When I first heard about hospitals making exceptions for doulas and not considering them as a “visitor”, I was thrilled.  It meant we were being recognized for our unique contributions to the birth team. Rather than restricting laboring people to one person for support, some medical systems were making exceptions for a professional doula to also be present.  However, this recognition is not without it’s shadow sides. Ironically, it has had an unanticipated negative effect on grandmothers and cultural traditions; and the medicalization of the doula’s role serves to divorce us from the roots of why we do what we do: autonomy and recognition of the rights of the person in labor.

First, let’s rejoice in the happy news that nursing and medical organizations recognize our value.  Both AWHONN and ACNM made statements or taken action supporting the unique role of the doula on the health care team. Certification has been functioning as it was designed to. It serves as a tool to legitimize the doula in a medical system. Systems can more easily assimilate a role when an individual can provide outward recognition of skill development and acquisition like licenses and certifications.  With their adoption of “one visitor plus doula” policies rather than “one visitor only” policies, hospitals and medical systems made it very clear whether they were centering the needs of the patient or centering their own. Through this process of recommending and creating policy, the legitimization of the role of the doula has truly publicly occurred. By being accepted and anointed by medical organizations, the birth doula’s role has been medicalized.

The medicalization of a body process excludes the family. As treatment for a condition moves out of the home and into a medical facility, the institution and values of greater society set the priorities, not the individual.  What the “one visitor plus doula” policy has unwittingly done is to pit doulas against grandmothers. As a doula trainer, I receive emails and phone calls every week from grandmothers who are no longer going to be able to attend the birth of their grandchildren. However they would if they were certified as doulas.

These phone calls are difficult; they always leave me with a heavy heart. You see, I’ve been around since the beginning.  I attended my first birth at age 20 in 1981; and my first birth as a doula in January 1987. Back then the whole idea is that we replaced someone’s mother or sister.  Either they weren’t capable or available. People in their childbearing years were highly mobile in the 1980’s, birthing far away from their families. That's a contributing reason why doulas rose in popularity. We also helped people to get the birth outcomes that they wanted as much as they possibly could by helping them to speak up for themselves.

My research shows that a birth doula’s effectiveness is primarily through meeting the attachment needs of the laboring brain.  I separate “brain” from “person” because person implies some level of choice; whereas the laboring brain acts as it does according to certain set of principles. The laboring brain needs to feel safe for a labor to be successful. Only in safety and trust does oxytocin flow. The person needs to be able to explore the territory of labor and have a “secure base” to return to, and a “safe haven” when things get rough.  These are the same functions that a parent begins to perform during the crawling stage of infancy.  So it is only natural that if the relationship is healthy enough, the pregnant person should desire the presence of their nurturing parent.  From a laboring brain perspective, to have to choose between one’s own mother and a “substitute mother” or doula is ludicrous.  

The whole concept of a professional doula is rooted in our contemporary society, how it functions and what it values. “One visitor plus doula” policies are absolutely an acknowledgement of our role and anointing of our validity.  However, the origins of our work are to replace the family and friend network that would exist if we had different values. We don’t value caregiving so we don’t teach it to family members and we don’t do it for one another; instead we have child and geriatric day care; doulas and nursing assistants of all kinds. Daily family life occurs in nuclear groups not intergenerationally, so life skills are lost rather than taught between generations. Because we are capitalists we charge strangers to assist with the most intimate of activities.  Any kind of labor or task we invent eventually becomes a commodity with a fee attached.

It’s true that birth doulas serve more functions in addition to support, especially when birthing in hospital systems that are not patient centered.  Ironically where people need representation most is likely in the facilities where doulas are not recognized; who only have “one visitor” policies.  Doulas provide empowerment and advocacy; communication and negotiation skills; positioning and comfort measure expertise, and more.  These also contribute to positive outcomes. But unless the laboring brain feels safe, the rest of these functions are useless. Oxytocin must pulse freely without being frequently countered by stress hormones. Only under these conditions will the process result in spontaneous birth. 

Lastly, one of the things that birth doulas have subtly stood for all along is patient autonomy.  That the patient should be the one driving the decisions and recognized as having the ultimate power over their own life and healthcare.  By dictating who that second visitor is, hospitals are making that choice and removing the autonomy of choice from the birthing person. 

Because of all of these reasons, I cannot in my heart of hearts be truly happy about labor support rules that recognize the specialness of the doula’s role.  While we want to be recognized for our unique contribution, it should not be at the expense of family members and cultural traditions.  It should certainly not be at the expense of the laboring person’s own power to make choices.  For this reason, I can support “two visitor” policies much more readily. 

Once the pandemic ends, I hope that most policies will change their language from “visitors” to “labor support team” members, and that two people will be allowed.  Nurses have been writing in forums for months about how much they love not having to deal with extended families and multiple visitors. Many times they feel these people are not in the best interests of labor progress or the patient’s well being; at other times, visitors are distracting.  On the other hand, people without good support can be more easily convinced to have an intervention desired by the nurse, physician, or midwife.

With grandmotherhood hopefully in my future, my heart feels for excluded family members. They've been thinking all their lives that they would be able to tend to their child during the labor of their grandchild. Now with the high rates of coronavirus, they're realizing that that may not be happening.  It is a bitter pill to swallow when hospitals will recognize a stranger over someone with so much investment in that family’s well being.  So what will the outcome of this situation be?  

Doulas may directly benefit from these policies and the recognition they bring.  As pandemic conditions wane, I predict the desire to keep visitors restricted will remain. This is an ethical decision because it involves the autonomy of the patient. Ethical decisions are complex because they force us to rank our values. It behooves us to remember the origins of why we do labor support to begin with. What is it that we value so much?  It is only because of living in a capitalist society that we have turned it into work, profession, and career.  Choosing what is best for our business is definitely a capitalist move and one supported by the majority culture. But does that accomplish what we stand for as a movement?  There’s the profession of being a doula; the work aspect of it.  But there’s also the reason why we do it - why we sacrifice for strangers: that we desire obstetric change that honors the person birthing, their body, integrity, and sees them as a whole person. That’s the social movement. Continuing “one visitor plus doula” policies is an area where the interests of the profession and the interests of the movement clash.  That’s the shadow side.  That’s the enduring conflict.

Humans birth in social groups so labor support helpers have always existed. What form those helpers take depends upon the society that humans have constructed at that point in time. It is only now, in our contemporary world, that we have created a paid role performed by an intimate stranger.  By understanding this and our deeper roots to support autonomy and meet attachment needs, we can be more effective in plotting our future course. We create the doula movement and social change by being activists outside the birth room.  How we balance that with being business people holds much of the future for the doula’s role.