The eight articles in this systematic review include four qualitative, one survey, two mixed-methods, and one prospective research study. Seven of the eight were conducted in the United States, and the eighth was conducted in multiple countries. Participants in these studies were birth workers, including doulas. The search identified forty-three publications: 15 in MEDLINE, 8 in EMBASE, 6 in CINAHL, 4 in PsycINFO, and 10 in the other databases (see Fig. 1). Deduplication and filtering decreased the number of documents to 22, which were evaluated for eligibility using the full text. After eligibility screening, the number of articles was reduced to 10, and these were critically reviewed using the Critical Appraisal Skills Program (CASP). Two reviewers (MO and AA) separately assigned a score of 10 to each paper by answering "yes" to all ten elements on the CASP checklist. Eight articles had a perfect inter-rater agreement (An overall understanding of 98 percent). A third reviewer (SB) resolved disagreements. On a scale from 1 to 10, two papers received a score of 9, and six papers received a score of 10; these eight were the final papers included in the study (see Table 3 and Fig. 1).

Fig. 1Table 3 Studies presenting results on the role of doulas in providing breastfeeding support during the COVID-19 pandemicDoulas providing breastfeeding and maternal health support during the COVID-19 pandemic

Although doula care has numerous advantages, accessing these services is not without difficulties, some of which have grown more restrictive since the COVID-19 Pandemic [32].To combat the spread of COVID-19, hospital systems implemented substantial modifications to their policies and standards at the start of the pandemic, including restricting visits and doula services [33, 34]. Evolving guidelines, uncertainty, and subsequent mitigation strategies altered mothers' expected birth location and nursing intentions [30, 35, 36].This situation was further exasperated due to a lack of appropriate legislation or hospital policies to acknowledge the vital work of doulas: they were deemed non-essential and largely unable to participate in births, even though expecting parents had come to rely on doula support [3, 32, 37]. Additionally, Doulas struggled to transition to virtual services during this time to deliver much-needed services. Home visits, a vital part of doula services, were also curtailed during the pandemic. These challenges underscore the lack of support, collaboration, and integration into the healthcare system, problems that doulas face even when there is no pandemic [3, 32].

The results from this systematic review emphasized the significance of breastfeeding support provided by doulas and its potential. The eight studies demonstrated that doulas found innovative ways to serve the needs of birthing and nursing mothers during the difficulties brought on by the pandemic, whether through virtual breastfeeding support, delivering essential supplies to clients, navigating racial tensions, or providing educational and mental health support [5, 13, 25, 27,28,29, 31].

A prospective, anonymous online survey of Gatekeepers at Connecticut agencies and breastfeeding networks of eligible lactation personnel reported associated changes in lactation services, even though breastfeeding continued throughout the epidemic. The authors concluded that breastfeeding inequities might be further exacerbated without fair access to lactation support, suggesting that future adaptive alternatives in the sector might be impacted by the difficulties and breakthroughs in virtual assistance [13]. There was a need for breastfeeding support and the potential benefits of enhanced mother-infant interaction during the lockdown period. Breastfeeding disparities might worsen for people who don't have access to lactation support. These individuals need in-person or virtual support to mitigate lactation-associated challenges [13]. This study reinforces the need to conduct additional research on the impact of the COVID-19 breastfeeding guidelines on doulas' support services during the pandemic in preparation for any future epidemic or pandemic.

Impact of COVID-19 guidelines on doula services

Studies that evaluated the impact of COVID-19 guidelines on doula services found that doulas clients experienced three primary pregnancy and childbirth barriers: (i) fear of exposure, (ii) limited access to their intended support systems, including doulas, and (iii) uncertainty about hospital restrictions and COVID guidelines on labor and delivery [25, 26, 31]. Doulas responded deftly, helping their clients face these obstacles. Studies demonstrate that doulas were willing to go the extra mile to help birthing people and nursing mothers navigate COVID-19-related barriers [25]. Despite the difficulties in providing remote services for clients during the pandemic, telemedicine gave doulas a way to connect with their clients and teach them coping mechanisms. These experiences of doulas during the pandemic may shape future care practices, especially for low-income and underserved communities [26]. However, doulas expressed significant concerns that their classification as "non-essential" employees continued even after COVID-19 restrictions were eased. Most doulas still could not attend births—limiting their ability to provide needed services like emotional and breastfeeding support to new mothers. Doulas had mixed emotions about virtual assistance effectiveness [26, 37]. They were concerned about COVID's long-term effects on their profession and worried about maltreatment and obstetric violence as birthing people enter hospitals unaccompanied. For various reasons, doulas prefer to work with their clients in person rather than virtually [37]. In evaluating the effect of the exclusion of doulas from delivery rooms due to COVID-19 restrictions, a shift in birth plans was noted by birthing people from hospital to home births where they could have doulas and partners present [31]. During the peak of the pandemic, most people hiring doulas were wealthy and educated. Low-income and underserved birthing people could not afford this benefit and were limited to the services that doulas could provide [26, 31]. This only increased the existing access inequalities that low-income and underserved birthing people face. Doulas were able to provide families with birth information and virtually support their clients during labor. The exclusion of doulas also critically impacted hospital staff, who expressed dismay that they could not provide women in labor and postpartum with tailored support during this period; in this situation, the presence of doulas in the hospital would have been beneficial [26, 38].

Adoption of COVID_19 guidelines and modification of service delivery methods

Two studies included in this review examined the impact of hospital and clinic restrictions, including restrictions on the attendance of birthing support staff, including doulas. Oparah collected narratives of Black and Latinx birth workers [27, 29]. In these studies, doulas devised innovative ways to deal with COVID-19 restrictions. They reported offering more prenatal and extended postpartum visits and maintained contact with their clients virtually and through telecommunication [27]. Many birth workers empowered their clients to self-advocate and take greater responsibility for their prenatal care. Doulas expanded their scope of work by helping with grocery shopping and other maternal health supports [27].To close the health disparity gaps, doulas helped their clients figure out telemedicine, especially for those who are not internet savvy or lack resources that can support virtual doula services. Black birth workers used a holistic approach to care during the pandemic, finding creative methods to establish a community that supported new parents. These approaches were key in addressing US maternal and child health disparities [27, 32].

In examining Black and LatinX community-based doula work transitions in the United States during the Pandemic, Rivera (2021) found that doulas had to adapt to new ways of delivering services to keep themselves, their clients, and the community safe. Doulas reached their community and birthing clients through free virtual childbirth courses, including breastfeeding support [29].In an investigation of how COVID-19 affected births in Puerto Rico and how the pandemic differed or is similar to past disasters, a study included in this review interviewed eleven Puerto Rican women working in reproductive health and justice. This study found that Puerto Rican midwives and doulas lacked institutional support despite the growing popularity of doula services and midwife-attended births. In Puerto Rico, the lack of legal recognition and rights for homebirth midwives and doulas is a severe concern. This suggests the need for legal recognition and the promotion of the rights of doulas [28].