Doulas provide continuous emotional, physical and informational support to pregnant people and their families. ‘One more breath, breathe with me, stay with your breath’, they say as they wipe foreheads, share supportive words, and hold hands with labouring people. Doulas move in and out of private and public spaces and build relationships that traverse families and institutions. Walking away from a person and their newly delivered baby, doulas carry personal knowledge and information about that person – evidence of their intimate exchange. However, beginning in March of 2020, the COVID-19 pandemic forced doulas to navigate new restrictions surrounding birth practices (Searcy and Castañeda 2020). Based on data collected from a qualitative survey from April to May of over five hundred doulas as well as subsequent follow-up interviews with select doulas in June, we found that doulas express a spectrum of opinions regarding transformations to the intimacy of birth work.
Doulas describe intimacy disrupted and reshaped by the pandemic. Doulas draw attention to the way intimate presence is shifted by hospital policies limiting who can attend births. They describe how intimate embodied practices become virtual due to COVID-19 and how the pandemic reshapes the intimate experience of birth when clients switch from hospital to home births. An analysis of doulas provides a unique way to think through the complexities surrounding reproduction precisely due to the latter's ability to navigate intimate labour while breathing between and across boundaries. As hospitals began implementing new COVID-19 protocols, doulas came up against immediate disruptions to providing their intimate care. Yet despite new challenges, they found ways to continue to breathe alongside labouring people.
Forced to Choose – Doula or Partner?
In the face of COVID-19, hospitals implemented policies limiting the number of people who could support a pregnant person during labour. Hospital policies range from allowing only one or two support people, requiring doulas to show certification in order to attend a birth, to restricting all support people. These policies disrupt intimacy as pregnant people face difficult decisions about who could be at their side during labour (Davis-Floyd et al. 2020; Searcy and Castañeda 2020). A critical aspect of doula work involves bridging intimate care both within and outside of an individual's home, crossing boundaries and blurring divisions between and across public and private spheres in their practice of intimate labour. Doulas often speak of their job as ‘holding the space’, a phrase that Cheryl Hunter (2012) points out indicates the ways doulas work to create intimacy. Holding space is about being present.
The current global pandemic challenges doulas’ capacity to ‘hold space’ when hospital policies prohibit them from occupying the same space. One doula shared that, early in the pandemic, hospital COVID-19 policies went into place during the middle of a birth: ‘The nurse came in and told me I had 15 minutes to produce certification or I would have to leave’. Another doula watched as her client ‘even left one hospital mid-induction to go to another hospital that would allow her doula (me) in’ (Utah).
Doulas articulate the cost of this disruption to families as they face impossible choices:
I've witnessed the absolute terror that families are feeling. Even my home birth clients are terrified that they will have to transfer [to the hospital] at some point and their spouse will ‘not be allowed’ to support them. Me? I can doula virtually, I can adapt. So at least I can soothe their worry as far as my support goes. But not having their partner with them is a huge mental and emotional trauma. And while I'm doing my best, I know from professional experience that there isn't much I can do to prevent the trauma of not having their partner there, of having their human right literally stripped away, making them feel powerless and humiliated. And I'm not exaggerating. The emotional birth trauma from this is already horrific. I can't even imagine what traumas I'll be trying to support families through during the next batch of births after this is over. (Texas)
This doula draws attention to the impact of disrupted intimacy at a critical life passage – pregnant people being asked to labour without their partners and other support people increases fear and anxiety, a shortening of breath. Recent research suggests a substantial increase in the rates of pregnant and post-partum depression during COVID (Davenport et al 2020). Doulas mark and observe the disruption to intimate support.
Pre-pandemic, doula-intimated labour involved multiple embodied practices, which ‘personalised’ (Morton and Clift 2014) and in turn produced intimate knowledge. In their intimate observation and bodily closeness, doulas privilege an embodied birth process that is holistic, highlighting emotional, physical and spiritual needs. The pandemic radically restricts doulas’ ability to offer in-person embodied care and so doulas have moved online (Searcy and Castañeda 2020). One doula noted that technology was always a tool, ‘but now, it is the tool’. Doulas, grappling with working remotely, also unpack larger questions about how to maintain intimacy. Previous scholarship indicates that the Internet transforms intimate labour (Constable 2009); doulas find that the loss of physical presence shifts the nature of their intimate work. They must find new ways to create embodied presence.
Doula work entails intimate labour (Castañeda and Searcy 2015). Eileen Boris and Rhacel Salazar Parreñas, define intimate labour as “work that involves embodied and affective interactions in the service of social reproduction” (2010: 7). In their intimate labour, doulas seek to cultivate trust with a labouring person through their use of observation, continuous care, touch, validation and listening. One doula emphasised: ‘It's the belief that you'll be heard … That's such a foundational piece of intimacy’. This type of active listening is important to produce a safe space for birth. As another doula described it: ‘It's that softening into trust that happens when we as doulas invite people in to feel safe with us’. Doulas use techniques like breathwork, position changes and embodied presence to foster intimacy and trust.
In pandemic conditions, doulas describe using some of the same techniques they use when physical presence is possible. Doulas use their voice, breathing techniques, responsive listening and observation while virtually attending pre-natals and births. One doula shares: ‘My voice has always been my main doula tool. So whether through a video or a phone call, it's just about asking questions, listening, and being empathetic and supportive’ (Rhode Island). A doula from Ontario details the embodied way she approaches establishing intimacy with her clients:
At the start of sessions, I pause for some mindfulness with clients – remembering our bodies, feeling our bodies’ connection to the earth, that I'm just ‘over here’. We are in time and space together. I hold this connection to myself for the interaction. I am learning to speak directly to the camera during video calls, so that the clients can feel that I am speaking to them. I'm reminding my clients that the more we can see and hear each other during labour, the more we both have to work with, the more connected we can be. But it is their choice how to connect with me during labour – text, phone or video. I hold space across a distance even when we are not connected by technology. When a client is in early labour, I light a candle for her and the baby. I may pray or meditate or say mantras for them.
This doula uses mindful embodiment in her own space, working to build and hold intimacy with the person in labour, breathing with and through her across space. Working virtually entails transformations to a doula's intimate labour, including shifting attention to their own embodiment during virtual visits with families.
From Hospital to Home Birth
The majority of births in the United States take place in hospitals, with home births only comprising 1.6 per cent of births (MacNorman and Declerq 2019). However, doulas report a ‘dramatic increase in requests’ for more information on home births, revealing ways that intimacy at birth is being reshaped in response to COVID-19. An Alabama doula shares how this decision impacts her and her clients:
I have had a lot more clients jump on board last minute, usually switching from hospital to home. I have had to turn down clients at the hospitals because I have more home birth clients at this time and feel it's in both our best interest not to attend hospital births. I am normally doing hospital births more, but for the safety of my family I am doing fewer births and most at home where known sick people are not.
Doulas share that clients are concerned about changes to visitor policies and afraid of the virus, as we heard from a Texas doula: ‘Clients are making fear-based decisions and changing to home births or birth centers’. A California doula confirmed this: ‘They [moms] feel that going to the hospital, without an advocate, where they are short-staffed and medical staff is stressed and the exposure is greater, is a health risk for mom and baby’.
Switching from hospital to home birth reshapes intimacy and facilitates new identities. The intimacy created at a home birth encourages a heightened self-awareness from a labouring person. ‘In asserting the value of intuition or “body knowledge”, homebirthers are claiming multiple, legitimate forms of authoritative knowledge’ (Cheyney 2008: 259). A doula in Ohio describes her experience:
The couple switched their plans from hospital to home at 37 weeks because the baby was breech, plus they were concerned about chance of infection and strict hospital policies around support people and rooming-in for babies at the hospital. The decision was not easy as this was baby number four and the other births had been difficult predominantly due to iatrogenic causes, but the mother had been led to believe firmly that she and/or the babies would have been injured or died if the medical professionals had not ‘saved them’. But once the decision was made, things moved quickly and smoothly and ended in a healthy nine-pound baby born in a birth tub in their bedroom attended by two Certified Professional Midwives, one CPM acting as doula, a birth photographer, and the family cat who never left her side.
The mother's decision to give birth at home shifted the intimate experience of birth. She was made to feel like ‘she was bigger than she thought she was, that she stepped up and accomplished something that felt scary, and part of it was that we did nothing but listen and support’. The doula went on to describe how the experience changed her client, noting: ‘She will be the first person to tell you: “I'm not the same person”’. This example illustrates how the intimacy of a home birth can facilitate a ‘sense of personal strength and power where women become their own authorities’ (Cheyney 2008: 260).
Additionally, the confidence this new mother gained through her home birth experience led her to reach out and ask for donated breast milk, as her doula recounted:
She just texted me the other day to tell me that one of my other clients is donating her 258 ounces. She's like: ‘I'm set!’ So that circle of intimacy continues, and these moments of contained intimacy that we create give people the courage to step out and be more intimate in their communities.
The intimacy of a home birth has ripple effects on the social support networks necessary to sustain new families (Cheyney 2008). COVID-19 had the unintended consequence of moving some births from the hospital to home. The shift engenders new intimacies that reshape the individuals involved, but it also has the potential to reshape birth on a larger scale.
As babies take their first breaths while COVID-19 is literally taking breaths away, doulas are committed to continuing to breathe with people – near or far. With doulas embodied, affective interactions with birthing people are disrupted by hospital policies, transformed by the need to work virtually, and reshaped as circles of intimacy move from hospital to home. Doulas’ reflections on maintaining, creating and reshaping intimacy during a pandemic emphasise the embodied nature of their work. Breathing with families across the chaos of a pandemic, through computer and phone screens and by their side, doulas seek to hold intimate space for families. Their stories illuminate the challenges of supporting birthing people, and raise questions about the current medical structure of maternal care. As they respond with flexibility, foregrounding the need for intimate support for birthing people, doulas provide a resource for rethinking how maternal care can look both in and after the pandemic.
Special thank you to the doulas who gave generously of their time and energy to respond to our survey and interviews.
Boris, E., and R. S. Parreñas (2010), ‘Introduction’, in Intimate Labors: Cultures, Technologies, and the Politics of Care, (eds) E. Boris and R. S. Parreñas (Stanford, CA: Stanford University Press), 1–17.
Castañeda, A. N., and J. J. Searcy (2015), Doulas and Intimate Labour: Boundaries, Bodies, and Birth (Bradford, ON: Demeter Press).
Cheyney, M. J. (2008), ‘Homebirth as Systems-Challenging Praxis: Knowledge, Power, and Intimacy in the Birthplace’, Qualitative Health Research 18, no. 2: 254–267, doi:10.1177/1049732307312393.
Constable, N. (2009), ‘The Commodification of Intimacy: Marriage, Sex and Reproductive Labor’, Annual Review of Anthropology 38: 49–64, doi:10.1146/annurev.anthro.37.081407.085133.
Davenport, M., S. Meyer, V. L. Mesh, M. C. Strynadka and R. Khurana (2020), ‘Moms Are Not Ok: COVID-19 and Maternal Mental Health’, Frontiers in Global Women's Health 1, no. 1: 1, doi:10.3389/fgwh.2020.00001.
Davis-Floyd, R., K. Gutschow and D. A. Schwartz (2020), ‘Pregnancy, Birth and the COVID-19 Pandemic in the United States’, Medical Anthropology 39, no. 5: 413–427, doi:10.1080/01459740.2020.1761804.
Hunter, C. (2012), ‘Intimate Space within Institutionalized Birth: Women's Experiences Birthing with Doulas’, Anthropology & Medicine 19, no. 3: 315–326, doi:10.1080/13648470.2012.692358.
MacNorman, M., and E. Declercq (2019), ‘Trends and State Variations in Out of Hospital Births in the United States, 2004–2017’, Birth 46, no. 2: 279–288, doi:10.1111/birt.12411.
Morton, C. H., and E. Clift (2014), Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America (Amarillo, TX: Praeclarus Press, LLC).
Searcy, J. J., and A. N. Castañeda (2020), ‘COVID-19 and the Birth of the Virtual Doula’, Medical Anthropology Quarterly, 19 June, http://medanthroquarterly.org/2020/06/19/covid-19-and-the-birth-of-the-virtual-doula/.