Sexual and Reproductive Health Matters

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm21“Doulas shouldn’t be considered visitors, weshould be considered a part of [the] team”:
doula care in Georgia, USA during the COVID-19
pandemic
Daria Turner, Alyssa Lindsey, Priya Shah, Ayeesha Sayyad, Amber Mack,
Whitney S. Rice & Elizabeth A. Mosley
To cite this article: Daria Turner, Alyssa Lindsey, Priya Shah, Ayeesha Sayyad, Amber Mack,
Whitney S. Rice & Elizabeth A. Mosley (2022) “Doulas shouldn’t be considered visitors, we should
be considered a part of [the] team”: doula care in Georgia, USA during the COVID-19 pandemic,
Sexual and Reproductive Health Matters, 30:1, 2133351, DOI: 10.1080/26410397.2022.2133351
To link to this article: https://doi.org/10.1080/26410397.2022.2133351© 2022 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group
Published online: 30 Nov 2022.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=zrhm21

RESEARCH ARTICLE“Doulas shouldn’t be considered visitors, we should beconsidered a part of [the] team”: doula care in Georgia, USA
during the COVID-19 pandemic
Daria Turner,a Alyssa Lindsey,b Priya Shah,c Ayeesha Sayyad,d,e Amber Mack,fWhitney S. Rice,g Elizabeth A. Mosley h,ia Master of Public Health Student, Center for Reproductive Health Research in the Southeast (RISE), Emory University Rollins
School of Public Health, Atlanta, GA, USAb Master of Public Health Student and Graduate Research Assistant, Center for Reproductive Health Research in theSoutheast (RISE), Emory University Rollins School of Public Health, Atlanta, GA, USAc Master of Public Health Student, Center for Reproductive Health Research in the Southeast (RISE), Emory University Rollins
School of Public Health, Atlanta, GA, USAd Master of Public Health Student, Georgia State University School of Public Health, Atlanta, GA, USA
e Graduate Research Assistant, Center for Reproductive Health Research in the Southeast (RISE), Emory University Rollins
School of Public Health, Atlanta, GA, USA
f Research and Policy Analyst, Healthy Mothers, Healthy Babies Coalition of Georgia, Atlanta, GA, USA
g Assistant Professor, Center for Reproductive Health Research in the Southeast (RISE), Emory University Rollins School of
Public Health, Atlanta, GA, USAh Afﬁliate Faculty Member, Center for Reproductive Health Research in the Southeast (RISE), Emory University Rollins
School of Public Health, Atlanta, GA, USA
i Assistant Professor, Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh,
Pittsburgh, PA, USA. Correspondence: eamosle@emory.edu, eam241@pitt.edu

Abstract: Doula support improves maternal-child health outcomes. However, during the COVID-19
pandemic, hospitals restricted the number of support people allowed during childbirth. An academiccommunity research team conducted 17 in-depth interviews and structured surveys with doulas in metroAtlanta, Georgia, USA from November 2020 to January 2021. Surveys were analysed for descriptive statistics
in Stata v. 14, and interviews were analysed in Dedoose using a codebook and memo-ing for thematic
analysis. All 17 doulas reported COVID-19 changed their practices: most were unable to accompany clients todelivery (14), started using personal protective equipment (13), used virtual services (12), and had to limit the
number of in-person prenatal/postpartum visits (11). Several attended more home births (6) because birthingpeople were afraid to have their babies in the hospital. Some stopped seeing clients altogether due to safetyconcerns (2). Many lost clientele who could no longer afford doula services, and some offered pro bono
services. Most doulas pointed to restrictive hospital policies that excluded doulas and disallowed virtual
support as they felt doulas should be considered a part of the team and clients should not be forced to decide
between having their doula or their partner in the room. COVID-19 has severely impacted access to andprovision of doula care, mostly due to economic hardship for clients and restrictive hospital policies. At thesame time, doulas and their clients have been resourceful – using virtual technology, innovative payment
models, and home births. DOI: 10.1080/26410397.2022.2133351
Keywords: doula, pregnancy, childbirth, COVID-19, pandemic© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://
creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction inany medium, provided the original work is properly cited.

1

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Introduction and objectives
Doulas are non-medical, trained professionals
that provide continuous support (informational,
emotional, physical) during pregnancy, labourand childbirth, and postpartum.1–5 Doula support
is associated with improved maternal-child healthoutcomes including better birthing experiences,less likelihood of induction or augmentation
with synthetic oxytocin, shorter length of labour,
higher rates of vaginal births, lower rates of Cesarean delivery, lower use of pain medication, higher
Apgar scores, reduced postpartum depression,and increased breastfeeding.1–4,6–12 For all pregnant people – but especially those who haveexperienced trauma or are living with post-traumatic stress symptoms – trauma-informed doulacare can also reduce the risk of birth trauma or
re-traumatisation during birth.10,13,14
Doulas can also “disrupt” the social determinants of health that predispose low-income
women and women of colour to worse pregnancy-related outcomes.15 They do this by providing health education at appropriate literacy levels,
offering social support and connection toresources, respecting the client, upholding theirautonomy and agency, enhancing communication
between clients and medical providers,11,16 andresisting racism (including provider implicit bias)
in the healthcare system.15,17 Doula support isparticularly important in settings like Georgia,
USA, with high rates of and wide racial/ethnicand economic disparities within maternal andinfant mortality and morbidity.18–20 In Georgia,
Black women are three times as likely to diefrom pregnancy-related causes as White women,
and Black infants are twice as likely to die in
their ﬁrst year as White infants.19,20 Researchers
have further demonstrated that higher levels of
income inequality exacerbate racial/ethnic disparities by worsening pregnancy-related outcomesamong Black women.21 Georgia’s high levels of
income inequality,22 therefore, suggest additional
need for doula services, particularly for Black andlow-income people.
Despite overwhelming evidence about the
beneﬁts of doula support, doulas have beenbarred from many hospitals during the COVID-19
pandemic.5,17,23–27 Early on during COVID-19, hospitals implemented policies limiting the numberof visitors birthing patients were allowed to havein the labour and delivery room.5,17,23–27 Nearly
all hospitals counted doulas as visitors rather
2than as part of the healthcare team.5,17,23–27
Emergent research has examined doula careduring the COVID-19 pandemic,5,17,23–27 yetmany questions remain. The current study builds
on this existing literature and explores: changes
in doula care during the COVID-19 pandemic,
challenges faced, and solutions for improving
doula care access during the pandemic andbeyond.

Methods
This study was conceptualised, implemented, andoverseen by the Georgia Doula Access Working
Group led by the Healthy Mothers, Healthy Babies
Coalition of Georgia (HMHBGA) with representation from doulas, hospital administrators, clinicians, insurance payers, and policymakers. Suchan approach ensured doula and relevant stakeholder engagement during the generation ofresearch questions, study instruments, and conclusions from the results.
Study design, setting, and participants
To achieve our study objectives, we conducted across-sectional, observational study using concurrent mixed methods (qualitative and quantitative)
to survey and conduct in-depth interviews withdoulas (n = 17) in metro-Atlanta, Georgia. All
study procedures were reviewed and approvedby the Emory Institutional Review Board (IRB)
with exempt status on July 10, 2020 because thehuman subjects’ identities are not easily ascertained and any disclosures would not place thesubjects at risk of damages [see rule 45 CFR
46.104(d)(2i((2ii))]. Our research team included
two Faculty Researchers (one is a White full spectrum doula, the other is a Black mother), a Lead
Graduate Student Researcher (who is a Black
woman) three Graduate Student Research Assistants (one is a South Asian-American woman, one
is a Black woman, and one is a Latinx-Asian/PaciﬁcIslander woman), and a Community Partner (whois a Black woman) from the community-basedorganisation, HMHBGA. Collectively, the team represents diverse perspectives from Black womenand mothers, doulas, and community organisations serving families in Georgia, each with ourown positionality. Research team members
received training in qualitative data collection,
qualitative analysis, reﬂexivity, communityengaged research, and reproductive justice. Aftereach interview and in group meetings, theD Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

researchers were prompted to reﬂect on how theirown identities (of marginalisation or privilege)affect their approach to this work, the data collected, and their interpretations of the data.
Doulas were recruited to the study between
November 2020 and January 2021 through emails
to the Georgia Doula Access Working Group, a statewide steering committee consisting of doulas,
doula-trainers, community-based maternal andchild health organisations, reproductive justiceorganisations, policy advocates, researchers,
healthcare administrators, insurance payors, andclinicians. Doula members of the working groupwere encouraged to participate, and all members
were encouraged to share the study opportunity
with doulas in their network. Eligibility criteria
included self-identiﬁcation as a doula, experience
practising as a doula in Georgia for at least 6months, English speaking, and over 18 years ofage. Study participants were also asked to sharestudy information with other doulas within their
networks. Participants were compensated with a
US$20 gift card. Our original planned sample
size was 20 participants. We concluded interviews
and surveys after we reached thematic saturationof our qualitative data at 17 participants.
Data collection
We enrolled the 17 doulas who expressed interestin the study, after they were deemed eligible by
the screening tool and verbal consent. From October 2020 to February 2021, the survey data collection was conducted using Qualtrics and took lessthan 30 minutes to complete (see Appendix A for
the full list of survey items). The link was emailed
to participants prior to their in-depth interview.
The survey included sections on: doula demographics, personal experiences with pregnancy
and doula care, doula training, client demographics, payment and costing, scope of doula
work, building doula businesses, and beliefs
about doula services. No identifying information
was collected, and all names were replaced byanonymous participant ID numbers.
Survey measures
The survey ﬁrst measured demographics. Participants were asked about their gender, age, economic status, highest level of education, current
employment, sexual orientation, and immigration
status. Immigration status was then categorised
into not an immigrant (self, parents, and grandparents born in the US), ﬁrst-generation

immigrant (born in U.S. but not parents or grandparents), or second-generation immigrant (selfand one/more parents born in the U.S. but notgrandparents). The survey also measured changes
in doula practices during COVID-19. D Doulas wereasked if they provided virtual doula services everand if they provided doula services during
COVID-19. We also asked “How do you connect
with your clients virtually?” Finally, we asked“What platforms do you use for video calls?” Notably, we protected conﬁdentiality by not reporting
categories with a single, identiﬁable respondent.
In-depth interview domains
After the survey, participants were scheduled for a
one-hour, in-depth interview over Zoom with
the Lead Graduate Student Researcher. The interview guide included sections on: doula training,clientele, payment methods, building doulabusinesses, barriers and challenges to providing
care, experiences as doulas, and ways to improve
doula care (See Appendix B for Interview Guide).
All interviews were audio recorded and transcribed by Zoom with quality assurance from theLead Graduate Study Researcher and the two
Graduate Student Research Assistants. All identifying names were redacted and/or replaced with apseudonym.
Data analysis
Data analysis occurred from February 2021 toApril 2021. The surveys were analysed using
descriptive statistics in Microsoft Excel and Statav. 14.12 Frequencies and proportions were calculated as all variables were categorical. The indepth interviews were thematically analysedusing Dedoose.13 Transcripts were carefully
reviewed, then the researchers wrote an interview
memo for each summarising the main content
and why the interview is important for the study
and 10 emerging topics of interest. The comprehensive list of emerging topics was used to create
a comprehensive codebook. This included deductive and inductive codes about training, doula
scope of work, increasing awareness about doulas,building doula businesses, underserved populations, payment, challenges, client stories,
beneﬁts of doula care, medical outcomes, ways
to improve doula care, and COVID-19. In Dedoose,the Lead Graduate Student Researcher and two
Graduate Research Assistants then horizontally
coded all 17 transcripts using the codebook. Twocoders were assigned to individually code each3

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

transcript; the two coders then came together todiscuss and reconcile their coding to ensure consistency across transcripts and full use of the codebook. The group then developed analytic memos
for each code in order to develop themes within
and across codes. This process was supported byadditional analyses within Dedoose includingcode co-occurrence and coverage across transcripts. The Lead Graduate Student Researcher
and Graduate Student Researchers met biweekly
with one of the Research Mentors for training inqualitative analysis, quality assurance of coding,and ongoing discussion about emerging themes.

Table 1. Demographics of the doula
sample (n = 17) in Georgia.
Variable

Frequency Percent

Femalea

17

100

White

9

53

Black

7

41

Hispanic/Latinx

1

6

25–35

7

41

Results

36–45

6

35

We interviewed and surveyed a diverse sample of
17 female doulas (see Table 1). About half wereWhite (53%) and 42% were Black. Over half of participants (59%) never experienced economic difﬁculty, and 41% experienced difﬁculty in the pastor currently. About half of the doulas graduatedfrom college (47%), with about one-quarter (24%)
having an advanced degree and 29% having lessthan a college degree. Most of the doulas were
heterosexual (88%) and 12% identiﬁed as lesbian
or bisexual. Similarly, most did not identify as
immigrants (88%) and 12% were ﬁrst-generation
immigrants.
There was a wide range of experience among
the doulas (see Table 2) with 12% practicing lessthan one year and 35% practicing more thannine years. There was also a wide range in thetypes of doulas: most practice birth doula services(82%), about half practice postpartum care (53%),
and another 41% practice prenatal care. Some
doulas also offer less traditional services including
preconception doula care (29%), abortion (24%) or
full spectrum (29%) care, and death support (12%).
Some doulas self-identiﬁed as radical justice doulas, which Imani – a Black full spectrum and radical doula – described as:

46+

4

24

Prefer not to say/Currently
experiencing economic difﬁculty2

12Experienced economic difﬁcultyin the past/temporarily in the
past/historically529

Never experienced economic
difﬁculty

10

59

Technical degree/non-clinicalprofessional degree212Some college

3

18

Graduated college

847

Clinical professional degree212Graduate degree212Yes, full-time

10

49

Yes, part-time

3

18

No, not looking for employment

318No, looking for employment

16Straight/heterosexual

1588

Bisexual/Lesbian

2

12

Not an immigrant15

88First generation immigrant2

12“To me a radical justice doula is basically an advocate … Me being a black doula … I am speciﬁc to
making sure that I am advocating and I’m you
know staying up to date on legislation and politics
and how that all effects access to having a doula
and the level of concern that your elected ofﬁcials
have for the fact that mothers, especially Black
mothers are dying or Black people are dying whenthey’re giving birth … the advocacy is a part ofbeing a doula and the justice part of it.”4

Race/Ethnicity

a

Age

a

Economic status

Educationa

Employment

SexualityaaImmigration statusa

Response categories were “check all that apply”.

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Our qualitative data about doula care during
COVID-19 revealed ﬁve major themes, which we
detail below: (1) loss of clientele during COVID19, (2) restrictive hospital policies, (3) increasinghome births during COVID-19, (4) prenatal andpostpartum doula innovations, and (5) the challenges of virtual labour and delivery support.
Loss of clientele during COVID-19
Doulas reported that due to the pandemicchanges in potential clients’ ﬁnancial situations(e.g. job loss), they either lost clients or wereunable to recruit new clients. Financial hardships
caused by the pandemic greatly limited doulas’client base, which in turn negatively impacted
doulas’ ﬁnancial stability. Some doulas, including
Imani, shared how they would provide pro bono
services for clients who couldn’t afford services:“And then the other issue is just people not being able,
like I had about three contracts that had to cancel
because they, you know, we’re now on unemployment
and they couldn’t justify you know the cost … So ofcourse offering I’m not going to leave you hanging
out there, as we’ve already started. So let’s just ﬁnish
it, and we’ll do [it] for free.”Another major contributing factor to doulas’ lossof clientele was hospital policies that limited thenumber of support people allowed in the delivery
room. Potential clients did not see the value inhiring a doula if their doula could not be in thedelivery room with them. Jasmine, a Black full
spectrum doula explained,“A lot of people like, What’s the point if I can’t haveyou with me. They only see doulas as one way andthat way has been taken away. We don’t have thatway anymore. And so they are starting to feel like,what’s the point? What’s the point if you can’t be
in a hospital with me? What’s the point if you, if I
can’t do this, that, and the third?”
Restrictive hospital policies
Overall, doulas reported that restrictive hospital
protocols were one of the biggest barriers to providing care, and the restrictive hospital policies
further drove a wedge between doulas and the
medical community. Two of the most common
policies were (1) limitations on the number ofpeople allowed in the delivery room and (2)requiring proof of doula certiﬁcation. Clients delivering at hospitals that restricted the number of
support people had to make tough decisions

about whether they would have their doula ortheir partner with them during their birth.
Susan, a White full spectrum doula, and Andrea,a Black birth and postpartum doula, shared similar “sad” and “heartbreaking” stories:“I had one client who chose to, because they have
two-year-old and they wanted to have somebody
advocate, they chose to have me instead of her husband at her delivery, which was really sad.” (Susan)“Parents having to decide on if it’s going to be theirdoula or their partner in the room because a lot of
the hospitals are saying, you know, you can have
either or. You can’t have both. You have to have
either or. So, that’s been a challenge within itself
because, you know, it breaks a lot of parent’s hearts,
because of course they want their partner to be there.
So, that’s kind of discouraging.” (Andrea)
According to our participants, these policies add
an extra layer of stress on the birthing process.
Doulas explained that the policies ignore differences in the types of support provided by adoula versus a lay support person during labourand delivery. Multiple participants pointed outthat a typical lay support person does not haveexpertise about supporting people during labourand delivery.
In response to these restrictive hospital policies
some birthing people chose to switch to providers
who work at hospitals or birthing centres thatallow multiple support people. Mira, a White prenatal, birth, abortion, and death doula said, “I’ve
had a lot of people just leave their practices and go
to a hospital or practice that is allowing in-doula
support or opting for home birth.” If families
wanted a hospital birth and their doula present,
they had limited options.

Prenatal and postpartum doula innovations
While COVID-19 hospital restrictions limited inperson doula services, some doulas were able
to expand their businesses through virtual services and/or extending prenatal and postpartum
services. Twelve (71%) doulas in the study offeredvirtual services during the pandemic (see Table2). The two most popular virtual platforms were
Zoom and Facetime. The prenatal educationaland birth planning components of doulas services were relatively easy to adapt to the virtualworld. Andrea explained how she adapted to virtual care,
5

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Table 2. Doula characteristics and practice changes during COVID-19.
Variable

Frequency

Percent

Less than 1 year2

12Time as Doula

1–3 years

635More than 3 and up to 9 years

318

More than 9 years

6

35

a

Type of Doula

Preconception/Fertility

529

Prenatal

7

41

Birth

14

82

Postpartum

953

Abortion4

24Full Spectrum

529

Radical/Justice

1

6

Death

2

12

Average % of clients who are Black–

42

Average % of clients who are White–45

Demographics of Clientele

Average % of clients who are Latinx–

3

Average % of clients who are Mixed–

5

Average % of clients who are low to low-middle income–

27

Average % of clients who are middle income–

41

Average % of clients who are upper-middle to upper income

–

28

17

100

Stopped Seeing Clients2

12

Unable to Accompany to Delivery

1482

Limited Number of Prenatal/Postpartum Visits

11

65

Increase in Home Births

635

Used Personal Protective Equipment

1376

Provided Virtual Services Ever

12

71

a

12

71

Zoom

9

82

Facetime

873

Google327

Messenger

1

9

Skype

1

9

a

COVID Changed Practice

Virtual Services During COVID

a6

Response categories were “check all that apply”.

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23“Basically, I offer the same services that I would for inperson. So, instead of two prenatal visits, I would
actually do one prenatal visit and I try to get it
done with the partner as well … I do like weekly
check ins with them. So, it’s either via FaceTime or
Zoom or Skype. I’m just checking in to see how they’re
doing, or I’ll even text them just to kind of see like, youknow, ‘have you had your water for the day, or for theweek, or how are you feeling, you know, just dropping
into check on you.’ Once the baby has actually
arrived, a week later I’ll hold another session either
Skype or Zoom or FaceTime, just to kind of see how
things are going and if additional resources areneeded for the parents since they’re at home now.”
Physical touch is a key component of comfort
measures during labour and delivery, so doulas
had to ﬁnd creative ways to train their client’s support person on providing physical support such as
massage, squeezing hips, and heat/ice. Some doulas, like Mary (a White birth and postpartum
doula), started to offer virtual classes for support
people who would be at the hospital with their client. She shared,“Learn, you know how to do virtual meetings, how
to also provide more training virtually for what isessentially a hands-on job to the birthing partner.
I have been training birthing partners essentiallyto do some of the services I provide as a doula soI’ve had to ﬁgure out how do I train birthing partners and provide information to them so they canbe not only the birthing partner, but also thedoula you know in these hospitals that aren’t allowing another support person.”
Of course, there were limitations in how well thevirtual trainings translated to actual birth support.
Imani explained:“I don’t know how comfortable their support person
really is with doing it. I can’t see if they’re really
doing it right and hitting the right point.”
Doulas like Andrea also mentioned that due to theunpredictable and stressful nature of birth, thosetrainings may not be enough:“And a lot of the parents, you know, they don’tknow what to expect or what to do because it’s
like we go through all of this training, but when
the laboring starts, all of that kind of goes out of
the window.” (Andrea)
Because they were losing clientele and notallowed in most hospitals during the pandemic,

some doulas began offering postpartum services.
They emphasised that their support was needed
even more during COVID-19, when family members weren’t able to assist their clients. Mary
described how she started postpartum care, ﬁllingin for family members who could not be there:“2020 is when I began offering postpartum doula
services … supporting a family once a baby ishome and so that could look like so many different
things. I’m cooking for the family, cleaning thehome, I’m helping with bathing the baby, feeding
the baby … while the mother takes a nap. I could
help with the older children. I could come in anddo their laundry, run errands for them. Basicallylike the best grandmother, aunt, doula, friend
wrapped into one. As far as those you know sometimes you can have a really great mother or grandmother, but maybe they don’t have some of theknowledge or training, you know, as far as likebreastfeeding goes … these days of families being
very spread apart, not being able to be together,international families, my three of my four postpartum families, they were not born in the UnitedStates. And so, they were not able to have their
immediate family travel to the United States
because of COVID so I was able to come in andyou know assist them in ways that maybe theirmother or grandmother would have been able tocome in and do that kind of care for them.”
The challenges of virtual labour and delivery
supportGiven the importance of evidence-based doulacare and the limitations of training alternative
support people, some doulas also began offering
virtual labour and delivery support. When a clientarrives at the hospital, the doula connects with theclient and their support person virtually via phoneor video. However, many hospitals were resistantto having doulas on the phone during labourand delivery. Imani recounted this story, where
she was not allowed to provide virtual care toher client:“I had an issue where my client, they told her toturn off the phone on her support person … They
would not allow me to support her through thepushing phase and they said, we can’t video record.
They’re like, oh, we’re not recording this is our doula
via FaceTime. They were like no, you have to shut
off the phone off sir, please turn off the phone.
And I’m like, wait what, so I’m like, go ahead and7

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

turn it off, it’s ﬁne. I don’t want you to just missanything that’s not but just, you know, call me
when it’s over. He called me when it was over andthey still asked them to turn off the phone. No,
no real reason or logic behind it, or policy that I
could ﬁnd, but they just wouldn’t allow me to support my client during this most trying sometimes
part of the labor process.”
Doulas described how this situation and restrictive hospital policies demonstrate the divide
between healthcare providers and doulas. Participants explained that providers’ and administrators’ misconceptions and lack of awarenessabout doulas leads them to believe that doulas
are neither essential, nor part of the care team.
Susan asserted,“The hardest part has been a lot of hospitals shutting down and even though I guess it’s the AWHONN[Association of Women’s Health, Obstetric and Neonatal Nurses] had written that letter stating that …
doulas shouldn’t be considered visitors, we should
be considered part of the care team.”
Increasing home births during COVID-19
Due to hospital restrictions and fears about being
in the hospital during a pandemic, birthingpeople are opting more for home births. Six doulas (35%) reported an increase in the number ofhome births they supported during the pandemic(Table 2). One doula, Denise (a Black prenatal andbirth doula) mentioned that the midwives she
normally refers clients to for home births were
fully booked,“Um, I have been referring couples to more homebirth midwives. And a few of the home birth midwives that I know have never been full for awhole year. Like I had a home birth midwife in
April, she was book for the whole year and that’s
never happened before.”
Doulas explained that while home births are an
option to avoid hospitals during the pandemic,
they may not be accessible to some birthingpeople because they are expensive and not normally covered by insurance in Georgia. One
doula, Jasmine, described some concerning
methods families were using to avoid the highﬁnancial costs associated with home births including unassisted births:“And so what I have actually been noticing is a lot of
women are choosing unassisted home birth. So they8

don’t they can’t afford a midwife, so they opt out of
having a midwife to have a doula there and of course
we don’t work in the capacity as a midwife.”
These scenarios put doulas (and birthing people)
in compromising and high-risk positions. With
such clients, Jasmine always makes it clear that
she is not a medical professional and that she is
not able to deliver their baby. She also educatesthese families about the importance of having
medical assistance during birth, but she is scaredand frustrated that this is their only option:“I know the reasons they’re choosing to do it, they’rechoosing to do because they’re afraid to have to bethey’re afraid to have their babies in the hospitaland they’re afraid to be in the hospital with no one
there to advocate for them, but they cannot afford
a midwife. They can’t afford $3000 $4,000 to havesomeone come to their home. So they’re choosing
the less costly option for them. And that scares me
because that shouldn’t be why, you shouldn’t choose
to have this birth because you just can’t afford to do it
any other way. You should be choosing it because
that’s what you vision for your birth.”

Discussion
The current study discusses one aspect of a community-engaged, mixed methods investigation of doulacare in Georgia during the COVID-19 pandemic. The
research team, including a community partner from
HMHBGA and a doula from the Georgia Doula
Access Working Group, surveyed and interviewed
17 doulas from metro-Atlanta, Georgia about thescope of doula work, barriers and challenges ofbuilding doula business, beneﬁts of doula care,and COVID-19. Notably, the ﬁndings and implications of this study must be considered in the context of its limitations. This study reﬂects theexperiences of a relatively small purposive sample
of doulas in metro-Atlanta, which means the results
are not meant to be generally representative (e.g. tothe entire country, to rural areas, to the perspectivesof doula clients) nor do they prove causation.
COVID-19 dramatically changed the landscape of
doula care and forced doulas and their clients toinnovate in new ways. During the pandemic, doulas
have experienced a signiﬁcant loss of clientele –either because of their own fears about COVID-19,
clients’ ﬁnancial hardships, or restrictive hospital
policies that force birthing people to choose only
one labour support person.17,23,28–31 In response,
doulas in our sample and from other studies have

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

innovated with virtual prenatal services, virtual
labour support (where possible), training the client’s
support person in basic birthing techniques, shifting
to home births, and expanding to postpartum services. Through this adaptive support, doulas areworking to mitigate the harmful effects of COVID19 on pregnancy, birth, and early parenting, particularly for their clients of colour and low-income
clients most affected by COVID-19 and its economic
consequences.
Yet our study and several others17,23,28–31 havealso documented restrictive hospital policies andprotocols during COVID-19 that limit the numberof birthing support people to the exclusion of doulas and detriment of patients. At the beginning of
the pandemic, some areas – most notably
New York City – forbade any support person toenter the labour and delivery room during childbirth, leaving birthing patients isolated andscared.28 Luckily these prohibitive policies were
relaxed over the course of the pandemic, andmost hospitals began allowing one support person
to attend a birth. Of course, this forced birthing
patients to choose between their support person(e.g. partner, mother) and their doula. Such policies ignore the vast health beneﬁts of doulas,8,32
which have been identiﬁed as the “essential ingredient”33 for signiﬁcantly improved birth outcomes
above and beyond the psychological beneﬁts of
having a lay support companion such as a malepartner – and the particular importance of
doula care during a pandemic.
Further, these policies delineate doulas as outside of the maternity care team, despite widespread evidence and calls to integrate doulas as
essential maternity care team members from theAmerican College of Obstetrics and Gynecology(ACOG) and others.34 Similar exclusion of doulas
from the maternity care team has been extensively documented in the literature, even prior
to COVID-19.11,16,35–37 Restrictive policies during
COVID-19 seem to exacerbate pre-existing tensions
between doulas and clinical care team members(e.g. doctors, nurses), who already misunderstandthe role and value of doulas.4,35,38 Researchers
have previously explained how doulas approach
pregnancy and childbirth in a holistic way thatcan conﬂict with the medical model of birth, particularly in hospitals.36–40 In fact, our ﬁnding that
hospitals were requiring doulas to have certiﬁcation in order to attend births during COVID ispart of a larger trend toward the professionalisation (and opponents would argue medicalisation)of doulas. While doula certifying bodies seek tostandardise doula training and the scope ofwork, critics note that mainstream certiﬁcation
trainings and procedures are not culturally sensitive. Traditional, holistic doulas serving lowincome communities of colour are less likely toaccess certiﬁcation and therefore more likely to
be excluded by hospital policies requiring certiﬁcation. Regardless of certiﬁcation status, doulas
are lower in the social hierarchy within medical
settings, meaning they have less power than clinicians and must, therefore, carefully navigate theirinterprofessional relationships so as to be allowed
to remain in the birthing space.36 This doula
exclusion is particularly troubling for Black,
Latinx, and other birthing people of colour who
experience racism, obstetric violence,41 poor
birth outcomes, and maternal mortality at higher
rates than White women, and who stand to beneﬁt
more from doula support.15,17,29 Moving forward,
hospital policies need to identify doulas as essential maternity care team members, who areallowed full access to their clients while at the hospital.29 Reparative work will be needed to establish
healthy working relationships between doulas andclinical care providers, in order to provide patientcentred, integrative and high-quality care.
The observed shift in doula work to virtual services during the pandemic echoes previous ﬁndings from studies here in the U.S andglobally.23,28–30 In Rivera’s23 study on Black and
Latinx community-based doulas in Central
New York, she found that doulas began offering
Zoom virtual childbirth classes, and some still provided virtual labour and delivery support. Other
studies have documented doulas’ attempts (andchallenges) providing postpartum support suchas lactation counselling.30 Yet there are major barriers to providing adequate virtual doula support
including hospital policies against the use ofvideo equipment, inequitable doula and client
access to technology, and the need for additional
doula training in virtual care provision.23,29 Ogunwole and colleagues29 explain that while hospitalbased and institutionally-funded doula programs
have the infrastructure and resources to provide
virtual doula services, community-based doulas
and organisations (who are more likely to serve
low-income and pregnant people of colour)
struggled to transition to virtual services. This
study and others observed that even when doulas
had the capacity to provide virtual services, medical staff created barriers to them holding space
9D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

with their clients by physically shutting down
computers or preventing the use of other devices
during labour.5,26 Moreover, doulas themselves
have emphasised their discomfort switching to virtual services because “touch is so important” andintegral to doula care.30(p.5)
Increasing demand for home births during
COVID-19 has contributed to and possibly accelerated the shift in birth location away from hospitals
and toward birth centres and home birth. Since
2004, the percentage of planned midwife-assisted
home births in the U.S. has steadily increased by
85% from 0.9% in 2004 to 1.61% in 2017,42 andmaternity care leaders – including the American
College of Obstetrics and Gynecology – haveacknowledged that midwife-attended home birthis a safe option for low-risk pregnancies.43
Granted, those organisations ﬁrmly maintainthat hospitals are the safest location for birthduring the COVID-19 pandemic.43 However, likethe current study, other birth research during
the COVID-19 pandemic documented similar
increases in the demand for and use of homebirth. Searcy and Castañeda found that, globally,
doulas saw an increase in requests for homebirth support since the beginning of COVID-19.26
Davis-Floyd and colleagues28 documented anincreased interest in home birth during COVID19 using their rapid-assessment in the U.S. fromMarch-April 2020. Reyes31 also noted a surge inhomebirths during her study of birth workers in
Puerto Rico during quarantine, as did Oparahand colleagues30 in their virtual communitybased study of Black birth workers during
COVID-19. Rivera23 similarly noted greater use ofhome births in New York during COVID-19, butemphasised barriers to skilled birth attendance,
including a dearth of midwives who attend
home births. In our study, we heard from one
doula about community-based doulas who arebeing expected by their clients to attend births
alone without a midwife – so-called “freebirth.”28This is because clients are afraid to birth at thehospital, because of COVID and/or being alone
without an advocate, yet they cannot afford athome midwifery care. Other researchers have
similarly reported an increase in freebirths during
COVID due to ﬁnancial constraints and fears ofbirthing in the hospital, as reported by doulas,
midwives, and obstetricians. Prior to the pandemic, some people chose freebirth intentionally,
but now COVID and economic insecurity appear to
be driving people to this decision.28
10

COVID-19 lays bare the fragmented and often
racist maternity care system here in the U.S.,
and the exclusion of doulas from hospital-basedmaternal health care teams is only one
example of systemic care fragmentation andracism.17,28–30 Other research has already indicatedthe concern doulas feel about hospital policies
regarding doulas as visitors extending beyond the
pandemic, and what it means for the maternal outcomes, particularly of marginalised mothers.24,26,27
Overwhelming evidence shows how Black, Latinx,
and Indigenous women experience obstetric racism
during hospitalised births,41,44,45 and doula care is
one of few practices shown to mitigate that racism
and violence.15,17,29 As Davis describes it, obstetricracism “lies at the intersection of obstetric violence
and medical racism”.46,47(p. 561) It is systemic violenceby physicians, nurses, and other medical professionals (through policies, within institutions, andinterpersonally) against people of colour with regard
to their reproductive capacities. For example, Black
women are ﬁnding their concerns about pregnancy
complications are not being taken seriously and arethen being blamed for resulting negative birth outcomes.47 Obstetric racism is rooted in gendered,racialised ideologies such as stratiﬁed reproduction(valuing the reproduction of White and afﬂuent communities over non-White and non-afﬂuent communities),48 stereotypes of Black patients (e.g. noncompliant), and dehumanisation of Black bodies(e.g. beliefs they are less sensitive to pain).46,47
Given their role as patient advocates – tasked to support pregnant, birthing, and postpartum patients’autonomy – doulas are well-poised to disrupt andprevent obstetric racism.15,47 In their research with
low-income women of colour, Kozhimannil and colleagues15 have previously described how doulas
interrupt negative social determinants of health bysupporting agency, personal security, respect, knowledge, and connectedness. In turn, the exclusion of
doulas from hospitals may enable obstetric racismand maintain or exacerbate current racial/ethnic
inequities in maternal and child health outcomes.
Implications
Used to being adaptive and resourceful, many
doulas can offer prenatal and postpartum services
virtually, but for some doulas and clients this is
not ideal. Working virtually prevents doulas from
attending prenatal visits as they often do otherwise, which eliminates opportunities for thedoula and maternity care team to become familiar, establish roles, and work together as an

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

integrative care team. If virtual services continue
to be desired by clients, doulas will need to be
trained and supported on various technology platforms. As Rivera reported, Syracuse-based reproductive justice organisation Village BirthInternational is providing trainings to community-based doulas on virtual technology for
doula care,23 and other organisations could follow
suit.
The policy implications of this study are multifold. They include (1) state-level reimbursementfor doula care among low-income women; (2) hospital-level policies that recognise doulas as essential
members of the maternity care team; and (3) organisational support for doulas. State-level reimbursement for doula care, either through Medicaid orcommunity health worker programs, would ensure
the most vulnerable and economically disadvantaged women have access to this life-saving service.49,50 At the hospital level, administrators andclinicians should be educated and mobilised on
the importance and value of doula care so theycan enact policies that integrate and respect doulas.
And professional organisations such as the American College of Obstetricians and Gynecologists aswell as the American College of Nurse-Midwives
should make clear position statements that support
integration of doulas as essential members of thematernity care team, particularly during the
COVID-19 pandemic.
Moreover, doulas need to be supported to continue their “advocacy” and “justice” doula work,
even during COVID-19. In order to address racismin maternity care and racial disparities inmaternal and infant outcomes, some doulas –particularly community-based doulas; Black,
Latinx, and Indigenous doulas; LGBTQ doulas;and self-identiﬁed “radical doulas” – groundtheir work in the birth justice movement, whichaims to “dismantle inequalities of race, class, gender, and sexuality that lead to negative birthexperiences,”30(p. 2),45 and the larger reproductive
justice movement.17,23,29,30,51–54 During the
COVID-19 pandemic and post-pandemic aftermath, birth and reproductive justice doulas frommarginalised communities are more needed
than ever before, particularly given the evidence
that doula advocates often drive policy change.55

The current study highlights important lessons
and potential opportunities for future research. In
the realm of maternal and child health during
COVID-19, research needs to be communityengaged, where those most affected have an
equal voice from beginning (conceptualisation)
to end (dissemination). Future studies need todevelop and demonstrate effective integration of
doulas into maternity care teams, moving beyond
documentation of challenges and barriers, whichhave been established. Finally, researchers need
to focus on racial equity including racial differences in the access to and experience of doulacare during COVID-19.
Acknowledgements
The authors would like to thank the Georgia Doula
Access Working Group for their support and oversight. Authors contributions: EAM, DT, AM conceived of the research idea and designed thestudy; EAM and WSR secured funding for the
study; EAM trained DT, AL, and PS in qualitative
research methods; AM facilitated participant
recruitment; DT conducted all interviews and surveys; DT, AL, PS analysed qualitative transcripts;
EAM analysed survey data; DT, EAM wrote ﬁrst
draft of manuscript; AL, PS, AM, and WSR provided
edits and revisions.
Disclosure statement
EAM serves as an evaluation consultant for Healthy
Mothers Healthy Babies Coalition of Georgia on the
Medicaid doula pilot project. No other potential
conﬂicts of interest were reported by the authors.
Funding
Anonymous Foundation through the Center for
Reproductive Health Research in the Southeast(RISE). This work was also made possible throughthe support of Collaborative for Gender and Reproductive Equity, a sponsored project of Rockefeller
Philanthropy Advisors.
ORCID
Elizabeth A. Mosley9534-2457

http://orcid.org/0000-0001-

11

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

References
1. Klaus MH, Kennell JH, Klaus PH. The doula book: how a
trained labor companion can help you have a shorter,
easier, and healthier birth. Da Capo Press; 2002.
2. Hunter C. Intimate space within institutionalized birth:
women’s experiences birthing with doulas. Anthropol Med.
2012;19(3):315–326. DOI:10.1080/13648470.2012.692358
3. Morton C, Clift E. Birth ambassadors: doulas and the reemergence of woman-supported birth in America.
Praeclarus Press, LLC; 2014.
4. Hunter CA, Hurst A. Understanding doulas and childbirth:
women, love, and advocacy. Palgrave Macmillan; 2016.
5. Castañeda AN, Searcy JJ. Practising intimate labour: birth
doulas respond during COVID-19. Anthropol Action.
2021;28(1):21–24. DOI:10.3167/aia.2021.280104
6. Bohren M, Hofmeyr G, Sakala C, et al. Continuous support
for women during childbirth. Cochrane Database Syst Rev.
2017;7. DOI:10.1002/14651858.CD003766.pub6
7. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support
for women during childbirth. Cochrane Database Syst Rev.
2012;10:CD003766. DOI:10.1002/14651858.CD003766.pub4
8. Steel A, Frawley J, Adams J, et al. Trained or professional
doulas in the support and care of pregnant and birthing
women: a critical integrative review. Health Soc Care
Community. 2015;23(3):225–241. DOI:10.1111/hsc.12112
9. Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on
healthy birth outcomes. J Perinat Educ. 2013;22(1):49–58.
DOI:10.1891/1058-1243.22.1.49
10. Simkin P, Klaus P. When survivors give birth: understanding
and healing the effects of early sexual abuse on
childbearing women. 1st ed. Quality Code Pub; 2004.
11. Thurston LAF, Abrams D, Dreher A, et al. Improving birthand breastfeeding outcomes among low resource womenin Alabama by including doulas in the interprofessional
birth care team. J Interprof Educ Pract. 2019;17:100278.
DOI:10.1016/j.xjep.2019.100278
12. Castañeda AN, Searcy JJ. Doulas and intimate labor:boundaries, bodies, and birth. Demeter Press; 2015.
13. Mosley EA, Lanning RK. Evidence and guidelines fortrauma-informed doula care. Midwifery. 2020;83:102643.
DOI:10.1016/j.midw.2020.102643
14. Fairley K. Trauma-informed birth support. Kenya the Doula;
2019. Available from: https://www.kenyathedoula.com/
trauma-informed-birth
15. Kozhimannil KB, Vogelsang CA, Hardeman RR, et al.
Disrupting the pathways of social determinants of health:doula support during pregnancy and childbirth. J Am Board
Fam Med. 2016;29(3):308–317. DOI:10.3122/jabfm.2016.
03.150300
16. Gilliland AL. Beyond holding hands: the modern role of theprofessional doula. J Obstet Gynecol Neonatal Nurs.
2002;31(6):762–769. DOI:10.1177/0884217502239215

12

17. Salinas J, Salinas M. Commentary: systemic racism inmaternal health care: centering doula advocacy for womenof color during COVID-19. Fam Community Health.
2021;44(2):110–111. DOI:10.1097/FCH.
0000000000000293
18. Healthy Mothers, Healthy Babies Coalition of Georgia.
State of the state report. Healthy Mothers, Healthy
Babies Coalition of Georgia; 2019. [cited 2020 Aug 6].
Available from: http://hmhbga.org/wp-content/
uploads/2019-HMHBGA-State-of-the-State-ReportFINAL.pdf
19. Department of Public Health Maternal Mortality Review
Committee. Maternal mortality report (2014). Departmentof Public Health; 2019. [cited 2021 May 3]. Available from:https://dph.georgia.gov/document/publication/maternalmortality-2014-case-review/download
20. Georgia Department of Public Health. Reducing InfantMortality Georgia. Annual report; 2013. Available from:https://dph.georgia.gov/sites/dph.georgia.gov/ﬁles/MCH/
RIM_Ga_2013report.pdf.
21. Vilda D, Wallace M, Dyer L, et al. Income inequality andracial disparities in pregnancy-related mortality in the US.
SSM - Population Health. 2019;9:100477. DOI:10.1016/j.
ssmph.2019.100477
22. U.S. Census Bureau. United States Census: explore data.
Data.Census.Gov.; 2021. [cited 2021 July 11]. Available
from: https://data.census.gov/cedsci/
23. Rivera M. Transitions in black and Latinx community-based
doula work in the US during COVID-19. Front Sociol.
2021;6:611350. DOI:10.3389/fsoc.2021.611350
24. Castañeda AN, Searcy JJ. Shifting landscapes of belonging:birth doulas and COVID-19. Pract Anthropol. 2020;42(4):5–10. DOI:10.17730/0888-4552.42.4.5
25. Vázquez-Xu S. From the Epicenter. At the apex: adispatch about birth and COVID-19 from New Yorkcity. City Soc. 2021;33(2):ciso.12330. DOI:10.1111/ciso.
12330
26. Searcy JJ, Castañeda AN. On the outside looking in: aglobal doula response to COVID-19. Front Sociol.
2021;6:613978. DOI:10.3389/fsoc.2021.613978
27. Adams C. Pregnancy and birth in the United States during
the COVID-19 pandemic: the views of doulas. Birth.
2022;49(1):116–122. DOI:10.1111/birt.12580
28. Davis-Floyd R, Gutschow K, Pregnancy SD. Birth and the
COVID-19 pandemic in the United States. Med Anthropol.
2020;39(5):413–427. DOI:10.1080/01459740.2020.
1761804
29. Ogunwole SM, Bennett WL, Williams AN, et al. Doulas and
COVID-19: addressing structural and institutional barriers
to maternal health equity. Perspect Sex Repro H. 2020;52(4):199–204. DOI:10.1363/psrh.12169

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23
30. Oparah JC, James JE, Barnett D, et al. Creativity, resilienceand resistance: black birthworkers’ responses to the
COVID-19 pandemic. Front Sociol. 2021;6:636029. DOI:10.
3389/fsoc.2021.636029
31. Reyes E. Born in captivity: the experiences of Puerto Rican
birth workers and their clients in quarantine. Front Sociol.
2021;6:613831. DOI:10.3389/fsoc.2021.613831
32. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support
for women during childbirth. In: Cochrane Database of
Systematic Reviews, editor. The cochrane collaboration.
John Wiley & Sons,; 2013. DOI:10.1002/14651858.
CD003766.pub5
33. Klaus M, Kennell J. The doula: an essential ingredient ofchildbirth rediscovered. Acta Paediatr. 1997;86(10):1034–1036. DOI:10.1111/j.1651-2227.1997.tb14800.x
34. American College of Obstetricians and Gynecologists.
ACOG Committee Opinion No. 766. Approaches to limit
intervention during labor and birth. Obstet Gynecol.
2019;133(2):e164–e173. DOI:10.1097/AOG.
0000000000003074
35. Lucas L, Wright E. Attitudes of physicians, midwives, andnurses about doulas: a scoping review. MCN Am J
MaternChild Nurs. 2019;44(1):33–39. DOI:10.1097/NMC.
0000000000000488
36. Adams C, Curtin-Bowen M. Countervailing powers in thelabor room: the doula–doctor relationship in the UnitedStates. Soc Sci Med. 2021;285:114296. DOI:10.1016/j.
socscimed.2021.114296
37. Adams ED, Bianchi AL. Can a nurse and a doula exist in thesame room? Int J Childbirth Educ. 2004;19(4):5.
38. Neel K, Goldman R, Marte D, et al. Hospital-basedmaternity care practitioners’ perceptions of doulas. Birth.
2019;46(2):355–361. DOI:10.1111/birt.12420
39. Deitrick L, Draves P. Attitudes towards doula support
during pregnancy by clients, doulas, and labor-anddelivery nurses: a case study from Tampa, Florida. Hum
Organ. 2008;67(4):397–406. DOI:10.17730/humo.67.4.
cj1v43277p63vu35
40. Norman BM, Rothman BK. The new arrival: labor doulas
and the fragmentation of midwifery and caregiving. In:
Wendy Simonds, Barbara Katz Rothman, Bari Meltzer
Norman, editors. Laboring on: birth in transition in the
United States. Taylor & Francis Group; 2007, p. 251–282.
41. Garcia LM. A concept analysis of obstetric violence in the
United States of America. Nurs Forum. 2020;55(4):654–663. DOI:10.1111/nuf.12482
42. MacDorman MF, Declercq E. Trends and state variations in
out-of-hospital births in the United States, 2004-2017.
Birth. 2019;46(2):279–288. DOI:10.1111/birt.12411
43. Daviss BA, Anderson DA, Johnson KC. Pivoting to childbirth
at home or in freestanding birth Centers1 in the US during

COVID-19: safety, economics and logistics. Front Sociol.
2021;6:618210. DOI:10.3389/fsoc.2021.618210
44. SisterSong, National Latina Institute for Reproductive
Justice, Center for Reproductive Rights. Reproductive
injustice: racial and gender discrimination in U.S. HealthCare. Center for Reproductive Rights; 2014 Available from:http://tbinternet.ohchr.org/Treaties/CERD/Shared%
20Documents/USA/INT_CERD_NGO_USA_17560_E.pdf
45. Black Women Birthing Justice. What is birth justice? Black
Women Birthing Justice; 2021. [cited 2021 Jun 3].
Available from: https://www.blackwomenbirthingjustice.
com/birth-justice
46. Scott KA, Davis D. Obstetric racism: naming and identifying
a way out of black women’s adverse medical experiences.
Am Anthropol. 2021;123(3):681–684. DOI:10.1111/aman.
13559
47. Davis DA. Obstetric racism: the racial politics of pregnancy,
labor, and birthing. Med Anthropol. 2019;38(7):560–573.
DOI:10.1080/01459740.2018.1549389
48. Colen S. “Like a mother to them”: stratiﬁed reproduction
and West Indian childcare workers and employers in
New York. In: Faye D. Ginsburg, Rayna Rapp, editors.
Conceiving the new world order: the global politics ofreproduction. Oakland, CA: University of California Press;
1995, p. 78–102.
49. Kozhimannil KB, Hardeman RR, Attanasio LB, et al. Doulacare, birth outcomes, and costs among medicaid
beneﬁciaries. Am J Public Health. 2013;103(4):e113–e121.
DOI:10.2105/AJPH.2012.301201
50. Mehra R, Cunningham SD, Lewis JB, et al.
Recommendations for the pilot expansion of medicaid
coverage for doulas in New York state. Am J Public
Health. 2019;109(2):217–218. DOI:10.2105/AJPH.2018.
304797
51. Ross, L. (2020). Understanding Reproductive Justice. In C.
McCann, S. Kim, & E. Ergun (Eds.), Feminist Theory Reader(5th ed., pp. 77–82). Routledge. https://doi.org/10.
4324/9781003001201-11
52. Ross L, Solinger R. Reproductive justice: an introduction.
Vol. 1. Oakland, CA: University of California Press;
2017.
53. Luna Z, Luker K. Reproductive justice. Annu Rev Law Soc
Sci. 2013;9(1):327–352. DOI:10.1146/annurev-lawsocsci102612-134037
54. Pérez M. The radical doula guide. A political primer for full
spectrum pregnancy and childbirth support; 2012.
55. Basile, M. R. (2012). Reproductive Jusitce and Childbirth
Reform: Doulas as Agents of Social Change. Available
from: https://iro.uiowa.edu/esploro/outputs/doctoral/
Reproductive-justice-and-childbirth-reform-doulas/9983776600802771

13

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Résumé
Le soutien des doulas est bénéﬁque pour la santématernelle et infantile. Néanmoins, pendant lapandémie de COVID-19, les hôpitaux ont limité
le nombre d’accompagnants autorisés pendantl’accouchement. De novembre 2000 à janvier
2021, une équipe de recherche universitaire etcommunautaire a mené 17 entretiens approfondis et des enquêtes structurées avec des doulas
dans la région métropolitaine d’Atlanta, Géorgie,
États-Unis d’Amérique. Les enquêtes ont été analysées pour en tirer des statistiques descriptives
dans Stata v.14 et les entretiens ont été analysés
avec Dedoose à l’aide d’un manuel de codage etla préparation de notes pour l’analyse thématique. Les 17 doulas ont indiqué que la COVID19 avait changé leurs pratiques : la plupartn’ont pu accompagner leurs clientes jusqu’à l’accouchement (14), ont commencé à utiliser unéquipement de protection individuelle (13), ont
eu recours à des services virtuels (12) et ont dûlimiter le nombre de visites prénatales/postnatales en personne (11). Plusieurs d’entre elles
ont accompagné davantage de naissances à domicile (6) car les mères avaient peur d’accoucher àl’hôpital. Certaines ont complétement arrêté devoir leurs clientes car elles craignaient pour leursécurité (2). Beaucoup ont perdu des clientes qui
ne pouvaient plus se permettre de payer les services d’une doula et certaines d’entre elles ont
assuré des services gratuitement. La plupart desdoulas mis en évidence les politiques hospitalières restrictives qui excluaient les doulas etempêchaient le soutien virtuel ; à leur sens, lesdoulas auraient dû être considérées comme faisant partie de l’équipe et les clientes n’auraientpas dû être obligées de choisir entre la présencede leur doula ou de leur partenaire en salle d’accouchement. La COVID-19 a eu de graves répercussions sur l’accès aux soins prodigués par lesdoulas, principalement en raison des difﬁcultéséconomiques des clientes et des politiques hospitalières restrictives. Dans le même temps, les doulas et leurs clientes ont fait preuve d’ingéniosité
en ayant recours à la technologie virtuelle, à desmodèles de rémunération novateurs et aux naissances à la maison.

14

ResumenEl apoyo de doulas mejora los resultados desalud materno-infantil. Sin embargo, durante la
pandemia de COVID-19, los hospitales restringieron el número de personas de apoyo permitidas durante el parto. Un equipo de investigación
académica-comunitaria realizó 17 entrevistas aprofundidad y encuestas estructuradas con doulas
en metro-Atlanta, Georgia, EE. UU., entre noviembre de 2020 y enero de 2021. Las encuestas fueron
analizadas para extraer estadísticas descriptivas
en Stata v. 14 y las entrevistas fueron analizadas
en Dedoose utilizando un libro de códigos y la elaboración de memorandos para análisis temático.
Las 17 doulas informaron que COVID-19 cambió
sus prácticas: la mayoría de ellas no pudieron
acompañar a sus clientas durante el parto (14),empezaron a usar equipo de protección personal(13), utilizaron servicios virtuales (12) y tuvieron
que limitar el número de consultas de atención
prenatal/posparto presenciales (11). Varias atendieron más partos domiciliarios (6) porque las clientas temían tener su bebé en el hospital. Algunas
dejaron de atender a clientas por preocupaciones
de seguridad (2). Muchas perdieron clientela que
ya no podía pagar por los servicios de una doulay algunas ofrecieron servicios gratuitos. La
mayoría de las doulas señalaron políticas hospitalarias restrictivas que excluían a las doulas y no
permitían el apoyo virtual, dado que ellas creíanque deberían ser consideradas como parte delequipo y que las clientas no deberían verse obligadas a decidir entre estar acompañadas en el
cuarto por su doula o por su pareja. COVID-19
ha afectado marcadamente la accesibilidad y laprovisión de atención por doulas, en gran partedebido a las diﬁcultades económicas de las clientas y a políticas hospitalarias restrictivas. Al mismo
tiempo, las doulas y sus clientas han sido ingeniosas, utilizando tecnología virtual, modelos depago innovadores y partos domiciliarios.

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Appendix A. Survey Instrument
Study ID: ____________
Demographics
1. With which of the following races/ethnicities do you identify? Check all that apply:□ Black or African American□ Hispanic or Latinx□ Asian or Paciﬁc Islander□ American Indian, Alaskan Native, or Native Hawaiian□ Biracial or Multiracial□ White□ Other (specify) ______________________________□ Prefer not to answer
2. How old are you in years?
□ Under 25□ 25-35□ 36-45□ 46-55□ Over 55
3. Have you had difﬁculty affording necessities such as education costs, food, clothing, transportation, housing, and medical care? Check all that apply□ Yes, currently□ Yes, in the recent past (within 3 years)□ Yes, in the past for a limited period of time (for example, while I was a student)□ Yes, historically throughout my life
□ No
□ Prefer not to answer
4. Are you currently employed? Check all that apply□ Yes, full-time□ Yes, part-time□ No, not looking for employment□ No, looking for employment
5. What is the highest level of education you have completed?
□ High School□ Some college□ Graduated college□ Graduate degree (e.g., MPH, PhD)
□ Clinical professional degree (e.g., RN, LPN, MD, PA)□ Non-clinical professional degree (e.g., GED)
□ Other (specify) __________________
6. With which of the following genders do you identify? Check all that apply:□ Female/woman□ Male/man□ Transgender□ Genderqueer□ Nonbinary□ Self-identify (please specify): ____________________□ Prefer not to answer
15

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

7. What is your sexual orientation? Check all that apply:□ Lesbian□ Gay□ Bisexual□ Queer□ Straight or heterosexual□ Don’t know/questioning□ Prefer to self-describe_________________________□ Prefer not to answer
8. What language do you primarily speak at home? Check all that apply:□ Arabic□ Chinese (Cantonese, Mandarin, others)□ English□ French or French Creole□ German□ Hindi□ Korean□ Spanish□ Tagalog□ Vietnamese□ Other (Specify): _______________
9. What is your immigration generation status? Check all that apply□ My parents and grandparents were born in the United States□ One or more of my grandparents were born in the United States□ One or more of my parents were born in the United States□ I was born in the United States□ Prefer not to answer
10. In which Georgia county do you reside?________________
Pregnancy Information
11. Have you ever been pregnant?
□ No → Go to introduction to doula work and training□ Yes→ Go to 11.1
11.1. How many times have you been pregnant?
□1
□2
□3
□4
□ 5 or more
11.2 How many live children do you have? ______________
11.3 For any of the pregnancies you mentioned above, did you have a doula?
□ No→ Go to introduction to doula work and training□ Yes → Go to personal experiences with doulas section

16

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Personal Experience with Doulas
For these questions, consider the last time you had a doula:
12. What type of doula services did you receive? Check all that apply□ Birth doula□ Postpartum doula□ Prenatal doula□ Abortion doula□ Full Spectrum doula□ Radical/Justice doula□ Death/Grief/Loss/Bereavement doula□ Prison doula
13. How satisﬁed were you with those doula services?
□ Very unsatisﬁed□ Unsatisﬁed□ Neutral□ Satisﬁed□ Very satisﬁed□ Mixed feelings (Explain: ______________________________________________)
14. How valuable were their services?
□ Not valuable at all□ Mostly not valuable□ Neutral□ Somewhat valuable□ Very valuable
15. How did the doula affect your anxiety about the pregnancy?
□ Negatively affected, increased anxiety□ No effect□ Positively affected, decreased anxiety
16. How did the doula affect your pain during childbirth?
□ Negatively affected, increased pain
□ No effect□ Positively affected, decreased pain
17. How did the doula affect your empowerment during the pregnancy?
□ Negatively affected, decreased empowerment□ No effect□ Positively affected, increased empowerment
18. Did you have any negative experiences with your doula?
□ No□ Yes: Please explain_____________________________________
19. Would you want a doula again?
□ No
□ Yes

17

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Introduction to Doula Work and Training
20.How long have you been a doula?_____ Years ________Months
21. What kind of doula do you identify as? Check all that apply□ Birth doula□ Postpartum doula□ Prenatal doula□ Abortion doula□ Full Spectrum doula□ Radical/Justice doula□ Death/Grief/Loss/Bereavement doula□ Prison doula□ Other (Specify): ____________
22. What, if any, doula training have you completed?
□ Doulas of North America (DONA) International□ CAPPA Childbirth and Postpartum Professional Association□ ALACE – Association of Labor Assistants and Childbirth Educators□ BirthWorks International□ Childbirth International□ HypnoBirthing□ N/A□ Other (Specify): _________
23. What, if any, doula certiﬁcationhaveyou completed?
□ Doulas of North America (DONA) International□ CAPPA Childbirth and Postpartum Professional Association□ ALACE – Association of Labor Assistants and Childbirth Educators□ BirthWorks International□ Childbirth International□ HypnoBirthing□ N/A□ Other (Specify): _________
24. How would you describe your yearly load?
□ Fewer than preferred□ Actual number preferred□ More than preferred□ Don’t know
25. How many clients (of each kind) have you been a doula for?
□ Birth doula clients_____□ Postpartum doula clients_____□ Prenatal doula clients_____□ Abortion doula clients_____□ Full Spectrum doula clients_____□ Radical/Justice doula clients_____□ Death/Grief/Loss/Bereavement doula clients_____□ Prison doula clients_____

18

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

Client Demographics: For the answers to each of these questions please estimate a percent for eachdemographic group (scroll over for 100% option)
26. Estimate the racial/ethnic breakdown (in percentage) of your clients (total in column should add
up to 100)

10 20 30 40 50 60 70 80 90 100
Black or African American
Hispanic or Latinx
Asian or Paciﬁc Islander
American Indian, Alaskan Native, or Native Hawaiian
Biracial or Multiracial
White
Other

27. Estimate the age breakdown (in percentage) of your clients (total in column should add up to100)

10 20 30 40 50 60 70 80 90 100
Under 25
25-35
36-45
Over 45

28. Estimate the socioeconomic status breakdown (in percentage) of your clients (total in column
should add up to 100)

10 20 30 40 50 60 70 80 90 100
Upper
Upper Middle
MiddleLower Middle
Lower

19

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

29. Estimate the highest level of education breakdown (in percentage) of your clients (total in column should add up to 100)

10 20 30 40 50 60 70 80 90 100
High SchoolSome college
Graduated college
Graduate degree (e.g., MPH, PhD)
Clinical professional degree (e.g., RN, LPN, MD, PA)
Non-clinical professional degree (e.g., GED)
Other

30. Estimate the number of pregnancies breakdown (in percentage) of your clients (total in column
should add up to 100)

10 20 30 40 50 60 70 80 90 100
1
2
3
4
5
Over 5

Clients, Cost, and Other Logistics
31. How do you primarily ﬁnd your doula clients? Check all that apply:□ Personal website□ Professional doula organization website/registry□ Word-of-mouth□ Other online forums□ Telephone□ Health care providers and institutions□ Community-based programs
32. What type of doula practice are you a part of? (check all that apply)□ Solo practice□ Group practice with 2-4 doulas□ Group practice with 5+ doulas□ Hospital-based practice□ Clinic-based practice20

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

33. How much do you currently charge ($USD)per:a) Prenatal visits________b) Birth visits__________c) Postnatal visits____________d) Bereavement visits__________e) Abortion visits____________
34. How much do you think you should be paid (ideally, in order to reach standard of living) per:a) Prenatal visits________b) Birth visits__________c) Postnatal visits____________d) Bereavement visits__________e) Abortion visits____________
35. How willing are you to do pro-bono or volunteer doula services?
□ Not willing at all□ Mostly unwilling□ Neutral□ Somewhat willing□ Very willing□ Mixed feelings (Explain): __________________________________
35.1 Open answer to explain your choice above:__________________________________
Beliefs about Doula Services
36. For each of the following, mark the answer that you most closely agree with.

Strongly
DisagreeDisagree Neutral Agree Strongly
Agree

I believe current pricing of doula services helps me toprovide doula services.
I believe current pricing of doula services helps myclients access doula services.
I believe current insurance coverage of doula services
helps me to provide doula services.
I believe current insurance coverage of doula services
helps my clients access doula services.
I believe current doula training helps me to provide
doula services.
I believe current doula training helps my clients accessdoula services.
I believe current doula certiﬁcation requirements help
me to provide doula services.

21

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23
I believe current doula certiﬁcation requirements help
my clients access doula services
I face challenges in starting my doula business.
I face challenges in building my client base for mydoula business.
I face challenges in making enough proﬁt to continue
my doula business.

Possible Changes for Doula Service Reimbursement
37. How interested would you be in Medicaid reimbursement for your doula services?
□ Not interested at all□ Mostly uninterested□ Neutral□ Somewhat interested□ Very interested□ Mixed feelings (Explain: ______________________________________________)
38. How interested would you be in Georgia doulas being classiﬁed as Community Health Workers
who are reimbursed through Department of Public Health?
□ Not interested at all□ Mostly uninterested□ Neutral□ Somewhat interested□ Very interested□ Mixed feelings (Explain: ______________________________________________)
Doula Services during COVID-19
39. In what ways have you and your work been affected by COVID-19? (Check all that apply)□ Stopped taking on clients□ Unable to accompany clients in the delivery room
□ Limited prenatal and postpartum visits□ Increase in client home births□ Use of protective equipment (i.e. masks, gloves) when working with clients□ My work has not changed as a result of COVID-19
40. Are you interested in providing doula services virtually (i.e. video and phone calls)?
□ Yes
□ No
41. Have you provided virtual doula services?
□ Yes
□ No
42. Have you provided doula services virtually during the COVID-19 pandemic?
□ Yes
□ No

22

D Turner et al. Sexual and Reproductive Health Matters 2022;30(1):1–23

43. How many clients have you served virtually since the onset of the pandemic? _______
44. Do any of your clients have difﬁculties accessing the internet?
□ Yes
□ No
□ Unknown
45. How do you connect with your clients virtually? (check all that apply)□ Video calls (Zoom, Microsoft Teams, Facetime)□ Phone□ Other: Specify _________
46. What platform do you use for video calls?
□ Zoom□ Skype□ Teams□ Other: Specify _________

23