Birthing Alone

Elizabeth Kukura

Throughout the COVID-19 pandemic, hospitals implemented restrictive visitor policies that have prevented many pregnant people from giving birth with their chosen support people. For some, this meant foregoing labor and delivery support by a birth doula, someone who serves in a nonclinical role and provides emotional, physical, and informational support to birthing people. Given that continuous labor support such as the care provided by doulas is associated with fewer cesareans and other interventions, less need for pain medication, and shorter labors, the promotion of doula care is a promising strategy to ease the maternal health crisis and, in particular, shrink the perinatal health equity gap, as reflected in a pregnancy-related mortality rate for Black women that is three to four times higher than for White women. As COVID-19 case rates declined and hospitals relaxed their restrictions, some doulas found themselves subject to new hospital credentialing requirements in order to attend births, even though they serve in nonclinical roles and are hired by the birthing person rather than the hospital. This Article explores the often-contested relationship between doulas and hospitals, and between doulas and hospital-based perinatal care providers, against the historical backdrop of other restrictions on birthing companions since birth shifted from the home to the hospital around the turn of the twentieth century. It details the important role doulas play in promoting good perinatal health outcomes and considers why many hospitals and healthcare providers perceive doulas as a threat rather than as a source of value in the delivery room, which results in strategies to restrict doulas through formal and informal mechanisms. This Article suggests that hostility to doulas and restrictions on birth support reflect central qualities of mainstream perinatal care, such as liability-driven decision-making, nonadherence to evidence-based medicine, medical paternalism, and fear, all of which interfere with efforts to improve health outcomes in the midst of a maternal health crisis that disproportionately burdens communities of color. Ultimately, this Article argues that doula credentialing is a regulatory mismatch that should be abandoned by hospitals as misguided and counterproductive, and instead identifies public and private policy changes, along with related advocacy strategies, that would provide appropriate recognition of doulas within the perinatal healthcare system and serve both patient and provider interests while protecting the autonomy of doulas to operate within their scope of practice. Increased attention to the United States' maternal health crisis and the opportunity to advance healthcare reforms that incorporate lessons from the pandemic make this a critical time to prevent the widespread adoption of credentialing requirements before they become the default norm, and instead to pursue investment in growing the doula model as an efficient and effective means to improve childbirth experiences and reduce the stark racial inequities in perinatal health outcomes.

Birthing Alone

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Birthing Alone

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Abstract

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