Update, July 13: George Washington University Hospital announced that as of July 10, labor and delivery patients will now be allowed to have two guests.
Emily Pearl Goodstein has accepted the fact that her parents and siblings will not be able to visit her in the hospital when she delivers her baby this summer, even though they live locally and she’d really like them to be present. She has also accepted the fact that she won’t be able to invite a photographer to document the birth of her child. In a past career, she was a birth photographer, so she assumed she’d bring in someone to capture the moment.
But due to the coronavirus pandemic that has killed more than 550 D.C. residents since March, local hospitals have had to restrict visitation. George Washington University Hospital, where Goodstein plans to have her baby, temporarily restricted all visitors except in select circumstances, including labor and delivery. The hospital has not changed its visitation policy since a public health emergency was declared on March 11.
“They don’t know how the reopening is going to unfold,” Goodstein says. “I appreciate they are being cautious and they are making these decisions to minimize COVID spread.”
But the hospital considers doulas to be guests and, based on its policy of one visitor per pregnant person, Goodstein will have to choose between birthing with her husband or her doula, whom she considers an extension of her birth team. Her doula, Casey Runck, is trained to provide emotional and physical support, has additional training in high-risk pregnancies, and has attended more than 250 births, including some at GW Hospital.
Having Runck at the hospital would make it easier for Goodstein to cope with the stressful experience. At 37, Goodstein is considered to be of advanced maternal age, and pregnancy complications are more likely. She is quick to recognize her privilege—she is a White woman who is close to her provider and believes her husband can advocate for her if need be—but she also recognizes this is not everyone’s experience. In her opinion, bringing doulas back to local hospitals is in the best interest for all pregnant people.
“I also just think about the irony. I just went to the dentist to have my teeth cleaned, and there were two people in the room with me then,” says Goodstein. “We could go eat at a restaurant … Someone told me you could even get a facial, but you can’t have your doula with you at your birth? Birth is scary. I have never had a baby before. I’m excited to have this baby, but I’m also scared. I’ve never stayed overnight in a hospital. I want the team that I put together there to support me, and it’s scary to think that I might not have that.”
The Bowser administration has allowed different sectors of the economy to ease restrictions and slowly reopen as the number of COVID-19 cases and deaths decrease since the first wave of infections and fatalities in late spring and early summer. The virus is still active and there is no vaccine, but officials argue the D.C. health care system is equipped to handle the current rate of infections, so phased reopening began in May.
While the Bowser administration has issued orders for when businesses and traditional public schools could begin phased reopening, it has not done so for hospitals. Individual hospitals are ultimately setting their own policies related to visitation, Bowser’s press secretary, Susana Castillo,tells City Paper. “The DC Hospital Association has pulled together a small group of subject matter experts to provide recommendations and guidelines in an attempt to somewhat standardize the policies across the health care system,” Castillo adds.
A City Paper review of visitation restrictions related to COVID-19 shows acute hospitals across the District have largely maintained a no-visitor policy over the course of the pandemic. There are limited exceptions for specific inpatient stays. In addition to labor and delivery, all hospitals have exceptions for end-of-life care and pediatrics. There are slight variances—Howard University Hospital allows only one visitor for end-of-life care, whereas Sibley Hospital allows two visitors at a time. And some, like MedStar Health, which includes Washington Hospital Center and Georgetown University Hospital, list exceptions for patients undergoing an urgent or emergency surgery. United Medical Center says it “is prepared to make exceptions on a case by case basis.”
Prior to the outbreak of COVID-19, visitors were welcomed into hospitals; they just named the patient and showed identification. There were designated hours, and the number of visitors a patient could see at a time were sometimes restricted, but there were waiting areas. “Visitors are an important part of the healing process,” Howard University Hospital states on its website. During the COVID-19 crisis, visitors pose a threat to patients and staff alike. They could have COVID-19. At one point during the pandemic, New York hospitals told pregnant patients they’d have to labor alone. This only changed after Governor Andrew Cuomoissued an executive order reversing the rule.
Strict hospital visitor policies can also be barriers for patients with disabilities. Not every D.C. hospital makes clear on its website whether it makes visitation exceptions for all patients with disabilities who require in-person support. In some states, there were no listed exceptions for this community until the government intervened. Disability organizations recently filed a complaint against the state of Connecticut and a local hospital there, alleging their no-visitor policies discriminated against patients with disabilities. As a result, the state ordered a policy change via emergency regulations. Tauna Szymanskiwith CommunicationFIRST, an D.C.-based organization that advocates for people with speech-related communication disabilities, says the ideal situation would be having a local government body set a clear policy that applies to all hospitals about how to balance coronavirus-related public health and safety considerations with the rights of people with disabilities to access in-person supports while they are hospitalized. She argues this would create greater clarity and continuity.
The DC Hospital Association just updated its guidelines for hospitals and health systems in response to D.C. entering Phase 2 in late June. The association is now recommending all patients be allowed one visitor “within designated visitation hours.” But it still recommends one visitor or support person per day whenever possible for select groups, including laboring patients. It also says patients who have or are suspected to have COVID-19 should still not be allowed to have visitors except in end-of-life situations. (City Paper requested an interview with the association, but did not immediately hear back.) The Centers for Disease Control and Prevention, for its part, recommends hospitals “[l]imit visitors to the facility to only those essential for the patient’s physical or emotional well-being and care.”
With no formal rules in place across the District, individual hospitals are having to make the difficult decision of deciding who to allow in their facility, as there is still a moderate rate of community transmission in D.C. There is also little opportunity for public input.
“As we watch the world open up again to normalcy, the hospital should be the safest stronghold for that next phase, and that’s what we are doing,” saysHoward University Hospital CEO Anita L. A. Jenkins.
Howard University Hospital is constantly evaluating its policies, and following what the hospital association recommends. By and large, Jenkins says, the hospital is very stringent on who is allowed to enter the facility. The hospital is not testing every visitor for COVID-19, she says, so it must be very methodical. For instance, it will not accept student volunteers over the summer.
“When you start talking about introducing additional layers of personnel in the hospital, we do want to be careful,” Jenkins says in response to this reporter’s question about welcoming doulas. “We want to make sure our patients are safe, that they are not exposed to unnecessary exposure from the community. That is first and foremost.”
Meanwhile, hospitals in other neighboring states have relaxed visitation restrictions. Virginia Hospital Center, for example, updated its visitation policy effective July 1 to allow obstetric patients to invite a partner and one certified midwife or doula. The update reflects decisions made by the individual hospital. “The safety of our patients and staff is our top priority,” a spokesperson writes via email. The hospital also relaxed other restrictions, such as allowing many outpatients to be accompanied by one support person and returning visiting hours in the evenings for select patient areas.
D.C. has been generally slower than its neighbors to reopen. Virginia has already moved to Phase 3, whereas the Bowser administration has yet to even publicly discuss what Phase 3 could look like. During daily press conferences, DC Health Director Dr. LaQuandra Nesbitt has credited the city’s comparatively slow phased reopening with why we have not seen an increase in infections as other parts of the country have.
The pandemic has not stopped deliveries, but it has changed them. And now there is a concerted effort to welcome doulas back into hospitals. The local affiliate of the American College of Nurse-Midwives wrote an open letter requesting that policymakers ease visitation restrictions to allow doulas in the delivery room, in addition to a laboring person’s select partner.
“Doulas should be utilized as a service to enhance goals to improve birth outcomes and reduce racial and ethnic disparities,” the letter, published May 29, says. “We urge health systems to avoid fear-based policies and decisions. DC ACNM advocates for the presence of in-person labor support persons and doulas in all but extreme circumstances where the risk of contagion outweighs the proven benefits of these individuals.”
Midwives at GW Hospital have also been advocating for the return of doulas. Jashia Pinkney, a certified nurse midwife who just completed a one-year fellowship at GW Hospital, says she and her colleagues emphasize the importance of doulas during town halls with physicians.
“In a big practice like GW, where as a midwife on call I can have up to three to four births, doulas are very essential,” Pinkney tells City Paper. “Just like a midwife, just like a doctor, doulas are essential providers and are trained to be able to help mothers during labor … Doulas are essential, and there is actual evidence published that supports the use of doulas for labor and birth.”
Pinkney points to a recent peer-reviewed, World Health Organization-supported study that shows individuals who received continuous support during childbirth were more likely to have spontaneous vaginal births and less likely to report negative feelings about their experience or use pain medication. “Subgroup analyses suggested that continuous support was most effective at reducing caesarean birth, when the provider was present in a doula role,” the study reads.
Some doulas have begun offering their services virtually. Runck, who is a solo doula and typically attends one to two births a month, still offers emotional and relational support over Zoom or other video chat platforms; she’s attended five virtual births during the pandemic. In Runck’s experience, clients are more likely to choose a partner over a doula. “It is a family that is born. It is not a baby that is born,” she explains.
It’s challenging for Runck to fully appreciate what’s happening in the delivery room with such a limited camera view. She recalls having to provide meaningful feedback to one of her clients who was pushing during delivery, but she couldn’t really see what was happening. She conveys her support through language because she is not able to provide the kind of physical support she usually does, from grabbing ice chips to offering massages.
“There are definitely benefits to a virtual doula. I feel very, very strongly that a virtual doula is better than no doula,” says Runck.
“Doulas have been left out of the conversation” around hospital visitation restrictions under COVID-19, Runck adds.
“Doulas are so passionate about what we do and making sure our families are safe that we would do what it takes—if it is testing, or whatever the case may be—to make sure we can get back in and support these families again,” says Amanda Coles, a solo doula serving patients in the D.C. region.
As of July 2, GW Hospital says it does not have plans to change its visitation restrictions. “Please know that we recognize the importance of each family’s birth plan and do not take decisions such as this lightly. We also understand how difficult it is to not be with loved ones while they are in the hospital and to have limited support from loved ones while in the hospital,” says a GW hospital spokesperson.
In contrast, a freestanding birth center at Community of Hope, a care organization that serves low-income and homeless D.C. residents has welcomed a pregnant person’s doula in addition to their one visitor during labor throughout the pandemic.
“At the end of the day, our main goal is for women or birthing people to be happy with their birth experience, and we understand that support has a huge role in that,” says Tracie Brown, a certified nurse midwife with Community of Hope.
She supports calls for the return of doulas to hospitals and worries about the unintended consequences of visitation restrictions. In trying to address D.C.’s high maternal mortality rates, particularly as it relates to Black women, health care leaders have been working to secure support systems, including doulas, for pregnant people. Barring doulas from in-person support for the unforeseen future without substituting this care could impact health outcomes, Brown says.
“How people birth and how they feel about their birth experiences impacts how they feel and how they transition. Depression and anxiety increase maternal morbidity, so it’s something that I think hasn’t been taken into consideration from hospital systems,” says Brown.