed positive for COVID-19 (with a molecular test less than 14 days after the result) even if asymptomatic.

a. Hospital staff must screen the support person(s) and doula for symptoms of COVID-19 (e.g., fever, cough, or shortness of breath), conduct a temperature check prior to entering the clinical area, and every twelve hours thereafter, and screen for potential exposures to individuals testing positive for COVID-19.

b. PPE must be given to and worn by the support person(s) and doula. Once in the labor and delivery unit, the support person(s) and doula must have extremely limited access to other areas of the hospital (except for the cafeteria and other open amenities for visitors) and must not be permitted to leave and re-enter the postpartum unit without being rescreened.

New York

This order should clarify that doulas are considered an essential part of the support care team and should be allowed to accompany a pregnant individual during labor and delivery as an additional support person, as medically appropriate.

Exceptions should be made only in limited circumstances and based on clinical guidance, such as availability of PPE.

Oregon

Oregon is more complicated. The Oregon Doulas Association has a link to a letter signed by Oregon Health Authority’s Health Facility Survey & Certification Program Manager stating that doulas would be treated as “outside medical personnel” for the purpose of visitation in acute-care facilities, and as such, need to be screened before entering facilities and could attend births. The letter references and links to a document, “Revised COVID-19 Guidance on Screening and Visitation at Acute Health Care Facilities: June 8, 2020,” which states that “outside medical personnel” may meet the hospital’s obligation to screen health care personnel at hospital entry by providing documentation from their employer affirming that they are screened before the beginning of every shift using criteria at least as stringent as the hospital’s. I am not sure how doulas could meet this criterion since they are self-employed. If you live in Oregon, you may wish to contact the Oregon Doulas Association for more information.

Why Are States Exempting Doulas from the “One Support Person” Rule?

Having a doula is not a mere frill. Abundant evidence affirms that one-to-one continuous care from a person trained to provide labor support who is neither a member of the laboring woman’s social circle nor medical personnel . . .

  • increases the likelihood of birth by the woman’s own efforts,
  • reduces the likelihood of cesarean surgery, and
  • decreases the likelihood of negative feelings or dissatisfaction with the experience.

(For the details of the doula research, scroll down to “Taking a Deeper Dive.)

The Take-Away

If you would like an in-person doula, get started right away. Find out whether the hospital where you are planning to have (or are considering having) your baby allows doulas. If it doesn’t, you will need time if you wish to campaign for a change in policy. Alternatively, if the hospital doesn’t allow doulas, and you don’t wish to try to change that, you will need time to research where else you might have your baby.

Tip #1: If you decide to campaign for a policy change, find out who has the authority to make the change and arrange a meeting. I’ve provided links to the state regulations in this post, and you may wish to print out copies to bolster your argument. Go in with a “Getting to Yes” mindset: you and the hospital are on the same side of the table, and the problem, allowing a doula, is on the other side. Be open and flexible during the discussion but keep in mind that any policy that applies to your support person could be extended to cover an additional person.

Tip #2: Find out the policies for labor companions, especially, under what circumstances would you be separated from your labor companion(s) during labor, birth, or after the birth. You want to avoid unpleasant surprises, and knowing the policies ahead of time will help you plan ahead.  

If you are experiencing a healthy pregnancy and not anticipating any problems at the birth, consider planning to birth at a freestanding (not part of a hospital) birth center or at home. Birth center policies are much more likely to be designed around your needs, and in your home, you call the shots.

Tip: If birth outside of a hospital is a new idea for you, educate yourself before making this choice. The low-tech, supportive care model practiced by birth center and home birth midwives differs greatly from the high-tech, medically oriented management typical at hospitals. You will need to be comfortable with and prepared for those differences.

If a birth center or home birth doesn’t seem right for you, or you don’t fit the eligibility criteria, and the hospitals in your community aren’t willing to accommodate you, consider having a virtual doula. Many doulas these days are working virtually, and the opportunity for consultation before the birth and having a doula with you during labor and after the birth, even if not physically present, is better than having no one at all.

Tip: DONA International’s website is a good place for finding out more about doulas and for finding a doula.

Taking a Deeper Dive

What are the benefits of continuous labor support?

A systematic review, meaning a “study of studies,” included 27 randomized controlled trials, that is, women were allocated by chance to one-to-one supportive care or to a usual care group, and totaled 15,858 women in all (Bohren 2017). Trials varied in many factors that might influence results, including who provided the supportive care (a member of hospital staff; a doula; or someone from the woman’s social circle, meaning a spouse or partner, female relative, or friend), whether the woman was normally allowed a labor companion, whether epidural analgesia was freely available, and whether continuous fetal monitoring was routinely available. Let’s look first at the overall results and then at the effect of who provided the care.

Pooling all studies together, continuous one-to-one support resulted in:

  • 6 fewer women per 100 reporting negative feelings or dissatisfaction with the birth experience,
  • 2 fewer women per 100 having cesarean surgery, and
  • 2 fewer women per 100 having instrumental vaginal delivery.

Focusing on who provided the care, compared with women receiving usual care:

  • Spontaneous vaginal birth, that is, birth by the woman’s own efforts:
    • 2 more women per 100 with a hospital staff person
    • similar rates with a person from the woman’s social circle
    • 9 more women per 100 with a doula
  • Cesarean surgery:
    • similar rates with a hospital staff person
    • similar rates with a person from the woman’s social circle
    • 7 fewer women per 100 with a doula
  • Negative feelings or dissatisfaction with the birth experience:
    • similar rates with a hospital staff person
    • 22 fewer women per 100 with a person from the woman’s social circle
    • 14 fewer women per 100 with a doula

As you can see, supportive care by a hospital staff member had a small positive effect on the likelihood of women having a spontaneous vaginal birth (2 more women per 100) but no effect on the likelihood of cesarean surgery or on having a negative birth experience.

Having a person from the woman’s social circle had no effect on rates of spontaneous vaginal birth or cesarean rates. Having a person from the woman’s social circle did substantially better at reducing birth dissatisfaction than having a doula (22 fewer women per 100 vs. 14 fewer per 100). This could be because in all three trials evaluating doulas and in three of the four trials evaluating the effect of a female relative or friend, or a spouse or partner, women in the “usual care” group were not permitted labor companions and labored alone. It may be that under those circumstances, having someone familiar in attendance trumps having a stranger. Furthermore, in one of the doula trials, support wasn’t continuous. Doulas were only there during the day, and in one of the others, most of the doulas were retired nurses, so while they weren’t currently on staff, they may have retained a medical-staff mindset.

Having a doula, by contrast, had a significant impact on cesareans (7 fewer per 100) and spontaneous vaginal births (9 more per 100), and while they didn’t do as well as someone familiar, they still had an important effect on reducing the likelihood of having a negative birth experience (14 fewer per 100).

Note: The reviewers didn’t report differences in instrumental delivery rates because the trials didn’t report instrumental delivery rates according to support-person type.

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