Abstract
Background
During the COVID-19 pandemic, many doulas shifted to a hybrid model, combining virtual and in-person support. Little is known about how doulas have adapted their practices to this new model of support.Methods
We conducted semi-structured interviews with 20 certified birth doulas from 11 U.S. states. Participants provided both in-person and virtual doula support. Interviews incorporated the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions implementation science framework to characterize practice modifications and included critical incident technique questions to elicit comparisons between virtual and in-person care. Interviews occurred from November to December 2025, and transcripts were analyzed using inductive thematic analysis.Results
Participants identified numerous advantages of virtual doula support for doulas and clients, including convenience, scheduling flexibility, reduced travel burden, accommodation of client preferences, and increased participation of geographically distant family members. Key disadvantages included challenges with rapport-building, lack of physical touch, reduced effectiveness during birth, and inability to provide hands-on postpartum assistance. Some doulas described how they modified their approach to deliver virtual support. Views on the comparability of virtual and in-person visits varied widely and appeared related to doulas' conceptualization of their role. Most participants viewed virtual birth support as somewhat inferior to in-person support, although exceptions were noted.Conclusions
Virtual doula support offers meaningful advantages such as improved access and flexibility but presents certain trade-offs. Doulas expressed different opinions regarding equivalence of in-person and virtual support. There is a need for rigorous comparative effectiveness studies to inform policy and coverage decisions as virtual doula support continues to expand.