- Malinda Nicholson
- Birth and postpartum doula Cassie Calderone helps a private client through labor at West Suburban Medical Center on March 27.
Birth and postpartum doula Cassie Calderone returned to work from her own maternity leave in late March, just a week after the city's shelter-in-place order went into effect. Her first birth was an induction, scheduled in advance, and the baby was born healthy and to happy parents at West Suburban Medical Center in Oak Park, just outside the city limits, on March 27. But because of precautions due to COVID-19, this birth looked different than any other in Calderone's four years of practice. Calderone, who has a preschooler with asthma and a three-month-old, self-quarantined for two weeks before and after the birth for her clients' and her family's safety. And, she said, after her client's 24-hour labor, she learned that the hospital had just implemented a new policy preventing visitors who left the labor and delivery unit from returning.
Fortunately for the couple, Calderone didn't need to return, and neither parent had a reason to leave the unit before they were discharged: this was their first child, so they had no older kids to pick up from the neighbors or the grandparents. But in other instances in birthing hospitals across the city, recently instituted and sometimes irregularly enforced visitor policies—introduced in an effort to slow the spread of the novel coronavirus—have kept doulas out of the delivery room, or even removed them in the middle of a labor, making the process of bringing life into the world a little more fraught.
"[Other birth workers] were saying, 'I went to Prentice [Northwestern Medicine's Women's Hospital] and I was allowed in, but while I was there, I was asked to leave,'" said Calderone, who works privately as well as through a community doula program at Advocate Illinois Masonic Medical Center. "Information was changing by the minute."
In response to the COVID-19 outbreak, hospitals have adopted temporary no-visitor policies in accordance with CDC and Illinois Department of Public Health guidelines, granting exceptions for patients in their labor and delivery units, among others. But not all hospitals are in agreement on the question of how many visitors to allow birthing parents.
West Suburban, a popular birthing hospital, is just one of a handful of area hospitals that continue to allow parents to labor with a partner and a doula after both have been screened for exposure to COVID-19 (at West Suburban, this means ensuring visitors don't have a cough, fever, or shortness of breath, though other hospitals may also ask about recent travel and contact with people who have tested positive for COVID-19); others include the Advocate system hospitals and Rush. In nearby Berwyn, the PCC Family Birth Center allows each birthing parent three visitors: a partner, another family member, and a doula. AMITA Health Saint Joseph does allow a doula in addition to a visitor, unlike other AMITA city hospitals. (The hospital confirmed this to Birthguide Chicago, which maintains a daily updated list of birthing hospital visitor policies.) But the lion's share of hospitals, including UChicago, Prentice, and Mount Sinai, have adopted a strict one-visitor policy for labor and delivery units, counting doulas as "visitors" rather than an essential part of the birthing team. However, there's still some inconsistency in how hospitals interpret their interim policies.
"The chain of communication in a pandemic is not great," said Qiddist Ashé, a birth and postpartum doula. On March 27, Ashé accompanied a client in labor to the University of Chicago Family Birth Center, where, she said, she had been assured by a staff member that she could enter in addition to her client's partner. But when she arrived, the person she had spoken to was not on call, and she wasn't allowed in. For the first time in her several years as a doula, she aided her client through labor virtually. A spokesperson for UChicago Medicine said in an e-mail statement that the birth center currently does not allow doulas to enter the hospital, but is working to facilitate virtual doula support.
"As doulas we prepare for the unknown, and help other people prepare for the unknown," Calderone said. "[During] a pandemic, how are we going to know? How is anybody going to know?"
Birth justice advocates worry that the one-visitor policies adopted by most hospitals will make it harder for them to fight against existing racial disparities in maternal health care. Having to choose between a partner and a member of your birth support team can cause "emotional stress and, probably, lessened physical comfort and all the consequences of not having a doula," said Anya Tanyavutti, executive director of Chicago Volunteer Doulas (CVD), a nonprofit birth justice organization that provides free doula care for its clients, the majority of whom are people of color.
Doulas, studies show, help improve health outcomes for parents and babies. Doula- attended labors are shorter and less likely to leave the mother with "negative feelings," as well as 39 percent less likely to result in a C-section. Regular prenatal doula meetings made at-risk parents four times less likely to give birth preterm. In a hospital setting, doulas can serve as advocates, making sure that all birthing people—but especially clients of color and Medicaid patients, who research shows are at greater risk for complications—have their voices heard and birth plan respected.
While the American College of Obstetricians and Gynecologists recognizes the significant benefits of doula-assisted births, it has not issued a statement on the topic of restrictive visitor policies during COVID-19: it recommended that patients ask their providers about specific policies for doulas. The Association of Women's Health, Obstetric and Neonatal Nurses, on the other hand, came out with a strong statement of opposition: "AWHONN opposes hospital policies that restrict the presence of a doula in the inpatient setting during an infectious disease break."
For parents of color, and especially Black parents, in Chicago—who due to decades of racist policies and health-care inequities face much higher risks than white parents of developing conditions or dying during pregnancy, birth, or the postpartum period—the prospect of giving birth in a hospital has become even more fraught as the peak of COVID-19 cases approaches and hospital beds fill up with people who are struggling to weather the respiratory infection on their own.
"What we see are some really tragic and unfortunate parallels that really demonstrate the levels of racism embedded in our medical institutions, our housing institutions, our economic institutions," said Tanyavutti.
In Illinois, Black women are six times more likely to die of a pregnancy-related condition than white women—almost twice the nationwide rate. A 2018 report by the Illinois Department of Public Health found that 72 percent of all pregnancy-related deaths were preventable. Last year, Illinois representative Mary Flowers pushed new legislation through to establish more legal rights for birthing parents as well as a task force to better understand the high death rate for Black mothers and babies.
The maternal health crisis for Black parents is compounded by the pandemic, which is also disproportionately affecting Black people in Chicago, who represent only 29 percent of the city's population but 70 percent of COVID-19 deaths as of April 5, according to WBEZ.
Ashé, who works predominantly with Black pregnant people and their families, said that these converging crises have raised the stress level for parents of color who are preparing to give birth during the pandemic. "A lot of [my clients] are feeling a greater sense of anxiety about the safety of them and their babies," Ashé said. "That anxiety is compounded on top of the concerns and valid fears around racism . . . within the medical system."
The desire to have a safer, more empowered birth experience in a hospital setting is what leads many of her clients to seek out her doula care in the first place, she said. Along with providing other labor support, Ashé helps to "protect the space" for clients, and make sure that their needs are heard and met.
Some of Ashé's clients have expressed interest in home births as COVID-19 cases continue to climb. But unlike Wisconsin, Illinois does not recognize or insure home births, and so there are few certified midwives who are willing to attend home births. Most of these midwives who do attend home births are now nearly at capacity. And since insurers in Illinois won't cover home births, it can be prohibitively expensive—anywhere from $1,500 to $5,000. Others are opting for free births, or family births, which is a birth in the home, supported entirely by family members and birth workers.
Ashé honors her clients' preferences, and will continue to support them if they choose to do a home birth or even a free birth. (Some doulas won't attend free births.) But most major health organizations, including the American College for Obstetricians and Gynecologists, recommend that pregnant people continue to give birth in hospitals. And for the vast majority of people, a hospital birth is the only choice.
Tanyavutti and Ashé (who is a Chicago Volunteer Doulas board member) are joining other birth workers across the city in lobbying Governor J.B. Pritzker to release a statement explicitly affirming doulas as essential workers, in the hopes that hospitals will consider doulas as integral members of the birth team rather than as visitors. They cite CDC-issued hospital visitor guidelines, which say "facilities can consider exceptions . . . when a visitor is essential for the patient's emotional well-being and care." CVD is also helping circulate resources and talking points for calling the governor and a Change.org petition started by Chicago Family Doulas to the same end.
Last month, in response to Michigan birth workers lobbying for their work to be recognized as "essential," Michigan governor Gretchen Whitmer released a statement saying that all birthing people should be able to be accompanied by a doula and a partner. In addition to helping support parents of color through an increasingly stressful hospital experience, Tanyavutti said the support of doulas can help free up already stressed hospital resources. "Our doulas help mitigate medical intervention," she said. "You'd think they'd want to lessen the need for medical intervention."
Even if lobbying does eventually allow doulas to be present for all births, doulas and organizations like CVD are coming to terms with the fact that COVID-19, and social distancing, may have a longer-term impact on birth work.
The doulas I spoke to are following the CDC recommendations, and in some cases taking additional precautions, to keep themselves and their clients safe. Calderone plans to self-quarantine before and after all upcoming births for the foreseeable future, though it won't always be so easy to do. The March birth was a scheduled induction, but babies don't always arrive in the time frame they're expected.
For the births she cannot attend in person, and for prenatal visits, she's switching to virtual care—both in her capacity as a private doula and as a community doula with the Healthy Families program at Illinois Masonic, where she sees mostly low-income, pregnant teens. It hasn't been easy. "I've been working incredibly hard to help everybody adjust," she said. "I was personally like, 'Am I doing enough?'"
The Ounce of Prevention Fund, an Illinois nonprofit that promotes early childhood development in low-income communities, is advising the ten community doula programs it funds in Chicago—including the Healthy Families program—only to meet with patients virtually or over the phone, including for birth. While virtual care is "suboptimal," especially because some families may lack the technology, spokesperson Corrie Leech said, it's in accordance with advice from public health officials to limit the spread of the virus.
While CVD is also providing prenatal care virtually, the organization is working on a case-by-case basis with its doulas and clients to help them make an informed decision about whether in-person birth support and postpartum care is safe. In-person postpartum care is especially important for some families, Tanyavutti said. It can be extremely difficult to make breastfeeding work, especially if it's not something that's "normal" to a parent's community or family, without early lactation support. "What we want to try to prevent is a generation of vulnerable birthing people and infants having less access to breastmilk and chestfeeding."
At a time when low-income families are experiencing severe income instability because of workplace shutdowns, providing safe, in-person lactation support is particularly important, Tanyavutti added. Formula is a major expense, costing parents on average between $1,200 and $1,500 in the first year of a baby's life. And there are long-lasting benefits of breastfeeding that can help reduce disparities in child health and development.
For others, virtual postpartum support may be enough. The couple whose birth Calderone attended in March needed her to be there and present for labor, but then were OK with receiving virtual support from her postpartum as they quarantined at home with their newborn. And after the shelter-in-place order was announced, Calderone made the choice to start seeing her own postpartum doula virtually, too. Even through FaceTime, being able to talk to her doula and having her doula talk to her preschooler so that she can focus on taking care of her newborn has been helpful.
While Ashé and Calderone still have clients—and therefore income—for the foreseeable future, CVD has had to adjust their fund-raising strategies since postponing its annual summer soirée, funds from which cover most overhead costs. Now, it's launched a spring donation drive and is planning to apply for payroll protection funding to make up for the lost funds. But Tanyavutti sounded optimistic, saying they've been "humbled and touched" by the support they've received already.
In a line of work that's traditionally hands-on, switching to virtual isn't always logistically easy. While the transition to FaceTime and Zoom has gone mostly smoothly for Ashé, she said it's not always easy to showcase the more physical aspects of birth preparation. "Just the other day I was trying to demonstrate birthing positions through FaceTime," she said, laughing. "So I get on the floor, I'm tilting the camera down, pretending to be a pregnant person and support person at the same time." At the births she has assisted virtually, though, she says nurses have stepped up, offering to help coordinate or carry out her instructions. She continued. "My hope is that in the move toward digital services, we don't lose our traditional and ancestral forms of working person to person. So much of the care that I offer, and that many people don't get in the medical model, involves physical touch."
As she looks toward the future, she says she's thinking of pregnant people who are incarcerated in the middle of a public health crisis that has turned prisons and jails into the biggest COVID-19 hotspots city- and nationwide. CVD continues to provide support to incarcerated people at Logan Correctional Center, a prison 30 miles north of Springfield, where they run a peer doula training program. While two pregnant people, one of whom is due in May, have been released and are receiving virtual support from CVD doulas, the incarcerated doulas in training are in lockdown; CVD is giving them extra communication credits so that they can stay in touch with their mentors and their loved ones.
"It's a frightening and frustrating time to see how vulnerable people are being treated in these moments," Tanyavutti said. "The reason why our work is so critical is not because of a problem we've created. We are mitigating a problem that the system has."
Ashé says she hopes that Chicagoans will be inspired to advocate and call for the release of all incarcerated people, but especially those who are pregnant or parenting while incarcerated. In the meantime, she continues to advocate for doulas to be considered indispensable parts of parents' birth team. And in the midst of the pandemic she's finding grounding in the depth and dedication of the birth worker community, in ritual, and in the resilience of the birthing body.
"Humans have been birthing for a very long time, and have gone through a lot of apocalypses," Ashé said. "The babies coming into the world right now are coming into the world for a particular purpose." v