This post articulates the shadow side of national certification (NC). Listening to shadows allows us to learn and become stronger from going deeper into a process. These 13 reflections are from my notes, your emails, Facebook and blog comments. So please be in a space of listening – and I hope you also feel heard.
1. No guarantees of results. Several of my hopes of what NC could do for doulas as a profession are just that – hopes. One hope is that NC would provide an avenue of acceptance and involvement with medical professionals and hospital programs. Another hope is that NC would substitute for each individual hospital developing their own doula approval program for independent practice (IP) doulas. This may not happen especially if we do not involve nationally respected members of those communities to participate in shaping our competencies. It also may not happen despite our best efforts. We also may go through all of this work and are still unable to obtain doula specific national billing codes for birth and postpartum doula services. It may not lead to creating a reliable third party billing and payment system. But if we do not have NC, there is no chance. As I see it, NC creates the opportunity.
2. NC would lead to the continued professionalization of “caring”, which is viewed as a “natural” behavior. People are not comfortable making a job out of behaviors they wish most human beings would display. In this concern, there are elements of the idea that doulaing is somehow a natural, innate, human behavior; and that there is no skill involved. Birth doula work is a highly skilled profession (Gilliland, 2012) which is why so few who take a training end up being successful at it long term. It isn’t the business part; it’s that supporting a lot of people you don’t know in a professional manner takes “people skills” that cannot be taught in a 24 hour workshop! Not everyone can be a successful birth doula but everyone should be able to take a training who wants to. We need an educated population who understands why birth matters and who wants to help ensure every pregnant woman and her baby get the support they desire.
The institutionalization of doula support began when organizations were started to teach people. Remember, the 1980’s doula movement is in response to a breakdown in the system of caring for laboring women. In her essay on titling the “Scandanavian Journal of the Caring Sciences”, Halldordottir writes eloquently on how important it is to teach caring – and research the science and behaviors that make a person feel cared for. Ask any doula who has been to over 50 births what she has learned about caring in that time – she could fill a book. Caring may be innate for some people, but for most it is a learned and highly skilled behavior. Does that mean it should be restricted to only certain individuals? Heck no!! We all need caring skills, but not everyone will pursue them professionally.
3. NC would lessen the power of experiential knowledge. Birth teaches us about birth. Mothers teach us about their needs. Reflection and support from our birth circles improve our skills. Education imparts knowledge and confidence. Since this is the core of doula learning for all, how can NC denigrate it? We must have experiential knowledge at the core of our learning, and NC competencies would incorporate it. Similar professions, such as massage therapy and lactation consulting, also have a strong experiential learning core.
4. “NC belittles the culture and history of doulas and disrespects the knowledge of learning passing from woman to woman.” NC is a tool for professional doulas to use as they advance in their careers. No one achieves that by not learning from women. Institutionalization and traditional and/or matriarchal learning seem to be at odds with one another – I get it. I’ve been immersing myself in these perspectives for many years, and I understand this dilemma. We want to be recognized as the women in the village with the specialized knowledge and dedication to this life transition. We don’t want to have to declare ourselves or compete. Yet we live in a world where there are barriers to support, and where there is little recognition that support is even important. We’re surrounded by institutions, many of them patriarchal. And if we organize and certify ourselves, are we participating in the patriarchy that we wish to transform?
5. “National licensing didn’t help midwifery.” Doulas are not midwives. We have a completely different history; we do not compete for market share with physicians or nurse midwives; certification is not licensing, which is a legal, government process. When you list the differences and similarities there are huge differences, which makes comparing the two professions ineffectual. Even though we can both be found giving support in the labor room, after that the similarities end. Doulas have more in common with lactation professionals, who have been refining their own certification processes.
6. NC would clearly draw the line between doulas who practice according to an evidence based standard and those who do not. NC is not for beginners; it would be a standard of achievement for people who have made a commitment to the doula profession as one of their highest priorities. That is not to say these doulas are any better at doulaing than people who only go to a few births a year or only doula their friends and family members. In order for many women to have access to doula support, we need all kinds of doulas. That is not going to change. My hope is that we can continue to respect and support one another in our local communities even though the role doulaing plays in our lives is different. Yes, NC will magnify these divisions – which already exist whether we formally acknowledge them or not.
7. “The national certification philosophy of doula support will become the only acceptable one.” NC would set competencies for doula behaviors and knowledge. It would not set an exclusive philosophy for conducting those behaviors, nor would it evaluate training programs. It is highly likely that multiple types of learning experiences would be needed to meet all competencies. The approach of an initial program would be chosen by the individual, just like it is now. If we want a doula for every woman, that doula needs to reflect the mother’s beliefs, language, and behavioral norms. Which means we need doulas from all communities and multiple training programs with different philosophies.
8. “National certification would define the standards for appropriate doula behavior, and I don’t want anyone telling me what I ought to do.” Yes, it would set standards for professional doulas and promote those expectations to consumers, medical professionals, and the general public. NC is voluntary and it is likely not for everyone. Some doulas are individualists – they have highly developed moral codes and are not really interested in following or scorning rules set by others. Other doulas have a rebel or subversive identity. They want to behave in ways that are “outside the system” or “according to their own conscience” or “tailor it to my client’s needs, not what I’m told by some organization”. People come to doula work with a variety of mindsets and beliefs and they will use their doula path (and their client’s births) to learn and grow. No matter what direction we choose, it will be problematic for some doulas on a philosophical level. For years doulas have been outside the system, working to change birth by showing over and over again that mother’s emotional needs, and those of her baby and partner, are equal in importance to physical ones. For some, it is being outsiders that is important. Once we become like the institutions we guide our clients through, they think we lose. Others have been waiting until there is a critical mass of doulas to set up a national certification system and welcome NC as weakening their outsider status.
9. “I don’t want to be controlled by “the government” or “the hospital”. This is a huge misunderstanding about who has power over who accompanies a woman laboring in a hospital. Many people seem to think it’s the woman. No, it is the hospital. Once a woman consents to have a birth in a particular hospital or birth center, she submits to their rules. Each hospital has the authority to decide who can visit a woman in labor and who she can have with her. There are no legal patient rights or guarantees about who can accompany her (except Minnesota), but even that is nullified if someone is perceived as getting in the way of the medical care provided by the hospital or a safety concern.
Hospitals in rural areas and large cities are already forbidding doulas and setting rules about who is allowed. If you don’t know this, you haven’t been paying attention. That’s one of the main reasons for NC now – to set up something that WE can agree on, so we aren’t barred en masse or have to succumb to rules that tell us what we have to do with our bodies, such as blood tests and vaccinations. When it comes to licensing, doulas do not have any behaviors that would invite licensing by any governmental body at any level. So this fear is unfounded. The only involvement of the government with doula care has been to create a law that the hospital cannot get in the way of doula support as long as the certified doula is following the hospital’s rules for her presence (Minnesota), or to allow for third party reimbursement for services (Oregon).
10. “Clients don’t care whether I’m certified or not.” They don’t care because we haven’t taught them to. Right now the client takes all the risk and places their trust in the doula. Inexperienced parents have no idea of their own needs or all the things a doula can do to muck up their birth, their relationships with their caregivers and even with their partner. Bad doulas do exist – its naïve to think otherwise. NC could offer optional background checks, assurance about back up doulas; and define standard industry practices (collecting fees before birth, typical letters of agreement, etc), and a grievance procedure with consequences. NC could offer a layer of consumer protection for parents that they now do not possess at all. Remember, parents’ primary reason for choosing a doula is whether they feel safe with her and trust her on an intuitive level. NC may be able to make that leap of faith more secure.
11. NC would restrict women’s access to doulas. Right now bringing your own doula into the hospital with you is up to the hospital. It is the hospital’s rules and women choosing to go along with them that will restrict women’s access to the doula of their choice. If a hospital states that a doula needs to be nationally certified to or follow a NC standard of practice in order to do labor support in their facility, that is their right. But that’s the idea: we would do a better job setting standards for ourselves than each individual hospital. If NC is successful in helping third party reimbursement to occur and in gaining grant monies to expand doula programs, it would actually expand women’s access to doulas.
12. “NC would restrict what I can charge, how I can charge or who I can bill.” This is erroneous as any restrictions on fee setting or billing would be considered price fixing under U.S. labor law. “We would have to listen to what insurance companies would want us to do or not do in developing or changing our standards.” Since getting insurance and Medicaid reimbursement is a part of this movement, having this information would be important. How it would be responded to is a different matter. In some ways its true – we may only be reimbursed for two prenatal visits and not three; a company may set a reimbursement rate for a whole state, which may not be high enough in a metropolitan area. It would be up to the individual doula whether to charge parents more than what their insurance would cover or not accept third party reimbursement at all.
13. Is NC coming from a place of fear or a place of power? I think it’s both. I think doulas feel powerful enough within to organize and say, “Hey! These are our standards for ourselves. This is the way we think professional doulas ought to behave, and what they ought to know.” But I also think its coming from a place of fear of the existing system having ‘power over’ us. Fear that doulas will not be allowed in hospitals unless following their rules; fear that doula support is becoming a wealthy woman’s indulgence; and fear that doulas will not be available to more women unless we do something. The idea of national certification brings up deep fear – colluding with the system/patriarchy/institutionalization; as well as providing some solutions to the problems that we face – restricted access in hospitals; and lack of recognition for our skills, achievements and professionalism. It has potential to shift and change the landscape for current and future doulas.
As a profession, I think we need to ask ourselves, who are we accountable to? What is our purpose? Does NC fulfill that purpose and accountability? Because of the differences highlighted in this essay, doulas will arrive at different answers. Will we end up at what serves the greater good, allowing the concerns of dissenting voices to also guide us? Will we consciously decide to stay unorganized and live with our current fragmented system? HOW we proceed next is just as important as WHAT we will create.
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Posts In This Series:
1. Social movements – The Next Step In The Doula Revolution
2. Balancing Dynamic Tension – Respecting All Doulas
3. Do We Want A Place At The Table? National Certification and Public Health
4. Benefits of National Doula Certification
5. This post: Fears, Downsides, and Challenges of National Certification
6. Back Door or Front Door? What the Process of NC Would Need to Include