Doulas Are Paraprofessionals

May 31, 2016 by

2DoulasAreParaprofessionals (2) copyEncouraging professional behavior by doulas is one of the purposes of this blog, but it needs to be clear that the doula occupation is a paraprofession, not a profession. Community based, hospital employed, and independent practice birth doulas clearly fit dictionary and research interpretations and even the U.S. Department of Labor classification. However postpartum doula work is not such a neat fit. One of the definitions for paraprofessional is that they work alongside of or under the supervision of professionals. While they may work and make decisions independently, there is something about the nature of their work that is connected to the stronger influence of a professional.

Profession vs. Paraprofession

A profession is any type of work that needs specialized and prolonged training, a particular skill, or a high level of education; often a formal qualification or licensure is required. A defining characteristic of paraprofessional occupations is that training can be achieved with only a high school degree or its equivalent. While some programs may offer an associate’s (two year) degree, this is often done for financial aid reasons, not because it is essential for training purposes. Because there are no impediments to offering services (some people don’t even take a doula training before doing the work), we cannot define doula work as a profession.

However, that does not mean that doulaing does not require a high level of specialized skills to perform well, nor does it mean that there are lower standards for professional behavior. In fact, several papers discuss the need for paraprofessionals in the family support services field to develop a professional identity as helpers of families, and to transform who they are and how they serve others as part of a successful training process (Behnke and Hans; Hans and Korfmacher).

“Paraprofessionals frequently associate significant personal growth with their training and work experiences. They connect their training to higher self-esteem, greater personal and professional aspirations, and the ability to engage in more effective interpersonal relationships (p.10)…An emerging identity as someone who plays a valuable and valued role helping other individuals seemed to be a central experience of doula training for the women who successfully became doulas.” The women who did not complete this transformation [or become doulas] felt they gained “mostly technical knowledge” but did not feel personally changed by the experience. In fact they expressed “a resistance to change” and seeing themselves in a helping role.” –Behnke and Hans (2002)

It also does not mean that the professionals we work alongside of can effectively do our job. This is not to say that the professional person can perform the paraprofessional’s duties.   The paraprofessional has specific skills and attributes that make it possible for the professional to accomplish more complex tasks and responsibilities.

Several sources discuss that when paraprofessionals fulfill their role, they boost the effectiveness and relationship between the client and the professional. They are able do their job better because we do ours. I think this is true in the perinatal context for doulas because our core values are good communication, maternal involvement in decision making and maximizing positive memories. Even though the labor and delivery professionals we work with may not have the same values, our presence often contributes to meeting their medical goal of “healthy mom, healthy baby”.

Doula Research

The defining of doulas as paraprofessionals comes initially from research articles published in the Zero to Three journal from 2000 through 2005. Researchers at the University of Chicago were invited to participate in a community based doula program called the Chicago Doula Project (now part of Health Connect One). Examples of other paraprofessionals: paralegals who work in attorney offices; paraeducators working in school classrooms; library assistants; nursing assistants; paramedics; veterinary assistants working alongside veterinary technicians (associate’s degree) and veterinarians (doctorate degree).

Another aspect of the paraprofessional is that the person is considered a good fit based on personality characteristics and social skills they already possess. Paraprofessionals often work with the people part of a situation; they need solid interpersonal skills and to be good communicators. These skills are strengthened during the training and early supervision process. This concept is clearly defined and repeated in the articles about community based doula programs and their staff selection process.

In the only national representative survey of doulas (so far!) published in a peer reviewed journal in 2005, the title is, “Doulas As Childbirth Paraprofessionals: Results From A National Survey”. Lantz, Low and their team state “doulas have become a new type of “paraprofessional” (or someone with a lower level of training and /or credentials who works in tandem with another professional) with a specialized role and an interest in finding clients who will hire them for their services. As such, doulas (who are also called labor assistants) represent a new addition to today’s maternity care team.”

Dictionary and Wikipedia Definitions

As an English prefix, the word “para” is used “in the naming of occupational roles considered ancillary or subsidiary to roles requiring more training, or of a higher status, on such models as paramedical, and paraprofessional: paralegal, paralibrarian, parapolice.” (Dictionary.com) “A person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.” (Oxford Dictionary.com) Wikipedia, which represents the generally understood meaning of a concept, states that “paraprofessional is a job title given to persons in various occupational fields such as education, healthcare, engineering and law, who are trained to assist professionals but do not themselves have professional licensure [note – in the U.S. this is administered by state]. The paraprofessional is able to perform tasks requiring significant knowledge in the field, and may even function independently of direct professional supervision, but lacks the official authority of the professional.”

Are All Doulas Paraprofessionals?

While the definition of paraprofessional is grounded in the early literature on community based doula programs, the nature of a doula’s labor and her support behaviors do not vary substantially for independent practice and hospital based doulas. While each may have their own niche and specialty skills, the actions of support during the prenatal, labor, birth and the postpartum periods are the same. In teaching how to support emotionally and physically; offer information as needed; and prompting clients to advocate for themselves, the skills do not change. The setting changes, and the background knowledge to effectively complete the task, but the behaviors of support are transferable. For example, an independently hired postpartum doula comforting a new mother about her birth will use the same skills as a community based birth doula. Building confidence in one’s ability to birth is similar to building confidence in one’s ability to breastfeed.

One of the conflicts inherent in these definitions is that the paraprofessional works for or under a professional. We can make the case that a birth doula would not be engaged for their services if the person was not pregnant and is almost always seeing a physician or midwife for prenatal and labor care. But what about postpartum doulas? While a postpartum person may also engage a lactation consultant or be seeing a doctor for checkups, there is no connecting relationship between them and their doula.

Is Being A Doula A Vocation?

Doula work may or may not be a vocation, which is a strong feeling of suitability for a particular career or occupation. In my files, there are plenty of interviews from women who state they could not imagine not being a doula – it fulfills their purpose in life. I’ve previously written about it being a calling. However, not all doulas feel that way nor is it a requirement for effectiveness. Therefore, it is not a vocation.

United States Department Of Labor Classification

In December of 2010, the Bureau of Labor Statistics Standard Occupational Classification Policy Committee (SOCPC) added “Doula” to category 39-9099 Personal Care and Service Workers, All Other. They declared that no formal schooling was needed although most in this category had a high school diploma or equivalent. I don’t think we can disagree with that. Those of us who have advanced degrees find them helpful but they are not required to perform the tasks of doula work effectively. Other occupations in this category are Butler, House Sitter, Shoe Shiner, Valet, and Magnetic Healer. While being lumped with shoe shiners may feel frustrating or upsetting to doula readers, from the SOCPC standpoint, median wages for doula work are not high and there isn’t an educational requirement, nor are there many doulas. But also consider butlers. The Guild of Professional Butlers has 10,000 active members (35% in the U.S.) who earn $50,000 to $150,000 a year. I’d also like to point out that each of these jobs require a high level of interpersonal skill to provide good service and personal care.

DoulaDeptofLabor

 

Abramson, R., Altfeld, S. & Teibloom-Mishkin, J. (2000) The community-based doula: an emerging role in family support. Zero to Three, Oct/Nov, 11-16.

Behnke, E.F. & Hans, S. (2002) Becoming a doula. Zero to three, (November), 9-13.

Hans, S. & Korfmacher, J. (2002) The professional development of paraprofessionals. Zero to three, (November), 4-8.

Lantz, P.M., Low, L.K., Varkey, S. & Watson, R.L. (2005) Doulas as childbirth paraprofessionals: Results from a national survey. Womens Health Issues, 15(3), 109-116.

Meyer, H., Kirwan, A. & Dealy, K. (2005) Expanding the Doula Model: An Illinois Replication Story. Zero to Three, 25(5), 35-42.

 

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Birthrape And The Doula

Apr 29, 2016 by

The (1)“At many births, while I have my hand on a woman’s arm reminding her to breathe, someone has their hand in her vagina digging around, her eyes are wide, she’s trying to get away, screaming STOP… What do I do? What do I say? How do I help make it right? I hate it. I hate it. I hate it. It seems so wrong.” [excerpt from one email among many I’ve received over the years]

Dear Doula,

I wish I could tell you that these kinds of things only happen to you, that they aren’t worldwide, that people aren’t suffering, that how one is treated during birth doesn’t traumatize a person, and that I don’t have multiple examples of this in my doula interview files. But that wouldn’t be true.

I wish I could explain what the medical careprovider is thinking or understand more deeply the processes that lead this person to conclude that what they are doing is right or that it doesn’t matter to the person in the body that they are touching. But that compassion is hard for me to come by.

What I can tell you is that the careprovider has somehow forgotten they are treating a person, not just a body. The medical detachment they learned to protect themselves has gone haywire, and so much so that they’ve forgotten that a real person is inside the body, and it is the person, not simply a medical situation they are treating. There is no detachment for the patient – and everything is experienced wholistically, meaning it affects their psyche and their spirit as well as their physical selves. Maybe the medical careprovider never learned this or maybe this knowledge has gotten buried.

But our focus needs to be on our client, on the person in the body. We are their amplifier, their voice, their conduit, when others who are caring for them aren’t listening. We are the one reminding that there is a person in the body, and that person has value. So what do you do?

  1. Be the voice. State what is happening in clear language.

“Dr. X, I hear [client’s name] saying “Stop” and “No”. Do you hear them?”

“[Client’s name], do you want Dr. X to stop?”

“Dr. X, is this an emergency or can you stop for a moment and let us all catch up with one another?”

Christine Morton and Elayne Clift, in their book Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, discuss the “interactional wedge” when doulas ask physicians to stop doing what they are doing and talk about it. It’s one of the main reasons doulas are often disliked by medical careproviders. (My opinion is this an asset for informed consent, which I discuss here). When we interrupt a physician or midwife, we are vying for power, so it must be very clear that we are doing it on behalf of our clients whose voice is not being heard even though they are expressing themselves.

  1. If the medical careprovider does not stop, appeal to the nurse.

“Nurse Y, I hear [client’s name] saying “stop” and “no”. Do you hear her too?”

“[Client’s name], do you want Nurse Y to ask Dr. X to stop?”

“Nurse Y, if this is an emergency, can you explain quickly to [client’s name] why Dr. X cannot stop? She needs to know this for her own well-being.”

Sometimes careproviders don’t stop because they think that whatever they are doing will be over quickly and just want to finish. Unless there is a medical imperative, this is selfish behavior because they are putting their own desire to be done quickly over the patient’s need for understanding and caring from them. Unfortunately, this is their prerogative as careproviders. As doulas we will experience a wide variety of responses to our clients’ needs for compassion and kindness from their physicians and midwives. Often the lack of it within a system is why we are hired as birth doulas.

  1. If the medical careprovider stops, facilitate the communication. Start with gratitude – really. Then help your client to gain information, preview what they can expect especially with bodily sensations, and encourage eye contact and affirming touch (if possible) between careprovider and client and nurse and client.

Your goals are:

  • To assist your client not to feel they are being treated like an object, and for the careprovider not to fall into the trap of treating the body as separate from the person inside of it (objectifying).
  • To assist in obtaining the information they need about what is happening and why.
  • To forecast what is going to happen and what sensations they might experience.
  • To re-establish a positive relationship with the physician or midwife and the client, and the nurse and the client, if possible.

“Thank you, Dr. X. I think [client’s name] needs a breather from all that intensity. Can you explain what is going on?”

“What sensations can [client’s name] expect?”

“What other procedures or people might we expect?”

“[Client’s name], what do you want Dr. X or Midwife Z to understand about what you were feeling or why you were feeling it?”

If the doctor or midwife seems disinterested, show it matters to you:

“[Client’s name], do you want to tell me more about what you were feeling or why you were feeling it?”

  1. What if it really is an emergency and there isn’t time for the physician or midwife to stop?

If the physician or midwife is really concentrating, we don’t want to interrupt them. So appeal to the nurse.

“Nurse Y, I can hear that [client’s name] is becoming really frightened/terrified (make sure you include an emotion) by what is happening and the pain they are in. Can you please get their attention and explain briefly why the doctor or midwife can’t stop?”

Use the Take Charge Routine from The Birth Partner to get through the painful procedure.

If the nurse is unavailable or busy, it’s up to us.

  1. What if the physician or midwife doesn’t stop, the nurse can’t help, and the situation is continuing? What do I do then?

You go further into what I call “trauma prevention mode”. You want to affirm that they are not alone in what they are experiencing, that you heard what they said, that what they wanted is not what is happening, and that you know how to help them get through it. If you can forecast any sensations or what might happen next, do so.

Get your client’s attention and look them in the eye. Grasp their hand, arm, shoulder, or side of their face firmly. Say:

“I’m right here with you and I’m not going anywhere.”

“Dr. X isn’t stopping but I hear your request and your pain.”

“Right now, let’s just get through this together.”

“This might get crampy or sharp before it goes away, but I’m right here.”

In the immediate aftermath, most careproviders and nurses will make some acknowledgement. “Sorry I couldn’t stop right then”, and then just go on to the next thing. For them, it isn’t any big deal. This is what I find the most frustrating – it’s as if they ignore the situation it doesn’t exist. I imagine that in their mind, that’s true, even if it isn’t our client’s reality. Whether to pursue a conversation at that point is up to your client, the situation, and how they like to handle conflict. We have to take our cues from them.

If you are a direct person, who is used to privilege and of having choices in your medical care, this might be very frustrating to not pursue the situation. But your client may feel that any confrontation may make things worse, or that they have to take what they get. Clients may be afraid of the consequences to them and their baby. These consequences may be very real, especially for people of color, immigrants, and those living below the poverty line. If you are white, or otherwise privileged it may be hard to believe but consequences for not being compliant exist.[i][ii][iii] This is hard because you are emotional too, but you have to keep in check what you would want to do. You will be leaving this client and their baby in a few hours, and they will have to deal with any aftermath.

In some cases where the doula is concerned about being asked or made to leave, it may be appropriate to go directly to option #5.  The doula who is in the room can offer more effective support than the one who has been restricted to the waiting area.  Use your skills to assess the situation.

Sometimes I find that clients are not interested in pursuing a conversation at any time. They just want to put the unpleasantness behind them. They may also have a different memory of what occurred, minimizing their experience. Don’t mess with this! The brain works to protect the psyche, and defense mechanisms are called that for a reason. They are defending against the negative impact of an experience. Often how a person thinks about what happened to them (cognitive appraisal) influences whether a situation is coded as traumatic or not. So, in the moment, they may make minimizing statements to try to soothe the chaos of their thinking – but whether that works in the long run remains to be seen. Increasing oxytocin flow by positive touch, eye contact, laughter, holding the baby skin to skin, etc, should be encouraged if it feels appropriate and congruent with your client’s feelings and experience of the moment. Oxytocin lowers stress hormones, which contribute to encoding memories as traumatic. After all, it’s still a birth! If the event really does become a source of anxiety and trauma, we can validate our client’s feelings at that time. Once again, we take our cues from them.

But what about us? As doulas we are often the ones left feeling raw and as if we witnessed a rape. I say that if you feel that was what you saw, then that was what you saw and you should seek counseling with that in mind. Your experience was valid even though it doesn’t jibe with what the medical careprovider, nurse, or client experienced.

If you have a positive rapport with your client’s nurse, you may want to discuss what you witnessed if you have some private and unhurried moments together. “It was really difficult for me when [client’s name] was crying out for Midwife Z to stop. My client sounded terrified, and then the midwife didn’t stop and it just continued. Can you help me to make better sense of this? What was that like for you?”

Hopefully you will get a good dose of understanding and some insight on the nurse’s perspective of these situations. You will get a snapshot of the nurse’s mindset if they feel free enough to share with you. I have found that some nurses feel exactly the same way the doula does, but they don’t know what to do either. Sometimes the discussion with the doula, who is an outsider, is the impetus for them to talk with the director of nursing about it.

Other times, the doula will hear a minimizing statement, “Oh, I knew it would be over in another minute and the mom sounded like she was overreacting.” Or, “Most patients wish Midwife Z would be gentler during that procedure but that’s just the way she does it.” If that’s the case, just thank the nurse for their insight and know that you’ve learned how they rationalize their way through these situations.

Note:  All my suggestions are based on my research, discussions with expert doulas, and conversations with medical careproviders.  I am steeped in white culture, the privileges of education, and being white. Please interpret my suggestions with that in mind – your culture and life experience may lead you to conclude that other actions are more appropriate or better than what I have written.  My goal is give doulas actions that are within their standards of practices as most define them – a beginning point to have a conversation, not to provide the last word for every doula.  

Is it rape? Aren’t you exaggerating?

Some people feel that by using the term ‘rape’, I’m overdramatizing these situations or minimizing the experience of people who have been sexually violated. But I don’t think so. The patient has given over their trust, their body, their life, to a medical careprovider who has a sacred covenant to treat that person and honor them. When they act in a manner that is dismissive, painful or coercive, they violate that trust. The careprovider is touching the most intimate parts of the body – places that may only have been touched by one or two other people besides the careprovider! They have power over the patient and are treating their body like an object. The patient is often lying down and is unable to move or get away. When the patient says, “No” and “Stop”, to me, they are voluntarily retracting their consent.

As a qualitative researcher, our ethics state that the person who is having the experience is the one who defines it. They choose their language and share with us their emotions and mindset. In recent Facebook queries with over forty responses from mothers and professionals, all of the people who felt they had experienced an assault during their labor used the term “rape” or “birthrape”.  Many had also experienced sexual assault or rape, and these people felt many links between the two experiences. The term “rape” has a visceral emotional component that grabs one’s attention in a way that “assault during labor” does not. That is what the victim or survivor wants – for us to acknowledge and see their experience as best we can through their eyes. These people didn’t feel assaulted, they felt raped.[iv]

Rape is defined as “unlawful sexual intercourse or any other sexual penetration of the vagina, sex organ, other body part, or foreign object, without the consent of the victim. An act of plunder, violent seizure or abuse; despoliation; violation. The act of seizing and carrying off by force.”[v]

If the person who had the experience describes it in terms of feeling their body was violated, that is an assault. If they say, “I feel like I was raped”, that counts. They may have signed a legal consent for treatment for a vaginal birth form upon entering the hospital. But that in no way gives medical careproviders, or anyone for that matter, consent to violate their person when they clearly state their wish for that person to stop.

The medical and nursing literature is full of research on traumatic birth and the role of physicians and nurses in creating that trauma. It is also full of the pain that medical careproviders experience when they feel they have been complicit with or damaged by the coercive tactics of their coworkers and colleagues. For more information, I would urge you to read chapter 17 in “Traumatic Childbirth” by Cheryl Tatano Beck, Jeanne Watson Driscoll, and Sue Watson, or access Beck, C.T., & Gable, R.K. (2012) Secondary Traumatic Stress In Labor and Delivery Nurses: A mixed methods study. JOGNN, 41, 747-760.

 

 

[i] Bridges, Khiara, (2013) Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization. UC Press

[ii] Oparah, Julia, & Bonaparte, Alicia (2015) Birthing Justice. Routledge.

[iii] The American Dream of Birth (2016) Video (Free and a good watch!)

[iv] If I was working with a group of medical care providers desiring to change their care practices, I probably would use the word “assault” repeatedly in discussion – it’s no good triggering their own histories of being assaulted or demeaned when the goal is lasting behavioral change. The majority of physicians have experienced bullying behaviors and mistreatment from professors and supervisors. The idea that physicians are perpetuating what they experienced as students and residents to their patients is a valid one. https://portalcontent.johnshopkins.edu/Housestaff/Uploaded%20Files/Medical_Student_Mistreatment_at_Hopkins_BRIEF.pdf

[v] http://www.dictionary.com/browse/rape

There are several good books about trauma and recovery but these are a good place to start:

The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms by Mary Beth Williams PhD LCSW CTSSoili Poijula PhD

In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter A. Levine

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others by Laura Van Dernoot Lipsky and Connie Burk

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The Time To Ask About Past Abuse or Assault is Never

Apr 6, 2016 by

TheOne of the most upsetting questions I have read on a doula’s personal history form is some version of this: “Have you ever experienced sexual abuse or assault, either as a child or as an adult?” While I realize the doula is trying to be helpful, the attempt is misguided at best, and can actually create problems and stresses for the client that negatively affect the doula-client relationship. What the doula really wants to know is whether there are ways to help the client more effectively, even if what the client wants may seem odd or unusual. There are better ways to obtain that information that don’t create more problems.

Asking the question automatically puts your client in a bind. They have to choose whether to be honest with you before they are ready to do so, or whether to lie. The issue with most survivors of abuse or assault is that the perpetrator took away their power of choice. Their body was not their own, it was the property of the perpetrator. The victim’s only choice was to submit or possibly face worse harm if they resisted. Part of offering healing is for us to allow self-disclosure if it is desired, and when the client initiates it. When we ask the question, it is to meet our own needs even though it is in the guise of good intentions. If our client does not wish to discuss these acts or even for us to know, their only other option is to lie. This dilemma is distressing for our client, which is not the doula’s intention. So don’t ask.

The truth is, what you really want to know is how you can help them more through their birth or postpartum journey. There are ways to get at that information without knowing exactly why. In fact, knowing details about the story is not necessary to offering effective support. Here’s what you really want to know, and I suggest you say something like this on your last prenatal visit (after establishing rapport):

Sometimes people have had life experiences that left them traumatized and that they had to recover from. Sometimes that involves assault or abuse, or even being in a car accident. There may be things that other people do or say that lead you to being instantly scared or startled or remind you of that original traumatizing experience. I just want you to know that I can help you best when I can help myself and others to avoid those behaviors, and what to do if they happen.

You can also offer examples:

  • Sometimes a person is easily startled and doesn’t want to be touched from behind without being asked first and waiting for a response.
  • Another person didn’t want to be in the bathroom alone with the door closed. The door had to be open or someone needed to be with them.
  • Another didn’t want people talking about her as if she wasn’t there. She insisted that they use her name and not call her ‘dear’ or ‘honey’ or ‘mom’.
  • Another was concerned that breastfeeding would bring up negative associations with a past experience involving their breasts. This person needed assistance in being anchored in the present whenever the baby nursed in those first few weeks.
  • Others don’t care for particular words, such as being told to ‘relax’.  

This is the kind of information we really want to know as birth and postpartum doulas. How those needs came to be is not important. We don’t need to know the story in order to be effective.  

At this point your client may choose to tell you the story. But I think it’s important to repeat that you don’t need to know their story to help them. Disclosure should serve a purpose and you want to make sure they don’t feel uncomfortable later if they tell you now. It could be a good time to get a glass of water or use the restroom to make sure their choice to disclose is one they’ve taken a few moments to consider. It is also okay for the doula to not want to know the story! Doulaing is a relationship and you get to take care of yourself too. Perhaps hearing their abuse or assault story would be triggering or upsetting for you, so its okay to ask that they keep their disclosure general rather than including emotional details.

My second point is that childhood sexual abuse is estimated to affect one out of every four women[1] in the United States, and one out of six men[2]. Sexual assault and rape are also common experiences[3], directly affecting at least twenty percent of the population. So, we’re probably better off as doulas if we assume an assault or abuse history rather than seeing it as exceptional. That doesn’t mean that every person who has been assaulted or abused will be affected by it during labor or their postpartum. In fact, some people are relieved to find that it didn’t have a negative effect in that part of their life.

In my experience there are two behaviors that new doulas are most likely to see and that they can effectively address. The first is disassociation – for some reason, the person in labor or postpartum doesn’t seem to be present anymore. They are not in their body, their present moment consciousness is somewhere else. The person may seem distant and unfocused, or may even be looking out the window or down and to the left (recalling a memory). The empathetic neurons in the doula’s gut are giving the message that the client isn’t with you anymore in the room, they’ve drifted somewhere else.

The other worrisome situation is when the laboring or postpartum person’s behavior seems to be totally out of proportion to what precipitated it. In other words, the way they are acting seems to be more dramatic or over the top and is disconnected from what they are responding to. This overreacting may mean they were reminded of something awful that happened in the past. They are responding to that experience rather that what is currently going on.

In both instances, the most effective actions by the doula are the same. Bring them back to the present moment, to being in the room with you, gently and without exerting your power or voice over theirs. This is usually more effective when the doula is quietly and gently persistent, rather than using a loud voice or giving orders.

  • Use your client’s name, use today’s date – or better yet, ask them what day and year it is.
  • Have them look at you, have your client tell you what is happening today, and where they are.
  • Have them notice objects in the room, prompting them with positive ones (flowers, baby book, etc).
  • If invited, touch them in a preferred way (you’ll know them) in a safe place on their body (this will differ). If you aren’t sure, ask. “May I put my hand on your knee, arm, hand?”
  • Rather than ordering them to do something, invite them. Let the client choose – this is very important. “If you can, let yourself come back to TODAY fully.” “When you are ready, let yourself explore feeling safe here in the room with us, letting your body to birth/breastfeed/nurture your baby.”
  • When it seems that your client is mostly back in the present moment, ask something like, “How can I help you to feel more safe right now? Even if it seems silly, please say it. Your brain sometimes has wisdom that doesn’t make sense at first.”
  • Follow through as best you can, with the extra blanket or the pink flowers from the gift shop or finding the right song on the playlist.

These can seem to be scary situations for newer doulas, but we can use the same skills with our friends and family members who have experienced trauma and are triggered in our presence. Sometimes they aren’t even aware that it happened, and our feedback is what helps them to notice that they aren’t in the present moment anymore. To me, because of the commonality of experience of personal violation, these are life skills we all need to see one another through the journey. It’s not about complicated strategies. It’s about being a safe and trustworthy person and allowing the laboring or postpartum person to have their own experience in a supportive atmosphere.

Some doulas have extensive counseling skills, degrees, or training. They have additional strategies to use than what I’ve mentioned here. The book, When Survivors Give Birth by Phyllis Klaus and Penny Simkin, is an excellent resource. There are also facilitators offering two and three day comprehensive workshops for birth professionals wanting to focus on this issue in their practices.

[1] http://www.oneinfourusa.org/statistics.php

[2] https://1in6.org/the-1-in-6-statistic/

[3] http://centerforfamilyjustice.org/community-education/statistics/

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Doulaing For Friend’s Births

Feb 25, 2016 by

DoulaingForFriendsIt’s so thrilling to imagine being a doula for your friend’s pregnancy and birth! For some doulas this is what draws them to the work from the beginning. They want to make sure family members and dear ones have the best experience possible and to help make that happen. But underneath these altruistic desires is the reality of what going to our friend’s births really means. Sometimes it’s a harsh learning.

Ever since I started doulaing, I wondered what was different about it. I thrashed the topic over with my fellow trainers and experienced doulas for years, and then I started asking about it in my doula interviews. Eventually I had enough data to analyze (stories to pick apart!) to get to some core truths. Author Julie Brill, in her compilation book, “Round The Circle: Doulas Share Their Experiences” graciously invited me to write my findings for a chapter in her book. Along with 22 other experienced doulas, we offer advice on unexpected home births, surrogacy, encouraging the mother-baby bond, self-care, and supporting religious belief that is not your own, as well as many other topics. But here is a sample of what I learned:

1. Despite your best efforts, you have an agenda. Pregnancy and birth are times of tremendous life change and shifting of identity. When you walk alongside your dear one, you are attached to them. You want things to go well and you will do what it takes to get a positive outcome. Contrast this with your clients. You care about them and want the best, but our role is to support their efforts and not be invested in their choices. You will likely see them a few times after the birth, but your role is to see them through this transitional period. With your friends, you expect to be in their lives and their child’s lives and to see them grow up. This attachment to a particular outcome shifts and changes your support and you can’t get around it.

2. No matter what happens, you will be associated with that birth and its outcome. Forever. Because of your expertise, you may be blamed if something does not go as expected. In order to get distance from the birth, the family may need distance from you. This need may be expressed by the partner or grandparent, not your friend. However they need to honor those feelings. That may mean not being invited to gatherings or even not having casual visits. It’s so easy to blame the doula, which is not a problem when it’s a client. We shrug it off. But when it’s your friend, you want to explain or work it out, but some feelings you can’t work out. They just are. Often it’s a big surprise to the doula when this happens.

If something goes really well, you may be assumed to have “magical powers” that you know you don’t deserve, which can also be disconcerting. What really matters is how closely the laboring person’s labor and birth expectations meet the reality. If expectation and reality are a close fit, then it is usually a positive for your friendship. If they don’t, it can have negative consequences.

3. Your relationship will change and neither of you can control it. Beyond the rollercoaster ride of many friendships, which have ups and downs and varying levels of intensity, birth does not bring out the best in us. It isn’t supposed to. It brings us face to face with who we are – our strength, our weaknesses, our fears, our beliefs about the world and our place in it. When a stranger is with you, you are able to be intimate, understanding that knowledge is held in a special private place and will not have repercussions for your future relationship. When your close friend sees you, they will know you that way forever. That knowledge and intimacy can make some people really uncomfortable afterwards (including you).

You will also see their partners and family members in a new light, which may or may not be a favorable one. As doulas of friends, we have a much greater emotional load to bear. When we care deeply, it’s very difficult to hide our feelings about a partner’s actions or a care provider’s options. We are more transparent. They aren’t used to our doula mask, and they know when we’re upset or hiding resentment. It can be done, but it’s darn hard.

So what’s a doula to do?

First, buy Julie Brill’s book and read the two chapters on attending the births of friends!  (BTW, I get no money from the sale or promotion of this book. I just think it’s a great resource so you should know about it.)

Second, contribute your baby shower, birthday and holiday gift money towards a doula’s fee and encourage other people to do the same thing. Your friend or family member still needs a doula, just not you! Imagine what a fabulous supportive friend you can be: a sounding board for feelings, an extra resource for information, and all without the full burden of responsibility. You get to show your excitement and your disappointment honestly, offering an extra set of hands whenever they’re needed.

Lastly, as an older woman I want you “youngers” to know how precious your friendships are! Having people in your life who knew you from decades ago doesn’t happen without conscious effort and cultivating compassion, caring, and humility in each relationship. As doulas we often have a leg up on those qualities – but sometimes not with our friends. There’s you, and your friend, and your relationship that all need tending – make sure that you’re looking after each one before deciding to be their doula.

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Are There Enough Clients For All Of Us?

Feb 6, 2016 by

Are There Enough Clients For All Of Us-Do you feel that you are competing with every other doula for clients? “There’s not enough for me and for everyone else. If someone else gets a client, that’s one I don’t have.”  And then you try to work harder to compete and get ahead. (Or you give up.) Fearing there isn’t enough to go around means believing in scarcity.

Let’s break down that idea – Are there enough clients to go around?

From a rational perspective, the answer is clearly “yes”. According to the Listening To Mothers III survey, 6% of people in the sample had a birth doula but 27% of them wanted one. That’s a huge gap between demand and supply. Granted not all of those people may be willing to pay a doula a sustainable fee. But the doula’s biggest market is second time parents! They are more aware of the doula’s value and will pay money not to repeat their first experience. Unfortunately they did not report on postpartum doulas in the survey, but many people have had postpartum experiences they don’t want to repeat either.

From a marketing perspective, the answer is also “yes”. By profiling and targeting your ideal client, you learn that the best person for you to work with isn’t “everybody who is pregnant”. No matter how wonderful you are, you are not everyone’s best doula. It really is a select group. When you compare your ideal client to those of other doulas, you realize that you are after different markets. Of course there will be some overlap and not all of your clients will fit the ideal profile, but many will be close to the target. I find that reassuring – we’re not all after the same person but different kinds of pregnant people.

From a personal perspective, the answer is always “yes”. People choose their doula based on who they feel safe with in their gut, not on how good your welcome packet looks. (The welcome packet opens the door and introduces you.) We have no control over that decision except to be our authentic selves.

For my nineteen years as a doula trainer, I have been preaching that it never makes sense for doulas to compete with each other, no matter what organization they trained with. There’s no economic reason to do that because the market isn’t saturated. When one doula gets a client, it generates interest in the market among other potential buyers of our services. The more people we serve, the more interest grows, and more our potential market grows. Every nine months there is a complete turnover. So our best strategy to grow the profession is to support each other while also pursuing our own individual goals. Abundance is out there. The more we work for success together, the more there will be for all of us.

Every doula I have trained understands this. There are plenty of potential clients and the more we work together to educate the public and careproviders, the more paying clients we will all get. The doula leaders in our region (past and present) also reflect this attitude, and because of it we have a more collegial and supportive atmosphere in our state than in many of the places I visit across the U.S.

When we choose scarcity, we choose fear. Fear that there won’t be enough. Fear that someone else will get the good stuff first. Fear that if someone else does well, that means we’ll do poorly. There isn’t enough cake for everyone to have a piece even if we slice it small! Our bodies end up feeling tight and tense and we worry about what we can do to get more and to get it for ourselves.

Rather than thinking “not enough”, think “there is enough”. It doesn’t cost you anything to shift from a mindset of scarcity to one of abundance, except your level of personal responsibility. With a scarcity mindset, all of your problems are “out there”. The locus of control is outside of you and thus uncontrollable. But when you believe that abundance exists, your attention becomes focused on how to tap into it. You have an internal locus of control – “what I do and how I do it influences my circumstances”.

As this process advances, you’ll become more optimistic – the best is yet to come! You’re more willing to take risks and share your self and resources with colleagues. You can learn from your competitors because you are all in this together. As your relationships with other doulas grow, you can ask for feedback and help without it feeling like a threat. Babies will continue to be conceived and people will keep recognizing that their emotional needs are not being met by current medical systems. That isn’t going to change anytime soon.

What about not having enough time?

My worst tendency towards scarcity is about time. I fear there will never be enough time to get everything done; that I won’t achieve my dreams much less what’s on my daily ‘to do’ list. “There just isn’t enough time!!” Sound familiar? I’m not competing with other people for time – its not like if I get more someone else gets less. I’m really competing with myself – and I never win.

The funny thing is that it’s not true. I do have enough time. Sometimes it takes me until Wednesday to get through Monday’s to do list, but it does get done. The small tasks and the big projects do get completed, for the most part. So what’s going on here? It’s all in my attitude. Being anxious that I don’t have enough time doesn’t get me more time, nor does it make me more creative or efficient. It just makes me jittery and unpleasant. So, what’s my alternative?

I decided to change my thought. “Time expands to meet my needs.” Whenever I begin to have the impending feeling of doom – “there will never be enough” – I realize it’s all in my head. Whatever really needs to happen will and I will have enough time to accomplish it. It’s been four months now, and I have accomplished everything I needed to do.   Some things got postponed, true, but it was mostly because the time wasn’t right – and even I can’t do everything at once. In some instances my priorities changed. But what was really different was my compassion for myself and my anxieties.

Our approach to life is up to us. We choose how we want to think about life. I prefer to choose abundance.

Many thanks to Jessica English of Heart Soul Business for inspiring this post. 

As always, please subscribe!  [Box is on the lower left.]  Thank you for your support!

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Fewer Blogs but More Amy

Dec 30, 2015 by

AmySmile2This year has been about serving you, committed birth and postpartum doulas, in a different way. I’ve written fewer blogs, but posts on higher impact topics like essential oils and universal certification. When I’m not blogging, it’s because I’m writing something else. This year alone I’ve had two book chapters published, one podcast, three videos, developed four new continuing education sessions, and one peer-reviewed journal article, all relevant to what YOU do. I also wrote a 350 page memoir, but that was a personal project!  Several of these resources are FREE. I’m committed to improving our profession and your experience of being a doula.

Round The Circle: Advice for New Doulas includes a chapter on the results of my research on Doulaing Friends and Family Members. Basically, it turns out well when what the laboring person expected to happen and what really happened are close to one another. If the birth or postpartum doesn’t turn out as expected, the relationship between the doula and friend or family member will change dramatically, and usually not for the good. Want more?  [Link to Amazon]

Doulas and Intimate Labor is an academic book published this month by Demeter Press. Edited by Andrea Castaneva and Julie Johnson Searcy, my chapter covers my scholarly work on Doulas as Facilitators of Transformation and Grief. As doulas we are present as the woman becomes a mother and must surrender her old self in order to become her new self (this research was done on cisgendered women). Change implies grief, which is one of the unacknowledged journeys of postpartum. In addition, this chapter covers doula’s experiences when the partner dies during pregnancy, and when the baby dies before birth (fetal demise), at birth, or in the immediate postpartum period. I’ve also turned this topic into a successful continuing education session. [Link to Amazon]

Why Do People Attend Doula Trainings? is an original solo research project. I collected data in 2010 and 2014, asking over 400 people why they were taking a doula training (before the workshop). Surprisingly, many people taking a training are not there to become doulas, but because they want a general education about birth! This topic is also a successful continuing education session. The full article is forthcoming in a 2016 issue of the Journal of Perinatal Education!

Sexuality and Birth Video and Podcast – In October, I had the opportunity to be interviewed by Penny Simkin on Sexuality, Birth and Postpartum. This eight minute video is going through approval to be recommended by Lamaze as a resource for parents and professionals. I’m thrilled that this free video, which gets at the sexual and emotional needs of people becoming parents, primarily connection and pleasure.  [Sexuality After Childbirth Youtube video]

Amy Neuhadel, of The Cord in Sweden, also interviewed me on sexuality and birth. We’ve gotten great feedback on how helpful this TEN minute interview has been for parents and for educators.  [Intimacy and Pleasure In Your Birthing Year Link]

Giving Fathers What They Really Need In Birth  – This YouTube interview conducted by Penny Simkin gave me the opportunity to summarize the research on men and fathers (male cisgendered perspective).  You’ve loved my conference sessions on this topic, so here’s a short resource you can use as a discussion starter in your classes, small groups, or just for yourself!  [The Role of Fathers YouTube video link]

Giving Birth, the birth video that I executive produced with director Suzanne Arms (it really is her baby) is now finally available on Amazon Instant Video!  It took me a year, but its now up!  Suzanne Arms sells it on DVD through her site.

Northwest Doula Conference presentation covering The Top Eight Challenges of the Birth and Postpartum Doula Professions. After two hours of listening to me and what I think, I got a standing ovation. And that’s after getting people to commit to making behavior changes to meet those challenges, not just passively listen and go on their way! I had multiple requests to turn this address into a podcast, but I’d really love to give it again live at another conference and record that. Anyone interested?

New workshop content – this year I wrote several new sessions for continuing education. Hospital Based Doulas: What’s The Difference? is based on multiple waves of research interviews with this HB doulas around the United States; Doulas as Facilitators of Transformation and Grief focuses on how to be this significant person in our client’s lives, as they shift into parenthood, face the possibility of loss, and experience grief as part of the transition into a different phase of adult life. It also gives us space to breathe as we recognize our shared responsibility for the emotional well being of our selves and each other as doing doula work changes who we are as human beings.

Communication Skills for Birth Professionals is a skill building workshop where you learn by doing – you leave with skills you didn’t have when you walked in the door! It is available in two, three, and four hour formats. Two hours focuses on listening; the third hour focuses on preparing yourself to communicate successfully; and the fourth hour adds conflict resolution skills focusing on typical situations that birth and postpartum doulas face. These sessions are not formulas, telling you what to say. They teach you how to think about a situation, so you can be authentically yourself in all of your encounters.

PTSD: How It Affects Childbirth And How To Improve Your Outcomes is the latest addition to my catalogue, which came my way because of requests from physicians and nurse groups. Yay! What most doctors and nurses don’t learn in school is how to show they care. They don’t learn the physical and emotional skills that communicate their internal feeling of caring for a patient on a personal level. In fact, for many professionals their educational experience is to have the emotional center pummeled away in order to follow good practices in medical care.  The ‘cure’ for preventing childbirth to make existing PTSD worse is authentic human connection.

If that isn’t enough for you, I also wrote a 350 page memoir of the experience of taking care of my terminally ill mother, who was misdiagnosed for the first half of her illness. Tentatively titled The Summer of Mimi, I hope to complete the second and third drafts in 2016. This was a personal goal of mine, but as I can’t stop being a doula all over my life, its has juice in it for all doulas too.

2016 promises more content and more projects!

As always, please subscribe!  [Box is on the lower left.]  Thank you for your support!

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Busting The Myth of Privacy in Hospital Birth

Sep 18, 2015 by

woman's fist 4One of the craziest misconceptions that first time parents have is that laboring in the hospital will be private.  Where did they ever get that idea?  You’re in a room that isn’t yours, it’s the hospital’s.  You’re a guest in their house – a paying one, yes, but it’s still their space.  In hospital language, the phrase “private room” means that you aren’t sharing it with another patient, not that you will have privacy in it.  A home-like room does not mean the same privileges as being at home.  Ask just about anyone that has had a long labor and they will set you straight.  The problem is, hardly anyone ever asks about privacy, they just assume they’ll be in control.

“We don’t want a doula because we want our birth to be private.”  This is one of the most common phrases almost any birth or postpartum doula hears.  Pointing out that privacy is an illusion or a myth has never really gotten me anywhere, because I immediately come off as argumentative.  It took me years but I finally figured out what to say. I have learned to ask, “What does privacy mean to you?”

Usually they look at me with a puzzled expression.  Then the person will usually list, “being left alone when we want to, being just the two of us, not having people coming in and out the door, focusing on each other, that kind of thing.”

Depending on what’s been listed, I slip one of these four responses into our conversation:

One:  “You’re right, privacy is so important to laboring with less pain and faster progress.  You’d think hospitals would take that into account with their procedures, but their system hasn’t adapted very well.  An experienced doula knows how to work that system to your best advantage and get along with nurses.”

Two:  “Oh, okay, do you know that you don’t really have any say over who is in your room?  Or that auxiliary staff that needs to talk to the nurse will just come in your room randomly?”  “The nurse’s pager is beeping with people talking to her almost constantly sometimes.  She can’t turn it off.”  [Note: State what is true where you practice; this is true in my area.]

Three:  “What if you need something when it’s just the two of you and you don’t want your partner to leave?  What happens then?”   “Labor usually lasts a long time.”

Four:  “Doulas have lots of strategies to maintain your privacy, that are difficult to establish and maintain on your own.  She can make signs on the door, talk softly to trigger others to do so, sit outside your door as a smiling guard, update and talk to visitors in the family area, and handle your texts and replies so you can focusing on laboring as a couple.”

Then I’ll usually conclude the conversation with one or both of these statements:

Your doula maintains your privacy for you.  She will sit in the corner or outside the room when you want, and be at your beck and call.  She’s there to support you both doing whatever you need to do.”

“Remember the movie Top Gun?  She’s your partner’s wingman.  (You can suggest an updated pop culture reference in the comments!)  That’s her job.  She can keep other people out or minimize any disruptions.  Wouldn’t it be great just to have some wait on both of you, who is there only to meet your needs?

This tactic of asking people what they mean by a concept gives us more information to expand the discussion.  Often an idea or concept, such as “privacy” stops us because we get caught up in our feelings about it.  Whenever we’re going on the offensive – even in the guise of giving information – it puts other people on the defensive.  Yet, when we ask questions, and listen to the answers, we avoid making assumptions. People reveal more about their priorities and perspective when we ask.  We learn more about what is important to our clients and potential clients and can target our information to their interests.  This ups our effectiveness as communicators and shows us as the caring people we are.

 

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