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  • Writer's pictureDalia Abrams

Doulas are “Critical Support Personnel” and Shouldn’t be Barred from Hospital Births

[First published June 15, 2020]

I had plans for the launch of this blog right about now… but that was before this Covid-19 global pandemic. Still, if there is one universal truth about doulas, it’s that we are used to adapting to the unpredictability of life. Since we never know when our client is going to go into labor - what will be interrupted, what will have to be rescheduled, postponed or canceled - we know how to do unpredictable.

So - Some thoughts about the importance of “visitors” to birth-givers in the hospital setting.

When Covid-19 cases started rising exponentially in the USA in March, hospitals quickly decided to exclude all visitors. This decision was made in the midst of chaos and panic with a laser focus on infection control, because the immediate concern was preventing the spread of the virus in the hospitals, especially among the staff, nurses and doctors who were (and still are) risking their lives daily to save ours. We know that there wasn’t enough personal protective equipment (PPE) stockpiled to prepare for the sudden surge in need. Thus, without adequate PPE, other measures HAD to be taken to ensure our medical professionals could continue to do the work of attending to sick, and highly contagious patients. And when visitors were restricted, infection rates among these professionals immediately declined.

But when visitors were banned, did we throw out the proverbial baby with the bath water?

Who is a “hospital visitor”? I think we can broadly separate them into two categories. First, we have a critical support person (CSP) or professional. CSPs help patients cope with hospital procedures, be informed about what’s going on, and help them stay calm and comfortable. It’s interesting to note that parents of small children (at least one per child) have been recognized as CSPs and have NOT been excluded from the hospital during this crisis.  The second type of “hospital visitor” is everyone else. Family and friends who come to lift spirits, bring gifts, flowers and food, keep people company, visit the CSPs, etc. In the case of birth, there are often a lot of people who come to take part in the event. This second type of visitor is helpful and welcome - but probably not critical. I think we can call them Visitors.

It might be sad when Visitors are excluded. But excluding CSPs can have serious short and long term negative impacts.

I believe that when deciding how to respond to a highly contagious and dangerous pandemic, we need to consider these two different roles separately. And I believe this is something we need to do NOW, because this Covid-19 thing isn’t over. Case rates are still rising in Alabama as I write this blog. Epidemiologists tell us case numbers are likely to surge again in the fall, maybe sooner, and maybe multiple times, until we have a safe vaccine and more effective treatments. So we need to decide who should be allowed to accompany people into hospitals in the time of a pandemic, and plan for how to do that safely. In Public Health this is called a Preparedness Plan.

So, when the risk of contagion is high, restricting Visitors seems like a reasonable decision. It will probably impact patient satisfaction, but also slows the spread of a virus and may not have serious consequences. But what about CSPs?

How do we quantify the value of having a partner, parent, loved one, doula, or any non-medical person you choose, with you when you are in the hospital? What is the value in improved patient outcomes –physical and mental health, short term survival, long term quality of life? What is the value in saved resources like PPE, especially when there is a shortage? What if CSPs lead to needing less equipment and medications or procedures, or shorter hospital stays? Do CSPs save money, or lives? Or ease the end of life transitions? And if they do, does their value outweigh the possible added risk of infection? Or is there a way to reduce the risks to make room for the benefits?

Now, because I am a doula, I want to look specifically at Labor and Birth (*L&B). L&B suites are actually unique spaces in the hospital setting; before Covid-19, they were among places in the hospital with the most liberal visitor policies. In L&B suites it is common to see CSPs AND regular Visitors, sometimes many, attending the birth of a baby.

Recent policy decisions regarding L&B offer a prime example of hasty decisions without considering broader consequences, followed by consumer outrage and policy reversals. When Covid-19 infections started to surge, visitor policies were tightened, and when things got really bad in New York City, ALL visitors, even partners, were banned in two private hospitals. However, there was a swift and severe outcry, and within days Governor Andrew Cuomo signed an executive order that birth-givers must be allowed to have a single person of their choice accompany them for their birth.

Currently, most hospitals, nationwide and all of them in Alabama, restrict birth-givers to one Visitor in L&B to reduce infection risk. However, some hospitals decided not to count doulas as Visitors. For example, here in Birmingham, one hospital (Princeton Baptist Medical Center) has recognized doulas as CSPs. In these hospitals, people have been able to have a chosen support person AND their doula with them for labor and birth. Everywhere else, birthing folks have had to make an impossible choice: Which critical support person should they choose? Partner? Baby’s father? Birth-giver’s mother? The doula???

As a result, the great majority of birth-givers are laboring and giving birth without the support they planned for - and specifically without their doulas. Research clearly shows that when doulas are present, labors are shorter, require fewer medical interventions and lead more often to vaginal births rather than c-sections(1,2). Furthermore, breastfeeding initiation(3) and overall success is enhanced when doulas support birth(4). Thus, not only can doulas improve the health of mothers and babies, but they can also help hospitals reduce the use of PPE and other medical supplies because fewer staff and nurses are needed for spontaneous vaginal births, compared to complicated labors and c-section. Thus, doulas ought to be classified as CSPs.

Doulas also help amplify the voices of birth-givers in the hospital setting. In a country with a maternal mortality rate higher than any other industrialized nation(5), where Black women are 3-4 times more likely to die due to pregnancy related causes (ibid), helping medical providers hear the voices of birth-givers is truly critical. [See my blog: Race is not a risk factor. Racism is.]

We are in the midst of what epidemiologists call a “natural experiment”. Many people have undergone procedures and hospital stays without the support they usually have from friends/family/loved ones and doulas under extraordinarily stressful conditions. Were outcomes adversely impacted when so many were considered Visitors rather than CSPs? Epidemiologists can compare the outcomes and see what the data show. Then we can create a Pandemic Preparedness Plan that lays out creative ways to enable all CSPs to stay with patients and provide their unique kind of support.

We didn’t have TIME to think through these options in March 2020. But we have time now! Let’s do the research. Let’s look at the data. Let’s make a plan to do better!


*No this is not a typo. Labor and Birth is what happens in these suites, not delivery. More on that in my upcoming blog post "Birth is not a Delivery".

See too this MDs commentary piece on Medscape "Let's Stop the Draconian Visiting Restrictions" published May 27, 2020.


  1. Bohren  MA, Hofmeyr  GJ, Sakala  C, Fukuzawa  RK, Cuthbert  A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6.

  2. American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014;123(3):693‐711. doi:10.1097/01.AOG.0000444441.04111.1d

  3. Futch-Thurston LA, Abrams DR, Dreher A, Ostrowski SR, Wright JC. Improving birth and breastfeeding outcomes among low resource women in Alabama by including doulas in the interprofessional birth care team. Journal of Interprofessional Education and Practice. 2019, Vol. 17:

  4. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing (JOGNN), 2009 Mar-Apr; 38(2): 157-73 (35 ref)

  5. E. Declerqc et al. U.S. Maternal Mortality Trends: Disentangling Trends From Measurement Issues Obstetrics & Gynecology. 128(3):447–455, SEP 2016

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