Doula Research Part III – Barriers To Approvals, Funding And Publishing Access

Nov 29, 2017 by

Untitled designMost people don’t know much about the research process or how difficult and time consuming it can be to publish in a peer reviewed journal. This essay exposes the barriers that are unique to publishing doula research examining obstetrical or neonatal outcomes. Part II covered the medical politics and power dynamics that negatively influence doula research projects, while Part I listed fourteen research questions that have not been answered in the 35 years since the first doula study. To conduct a doula study similar to the ones I listed in Part I, there are four to six different groups who will need to approve of the project. But first, the whole study has to be planned out in advance – and that’s before anyone ever gets paid for doing that work. So barrier number one is having the economic independence to spend the time planning a detailed doula study without any idea whether it might be funded or approved.

Graduate Student Researchers

Graduate students are more likely to pursue a doula study than a professor at a university. I judge this by the number of published theses and dissertations on doula topics. If a graduate student’s goal is an academic career, their thesis and dissertation need to be intriguing to future employers. Plus they want to hire people who have received grant money. So one’s choice of topic influences one’s employability.  That might lead people away from a doula study because you want to choose a topic that looks appealing to funders for the long term.

Graduate students have the added burden of having to pay tuition while they are waiting for project approvals. Most of the time a student can’t propose a project until after all of their classes are completed. Tuition needs to be paid to keep their student status while the project is being approved. As you can see this is often an insurmountable financial barrier. One recent graduate who wanted to study doulas and breastfeeding outcomes confided to me that her committee steered her away from anything medical because it would take about a year to get the approvals and cost additional tuition (typically US $10,000).

Some graduate students develop small projects nested inside the larger research study of an established university professor. But to my knowledge only one person, Katy Kozhimannil, is consistently publishing doula studies. So they are not attracting graduate students to work on their projects or develop expertise on the subject. While not exactly a barrier, this factor definitely influences why there have been few researchers pursuing doula support studies.

Funding

How might one fund a doula study? The first option is grant funding by the National Institutes of Health, which is based on what they determine to be health care priorities. In years past there’s been specific funding priorities for research on opioids or obesity and their effects on pregnant women and babies. These priorities eventually show up as a publication trend in research journals. Less money is “unspecified” so a doula project would be competing with other proposal topics like infant sleep, breastfeeding, and long-term effects of third degree lacerations. NIH grant funding has several cycles per year and the applications are slightly different depending on the priority. So part of the research question and hypotheses might be changed to fit the funding criteria.

A second option is to apply for private foundation grants like those from the March of Dimes, Kellogg Foundation, or Robert Wood Johnson Foundation. Once again the project will need to fit their funding priorities. Each of these organizations has funded doula studies or programs in the past (see pdf below). The budget will need to be precise and include compensation for the researcher, study director, doulas, study participants and cover any project expenses (rent, paper, and so forth).

Lastly, some smaller studies are funded by multiple small grants from local funding sources who are interested in a specific outcome. For example, if a specific population of people is targeted, there may be funds from an organization to see if breastfeeding initiation increases when doulas support this group. That might not be the main point of the study but by including this outcome you can receive financing. So funding sources influence the research proposal and design too.

Planning The Study and IRB Approvals

When planning a study, most people might think a detailed outline would be sufficient at this stage. Actually, every decision is made during this early planning stage down to the smallest detail. The first task is to read everything already published and summarize it in a literature review. Then all the decisions about research methods are made including hypotheses, data collection methods, sample size and recruitment, analysis methods, and statistical power. This research plan or proposal includes the small details that are needed to implement the project such as participant recruitment letters and emails, interview locations, and compensation. This is a good time to ask for input from the people whose cooperation will be needed to conduct the study, such as physicians, nurses and other hospital staff. Funding possibilities and journal requirements also influence the study’s design. Coming up with a plan that meets research goals, funding priorities, and is amenable to the facility and staff where the researcher will be conducting the study is imperative to its success.

A graduate student would make changes to their proposal until the three to five members of their committee approved it. After that they are in the same position as a university faculty or staff researcher, and the plan would be submitted to the Internal Review Board (IRB) of the college. They examine the proposal for its impact on the human participants in the study. They also examine funding sources for possible conflicts of interest.

If researchers are collaborating from different universities, the project needs to be approved by each university’s IRB. At any point the review board can request changes that they feel improve the project. Each request often takes another week to ten days to address and may require significant changes to the proposal.

Once the university approves the project it is time to formally approach the hospitals to support the study. The proposal now needs to go before the hospital’s IRB, which has different priorities and concerns than the university’s review board. Hopefully the researcher has connections with the hospital staff and administration who are open to the changes that conducting a doula study within its walls will bring. The project will also require permission from the physician head of obstetrics, the director of nursing for the labor and delivery unit, and other affected departments. But since it’s already been approved by two IRB’s, no changes to the proposal can be made at this stage. By this time a year may have gone by. Remember, no one has been paid yet.

What Journals Will Publish Your Doula Study?

Along with applying for funding and IRB approvals, a researcher is also considering which journals will publish their doula research study. This is really difficult, much more so than with other perinatal topics. Doula research has no journal home. The Journal of Perinatal Education has published more doula studies than any other journal, however the theme of perinatal education needs to be relevant in the study. Midwifery has been inclusive by publishing doula studies from across the globe, including mine. But it is a very competitive journal. Nursing journals such as MCN or JOGNN reject studies that do not have clinical implications for the ways nurses practice. Many of the doula studies I’d like to see won’t have those clinical implications as a main finding, making nursing journals a poor prospect. Physician journals have similar standards for providing strong clinical implications for the practice of physicians and desiring physician authors.

On top of that, no profession pays attention to findings published in another profession’s journal. This tendency to isolate research findings to a specific profession is called “silo-ing”. Like corn stored in a barn silo, knowledge is kept separate and locked away. This practice is named as one of the main barriers by perinatal health care quality improvement organizations to applying evidence based practices in a timely manner.

While there are many lesser journals and open source ones available, that will not help a doula study to be spread widely unless the journal is peer reviewed AND included in respected databases. I’ve been personally facing this dilemma for years. I have a completed study on the experiences of hospital-based doulas from four different programs but no clear place to submit it. It has few clinical implications for nurses or physicians, but plenty for administrators of doula programs and other doula researchers. But what journal would welcome this piece? One of the main reasons I started this blog was to publish many of the smaller research findings in my doula studies. I’ve been able to disseminate them in an informal way and reach the people who find them useful.

Savvy researchers know the journals they want to submit to when they are in the planning process and will create hypotheses and a research design that they know will appeal to the reviewers for that journal. Even though reviewers are anonymous and change depending on the subject matter of the submitted article, the journal’s previous publications and criteria for inclusion make their priorities known. Without a research “home” for doula studies, this part of the process is more difficult. What Birth publishes is different from the Journal of Midwifery and Women’s Health.

Multiple challenges inherent to the process of conducting a doula study have led (in part) to a dearth of research. Along with the political pitfalls of challenging the status quo in how perinatal care is practiced, and lack of a political agenda that reflects the entire spectrum of how women live in their bodies, there is a trifecta of influences keeping any new knowledge contained. The real tragedy is that without the research exploring the possible greater impacts of doula support we don’t know what other positive effects we are missing.

Related Content: Sustainable-Funding-for-Doula-Programs-A-Study_for-web  For more information, please visit Health Connect One.

Coming Soon: Part IV: Being Let Down By The U.S. Women’s Movements and Moving Forward

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Why The Doula Research We Need Doesn’t Exist: Part II – Medical Politics and Practices

Nov 6, 2017 by

DSC03787As a young woman, I naively thought that the evidence was so overwhelming that we’d steadily see doula research in major medical journals. Nursing and medical students working on research degrees would pair with their professors and community members to answer these pressing questions. The fact that our answers could impact future generations would provide enough incentive. We could stop women’s bodies from being permanently damaged by outmoded obstetric practices and facilitate trust and communication between client and caregiver. We could help mothers and babies have the best possible connection from the very beginning. We could increase physician and nurse sense of connection to patients and colleagues thus positively impacting their mental health outcomes. Doulas do this by offering two commodities that are scarce in the hospital system: time and a listening ear.

I am no longer young. Anyone wanting to study doulas from a medical perspective has been shushed or shut down – that’s my only explanation. They’ve been quietly steered to other topics that would be more acceptable to medical or nursing professors serving on the approval or review board committees. While there are plenty of theses and dissertations on doula topics, very few of them actually add to our understanding of doula support. They are almost exclusively from the social sciences not a medical field. Most focus on the way labor support is experienced by parents or doulas because that aspect is accessible.

My conclusion is there are few doula research studies because of obstacles from medical politics and outmoded beliefs which I explore here. Part III will cover difficulty in research approvals, funding and publishing access; and the feminist political agenda of the U.S. women’s movement.

Politics and Power:

  • Doulas represent the laboring person. They don’t want to maintain the system as it is, they exist to disrupt the system from offering impersonal care. Their very existence demands that the hospital see the patient as an individual, with their own particular needs. Anyone who has a vested interest in maintaining the status quo will actively resist any research on birth doula support.
  • Doulas are unpredictable. Because they make a stand for the primacy of their client’s interests, no one is quite sure what they will do. Ask for the squatting bar? Even wanting a spontaneous labor to take as long as it needs to rather than following a predictable timeline is heresy in some labor and delivery units. Doulas actually interrupt physicians from doing interventions so they can be discussed with the patient first.
  • Doulas disrupt the power imbalance in the labor room. Doulas insist that power be shared with the laboring person (patient) and that medical careproviders discuss benefits, risks, and alternatives. Doulas assist their clients to develop a collaborative relationship with their doctors, even when that is not the wish of the physician. Many doctors are used to making autocratic decisions and not having their opinions questioned. They do not see the benefit to the patient or to themselves, even though it leads to charting of the conversation that benefits the physician if there is need for a review or inquiry.
  • Doulas empower women. Current western society is still built on the premise that women are not equal to men. These patriarchal beliefs are woven into our majority culture along with white supremacy, colonialism, and racism. Anytime an oppressed group exceeds their allotted power in the system, the fear grows that it will spread to other groups. The existing system sees sharing power as a loss rather than a gain. Since doulas are basically disruptive to the status quo they cannot be empowered in any way including research funding or internal review board project approvals.
  • There’s no clear way for hospitals or medical systems to make money exploiting doula support. Although there’s a lot of controversy about the unpredictability of maternity care billing here and here, as a general rule the current system pays more money for a birth when more interventions are used. Since doulas have been shown to reduce the need or use of those interventions, and doulas cost money, there’s no financial incentive to explore labor support. Until the billing and funding systems change there will remain no financial reason to explore doula care except for Medicaid patients.
  • The only medical systems that employ doulas do so because it solves their other problems not because it primarily benefits women or babies. That’s why these systems haven’t published on positive obstetrical outcomes, because there aren’t many. In my own observations, these programs only exist when they help the hospital to attract customers or when the doulas solve other problems in the labor and delivery unit. They don’t exist to get better outcomes, lower complications from interventions, or empower patients in the medical system.

Outmoded Beliefs:

Our medical systems don’t value individual people very much. This is ironic because our medical system is supposed to help people, but when it comes to how obstetrics is practiced people are damaged as well as helped. This is true for physicians, midwives, and nurses as much as it is doulas and patients. No one personally benefits from our current system of labor and delivery care. Only the system itself does. We have to remember that the hospital system of obstetric care was founded on several beliefs:

  • Babies don’t feel pain or remember what happens to them so whatever you do to them doesn’t matter.
  • Women’s bodies are mechanical in nature, so treating the body as a machine with technical difficulties is the right approach. The fact that there is a person inside the body influencing how the body functions was not a part of that original thinking.
  • Physicians function best when divorced from their own lives and feelings and practice in a vacuum, focusing solely on the mechanics of the body and objective data.
  • Nurses are there to be the physician’s hands and eyes, not to have a voice or their own unique knowledge and contributions.
  • A mechanized system of medical care delivery, based on a factory model, provides the best results for the majority of people and the system itself.

We can see how toxic each of these beliefs are. Yet they are still present in how labor and delivery units are designed and how people do their jobs. Acting as if those beliefs are wrong is heresy! Yet that is exactly what doulas do. So no wonder no one wants to pay money or spend time to do research on birth doulas unless they are also invested in changing the way medicine is practiced. Think about it. The changes that many wish to see in the way obstetrics or hospital midwifery is performed challenge one or more of those founding beliefs. My cynical side says that they have no reason to worry as it takes 17 years for the best evidence to actually become medical practice.

In Part III of this series, I’ll explore the obstacles inherent in the research process.  Part IV covers how the lack of any kind of childbirth rights agenda from U.S. mainstream feminist organizations affects doula studies.  Part I covers the doula research I thought we’d have in the 37 years since the first doula study was published.

 

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine104(12), 510–520. http://doi.org/10.1258/jrsm.2011.110180

Free SlideShare Presentation on Why It Takes 17 years  (See Slide 7):  https://www.slideshare.net/iHT2/health-it-summit-san-diego-2015-panel-research-evidence-and-clinical-realities

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Why Don’t We Have The Doula Research We Need? Part I of IV

Nov 3, 2017 by

070The Cochrane Collaboration updated their doula research review this year. They added four, only FOUR new studies – and none of them advanced our research conclusions in any significant way. Birth doulas have the potential to be the most influential factor in lowering negative birth outcomes and optimizing positive ones for mothers and babies. We’ve known that for over THIRTY YEARS – that’s a whole generation of people who could have benefitted but didn’t.

No one, and I’m pointing my finger at academics and medical careproviders and political women’s organizations, has bothered to do any significant research or insist that it be done. Instead the established power systems are hoping doulas will just go away. They want to keep us small and bickering amongst ourselves, which happens to any group when they experience some success. The established power structures don’t want to change and any good doula research would show that hospital systems have to change in order to get better results. I’m angry, and I rarely get angry.

Here are the research questions I expected to see answered in the past 37 years since the first (Sosa, Kennell, & Klaus et al., 1980) doula study was published:

  1. In a randomized control study or a matched pair study of people who did and didn’t have a doula, do we see consistent outcomes in perception of pain, length of labor, intervention rates, breastfeeding initiation and longevity, birth satisfaction, partner satisfaction, postpartum wellness, and the feeling that ‘my baby is better than other babies’?
  1. What factors interfere with the doula’s ability to affect obstetrical outcomes?
  1. Does partner involvement with labor support (not the birth itself) make a difference in outcomes?
  1. How do doulas benefit partners and/or have an influence on parenting relationships and partner/marital relationships?
  1. Do prenatal visits make a difference in obstetrical, birth satisfaction, maternal and infant outcomes? The way most birth doulas practice is 2-3 prenatal visits, continuous labor support at the birth, and one to two postpartum visits. But we have no data on whether that is the best way to practice or not. Are labors still shorter? Do laboring people have less pain or use less pain meds? Are people more satisfied with each other or with their doctors or midwives when they have a doula?
  1. Does having a birth doula affect a pregnant person with a perinatal anxiety or mood disorder? When someone is supported by a doula during labor are they less likely to have postpartum depression? How about with a postpartum doula?
  1. Under what circumstances does it make financial sense to fund doulas or doula programs? Rather than spending money on other labor interventions, is it more economical to pay for the doula? Along with Drs. Will Chapple and Dongmei Lee, I published a study in the Wisconsin Medical Journal exploring this question. Katy Kozhimannil co-authored a study on Medicare costs for doulas. Where are the rest?
  1. In 2010, I published a study on birth doula’s emotional support strategies. Four were the same as those in the nursing literature, but the other five were sophisticated counseling or therapy techniques. The doulas in my study were never formally taught those strategies, they arose spontaneously from the doula. Why hasn’t anyone actually observed doulas to see what they actually DO at a birth that makes a difference?
  1. Where are all the research reports on hospital based (HB) doula programs, where the doula is a paid member of the hospital staff? What are their outcomes? Who benefits from the doula program? What models are more effective at getting which outcomes? I’ve interviewed 15 HB doulas from four different programs. Why am I the only one? (Why that data is not published is in the next blog post.)
  1. Are doula programs staffed by volunteers effective?
  1. What are successful models of doulas and nurses working alongside one another that increase both job satisfaction and positive patient outcomes?
  1. There are no studies on physicians and doulas, exploring how people in each role perceives the other, how they can optimally work together, or any models of doulas working for doctors. Why not?
  1. Does continuous care matter? The only reason we know that is from two meta-analyses that are both twenty years old. Is that enough?

These are all of the things that I thought we would know in thirty years.  Each time a research review on doula support is published, I’m eager to discover any articles I might have missed. But there aren’t any.  In my next posts, I’ll explore why we don’t have the research I thought we’d have. My conclusions?  There are few doula research studies because of obstacles from medical politics; outmoded beliefs; difficulty in approvals, funding and publishing access; and yes, the priorities of the U.S. women’s movement. Look for it in your inbox in the next few days.

 

Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E.. (2013) An economic model of the benefits of professional doula labor support in Wisconsin births. Wisconsin Medical Journal, 112(2), 58-64.

Gilliland, A.L. (2011) After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada. Midwifery, 27(4), 525-531.

Kozhimannil, K.B., Hardeman, R.R., Alarid-Escudero, F., Vogelsang, C.A., Blauer-Peterson, C. & Howell, E.A. (2016a) Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth-Issues in Perinatal Care, 43(1), 20-27.

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Sosa, R., Kennell, J., Klaus, M., Robertson, S. & Urrutia, J. (1980) The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine, 303(11), 597-600.

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Who Are You And Why Should I Listen To What You Have To Say?

Sep 16, 2017 by

AmyGilliland-5Demands for transparency in science and accountability for potential bias in researchers are relevant to doulas because so much of what we do is research driven. People want to know who is generating knowledge and how their backgrounds inform their findings. Since I’m about to embark on some rather provocative blog posts I wanted to share information that I think is relevant for my readers to know.

I was twenty years old when I unexpectedly went to my first birth and ended up doing all the labor support. I knew very little so I left with lots of questions. My curiosity led me to have a midwife attended birth myself a few years later, and I became a childbirth educator and professional birth assistant at age twenty four. That was over thirty years ago and I’ve never stopped being a doula or involved in birth work. Throughout the years I’ve been a La Leche League Leader, an Informed Homebirth/Informed Birth and Parenting and ALACE Certified Childbirth Educator and Birth Assistant, a DONA approved Birth Doula Trainer, Advanced DONA Birth Doula, and an AASECT Certified Sexuality Educator. I served on the boards of DONA (’95-99), Wisconsin Association for Perinatal Care (’12-present), and have given general session presentations at international conferences including DONA, CAPPA, ProDoula, and Lamaze. My full CV, listing presentations and work published in peer reviewed journals, is here.

That’s what looks good on paper. But what about me personally? I became a doula when my adult identity was cementing. I’ve never not been a doula or surrounded by doulas. For my research studies, including my master’s thesis and doctoral dissertation, I interviewed over sixty doulas and forty parents about their experiences with labor support. My goal is to increase the legitimacy, understanding and professional respect for the doula professions. A secondary goal is to empower laboring people and careproviders to create a respectful, cooperative system of perinatal care that allows for differences in philosophy and practice.

For fourteen years I’ve taught university level courses in the psychology of human relationships, human sexuality, introduction to psychology, and public speaking. I have a graduate certificate in prenatal and perinatal psychology and believe the newborn is conscious human being capable of complete sensation and the creation of memory before birth. I believe in the empowerment of people in labor, no matter what their gender or sex, and the individualization of care towards that person. I believe the medical system is toxic for most nurses, midwives and physicians and that system change is possible when we are all willing to subvert the existing power structure. However I’m not an activist or an agitator. Those roles are necessary and valuable for social change, but it’s not my gift.

Instead, I’ve noticed that lasting change comes when people are open and you can make an individual connection. So I teach. I facilitate. I lead. My workshops are grounded in research – it is what we know and trust as a society – as well as teaching the skills of connection and communication. Those ‘soft’ processes are the ones that bring differences in neonatal and obstetrical outcomes at a birth. After all my years of research and reading, that is my theory. Doulas make a difference because they are able to meet a laboring person’s attachment needs.

Others have described me as a thought leader and visionary in the doula world. I spend a lot of my time thinking, pondering, considering, ruminating, and gestating my ideas. This blog is a culmination of much of that effort. Many of these essays have been worked on for four months or more before they are posted. For those of you who are still reading, I am constantly trying to answer the question, “What are the influences on this situation? Why are things the way they are?” My research interests have landed me a postdoctoral fellowship at the University of Wisconsin Madison School of Human Ecology’s Center for Child and Family Well-Being. This enables me to access the university’s resources to continue researching and publishing my studies on labor support and doula care.

People have criticized me for being too detached, not emotionally involved enough, or not having a strong enough opinion. As a trained scientist I really strive to be aware of my own biases and to include them when they are an influence on my conclusions. This detachment may come across as uncaring in my writing.  On a personal level, I’d been attending births for a decade before I called myself a “doula”. I didn’t really care for the word – I was a professional birth assistant – but it was the word the market chose for what I did. I rationalized that it took up less space on my business card. Birth trends have changed, what mothers want has changed, who is birthing has changed, men’s roles in society and parenting have changed, and so have public attitudes about childbirth. Having lived and adapted my practices to accommodate all these changes, I just don’t get as emotionally invested anymore. I’m not uncaring, I’m just more protective about what I allow to make me angry or upset. When I wrote the Birthrape blog for example, it wasn’t going to help anyone if I ranted. What doulas really wanted was solutions – a recipe of what to do and some understanding of why medical careproviders ignore the protests and cries of their patients during a painful procedure.

Anyone who knows me knows that I care deeply about doulas, about how people birth and are born on this planet, and creating lasting social change that honors our brains, psyches, and bodies. Otherwise I would not have dedicated my life to it.

 

Facts About Me That People Find Interesting:

  • “Giving Birth The Movie” – (2006, 2000) I executive produced this DVD documentary with director/producer Suzanne Arms   – available for viewing on Amazon.com for $2.99!
  • I have a research chapter called “Doulas As Facilitators of Transformation and Grief”, (2016), in the first academic book about doulas, Doulas and Intimate Labour: Boundaries, Bodies, and Birth, edited by Angela Castaneda and Julie Johnson Searcy.
  • I have a research chapter in Julie Brill’s book called “Attending the Births of Friends”, Round The Circle: Doulas Share Their Experiences, by Julie Brill (2015).
  • In 2002/2003 I lost 100 pounds and have kept 90 pounds off for fifteen years.
  • I married my fourth husband in 2013 and am the happiest I have ever been.
  • I birthed three children out of hospital with midwives, and am stepmother to a fourth.
  • I grew up in a family with only women and went to all girl’s school and camp.
  • I have no cousins, aunts, uncles, or siblings. My family of origin has all passed away.
  • I have done end of life care for several people who I have loved.
  • I am committed to being the best multicultural birth doula trainer I can be and actively work at uncovering my own internalized racism from living in a racist society. Towards this end, I have an accountability group and take workshops on a regular basis.
  • Like many women, I have survived sexual abuse, sexual assaults, marital rape, interpersonal violence, and stalking. I moved to Wisconsin to get away from the stalker. I believe we have to share this herstory otherwise victims/survivors feel isolated or ashamed. It was not our fault.
  • My areas of privilege are socio-economic, education, cisgendered, white, and the ability to pass in most other areas where I do not possess societal privileges.
  • Since I was born I’ve never lived without a cat.
  • I hiked for eight hours on an erupting volcano. Yes, it was dangerous!
  • I grew up on a rural California cattle ranch, a Napa historical home, and in the cities of San Jose and San Francisco. I can ride a horse, ski down a mountain, and swim in the ocean.
  • The Wisconsin State Journal published two articles about me and I’ve been featured in a regional women’s magazine (as a doula) and Florida and Wisconsin regional home magazines.
  • I’ve rehabilitated or extensively remodeled five homes and planned and pulled off six weddings. I love being inspired by the potential in homes and people to be their best.
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There’s 67 Different Doula Training Organizations! Uh oh! Or maybe not?

Jun 13, 2017 by

Version 2Recently, Kim James of DoulaMatch.net reported that birth and postpartum doulas have listed 67 different training organizations in their online profiles. Why are there so many? What are the implications for our profession?

If you think about it, there are few ways for someone to utilize the knowledge they’ve gained as a doula except to train other people. While some organizations have individual recognition for a member’s achievements, that’s about it. There are no national awards and no career ladders to climb. Expansion into more lucrative positions is expected in other paraprofessions; but if you want to continue as a doula the only obvious paths are to train others or start an agency. So that’s one reason – individuals want to move forward in their career options.

Unfortunately, some people are more invested in making money than in furthering the doula profession or ensuring that the doulas they do train are qualified. Anytime price or speed of “certification” is advertised over the educational experience, I know those people have missed the point. These days it’s easy to offer an online course. The problem with online courses is that doulaing is a relationship that is based in touch, eye contact and the stimulation of oxytocin, and you can’t effectively teach most people how to relate to others in those ways unless you are also face to face. Some online courses include a Skype or FaceTime mentor, which is better than nothing. But I have had several people who took an online course subsequently enroll in my in person workshop. They were familiar with the concepts but didn’t have the deep knowledge or confidence to actually apply them with a client.

Sixty seven different training organizations means we have little unity and uniformity in training standards. Preparation could be sloppy or exhaustive. Doulas could learn its okay to judge people’s choices and that some ways to give birth are better than others, and our role is to herd people into those “better” ways. There is no standard ethical platform. No practice standards that we all agree on. There is no unifying principle that we can assume about one another.

The certification that is offered by most of these groups has no vetting. To me, “certifying” that someone is a qualified doula simply because they wrote an essay, read some books, made it to a few births and summarized them is not enough. Is anyone making sure they are good ethical people? Has the organization contacted and spoken with several of the doula’s references? Will the organization stand by its certifying of the doula if a complaint is made? I consider an organization to be a strong one when they will stand behind their doulas, stating they have been trained in the most rigorous way possible.

If consumers or careproviders have a complaint about your behavior, they can bring it to the organization’s grievance committee and be heard. They have recourse. From my checking, very few groups certify doulas at this level. What they call certification is merely the completion of a checklist of requirements. There are few qualifications for character or job performance, and no recourse for future complaints.

Because training quality is so variable, it contributes to an “anything goes” atmosphere. We look unprofessional and unorganized to outsiders. This fuels the reluctance many medical professionals have in generally recommending doulas. They may recommend an individual doula, but not doulas in general. There is no guarantee of quality and no consumer protection. If parents are unhappy with their doula’s performance, they may not have any recourse. This could bounce back to the medical person who recommended them.

Now I’ve been doing professional labor support since before the word “doula” was in use. I was a part of the conversation when the first four large scale training organizations (ALACE, DONA, CBI, CAPPA) went from an idea in someone’s head to creating certification standards. It used to be that calling yourself a “doula” meant that you could assume certain things about that person. With the differing standards and philosophies from sixty-seven organizations, that is no longer true. Because we have a diluted group identity, I see many people seeking strength in an organizational identity.

Globally, we are in a time when nationalism has become more prominent. Rather than thinking about what is best for us on a planetary or humanitarian scale, people are concerned about the well being of their own nation. They see themselves as belonging and being similar to that group, rather than to people as a whole. I see the same thing happening with doula identities. Are you a “Xxxxx doula”? Are you “Xxxxx proud”? The organizational identity substitutes for the larger sense of connection we had with one another no matter what our training and certification affiliation. Being independent and staunchly unaffiliated with any group is also an identity. While this might work for an individual or the organization, it doesn’t serve the movement as a whole.

At the same time, I don’t think this scattering of training organizations is something to get too excited about. For one thing, when I examine the histories of both social movements and the growth of professions, it seems that this diversification is a natural stage of development. It is a part of the spreading of the movement’s belief system and the increased demand for workers to do this job. It is unhappiness with this stage and the lack of uniformity in standards that usually leads to large scale organizations to create universal standards. The desire for this comes from within and without. For example, doulas who see the need to affiliate around common values and behavioral standards. But that isn’t enough. There is usually public pressure to provide standards that protect consumers and offer remedies when [in this case, a doula’s] promises are not fulfilled.

So, if I take a step back and look at things over time, I can see 67 training organizations as a positive sign of growth in the demand for doulas. It is a stage in our profession’s development. For the most part, growth has been driven by people who want to offer the service, not by people demanding the service. It’s been up to doulas to educate the public about why they would want a postpartum or birth doula. As far as I can find, no one has tried to educate the public about why they would want a doula whose certifying organization has personally screened them and who offers a grievance procedure in case there are problems. Nor has anyone, besides me, tried to guide wannabe doulas into asking questions about a trainer or training BEFORE they’ve spent their money. Several high quality trainers have mentioned that they are asked for discounts for their workshop because someone already spent their budget on a lousy one.

What about if we look at The Really Big Picture? Where did doulas come from anyway? We came from women helping other women to flourish during pregnancy, labor, birth and postpartum. We came from a tradition of listening to one another and respecting one another. For those of us who had no formal training when we started (like me), we learned from doing the work. We learned from going to births. We learned from listening to women. We learned from listening to one another. Birth itself is always our biggest teacher. I have hope that even if someone is poorly trained, if they are paying attention and asking to learn, Birth will step up. Birth is the most important trainer of all.

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It’s Your Turn to Make Doula History

Apr 3, 2017 by

AmyConf1993

Amy Gilliland, Madison Area Birth Assistants booth, Oct 1993, Madison Women’s Expo

Lately I’ve thought a lot about what’s left after someone is gone – and who tells their story. It has made me really think about who is going to write the story of our movement. Traditionally history is written by people after events have happened, after the world has already changed. It’s written by people who have the power to write and disseminate information – which is why so many of our perceptions of history are distorted.

What about us? What about our history? Who will write the story of birth and postpartum doulas across North America and the rest of the world? Who will point out the indigenous women who never abandoned each other under the pressures of western medicine? Who will write about the women in the seventies and eighties who said, “I will go with you and I won’t leave you”? Who will write about how we took care of each other when our own families would not support us in breastfeeding or avoiding another cesarean?

The battleground of the doula revolution was not on a national stage. It was quiet, in every labor room across the planet, where one woman held another’s hand and said, “You can do this, I believe in you.” We made a stand for another person’s mental and emotional wellbeing in a system that had little room for it. We protected the space. We stood by her side when she said, “No.” We agitated the system with a smile on our faces. We kept doing it, over and over again, for years, until eventually those in power could no longer ignore us or their own research.

That’s the big story. But what about the little stories? What about the doulas in Pueblo, and Springfield, and West Bend? How did birth change there because of the presence of those early doulas? All of our communities have little stories. Each weaves a thread into the tapestry of our great big story of doulas changing birth in the world. Where are those stories?

Who came before you, person reading my blog? And what was birth like in your town? The time has come for you to seek out retired doulas and nurses and midwives and find out.

You see, if we don’t write our own stories, someone else will tell a tale that serves their own purposes. Or they will be forgotten, seen as not being important. Much of women’s daily lives has been unimportant to historians. But doula history is significant. If any one movement will be singled out as creating change in our system of birth, it is going to be birth doulas. Mostly we’ve been like dripping water, slowly eroding rock, getting the system to change. Lots of drips lead to pitting a foundation, causing it to change in response or else collapse. So while we may not be at most births, we don’t have to be. Our impact continues to grow. We aren’t done yet.

What is your community’s story of change?

Starting in the 1990’s I was the Archivist for Doulas of North America (DONA). Doulas sent me articles from their hometown newspapers. Back then it was a rare occurrence. While we might have wanted to change birth, what we really wanted to do was make sure women didn’t lose their power while having their babies. We couldn’t do that for everyone, so we just focused on the family in front of us. We hoped that over time the value of what we did would show.

Our strategy (if you can call it that) worked. Nowadays there are tens of thousands of trained doulas, and many cities have well established doula communities. ACOG recognizes the value of birth doulas. That means to me that it’s an excellent time to look backwards.

That sounds good to me, you say. But what are you suggesting I DO?

  1. Have fun! Talking about this history of birth in your town can be really fun. Most people like to reminisce and are excited that their memories are important.
  2. Investigate! If you don’t know who came before you, start asking. More experienced doulas may be able to remember a name or two. But don’t stop there. Ask the nursing unit director, the lactation consultant in her sixties, and your local midwives. Childbirth educators often last for decades and may be very knowledgeable about past trends. If everyone is young, ask who they’ve heard about being important in years past. Sometimes the only people who are remembered are the ones people didn’t like, but they don’t want to admit it! That’s fine. One name will lead to another. Look for old newspaper articles in the online archive. Most articles will reference older ones, sometimes going back ten years or more.
  3. If you can’t find a specific person, ask retired perinatal professionals about birth trends. Hospitals were remodeled, attitudes towards induction, breech birth, VBAC, episiotomy, cesarean birth, and having family members present have all changed dramatically in the course of my career.
  4. Interview alone or have a party! Sometimes a celebration is in order. In fact I think we need more parties in our lives that celebrate our accomplishments, especially when it comes to birth. Instead of interviewing one person, you could lead a group of people to reminisce. That might be more enjoyable for everyone.
  5. Ask questions that encourage explanations and depth about events. Here are some OralHistoryTips (pdf doc) I compiled to help you.
  6. Create a timeline of the order of events and include anything that might be relevant. This will likely lead to more interesting questions and observations. If you like mystery novels, this is your project! It’s a discovery of how your community moved from where things were in 1980 to where they are today.
  7. Record your interview and make sure your participant has a microphone near their face to avoid recording background noise. Many smartphones can do this well.  There are apps that can transcribe your interview into written form as long as there is no background noise. You may end up with a really interesting podcast, or a local historical society or oral history project may want your recordings for their files.

Then what?  If you complete your local project, I will publish it on a web site devoted to doula history that is available for everyone to read, including students of history to use in their papers.

This project is about more than you. It’s about those who came before but also for those who will come after. You may not know what they will look like or how they will interpret doulaing for their generation, but our history is important for them to know. And if you don’t record it, probably no one will.

 

Resources:

Christine Morton covers much of the big history of doulas in her book, Birth Ambassadors: Doulas and The Re-Emergence of Women Supported Birth in America. It’s our most extensive resource. Since I lived that history, what struck me the most was what wasn’t in there – including all of our small struggles in our own communities. It’s our responsibility to build on Dr. Morton’s achievement and share our stories to build a more comprehensive history.

Along with Mothering magazine, in the 1980’s and 1990’s many of us eagerly read The Compleat Mother, a quarterly newsprint periodical that espoused a radical wholistic philosophy of empowering women through childbirth.  It was more raw and less polished than Mothering. It did not shy away from exposing the patriarchal philosophy entrenched in the medical system and the feminist power available to us when we took charge of our bodies.  Famous Midwife Gloria LeMay wrote “Remembering Catherine Young”, founder of The Compleat MotherRemembering Catherine Young, 21 July 1952 – 11 September 2001

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“To Heal and Protect”: Attending Birth Doula Trainings for Personal Reasons

Jan 26, 2017 by

-To Heal And Protect-A small but influential group of people attend birth doula trainings not to become doulas, nurses or midwives, nor to positively influence births in other jobs, but to help heal from their own birth experiences (Gilliland, 2016). In any 10 to 12 person training, one or two people are there primarily to make sense of their own births or to make sure their future births are better. Although small in number, their motivations influence the type of discussions that occur in a workshop which makes their presence a significant one.

In this study, this group was defined in two ways. When forced to choose their top five reasons for attending a doula training, participants chose “understand my own labor(s) and birth(s) more deeply” or “make my future labor and births better” as one of their top two answers (n = 38; 8.2%). They also ranked professional reasons lower in their top five answers or omitted them. In the general question (“choose all reasons that apply”), members of this group also selected significantly fewer professional reasons for attending or none at all. There was a very clear demarcation between the “professional” attendees and the “personal” ones. However, this was the only difference. When these two groups were compared to one another on the other variables (age, births attended, parity, etc.) there were no significant differences.

In addition to this well delineated group, about 20% of all attendees chose “understand my births” as reason to attend. So while it’s a primary motivating factor for 1 out of 10, another two people in that training group also have lingering questions. This is a when my knowledge as a trainer with twenty years experience takes over in interpreting the research results from the study.

People who are in a birth doula training to gain healing from their own experience are not primarily invested in learning doula skills in order to use them with another person. They are there to figure out and make sense of their birth. By gaining information about what people need in labor and the components of support, they think they will better understand their own experiences. My hope as a trainer is that these people also develop more compassion for themselves.

In exploring this theme with small groups outside of the published JPE research study, there were five repeated themes in our conversations. They viewed a birth doula training as an avenue for healing because they felt:

  • People in the doula training will understand my story.
  • I will be treated with compassion and not dismissed.
  • I will be able to figure out what happened to me and why it happened.
  • I’ll be able to figure out why I feel the way I do.
  • I can keep what happened to me from happening again (to me or to others).

People seeking healing from a past birth experience have been a part of birth doula trainings since they started happening. In the 1980’s, I took “introduction to midwifery” workshops as well as ones designed to help you become aware of how your own births and growing up in our culture shaped our attitudes. In my decades as a trainer, I’ve learned how to make sure that people with these needs have opportunities to reflect and make sense of their experience – but not at the expense of hijacking the learning needs of the larger group. My primary purpose is to teach the skills that lead to doula success, not to lead a counseling group.

When you think about it, people who want this kind of healing have few opportunities to get these needs met. Where else can you go in our culture where you can get this level of understanding and compassion? Where can you get the information to assess what you actually needed at a significant time? It isn’t just emotional support but information and context that is often lacking when people are making sense of their births. An effective birth doula training can offer all of these things.

What we need to understand is that doula trainings are about training doulas – and part of that is teaching them to all the skills that come with compassionate listening, boundary setting, and putting clients at the center of their own decision making processes.  We have to be aware of and responsible for our own emotions at someone else’s birth or postpartum. The participants who need to heal offer trainers the opportunity to model compassion for ourselves. Further, they offer a living example that to be of service to another birthing family, we need to leave our own attachments outside the door.

Lastly, with these participants we are able to confront the thought that we can protect our clients or keep bad things from happening. We are not omnipotent nor are we the decision makers. Human beings, which includes our clients, are also notorious for learning best from making poor choices and living with the consequences. So doulas may find themselves second guessing a client’s choices or being judgmental. Participants who are processing their births may voice negativity about their choices or themselves during that past birth. When this situation arises in a workshop, it gives trainers a ripe opportunity to model kindness and tenderness towards oneself and others, and the personal empowerment that comes from owning one’s past choices.

As birth doula trainers, our job is significantly more complex than it looks on the surface. While we think we are there primarily to teach strategies to prevent labor dystocia, we are really there to help a whole society heal from damaging birth experiences and learn a greater sense of compassion for one another as we stumble through life.

Gilliland, Amy L. (2016) “What Motivates People To Take Doula Trainings?”Journal of Perinatal Education Summer 2016, Vol 25, No. 3, p. 174-183.

This is the third in a series of posts interpreting this journal article.  The first reflects on people who don’t want to be doulas but want birth knowledge, “Take A Doula Training, Change The World.”  The second focuses on “Career Minded Participants In Birth Doula Trainings“.

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