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Giving Birth in Times of Corona Vol. II: The Insights of a Doula

Aktualisiert: 5. Apr. 2020


Picture taken from Carolina's website

Dear moms and parents to be,


During the last days, I have noticed that there is still a lot of questions and doubts in parental forums for migrants in Berlin regarding all the changes in birthing facilities and hospitals due to the current situation with Covid-19. For many, life has been turned upside-down.


Last week, I informed about the situation at Berlin hospitals provided by the medical staff at their departments for obstetrics. This week I wanted to gain further insights from another profession which is very close to the birthing process, the doula. Therefore, I interviewed Carolina Alarcón, a fellow expat from Colombia, mom of a son and practicing doula in Berlin. I invite you to know her point of view about how to handle Covid-19 and read her advice and recommendations on how to cope with the current situation.


Please note that the gathering of all this information was initiated only by myself in a non-profit manner, with the only aim of providing helpful insights.


Dear Carolina, what is the job of a doula? How important can it be for a family to have one these days?


A doula is a person who accompanies a family throughout their journey from the moment they get pregnant or even before, if they are having fertility issues for instance, and until the postpartum period. They can be contacted at any stage of the pregnancy. During birth, the doula offers support, not only to the birthing person but also to the partner or whoever is accompanying the birthing person during labor and postpartum time. There are many kinds of options in terms of what a doula can do for a family. The most common work that a doula offers is when the family reaches out and needs extra support appart from the obgyn and/or the midwife. The reason why a family might have the feeling that they need this extra support lies in the amount of intimacy a doula can offer. It is a one on one support in which the doula grows really close to the family and learns about their needs, wishes, fears, priorities, situations and history from an emotional, physical and informative perspective. The doula is the go to person where you don’t have just fifteen minutes like at the doctor's when you might be feeling vulnerable, sick or uncomfortable. The doula is there for you to meet your needs. It is something very unique, because, on one hand, it is not usually covered by health insurance companies. In Germany, the service might be covered but usually only for postpartum doula offerings. So it is a service privately paid, where doulas do not have to respond to the health system, a company, hospital or birthing facilities. This offers very tailored support with somebody who knows the family well.


Unfortunately a lot of times at hospitals, the staff might be overworked or understaffed. Even when a midwife really wants to be there for the birthing person during the entire labor, they might have to check on six families simultaneously. So, many times, a family is left on their own with a lot of questions, doubts and fears. The advantage of a doula is that they don't have shifts at hospitals and offer a continuity of care. They are someone you can meet early enough during the pregnancy and is there for the family during the entire labor. They will be there during the postpartum visits to talk through the processing of the birth experience, something many families wish they could get from their doctors or midwife but unfortunately they cannot as the system has a different set up. Therefore, the doula fills a gap in the system. They also offer information of what happened during the birth to calmly process it and hold space to process traumas that can have an important effect on the body and soul of everyone involved.


The doula's job is to inform families about all the options they have so that they can make an informed decision. The responsibility is completely different from that of midwives or doctors. A doula does not recommend any step to be taken but rather informs about the pros and cons of all options, the resources, and gives support on the choices a family makes. This is very different from the care providers who diagnose, prescribe, and suggest specific ways of action. Doulas don't have the liability issue of prescribing a medicince, for instance. That is why the level of relationship with a family can be very open, intimate and without the extra layer of medical responsibility but focuses on the emotional and informative holding space of each family.


The fact that a family feels that the doula is there just for them, creates an amazing level of trust and can have a positive effect of the birth experience since labor is very much about hormones and the response of the body to the environment and the support system. If a person is feeling really well supported and not rushed through when they have questions, chances are that interventions during labor are reduced. Even if they want all the pain relief, for instance, a person should make her own decision on whether it is good or not for them. They will have the opportunity to talk through all the process with their doula and so make sure that they will not have to discuss all those topics in the middle of labor. If you go to a hospital in Berlin, you won’t know who is going to be there on duty. You might develop a good relationship with a midwife but then their shift ends and you have to start from scratch with the new midwife in duty. In contrast, the doula can provide continuity of care, staying close to the family throughout labor.


How do you carry out your job in times of Covid-19?


Now, Covid-19 has changed many things in a very short amount of time. Right now, it can be very important to get extra help and support from a doula but it would look definitely different than usual. Doulas tend to offer prenatal visits in the family’s home for several hours where they are not not just talking everything through with the family but also suggesting different kinds of exercises that they could try out to see if their bodies respond well to them, like prenatal yoga, breathing exercises, meditation or even teaching the partners certain massages or acupressure techniques. It can be very hands-on. But now, due to physical distancing and sheltering in place regulations, doulas are not able to meet the families in person. However, they can still offer their support virtually, working with them during virtual sessions and suggesting various kinds of techniques mentioned above. What we are missing right now is only the physical contact part, the in person presence, but the emotional support and informative service are still there. A doula can still offer high quality resources, hear the family out, support them as they choose their birth preferences list. For example, a family can ask about certain interventions, let’s say, induction, and the doula would inform about the different options and rights they have. Because many families cannot have as many check-ups with their midwives or doctors anymore, doula support can be very precious right now as the families are left with even more questions and have fewer opportunities to meet their health care providers.


What happens right now during labour is that although the regulation in Berlin at most hospitals allows two (sometimes three support persons), they are now allowing just one into the delivery room with no possibility of switching between partner and doula. A lot of hospitals think that this will reduce the exposure of people being sick and bringing in the virus into the delivery room.


Since the pandemic reached Germany, which impact did it have on your profession and your families?


Since the pandemic reached Germany, it affected everybody in different levels. In terms of our work as doulas and in the birthing community, there are many things to say and bear in mind. Because there is so much uncertainty about this and it is also unprecedented, there are barely any studies about it that we can work with and that are evidence based with best decision making procedures. Right now, many things and policies are being improvised and guessed because the situations change from day to day, regarding what the scientists are finding out about the virus. Since there is so much uncertainty, our work needs to be adjusted, not only daily but also hourly. At the very beginning there were only a few hospitals that were not allowing more than one person to be with the birthing person in the delivery room and when this started, it was quite a shock for us doulas.


Although in some countries or regions inside the country they forbid a doula joining a birth, in Berlin we don’t have that. We are not forbidden to join the labor and delivery rooms at any point. But all of the sudden, doulas started to receive documents informing that due to COVID-19 only one person can stay with the birthing person and support persons cannot switch anymore. That would happen in the middle of labor without this having been disclosed before, because the regulation just happened to be enforced from that day while a family was in labor. Therefore, it is a shock for both families and doulas in terms of things you cannot forsee. However, there should be some things that families should always be allowed to choose and should be respected, even now. This includes the birth facility and who you want there with you.


For instance, before Covid-19, if a family was having a doula and a support person and suddenly there was the need of a cesarean, then only one person could join the birthing person in the surgery room. In Berlin it is not possible in most cases that both support persons, partner and doula, join the cesarean procedure. Birthing people tend to have a talk during prenatal sessions with their doula where the doula explains the regulations of the birth place. Families then have time to discuss and process the information given, for instance of who is the best choice to be there during an eventual cesarean procedure. If the partner is too nervous, they might prefer to not enter the room and then the doula can be the support person during the surgery. There is also the case when, for instance, the birthing person needs to be separated from the baby for postoperative reasons, so they need to decide who stays with the baby and who takes care of the recovering birthing person. Families make their choices with enough time but nobody saw Covid-19 coming and nobody knew how it would affect all of us, so there was no time to prepare.


But the doulas are advocating to be included in labor for the well-being of the families…


Right now, there is this petition by doulas in Berlin asking to let them provide support during this corona-crisis. The idea is, just like there are urgent and necessary jobs that are being protected from the quarantine because they are needed to maintain all social systems working, doula support is not something that can be only optional but it is essential. During this virus the care provided by a doula is urgent for families as they can be having fewer opportunities to be supported by their health care providers. During labor, hospitals might be even more understaffed than before. Many families might have their birth plans switched all of the sudden. Maybe they were hoping for a birth at a birthing center and then something related to the virus changed the policies in birth centers so that they have to go last minute to a hospital and it is something that definitely can affect the birthing experience, to have your birth at a different place than where you feel safe at. Many couples could be facing the aftermath of a difficult birth story for years to come because of last minute changes and if you add to that the impossibility to have your chosen support person by your side, the consequences can be huge. It is quite essential that a doula is there if the family feels that it is a support they need.


When is the best time to go to the hospital once the contractions started?


This is a very complex question usually but more so currently. Some families might hate hospitals and this is why they choose birth centers or a home birth, because they trust that environment and their body's ability to give birth without medical interventions, and they have had a pregnancy without complications. But other families feel that the hospital is the only safe place for them to welcome a baby. However, right now hospitals are equated to being the most dangerous places since they are where people who might be sick go to, so they are centers of possible spreading of the virus. They have a huge decision to make, whether they can switch last minute to a home birth option and find a home-birth midwife who is still available which is something that is not easy to find in Berlin, or they decide to go on with their birth at a hospital but stay longer at home during labor to reduce the chances of catching the virus. Early labor can last many hours, eight, fifteen, twenty hours. Now partners have to be present during the entire labor process more now than ever before because of staying longer at home before heading to the hospital or because, once there, the midwife might have even less time than usual to be with each family which was already happening before Covid-19. The system is struggling because there are more families giving birth than Berlin is ready to fully support and if you add to that a critical situation as with Covid-19, it just spirals to very tense situations. So, it could be recommendable, if possible, for a family to make themselves as comfortable as it gets at home during the contractions and reach the hospital when the birth is imminent. This kind of decision should be discussed among the couple, they can seek their care provider’s recommendations, and talk all this through with their doula.


How can doulas help the health care system in the current situation?


On a positive note, there are very nice movements coming from the birthing community in Berlin. There are also a lot of prenatal classes that are now being offered online by doulas as the pressential ones are being cancelled. Doulas have less bureaucratic work to offer these classes online (midwives’ courses are covered by the health insurance so they need to wait for the approval and all the logistics around that). And, although it can give the impression that a doula is only an option for wealthy families, the truth is that there are many price ranges that make doula services more affordable for families in general. For instance, recently trained doulas might be looking to gain more and more experience and offer therefore lower fees. Other doulas offer their services in a voluntary manner for people who are new in the city and are not in a good financial situation or are unemployed.


At the same time, as doulas are freelancers, and all of the sudden families are no longer allowed to bring them into the delivery rooms, many doulas are losing these jobs and live in uncertainty as well. While many families are already asking for their services, for instance in September, nobody has a clue yet about how the situation with Covid-19 is going to evolve and be like then. Nobody knows to what extent regulations will be changed or pulled back. Therefore there is a lot insecurity for both doulas and families. But the birth community in Berlin is doing its best to ensure that help is there for those who feel they need it.


It is known that only one accompanying person is allowed to the delivery room, at least in Berlin. In other cities they are not allowed to go in anymore. How would you act in that case?


This is a very difficult question and reality. The WHO has already given their statement that it is not evidence based practice to have a family not have an extra support person during labor. There is no evidence that shows that that would diminish the chances of being infected. On the contrary, it’s proven in many studies, (for more information you can check www.evidencebasedbirth.com), that having a doula can positively impact how the birthing person feels about the birth experience, how the birthing person, with the right support by their side, may need fewer interventions during labor. Going into the delivery room with a doula can have a positive impact and it can even make the job of midwives and doctors less hectic and tense because they know when leaving the delivery room there is somebody who is a professional in their job, not a medical professional but someone who can support emotionally and physically with techniques that are non invasive like helping the birthing person go into the bathtub, change positions or take a shower as a few examples. Doulas can make use of the rebozo which is a Mexican tool to give massages and some kind of accupressure to offer pain relief or reduce the perception of pain.


Although there is this world wide recognized organisation saying doulas need to be able to attend a family’s need, hospitals are not yet listening to this. It usually takes a while until policies are written or counter-argumented. So right now, what it means is that families are left without the support they wish for and actually need. If this were to happen to a family that I am supporting, I would explore with them how they would feel about the option to birth at home because then you have the person you wish there, in your own space and under your own regulations. If the family is comfortable with this, we would see if midwives are still available. I know there are quite few trying to make everything possible for the families who really hope for a home-birth experience. If a family would not be comfortable with this option, I would talk with them about imagining how they feel so that they can stay at home the longest time possible during labor and then go to the hospital before the baby is born. This way they can stay as comfortable and safe as possible and spend less time at the hospital.


As a doula, I would offer as many opportunities as possible to talk this through, regarding what it feels like to them to suddenly have all circumstances and expectations changed, and explore how this can not only be a source of fear but also a source of an opportunity to look for extra techniques at the beginning of the pregnancy and birth, thus engaging the only support person, that is i.e. the partner, even more in order to be prepared. That means focusing prenatal sessions on this, for instance, reading the book The Birth Partner by Penny Simkin, where the partner can find not only suggestions but information about what certain situations can look like, what can happen, what they can do for the birthing person, what they should not be doing. Here, the most important thing would be to offer to talk this through in detail with the family and hold the space for all the emotions that are about to come, the high levels of anxiety, sadness, loss, grief regarding what is currently happening in the world. A pregnant person can feel all this even more, not just because of the hormonal process but also because it is the beginning of their family story and it is not easy at all to face all these very difficult circumstances.


What are your recommendations for the first weeks with a newborn in times of social distancing and quarantine?


The most basic steps for pregnant couples or families with small children or anyone is washing hands often, wearing a face mask if you are going out, avoiding contact with more than two people, staying at home if possible, being very careful if they are getting packages sent to them or getting groceries themselves or delivered at home. Trying to avoid any kind of risk situation or of exposure with to the virus. This also includes wearing gloves, properly washing or disinfecting all the bought items and being aware when washing hands of the proper technique and the products we are using. Cleaning their cell-phones and changing of clothes when they return home, among others.


For the post partum time, and this is a conversation we always have in the first appointments as doulas, we find out what their expectations are and talk through a postpartum plan: When will the first person outside of the couple meet your baby, do they want to have all close friends at once coming, when will the grandparents come, are they ok with them coming and staying in the house, cooking for them, helping out with the baby or do they want something much more structured, only one hour a day, at a given time. We really go deeply into these details. This is a great opportunity to say now, with the Covid-19 situation we want to expose the least every member of the new family, including the partner who will be running all the urgent errands, cooking, changing diapers. I would offer the opportunity to process all this from an emotional perspective, offering a chance to grief whatever losses they anticipate having.


Giving birth in a foreign country far away from family and friends is already in normal life quite tough for expat moms. From expat to expat and as a doula, what would you tell them? How can they be reassured and encouraged in these corona-times?


Immigrants in Berlin usually count on the support of their families coming from abroad, from their home countries and staying for weeks or months. It is a huge blessing having your own mother come and help you out with the newborn if that feels right to you, it is not possible anymore because a lot of countries have their borders completely closed, flights are being cancelled, there is also a lot of risk exposing a grandmother or grandfather traveling across borders and through usually big and crowded airports like Schipol in Amsterdam or Charles de Gaulle in Paris, although they now are running at a 15% or 20% capacity compared to normal times, the risk is still there. Many families know that they cannot put their relatives through this kind of risk. A lot of people are meeting their nieces and best friends’ babies through a window because they cannot come into the house. The burden for the families who all of the sudden had their plans changed is to take care of themselves by themselves with no help. This is a huge ordeal and needs to be thought through: what it means, what are the losses, what are the positive things. Maybe they did not want to have their in-laws around and now they have the perfect reason to postpone visits. There is always a way to turn things around and find some humor in the situation. Keeping the sense of humor in these times is very important.


***


Carolina is not only a doula but also a manager of the international team at Cleo, an international service and network based in San Francisco whose mission is to “build trust and connection with families, guiding them on their journeys through life as parents” while also offering counseling to employers in order to better support working parents. Cleo has been offering lots of information for parents-to-be in order to better cope with the current reality due to Covid-19, including blog posts and webinars by midwives and doulas around the globe. I happened to watch one of the latter which proved to be very helpful in complementing Carolina’s guidance.


Regarding postnatal depression triggered by confinement, the team agrees that it is a huge concern of new parents. Anxiety can be controlled by uncertainty. Thus they recommend to welcome the feeling and know that it will leave again. Feelings are valid and should not be dismissed. Instead, they recommend to give yourself self compassion, take care of yourself. Find a good mental health provider for the postnatal period. Many of them are offering online support. Check Postpartum Support International for more information. Look out for virtual support groups in your neighborhood or city bearing in mind that “it takes a village to raise a child”. Zoom dates with other new parents for example. In Germany, you can also take a look at Afloat, a support group for international moms based in Heidelberg which advocates for maternal mental health. They also provide information about mental health providers.


In order to prepare for postpartum while social distancing and while your “village” is far away, Cleo’s team also recommends to grieve the loss of not having family and friends by your side. We have the blessing of technology. Talk to your partner ahead of time how you can plan the daily schedule. Get virtual support from a postpartum doula. Support groups are a great idea, connecting with parents in a similar situation. Listen to podcasts in order not to feel isolated. Many dream about the moment of introducing the baby to the family but now you are invited to understand that that moment is only postponed, it is going to happen. In the meantime have as many meetings online with the grandparents and relatives as you wish. Grandparents can talk to the babies via zoom and read them stories. The babies will appreciate it.


On the other hand and as good news, the midwives and doulas agree that the virus is not transmitted with breastfeeding. In fact, it is a huge immunological help and the baby’s actual first immunization. If you or your partner have the virus, wash your hands always before touching her and her things. Avoid sneezing or coughing next to her and use a face mask. Using face masks helps not to touch your face. For your older siblings, try to keep their hands cleaned at all times and not touch things if you need to go to the doctor with them.The bonding and the wellbeing of the baby should be established in the first days while taking all the precautions above. Take also a look at the WHO resources about how to keep your family safe in these times.


And remember, fresh air is still allowed. Do what you can to get sun and fresh air. It is also important for early postpartum for your emotional wellness. Just go out for a stroll around the block or out for some minutes, always keeping enough distance.


I hope that Carolina’s insights and information can be helpful for you, your pregnancy and your family and can make you feel better, less anxious and more confident. I can only wish you the best and recommend to always stay as positive as possible. Your baby will feel it and all will be fine.


Big thanks to Carolina for taking the time to answer all my questions. If you would like to know more about her job and services as a doula, you can take a look at her website.


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