Pandemics have the power to suspend normal rituals, including those surrounding birth and death. Doulas, labor assistants dedicated to providing continuous emotional, physical, and informational support to pregnant and laboring people, found their work of “mothering the mother” (Raphael 1973) disrupted by the impact of the pandemic, which stripped people of communal identity-making rituals such as births, weddings, and funerals. And while many birthing people were confronted for the first time with the inability of our healthcare system to deliver quality care, for others the pandemic added another level of fear for those already receiving inadequate care due to biases and medical racism (Davis 2019). Early reports detailed the ways this pandemic widened inequalities such as disproportionate death rates based on race and ethnicity (Andaya and Bhatia 2021) as well as increasing gender and income inequality (Ralph 2020; Villarosa 2020). It also deepens these inequalities among some of the most at-risk populations, in particular, pregnant and laboring people (Davis-Floyd, Gutschow, and Schwartz 2020). Our research focuses on doulas working on the frontlines of birth with many expectant people and families, who speak to the way COVID-19 exacerbated stratified reproduction (Colen 1995; Ginsburg and Rapp 1995). Using a mixed methods approach including surveys and interviews from hundreds of doulas in the United States, we demonstrate how doulas can help center conversations on inequalities in birth for people most at risk.
As doulas and anthropologists, we have been working collaboratively on doula scholarship for over a decade. During this time our understanding of the embodied knowledge crafted at a birth increased with each birth we witnessed and every story we collected; further highlighting the intimate labor of doulas (Castañeda and Searcy 2015). Our birth bags, initially overflowing with tools for use at a birth, eventually became lighter and lighter as we came to see our bodies as our main tool for doulaing. So when the COVID-19 pandemic swept over the world, we held our breath as this new virus pushed to keep bodies apart while asking ourselves – what would be the impact on birthing people and how might doulas help us provide a window into what was happening? In this article we focus our research results on what doulas reported about inequality and the pandemic, using their words and experiences to draw attention to those most at-risk.
The research for this project focuses on the experiences of doulas during COVID-19. The data is drawn from a qualitative survey collected at the height of the first U.S. wave of COVID-19, in March thru April of 2020, and a follow-up qualitative survey in July 2020. For the purposes of this essay where we examine U.S. health inequalities, we draw on survey responses only from doulas in the U.S. In the first survey, 373 of our 515 responses came from doulas in the United States. In the smaller second survey, 34 responses came from doulas in the U.S. – 27 of which had taken the first survey. Together the surveys yielded over 400 responses from doulas in the United States. Survey data was complemented by dozens of additional interviews conducted virtually in 2020 to assess how doulas saw the pandemic continuing to affect their ability to provide care. We separately coded each survey response, line by line, looking for themes and concepts and prioritizing the language doulas used to describe their work during this pandemic. We then compared and analyzed our coding to cross-check themes. We used the same process with the follow up survey responses and interviews.
A New Landscape for Birth
Doulas practicing across the U.S. reported rapid changes in hospital policies with the onset of COVID-19 (Castañeda and Searcy 2020; Searcy and Castañeda 2021). These new guidelines spanned from allowing only certified doulas, often with their own personal protective equipment (PPE) and on pre-approved hospital lists, to forcing pregnant people to choose only one support person, and in extreme cases, to banning any labor support– whether partner or doula (Gan-Or 2020; Thayer 2020). Despite the variation in public health strategies reported from different states, the overwhelming universal restrictions on doula support in hospitals, and even in some birth centers and at home births, spanned the U.S., and it aligned with a sharp increase in virtual doulaing. With this new practice, doulas had to rethink their ability to provide support while simultaneously refashioning their work for virtual formats. Doulas relayed how they made Whatsapp calls, sent voice messages and birth affirmations, and provided flash drives with hypnobirthing music. They described investing in new microphones and lighting to use with such platforms as Zoom, Loom, Facetime, WhatsApp, Slack, Marco Polo, Skype, BlueJeans, GoToMeeting, and Hangouts. New services were crafted including creating relaxation scripts, virtual meditations, comfort measure videos, online perinatal education, and facilitating chat groups for moms. Many felt online support restricted their ability to protect birthing families. Some doulas saw the impact of restrictive policies as trauma on vulnerable bodies, as one doula noted, “I’m seeing responses to birth, in pregnant people, to these new policies that I usually only see in assault survivors who are giving birth. So, it has affected my work in every way” (Texas). The concerns raised by doulas in our study illustrate how the forced shift to virtual doula care prevented doulas from doing the embodied work that helped them act as a buffer for a medical system that routinely marginalizes some people giving birth. In this article we focus on how doulas saw these changes the pandemic necessitated to their work impacting existing inequalities.
At Greater Risk
The United States spends more than any other country in the world on healthcare (Tikannen and Abrams 2020) and yet alarming inequities in maternal and infant morbidity and mortality along economic and racial lines persist (Davis 2019, Vedam et al 2019). For instance, Black and Indigenous mothers are three to four times more likely to die than non-Hispanic white mothers (Center for Disease Control 2020). The coronavirus pandemic has amplified the impact of existing biases and drawn increased attention to gaps in perinatal outcomes (Ralph 2020; Villarosa 2020; Davis-Floyd, Gutschow, and Schwartz 2020; McLemore 2020). Removing support teams from people giving birth during COVID comes at a cost to all, as continuous support “improves maternal and newborn outcomes” (Thayer 2020). But removing support teams from Black, Indigenous and people of color (BIPOC) and other birthing people already more likely to be treated poorly by hospital staff (Martin 2017) amplified existing inequalities and biases. As we listened to their stories, we heard doulas share 1) their concerns about being absent from births and 2) actual harmful outcomes as reported to them by the people they worked with.
Within both of these categories of concern, we see doulas reporting from the frontlines, about the way medical racism (Davis 2019) and stratified reproduction (Colen 1995, Ginsburg and Rapp 1995) within the health system create conditions for obstetric violence (Diaz-Tello 2016). Doulas expressed concern about the way people marginalized would experience birth. This echoed scholars who have long linked reproduction and racial inequality, particularly for Black women in the U.S. (Roberts 1999, Davis 2019, Owens and Fett 2019). Doulas’ closeness to the lived experience of people giving birth, means they are often very aware of the:
subtle and sometimes not-so-subtle ways in which the medical complex, in each of its parts, cumulatively dismisses, misdiagnoses, and undermines women’s feelings and intuitions about their reproducing bodies and, more specifically, disproportionately undermines Black women’s reproduction (Davis 2019, xv).
Doulas expressed concern about the actual outcomes of medical racism, helping provide a more detailed picture of the way reproduction is stratified in the U.S. Stratified reproduction offers a framework to describe the different forces that structure reproduction, and as a theoretical frame it asks how political, economic and social forces create the conditions under which people carry out reproduction (Colen 1995, Ginsburg and Rapp 1995). Doulas’ survey responses and stories pointed to their concern and awareness of the ways the pandemic pressured already stratified systems into increased inequalities, often perpetuated by medical racism. For example, one California doula working with Asian American Pacific Islander communities shared:
This was an issue prior to COVID-19, so I am not surprised that this would be compounded further during this fearful time. If there are POC in the birth room, all the more reason they need to have doulas as advocates to help stave off trauma caused by a disrespectful birth in which POC are more likely to be taken advantage of.
We heard doulas articulate deep concern for the lived experience of the families they worked with. Attention to these concerns around lived experience can help move us, in discussion about race and reproduction, beyond seeing race as a social construct and towards understanding race as lived experience within systems of stratified reproduction (Mullings 2005, Davis 2019). As doulas talked about this, we heard their worry about increased obstetric violence – a form of gender-based violence including cruel, inhuman, and degrading treatment (Diaz-Tello 2016). What happens when no one is in the room? In what ways do women become more vulnerable?
Doulas’ Concerns About their Absence
From rural to urban spaces, some doulas described a digital divide based on race and class inequalities. In Rhode Island, a doula wrote, “I primarily serve in the Black community, so it’s hard for me to hold space when my clients don’t have Internet and have a limited cell phone plan.” If clients didn’t have access to high-speed Internet, doulas were unable to offer women their “continuous presence,” which is the hallmark characteristic of doula care. Yet it is paramount to note that this situation, caused by changing pandemic rules, impacted birthing people differently. Doulas from across the U.S. shared, “Unlike many of the doulas I have interacted with, whose clients have additional support, my clients are young teen mothers who live in a shelter. In some cases I am their only support person” (New Jersey) and “The clients I support are women in shelters/rehab or low income and really need the support and it is heartbreaking not to be with them” (Arizona). Doulas stressed the importance of recognizing how the pandemic impacts different communities. A doula from Illinois expressed:
I work with young women (13-24 years old) who live in low-resource communities, are low-income or experiencing homelessness. I provide so much more support than just typical doula support so not being able to physically support them is terrible.
She went on to describe how being absent from a birth impacts her and her clients, “When they are in labor, my body is not with them but my mind still is, and I can’t advocate for them if they are experiencing injustices” (Illinois). Doulas’ concerns about the disproportionate impact of the pandemic for some women, points to the way stratified reproduction imperils certain groups of people giving birth. These women giving birth faced structural injustice without the support of a doula beside them. And doulas felt their absence in their bodies when they worried that their absence would mean a more difficult and possibly traumatic birthing experience.
Many doulas in our study were most concerned about their absence at birth, and these concerns were only heightened for doulas who work in communities disproportionately impacted by maternal health inequities. As one doula explained:
Honestly, I wish healthcare weren’t such a racist system, then I would feel more comfortable supporting clients virtually as I see others doing. The overwhelming vast majority of my clients are Black — and leaving them without advocacy support also puts them at great risk. (Washington)
Similarly, from Rhode Island, a doula shared her greatest challenge involved navigating:
The fear and the emotions – [both] the clients and ours…. And thinking about vulnerable clients having to birth without advocates and support being physically present- especially BIPOC birthing people, Queer birthing people, overweight birthing people, and birthing people with disabilities. The systems are already violent for those folks, and having extra stress on the system and fewer supports and advocates is fucking scary.
Like the doulas who worked with people in low-income communities, these doulas’ deepest concern lay with their absence at the births of people they hoped to support. Without their physical presence, doulas could not advocate for birthing people, in a system rooted in bias and racism. In one instance, a doula from Texas retold her most difficult pandemic experience involved:
Having to leave my client in the middle of a labor while she was crying out of fear and anger…the way she looked at me like begging me not to leave her…Also she didn’t speak any English, I was the one translating very carefully everything to her, I’m a Bilingual doula. Her husband speaks English and Spanish too, but he didn’t understand some things, he was not familiar with some of the medical terms, so he wasn’t able to keep her informed the same way I did. They didn’t have a Spanish speaking nurse there.
In this moment, the doula was forced to abandon a woman in the middle of labor, leaving her without access to information her translation support was providing. She points to the way the hospital system itself did not provide translation services and the fear she saw in her client’s face. Doulas’ concern about their absence, centers around their fear for women who they worry will encounter difficulties finding resources, mistreatment, poor care or dismissive behavior from medical professionals.
Outcomes of Absence
As doulas were forced out of hospitals, they were often left to piece together what happened at a birth, relying on the haunting reminders from previous experiences. For example, a doula from Rhode Island reflected on what it means to be absent at a birth:
These changes in practice have had a great impact on me and my clients. My clients are young, single, clinic patients who are typically women of color. Their care within the hospital is not given with dignity and respect. I have seen it with my own eyes. Without having a doula there for support these girls are at the mercy of the doctors and nurses, as they don’t feel empowered enough to speak up or question anything. It saddens me greatly, as this was why I got into doula-work.
As witnesses to a birthing system rooted in medical racism (Davis 2019), doulas recognize the powerful impact of new COVID-19 changes to hospital protocol. There is no room for emotional confirmation when absent at a birth, as one doula shared the difficulty of virtual doula care, “For the African American community that I serve, validation can come in the form of facial expressions or sounds” (Washington). The doulas’ ability to hold space by witnessing and validating a birthing person’s lived experience becomes impossible when they are absent at a birth. Doulas articulated the impact of their absence in these stories; people giving birth were left alone to navigate birth in sometimes hostile contexts without the physical presence of doula support.
While not able to be present at a birth, doulas continued their work postpartum by holding space for new parents to retell birth stories. Through these lived experiences we also gain a window into birthing during COVID-19. For example, in Florida a doula shared:
I have clients telling me that the hospital staff isn’t informing them of the benefits and risks of treatments and interventions. I’m sick over it honestly. I have never had clients who were treated this way when I was present in the room with them. It is very clear that the quality of care is not acceptable.
As doulas help people process their birth experiences, they are left to grapple with what could have been different if they were allowed to be present at a birth. The negative and disempowering impact of COVID-19 on birthing people and birthing advocates is a haunting reminder for doulas of the inequities in birth:
I have a Black client that had a less-than-ideal birth experience during this time that I think I potentially could have helped have a better experience, had I been able to be there in person. I feel like doulas are still not perceived as professionals and that COVID has taken existing issues with how we’re (mostly not) integrated into medical maternal care and made them even more apparent. I feel like if I was seen as the professional that I am, I would never have been barred from attending births. I feel like I’ve betrayed my client for not being there when they needed me the most. (Iowa)
Not only does this doula raise concerns for the quality of care for Black clients but she also points to a worry surrounding the long-term impact of COVID-19 restrictions for birth advocates like doulas. As doulas spoke with new parents, they shared the outcomes of their absence – no informed consent, care without dignity and respect, and women stuck in a system that does not allow them to advocate for themselves. It is important to note here that these outcomes were shared by BIPOC – the very communities that are already experiencing health inequalities.
The COVID-19 pandemic comes on the heels of increasing attention to a maternal health crisis that disproportionately impacts historically marginalized communities including BIPOC. The impact of COVID-19 on birthing people, care providers, and birth culture is just beginning to come into focus. Our research demonstrates how doulas can help center conversations on inequalities in birth for people most at risk. Just as there have been critiques of doula services catering to affluent white cisgender populations (Bobrow 2018, King-Miller 2018), our research found the new reliance on virtual care caused by changes to hospital policies further exacerbates structural vulnerability (Quesada, Hart and Bourgois 2011) and worsens existing inequities (Andaya and Bhatia 2021; Davis, Gutschow, Schwartz 2020). Doulas, long seen as serving upper middle class white women, are increasingly becoming a valuable source of advocacy in the face of birth disparities, especially when serving in community-based doula practices (Davis 2019). As a doula from California suggested, “We need representation for POC [people of color] in the industrial hospital complex; otherwise, more human rights infractions will continue to occur. We need skilled support in those hospitals to help pregnant POC.” Anthropologists have documented how Black and brown bodies are mistreated and often described by care providers as “unruly” (Bridges 2011) or “undisciplined” (Andaya 2014), which further supports concerns from doulas about what happens when women of color are left without an advocate or witness when birthing in a system rooted in medical racism (Davis 2019). For the majority of doulas in our study who work in cisgender white communities, the new COVID-19 restrictions brought to light the struggle that many BIPOC have always confronted. As one doula explained:
They have turned hospitals from a place women go to give birth and expand their family… into an experience noted as walking onto the battlefield in which you must FIGHT for your legal right to bodily autonomy, your right to have alternative treatment measures & your right to having the support you deem necessary for yourself. As well as the fact that these facilities are no longer providing these birthing women with the “highest level of care.” They simply aren’t providing it.
For BIPOC communities the hospital has always been a battlefield, and COVID-19 has further exacerbated an already unjust system. We have just begun the work to truly understand the ripple effects of the COVID-19 restrictions on birth. As we look to understand what COVID-19 means for birthing families and their care providers, doulas provide detailed accounts about birth across the United States. Their stories and concerns point to the widening stratification in birth and demonstrate the need for systemic change to better support all people giving birth, especially those who are at greatest risk.
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