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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Back Door or Front Door?

Feb 20, 2015 by

Back DoorIn Jennifer Torres’ article, “Breast milk and labour support: lactation consultants’ and doulas’ strategies for navigating the medical context of maternity care”, the author makes a declarative statement.  She says that both professions have filled a niche in maternity care practice that is not covered by nurses or physicians.  However, lactation consultants have been able to influence medical practice directly.  They entered through the “ front door” and have been welcomed by medical professionals, because breastfeeding is seen as a medical event.  However, doulas are not recognized as having anything meaningful to offer to medical professionals, and as such are seen as entering through the “back door”.

When the doula movement began in the late 1980’s, we were really trying to figure out how to get in through the front door.  Doulas have often read the same journals as medical professionals, and many of the doulas I know have college or advanced degrees.  We really thought that once physicians saw what we had to offer their patients we would be welcomed on the maternity care team.  However that was not what happened, and we have been relegated to the back door ever since.

One of my missions has been to do doula research that will convey the complexity of birth doula skills.  If we have enough evidence, eventually it will be too much to ignore.  But I’m also struck by the way we delegitimize ourselves.   We have had no choice but to declare our power as outsiders – we have had few opportunities to be insiders!  Having our knowledge and contributions to labor progress be ignored is seen as normal; we are used to this position.

So when I look at national certification efforts, I realize that there will be no recognition from other sources unless we do it ourselves first.  When the NAACP Image awards were televised last week, actor Laurence Fishburne made a statement along the lines of ‘we have to recognize ourselves first before expecting anyone else to see our worth.’

However I believe most strongly that the process in which national certification for birth doula efforts is absolutely vital to its success. In order to maximize its impact, it needs to:

  1. Be self sustaining from the very beginning.  No one goes into debt creating an organization.
  2. Be transparent.  There is no reason for secrecy.
  3. Incorporate the voices of experience with the voices of tomorrow.  People who have been doulas for years know a lot.  People who are new will be doing the work for years to come.  Both are needed.
  4. No existing organization should be in charge.  However, having a representative from each successful doula organization of significant standing who believes in NC should be invited to the table.
  5. National certification needs to arise organically from several different spheres involving doulas with different priorities but focused on one goal: a vital and effective national certification organization for birth doulas.
  6. Utilize current and emerging technology to create and communicate.  Its important to have a smaller working group that actually meets face to face especially in the beginning stages to outline decisions, craft a timeline, and organize projects.  But a larger ring of committed, strategically chosen doulas and invested stakeholders would be another working group.  This outer ring would be involved over time to listen and hear what the working group discussed and decided.  They would then be able to consider options and provide feedback.  They would not meet face to face, but would be involved through communications technologies.
  7. A working group needs to be experienced in a variety of areas and chosen for areas of expertise that can make progress happen.  Those not in the group needs to feel a sense of confidence in the people who will be doing the work.
  8. Obstetricians, midwives and nurses, represented individually and by their leading organizations (ACOG, AWHONN, MANA, ACNM) need to be involved from the beginning.  If we want to create an organization that “speaks” to their interests and want to be invited in the front door, this is absolutely necessary.
  9. Health care, insurance, and Medicaid consultants need to provide input to maximize the opportunity of obtaining reimbursement.
  10. Policy makers and community health education/worker industry leaders need to be consulted to discover how birth doula national certification could be bridged to be a part of CHEW programs and jobs.
  11. Health care consumers, parents who have used doula support, need to have a voice in setting priorities.
  12. Consensus decision-making, not majority rule.  With consensus you spend more time discussing, but more gets done in the long run because people are committed to the eventual decision.  Disagreements are aired.  With formal consensus, those who disagree can choose to do so but not stand in the way of action.  Or they can choose to go on record as blocking, knowing there is no compromise they can agree with.  In my 20 plus years of using consensus (I’m formally trained), only one time has someone blocked.

This is a large undertaking.  It is not a kitchen table project.  We are talking about transforming the birth doula industry from one that is totally unregulated and provides no consumer protections.  National certification may be optional, but market forces will determine if it becomes the future standard for the profession.

Many of you have written to me asking when we will get started or even when it will be completed.  My commitment was to write about national certification in a way that would expose the issues involved, and to get doulas and other people talking.  I have completed that commitment, and it was my gift to my community.  I want us to make conscious decisions about our direction and our future and that only comes from considering various points of view over time.

I do not have any plans to create a national certification organization.  There are other projects in front of me.  I would appreciate consulting with any serious efforts to organize, because I feel I could offer a rich perspective.  I still have reservations that make me doubt what is possible, or if it should be done.  If NC is part of an effort to transform maternity care, reduce disparities in birth outcomes, or increase job opportunities in urban areas, there is possible foundation money available to fund our efforts.  It will be interesting to see what happens next.

Torres, J.M.C. (2013) Breast milk and labour support: lactation consultants’ and doulas’ strategies for navigating the medical context of maternity care. Sociology of Health & Illness, 35(6), 924-938.

 

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.  Fears, Downsides, and Challenges of National Certification

6.  This Post:  Back Door or Front Door?  What the Process of NC Would Need to Include

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The Fears, Downsides, and Challenges of National Certification

Jan 7, 2015 by

rock-climbing-403484_640This 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.

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

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

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Benefits of National Doula Certification

Dec 3, 2014 by

CleanPlusFadeNational certification is a tool to enable professional doulas to move in a particular direction.  What benefits could a program with strong behavior centered standards of practice offer?

1.  Respect from and engagement with physicians, midwives and nurses at every hospital because they have a clear understanding of the accepted standards of practice of nationally certified doulas.  They could ask one question and know what to expect:  Are you nationally certified?

National standards means a group of doulas in a community could negotiate with a hospital to gain privileges and respect for their knowledge.  Possibilities include getting into the OR reliably, being consulted about their client’s progress, sharing knowledge at educational meetings, and discussing conflicts in an arena of professionalism.  Both birth and postpartum doulas could be considered part of the team rather than adjunct or isolated from their client’s care.  Some doulas already have this situation.  But out of the tens of thousands of hospitals and hundreds of thousands of medical staff, I can count those places on my fingers.  Wouldn’t it be great if we all had that negotiating power?

2.  We get to define the standards for appropriate doula behavior, not each individual hospital.

3.  Respect and easy establishment of credentials when moving from one area to another.

4.  Consumers (parents) would have clear understanding of national, evidence based standards of practice and materials that explain “What to expect from a nationally certified doula”.  They would have an established outline of what to do when those expectations are not met, someone objective to listen to their concerns, and an organized grievance procedure.

5.  National behavior centered competencies would outline uniformity in services offered so a unique, standard billing code can be used with Medicaid and other insurers.  There is no guarantee of this, but scientific evidence plus strong standards equal a greater likelihood of this occurring.  I cannot see it happening without it.

6.  The opportunity to participate in public health initiatives based on doula credentials, not on academic or nursing credentials or having someone vouch for you.  Doula support is a key part of the solution for many maternity issues.  But we are not included (or taken seriously) because there are no strong national standards.  Initiatives cannot plan to include doulas because they have no easy way to say who will be eligible to fill the doula’s role unless they do all the training and certifying themselves – which is an initiative all on its own and beyond the scope of the funding they are applying for.  So doulas are left out.  These are missed opportunities for jobs, influence on the maternity care system, and better care for mothers and families.

7.  Doulas are seen as a luxury rather than a necessity for birth and postpartum families.  But for maximum health and well being, there is no substitute for the one on one care a doula provides.  Done well, national standards allow our profession to grow so that not just wealthier families or women lucky enough to live in areas with community-based programs get this service.

8.  Right now, there is no system that recognizes achievement as a doula.  One of the possible reasons we have so many training programs is because the role of “trainer” is the only one achievable after “doula” or “certified doula” in a particular group.  Recognizing levels of achievement and leadership within the profession would meet this very human need to strive for something and be recognized for it.

9.  Separation of training and certification.  A national certification organization would set competencies to be met.  The applicant’s responsibility would be to meet those competencies – likely from a variety of sources and beyond the initial two or three day training workshop or correspondence course.  The term “competencies” is used in many professions especially those that involve education and caring at their core.  Competencies state an area of expertise and specific behaviors that demonstrate that ability.  In your comments to me many of you have mentioned that you deal with competencies in order to be certified as massage therapists, realtors, respiratory therapists, and certified nursing assistants.  For an example of how a competency based system works, go to this home visitor organization web site, and click on the “gold” list.

The next question is, “Who sets the competencies?” and “Who provides the training for these competencies?”  The answer is we do.  This system allows for a natural progression of training that focuses on obtaining the skills that ensure doula success but cannot be taught in an initial 16 to 24 hour basic course.  Interpersonal skills such as listening, relationship closure, debriefing, minimizing trauma, and conflict management come immediately to mind.

10.  National certification with competencies and behavioral standards would allow for expansion of the doula role into other fields.  Community health education workers and home visitors could easily include doula work into their own job descriptions, or permanently include doulas into their programs.  While this is occurring in a few places (Illinois’ the Ounce), it is most often haphazard and dependent on a single person or limited time grant.  Even though the evidence is available and there is a program to replicate, other stakeholders outside the program also need to be convinced.  Funders may also not be able to give money for initiatives where workers do not have established competencies.  Evidence based national certification standards set by doulas makes it more difficult to minimize our effectiveness or brush our contributions aside.

11. National certification available to all shows that we take ourselves seriously, have professional competencies that define our role, and makes that statement to the world.  We are not just hippies, hipsters, yuppies, hobbyists, bored at home parents, soccer moms/dads, frustrated midwives, or trying to exert power over someone’s else life experience.  The market demand for our services shows that we have a part on the team to play, we are here to stay, and we believe that what we have to offer makes a positive difference in the quality of health care and the emotional lives and memories of the families we serve.

12.  Being a part of other health related professions would expand doula employability, wages, and the number of mothers who could receive doula services.  It would also enable more people to become doulas and hopefully at a wage that would support their families.  Many trained and effective doulas are not cut out to be independent business owners.  But this is the only choice for many.  Respect for and expansion of the doula’s role would allow for different models of employment, such as working for social programs, agencies, HMO’s, physician and midwife groups, and collectives.  We don’t have this now because there are no strong standards for employing doulas on staff or for third party reimbursement for their services (see #5).

In sum, national certification offers us legitimacy and opportunities to move our profession forward.  Some of those directions are dependent on interaction with others, however once we start taking our work seriously it will positively influence how we are perceived.  Most likely it will open doors that cannot be imagined today.

 

Note:  What’s the difference between accreditation or certification?  Certification verifies that a person has attained a level of competence and met requirements to practice in a certain discipline.  Accreditation evaluates institutions and programs and ensures they have met standards.  Click here for more.

 

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

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.  This post: Benefits of National Certification for Doulas

5.   Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

read more

Do We Want A Place At The Table?

Nov 11, 2014 by

PlaceTableOne of the possibilities offered by national certification is the ability of doulas to have an impact on public health objectives. Because of the level of intimacy we have with our clients, doulas are uniquely situated to relay information about health conditions and detect possible issues.  In 2014 alone, at the top of the perinatal agenda are initiatives to end racial disparities in perinatal outcomes, detection and prevention of birth related trauma, the CMQCC multi-level project to increase health care response to pre-eclampsia, and promoting awareness of postpartum kidney disorders related to pregnancy illness.

However, established medical groups and public health organizations repeatedly ignore birth and postpartum doulas as vital conduits of information and support.  When women have problems, they are more likely to self disclose to the doula who they trust and know intimately.   The evidence is very clear and positive.  The October 2013 Cochrane Collaboration released its fifth review of labor support, once again finding there are no negatives to continuous professional labor support provided by trained people unrelated to the family.  The American College of Obstetrics and Gynecologists (a trade organization) released a statement in February 2014 acknowledging the value of birth doula care by a non-family member to laboring mothers.  Medicare rules may allow for the reimbursement for doula care, but it is unclear on who gets reimbursed and under what circumstances.

This leads me to two very clear questions.  Do we, as professional doulas, want to be a part of solving these health care issues?  Do we, as a professional group, want to be respected for our value, compensated for our worth, and treated as having unique and valuable knowledge by perinatal professionals (nurses, family practice physicians, obstetricians, midwives) and policy makers?  Do we want to be reliably paid a living wage by insurance companies and other third party payers?  Are we willing to generate change in order for these things to happen?

If the answers are “no”, then let’s continue to go on as we have been.  Some individuals will garner respect and have additional privileges, but as a group we won’t.  If the answers are “yes”, then we need to make some changes.

First though, why don’t health care organizations and professions already include doulas in their educational and support solutions?  For one, training quality varies a great deal.  Certification is uneven at best.   There are no standards for professionalism.  Backstabbing and insults towards different organizations is common on social media.  It’s the Wild West, with almost every doula for him or herself.   New training organizations are emerging every month.  In September 2013, I located 14.  In September 2014, I stopped at 24.  New or old, they are of various levels of quality.  Most say they “certify” their participants, but often it is only a certificate of completion of a checklist.  Some small local organizations garner respect, and some larger ones dominate a particular geographic region.  So the first step is separating out training from certification.  Once it reaches a certain point, no similar profession does both – its time we respond to these growing pains.

Secondly, doulas are unorganized.  As a whole there are no centralized standards, professionalism is voluntary, and ethics are not clearly defined.  If one chooses to participate in a certification program that has this level of organization, then the burden is on that individual doula to prove herself to every hospital or perinatal professional.  There is no universal acceptance that says, “You can trust me because I’ve been vetted and endorsed by this organization”.  Medical staff can make no assumptions based on a doula’s credentials.   This leaves policy makers, grant writers, and public health programs with few mechanisms to fund doula programs.  It also means HMO’s, insurance companies, and other third party payers without a standard to pay for doula services.  Without high national standards, it isn’t going to happen.

If we want a place at the table, that would mean creating a certifying organization only.  No training, no education, just certification.  I think it needs to offer multiple levels of certification, so there is recognition of higher levels of achievement and service.  My vision is something that leaders who possess different perspectives would collaborate and create, with standards of practice that are versed in reality and a philosophy that is well explained.  With today’s technological tools, it likely will not take as long as CIMS did in the 1990’s.  But we are talking about institutionalizing our profession here.  There needs to be a universal buy-in by different stakeholders.  We will need to collaborate with organizations who we want to respect us – which means ACOG, AWHONN, as well as key policy makers.  The current ACOG leadership is more likely to be doula-friendly.  Otherwise the February statement would not have been released.

This institutionalization has already begun.  Birth doula care is a protected right in the state of Minnesota.  Medicare wants to reimburse for it, but with no national standard available to all doulas regardless of training it is very unlikely that many doulas would be able to take advantage of that.  Once there is a code, doulas can likely use that with other payers.

Based on your comments, I know many of you have a knee-jerk fear to anyone telling you what to do or how to do it.  You have a fear of doulas being co-opted by the institutions that you want to change – hospital policies, ACOG, nurses or doctors as a group, etc.  However, our profession has a history of negotiation skills, of creating opportunities for empowerment and communication.  Don’t we do that every day with our clients?  I have a very high degree of confidence that experienced doulas leading this shift will utilize those skills to create an organization that works for us AND for other professionals who want to work with us.  I encourage you to sit with your fear and let it lead you and us to wisdom and possibility, rather than shutting a door.

 

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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.  This Post:  Do We Want A Place At The Table?  National Certification and Public Health

4.  Benefits of National Certification

5.   Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

 

 

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Doulas: Balancing Dynamic Tension

Oct 26, 2014 by

Downward-Facing-Dog22“National Certification will mean that I can’t…”  “I’m a traditional doula and I don’t want a national certification organization to tell me that…”  “I don’t want to go to a lot of births, will NC mean that I have to…?”  I have said it before and I will say it again, clearly, out loud:  We need all kinds of doulas.  There are all kinds of women in this world, who need a doula who they feel safe with, who they can trust, who believes the same things they do, and who supports her birth and/or postpartum vision.  No one doula can be the right doula for everyone.  Ergo, we need all kinds of doulas.

A national certification organization will not be the right fit for everyone.  However it can, if we create it in the right way, be a very effective tool for the vast majority of existing doulas.  But the real growth is in our future – to pave the way for ethical and professional behavior for people who haven’t yet become doulas.  We have an opportunity to impact doula work and the American way of birth itself.

First we have to embrace this primary task:  balancing the dynamic tension of creating a professional doula certifying organization and embracing the reality that we need all kinds of doulas.  Does that mean all doulas must achieve certification with the organization?  No, not at all.  We need to respect that doulaing is an essential task – one that exists in a professional way and one that exists in a non-professional way.  Neither way is better than another, they are just different.  Both are meeting women’s needs – the women who need one or the other are different!!!  If we are to go forward in a positive way, we need to respect one another.  Multiple ways of being in this world need to be respected by ALL of us (or at least most of us).  Otherwise we’ll end up bickering amongst ourselves and accomplish nothing on a larger agenda.  That would be pointless and a waste of energy.

What does it mean to balance dynamic tension?  In yoga there is a pose called Downward Dog.  In it, one’s body creates a triangle, with both feet and hands on the floor and one’s hips at the top of the triangle.  The goal is to elongate the spine and the legs, raising the hips to the sky while simultaneously reaching one’s heels towards the floor.  This creates tension between the legs moving in both directions simultaneously, however both directions need to be strived for in order for the position to be effective.  Back, forth, up, down, hips, heels, the body dynamically balances the tension of both muscles stretching in each direction.

Balancing dynamic tension is not a task that is completed once and then forgotten – it is a way of being in the world.  Like a yoga, this is a task we do all the time as doulas.  We support a mother in her sacred vision of her birth in a hospital that is not set up for it.  We believe in a woman when others do not, whether it is in her ability to birth or breastfeed or nurture her child.  Development of this skill – holding the space for all things to be possible – is essential for the effectiveness for ALL doulas.  I do not think it is beyond reason that we apply it to ourselves and our profession as we grow.

It is why I believe we can value all kinds of doulas and simultaneously have a strong national certification organization.  Not everyone will need it in order to practice in their area.  Not all will follow its standards of practice (for a variety of reasons) even if they are clearly evidence based.  I do not believe diversity is antagonistic to the cause of national certification.  If we gather together to create it, NC has the possibility of offering us legitimization to medical people ON OUR TERMS.  If it has the highest standards possible, it can lead to consistent compensation at a livable wage from third party payers, this will enable all women – not just wealthy ones – to access doula support.  It can offer consumers a measure of protection which they currently lack.  Consumers will make up their own minds about what kind of doula they want and what kinds of standards are important to them; that is one of the main principles of a market driven economy.  We live in a world where most people use the energy of money to compensate for products or services.  Accepting payment for an energetic exchange is not demeaning of doula service; it is how we as a society have agreed to compensate one another.  Now there are doulas who are not interested in any of those things, but there are many who are.

Those of you who might say, “Amy’s always followed DONA’s rules, so she doesn’t get it” are wrong.  I spent my first eight years as a professional birth assistant, I trained and used homeopathy for births and even learned to do vaginal exams, palpation, and listen for fetal heart tones.  So I do understand that in some practices you might want to offer those services, even though I now feel they undermine the true power of service that is the essence of doulaing. I have Been There.

We need to hold both truths simultaneously, side by side, as valid.  When doula services are ethical and the mother is placed at the center and not the doula, we are both on the same side.  Our venues are different, our clients are different, our ways are different, but our aims are the same.  We just need different tools to meet our own and our clients’ needs.

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Posts In This Series:

1.  Social movements – The Next Step In The Doula Revolution

2.  This Post: 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.  Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

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The Next Step In The Doula Revolution

Oct 16, 2014 by

Steps2One of the most urgent issues facing birth doulas today is our future.  Very few doulas seem to realize this because they are focused on their own businesses.  In many ways the social revolution of birth doula support has succeeded.  According to the Listening To Mothers III survey, 6% of women had birth doula care.  ACOG recently recognized birth doula support as an effective method to lower cesarean rates.  Decades of research has shown no negative effects with the presence of a trained birth doula.  Capitalizing on the growing demand for trained labor support, many small organizations are cropping up to instruct doulas.  These groups are of varying quality, but so are individual instructors within a larger organization.

When I look back on 27 years of doulaing and 17 years of being a trainer, I feel a sense of accomplishment.  My mission was to educate women about the importance of birth in our lives and to ensure that mothers and their partners have supported, caring birth experiences.  Usually that means a doula.  Generations of people needed to “get it” in order to create cultural change and to listen compassionately to the women sitting next to them tell their birth stories.  Both missions are incredibly important if we are going to turn the tides.

From my readings on social movements, especially those similar to doula support, the next step is for doulas to become part of the established system.  Yup.  It has started in several ways – hospital based doula care, community based doulas, and doulas who work for physicians, midwives, or birth centers.  For the most part these programs are very tenuous.  They are based on the champion of one person who keeps the program continuing.  When they leave or funding dries up, the program also folds.  It is most likely to last when hospitals are competing for market share and the doula program attracts mothers to their facility.

For many years being a successful birth doula implied a willingness to work independently and to create a new path.  It necessitated some personal sacrifice to promote the cause of labor support.  Newer doulas are less likely to want to do this.  They have matured in a culture that promotes mentorship and the idea that there is an established map for success.  Younger women today act as if doulas were always around!  I don’t think this difference is entirely generational but a part of the success of birth doulas. Many older doulas feel their hold is more tenuous because they had to break ground.  So there is a turnover in attitudes because of our success, and the personality traits needed now are different.

Another change that I see coming is the institutionalization of doulas.  Almost any social movement that has become established in our society has been absorbed by the institution it desired to change.  It developed as an alternative.  Then once the concept was recognized as being a significant and positive thing, it was brought into the fold of the institution.  You can see this with home schooling.  Once an outside alternative movement that had to fight for recognition, it is now an established method of educating one’s children.  You can even purchase established curriculums from public school districts.

When I wrote about this issue last fall, several people brought up the argument that having national certification didn’t help midwifery.  Instead it brought about divisiveness.  However, midwifery and doula work have very different histories.  In addition, we don’t have the institutionalized power struggles that occurred with nurse midwives and professional midwives.  We don’t compete for market share with any other profession like physicians and midwives do.  Does that mean that we don’t have struggles?  No.  But our growing pains are not their growing pains.

What brought this to a head for me is the realization that even though ACOG wrote about doulas in February, we are still not taken very seriously.  There are several public health issues where birth and postpartum doulas could easily be part of the solution.  But we aren’t even mentioned.  Doulas can have a key role in recognizing the symptoms of perinatal anxiety disorders and postpartum depression, yet any training we get is haphazard.  If a mother spends 10 minutes actually interacting with a physician or the nursing staff at a clinic visit, and we spend 90-120 minutes at our visits, who has the better chance of viewing any symptomology?

One of the first questions we need to ask ourselves is do we want to be a part of that system?  Do we want to provide a stronger, organized social support component?  Do we want our prenatal role to be taken more seriously by other members of the health care team?

Of course there are pluses and minuses to each, which I’ll be exploring in future posts.  With less organization, doulas can continue to practice independently incorporating whatever points of view they wish into their practice.  This allows for a somewhat uneven delivery of services and an atmosphere of “let the buyer beware”.  We can vouch for ourselves but not for our doula sisters – unless we know them personally.  With a stand alone certification organization, we could allow for different types of training and practice styles while maintaining high standards for ethics.  As I have stated before, I am quite concerned that if we don’t do it ourselves, physician, nursing, or public health organizations will do it for us. Some hospitals already have rules allowing only doulas who agree to them to accompany mothers.

Legitimization and set standards for birth doula care IS going to happen.  It’s a matter of whether we’re going to be in charge of it or not.  What do we want that to look like?

 

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

Posts In This Series:

1.  This Post: Social movements

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.  Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

 

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How Doulas Undermine Our Own Value (it’s not free births)

Jul 9, 2014 by

How Doulas Undermine Our Own Value (it’s not free births)

Anytime I read a “doula” writing online that she knows everything she needs to know already, I want to burst. You know what? You don’t. When you say that, you devalue the entire process of skill development in labor support. What you imply is you already know everything you need to and that anyone can do labor support effectively with only a few days of training (or a few months in a correspondence course). I have never interviewed an expert doula or one who had been to several hundred births who said there wasn’t anymore to learn. Typical comments that I read on Facebook:

“I don’t understand why I need to recertify.”

“I like this organization because certification is for life.”

“I don’t need any more education. I learned everything I needed in my doula training.” OR “I don’t even need a doula training.”

The truth is that you know enough to be of more value than someone who knows nothing. Your heart is in the right place and hopefully that will keep you in a space of observance and support rather than judgment and superiority. But you don’t possess many skills. You haven’t applied most of the knowledge that’s in your head. As a novice or advanced beginner doula, you don’t know what you don’t know. It’s fine to be a beginner but have some respect and humility for the profession.

I have talked to thousands of doulas, yes thousands, in the last 30 years. I have spent years of my life dissecting the minute actions of birth doulas at various phases of skill development (novice, advanced beginner, seasoned, proficient, and expert). I wrote the research on those five phases of skill acquisition! There are fewer doulas at each one of these advanced stages because not everyone can meet the challenges of each phase. [While I am currently revising it, the current version is available here.]

Birth doula work is not about double hip squeezes. It isn’t about birth plans. Birth doulaing at its heart is a spiritual path that will rip away your narcissism and your selfishness. It will restructure your values and strengthen your compassion and empathy for all people through pain and humility. It is about learning how to BE in the presence of conflict and the human experience of living at its most raw and gut wrenching. Birth doula work is not for sissies.

And you know what? A three day workshop, even mine, is not enough to teach you how to do that. You need to learn how to show up for somebody without that person having to compromise because of what you value or think is important. Birth will teach you, but you need support and information too. Learning to communicate effectively with people in power, how to deal with difficult people, and how to listen. These are not things that come easily or that are mastered except with years of practice.

As a professional doula, you know there are many areas where you can improve yourself and your practice. Only someone who is ignorant thinks they know everything there is to know – until they’ve put in the decades to achieve expert status.

Certification has never been primarily about impressing clients. It is about achieving credibility that speaks to the other career professionals you work with.

So when you’re whining about educational requirements or recertification dues, think about what those remarks imply.  They say to me that you don’t value developing the skills needed to improve as a doula because you already know it all.  And there really isn’t much to this doula thing – anybody with a smidgen of education and a few births under their belt can do it well.  These attitudes perpetuate the myth that “Any Woman Can Be A Doula”.   Now think about the damage these comments do to all doulas everywhere – and to gaining the respect we need for our profession.

 

 

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Top Ten Questions For Choosing A Doula Training

Apr 21, 2014 by

Top Ten QuestionsTo AskWhen ChoosingADoula Training (1)I hear a lot on Facebook, “If I’d only known that before I took my training…”  The market for doula training has changed incredibly, especially in the last 5 years.  There are now at least two dozen doula training organizations with programs of varying quality.  The onus is now on the prospective doula to figure out which trainer and organization is the best fit for their personal and perinatal career goals.  My hope is that doulas will circulate this post to help our future colleagues make their best choice.  I’m a firm believer that the best match for you might not be the best match for your best friend.  I’ve specialized in adult education for over twenty years and as a doula trainer, I’ve done over 80 beginning and advanced workshops – and loved every single one!  Educating adults is my passion and I feel that the more people understand the deeper meaning of birth, the more we will change the world.

Here are some important questions to consider when choosing a training:

  1. Why do you want to attend?
  2. Does this trainer have knowledge of your local birth scene? 
  3. Where were the doulas in your area trained?
  4. How do you learn best? 
  5. What are the trainer’s qualifications, experience, and philosophy of teaching?
  6. What is included in the curriculum? 
  7. What are the certification requirements of the organization?
  8. How do the certification processes of the different workshops you’re considering compare?
  9. What is your budget for doula career training? 
  10. What other knowledge will you need to gather in order to be successful? 

Why do you want to attend?  A recent study I’m preparing for publication identified 17 unique reasons women attend doula trainings.  They fit into four major areas.  One, advancing the career they already had.  Two, gaining education for a future career goal in nursing or midwifery.  Three, becoming a volunteer, hospital-based, or independent practice doula.  Lastly, personal reasons that included making sense of their past births and/or preparing for future pregnancies, or attending the births of family members.  Being clear on exactly why you want to attend can help you ascertain what training is best suited to meet those goals.

Does this trainer have knowledge of your local birth scene?  Is this important?  If you live in a rural area or disenfranchised community, having a trainer who understands and can help you with your unique challenges can be critical to your success.  If she knows the staff and preferences of the local hospitals that can be a real plus.  You can learn the behavioral norms, expectations, and attitudes about doulas in the workshop rather than trial and error on your own.  This may be less important if these answers are easy to discover or where there are many hospitals with a large staff.

Where were the doulas in your area trained? Are they open to doulas from other organizations?  I’ve spent many years combatting cliquishness in doula circles.  My attitude is that there’s no need to compete with other doulas because mothers choose whom they feel safe with in their gut. This has nothing to do with the doula and everything to do with the mother.  When we promote the doula profession together, we create a market.  However, my attitude is not shared universally!  Do some investigative work on the Internet and/or go to a Meet The Doulas event or doula meeting (ask them if its alright).  Find out where they got their training.  Ask them what trainers/organizations they respect and what topics they wish had been included in their workshop.  I’m not advocating going against your heart.  But if you are going to practice in an area, it can be easier to get along with others and get referrals when people know that you’ve had training similar to theirs. (Unfortunate but true.)

How do you learn best?  Do you prefer hands-on instruction, one on one attention, reading or hearing information?  Do you like to move at your own pace over a longer length of time or a challenging intensive experience?  To me, effective doula training is career preparation as well as a personal examination of one’s perspectives.  Choosing the right environment to optimize learning can be a critical factor in your success.  As a face-to-face [F2F] educator, I recently challenged myself to train as an online instructor.  It made me realize that for some people and situations, online learning can be equally effective with a dedicated instructor utilizing high quality resources.

Who is the trainer?  What are her qualifications, experience, and philosophy of teaching?  What are the testimonials and ratings on her web site?  What is her reputation among the doulas in your area?  The trainer makes a HUGE difference in your experience – they vary a great deal in their teaching ability and emphasis on what they consider important.  If they don’t have testimonials on their site, ask for references.  Make sure their teaching is a good match to your learning style. If you are serious about doula work, putting forth some additional money and time is an investment in your future career and self-confidence.  You may need to travel or wait a few more months for your best workshop.  Your doula workshop should change your life!

What is the curriculum?  What will you be taught?  What does she emphasize in the workshop?  Each trainer in an organization likely has a personalized curriculum.  If this is not listed on the web site or given in response to your inquiry, ask for a schedule and list of educational objectives.  Is this what you want to learn?  For example, while DONA has a core curriculum, all DONA trainers can add to that curriculum as they see fit (it must be approved).  Mine is an 8 additional hours and 114 additional pages in the manual than what is required – and I am not unique.

In addition, people have different levels of education, experience and career goals.  The person who has been to 10 births and knows they want a doula business has different learning needs than the woman just hired by a community based agency to work with Early Head Start clients.  While both need ethics training, one needs doula business planning and the other needs to know how to work with clients with few medical care options.

Each workshop also has its own mood.  I adapt my material for nurses, nursing students, midwifery students as well as open workshops.  I’ve done workshops in hospitals, birth centers, and my living room.  Each group has unique needs and to be respected and inspired.  It’s the same material but I do it differently. Do the materials give you a classroom feeling or a Red Tent feeling?  The group influences the trainer, but the trainer sets the tone.  Is that tone a good fit for you?

What are the certification requirements of the organization?  Do they offer certification with a variety of educational and experiential requirements and where your references will be checked?  Are they certifying that you as an individual are qualified to do this work?  Are you required to follow behavioral standards that protect you, your clients, and thus the reputation of the doula profession from misconduct?  Or is there a certificate of completion of the organization’s requirements that they are calling “certification”?

Of the trainings you are considering, how do their certification processes compare?  Do you understand them?  Which ones do you agree with?  Certification is an issue that may become critical to your career.  With changes in health care, third party reimbursement may only be possible to doulas with a certification process as already described.  Hospitals may bar access to doulas who do not have certification from an organization they recognize.  Disgruntled consumers are blogging on the Internet about how they didn’t understand the meaning of certification.  If you don’t agree with the behavioral conduct outlined by certification process, be clear with yourself about why.  Discuss this with other practicing doulas and both of the trainers you’re considering.  Since this is a decision that may define the future direction of your doula career, become clear on your stance and options now.

What is your budget for doula career training?  What does this workshop cost?  What other costs are there besides the workshop? If you want to be a professional doula, it is highly likely that you will put more money into your education and initial business plan in the first years than you will make in income.  However, training is an investment.  Spending an extra $200 or $300 for an educational experience that meets your needs will be cheaper in the long run.  You’ll feel more confident and be more likely to follow through with getting new clients and integrating into your new peer group (thus getting referrals).  If money is an issue, contact the potential trainer and ask for options.  There are several who don’t advertise it, but have full or partial scholarships or payment plans.

What other knowledge will I need to gather in order to be successful?  Are there other low-cost resources available?  Many doulas don’t approach birth or postpartum doula work as a business or as a significant lifestyle change.  In many areas, colleges and universities offers inexpensive short courses in beginning a small business that are applicable to doula work.  Some hospital staff will be appreciative if you take their volunteer training to learn how their system works.  This will usually cost you a few hours a month volunteering but can offer valuable knowledge and familiarity with a medical setting.  Can I volunteer my services and gain experience? Will what training I take matter?

The first step in making an informed decision is knowing what you need to be informed about!  Asking these key questions will hopefully help potential doulas find the best fit rather than the cheapest training or the one that is currently trending.  A good doula training strongly influences your career path.  While you can take a second workshop if you didn’t like the first one, that’s an expensive option.  By doing your research now, you will feel more committed to your decision because you know its right for you.

 

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Christine Morton On Certification and Professionalism

Dec 2, 2013 by

Agreeing with me while also challenging some of my perceptions, Christine Morton has been researching doula care for as long as I have.  Dr. Morton* writes for the Lamaze International blog, Science and Sensibility, and she is the author of the forthcoming book, Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America, (with Elayne Clift).  She is not a doula although ten years ago she trained and certified through Pacific Area Labor Support (PALS) in Seattle and attended a dozen births.  She is not a doula trainer nor a current member of any doula organization.  Her interest comes from her background and training as a sociologist.  (Note: Bold and italicized type are my additions – ALG)

In response to my recent blogs, Dr. Morton writes:

I’ve done a bit of historical research on the history of the doula role and some critical thinking about what I’ve called the “organizational diversity” of the doula training/certification landscape.  Most of that work was done several years ago and it was an issue then and (not surprisingly) continues to be an issue now.  You count 16 organizations – and I bet there are many more in local contexts that do their own version of training/certifying doulas.  I’ve identified at least five in the San Francisco Bay Area alone!

The idea of an “umbrella” or “universal” organization that would certify doulas regardless of how they were trained was a vision of the first national organization – National Association of Childbirth Assistants (NACA), headed by Claudia Lowe in Northern California from 1984-1994.  I know that DONA founders had some interactions with Ms. Lowe in the early 1990s and there was a sense that DONA could serve that universal certification function.  NACA ceased to exist in 1994, a mere two years after DONA was founded.**

I suggest that the key challenge here comes from how the doula is defined.  There is an internal contradiction in the definition of a doula – that this person is a caring, kind individual who only needs to be co-present with a laboring woman as well as a skilled provider of specialized services, the provision of which is associated with highly consequential health outcomes for the mother and baby.  It seems to me the broad community of doulas can’t have it both ways.  I think the tension in this definition is the crux of the issue of certification.

Sociologically, doulas are far from being a recognized “profession” in the sense that there are no barriers to entry to the role (anyone can say they are a doula) and there is no formalized route to training nor admittance into the role  such as accredited education programs and licensure.  There is no regulatory board which might hear grievances or complaints about a lapse in service or care.

The grassroots (primal) origin has been a fascinating and compelling feature of the doula role but you are right in pointing out that changes are on the horizon.  The train is coming down the track and doulas can either jump aboard while it’s still in the station and attempt to drive it (and fuel it) or can be run over by it.  Maternity providers face the same thing with regard to the changed landscape of quality measures in perinatal care.

Given the past history of doula (and childbirth education) organizations, I am not optimistic that doulas and their organizations will be able to overcome the definition issue, in part because of the ideological diversity in their members.  I’m part of a research group that has surveyed doulas, childbirth educators & nurses in the US and Canada on a number of issues (MaternitySupportSurvey.com), and preliminary results show that doulas hold views on the most extreme ends of attitudinal measures on childbirth practice and beliefs.  The data from that study will be informative for this and other issues facing doulas today.

The current state of doula organizational diversity reflects the historical state of childbirth education/home birth midwifery organizations in the 1960s-1980s when doulas entered the scene, and now reflects intra-group differences, driven by a number of factors, including access to power, resources and perhaps, inability of strong minded individuals with differing views to understand the importance of working together.  Without the temporizing effects of larger institutions (think: universities or colleges with established means to organize and manage education) and without the infrastructure of formal management techniques and systems, membership organizations run by doulas for doulas lack necessary access to resources and power to effectively negotiate and mediate different viewpoints. 

Unless representatives of doula organizations come together with a collective desire and will to bridge this history, and define a common goal and work to achieve it, I don’t see how it will happen.  Anyone can claim to be a doula, anyone can claim expertise to open up a training and certification enterprise, and unless the doula role is substantially redefined so that only those with access to specialized training and /or licensure can legally charge money to provide defined services, there will continue to be an open field.

Other occupations have similar dilemmas where in theory “anyone” could do the service but to provide the service as a ‘business’ and charge a fee, there are regulations — think: childcare worker, especially home based childcare providers; barbers/hair stylists; dog groomers; caterers; teachers/tutors; massage therapists; personal/career coaches; home organizers; housecleaners ….. what we are seeing is the professionalization of service providers …. (this does not make these occupations “professions”, however).

I will leave you with another thought and another route to consider.  Patient advocates. Patient navigators. There is growing recognition that all patients in US hospitals would do well to have an advocate by their side.  Hospitals are complex systems where medical errors and communication mishaps inordinately account for a large number of preventable morbidity and mortality.  Maternity does so well relatively speaking because so many of the ‘patients’ are healthy to begin with and because there is poor surveillance of health outcomes (think hemorrhage, which is known to be significantly undercoded).  A strategy that frames doulas more as patient advocates runs the risk of defining laboring women within the context of a ‘patient’ and all that means, but one thing that doulas know well is that women who enter hospitals to give birth do become ‘patients’ — that powerful institutional fact is exactly why doulas are there – to provide some counter weight to the institutionalization of birth.  But an individual is no match for an institution.

There are some strong and growing organizations devoted to patient advocacy and shared decision-making, mostly in other areas of health care (it’s ironic that childbirth, the site of the original advocacy and patient-centered care is nowhere represented in these organizations, but that is another discussion).  Perhaps doulas can partially reframe their role to align with the agendas of these groups, who are increasingly present in forums and meetings on health care services and policy.  Doing so would de-center the ‘mystical and sacred’ elements of birth but not wipe them out completely.

Christine H. Morton, PhD
Research Sociologist, California Maternal Quality Care Collaborative
Author, with Elayne Clift, Birth Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America (forthcoming, Praeclarus Press, 2014)

christine@christinemorton.com
http://www.birthambassadors.com

*I use “Dr.” not to separate ourselves from everyone else, but because as women we rarely acknowledge our accomplishments.  To use the honorific Dr. when appropriate says “Hey, you achieved something!”  Because I work at home mostly I hear “Dear” and “Mom”, not Dr.

**I was in contact with Claudia Lowe in the late 1980’s as I was a member of IH/IBP and seeking out any other birth assistants I could find in the U.S.  Claudia Lowe lived in my hometown, in fact in my old neighborhood.  What Claudia Lowe told me at the time was that NACA’s dissolution was due to her and her business partner’s change in interests and not anything to do with DONA.  (I was not involved with DONA until October 1994 – after NACA folded.)

 

 

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What It Means To Be A Professional Birth Doula

Nov 26, 2013 by

There is a line between doulas who are professionals – where this is the source of their livelihood and the mainstay of their lives next to family and self – and other women who doula occasionally.  Not all doulas are professionals nor is it a goal for all doulas.  There is a place for all kinds of doulas and we need everyone if we are to reclaim our understanding of birth as important in women’s lives.  We lost it in the last century and taking a doula training or doulaing friends and family is a way to reclaim that.

Being a professional does not diminish the spiritual value we find in our work or the fact that many of us find it to be a calling.  We would be diminished in some way if we could not be doulas.  We have the joy of being in a life situation that enables us to do work we are passionate about, change the world for another family, and create income at the same time.

In my writings, I frequently use the term “professional doula”.  It is on a lot of web sites – even in the names of international organizations.  But no one has really defined specifically how it applies to our profession.  So I analyzed data from my 60 doula interviews, sifted through what I was reading on social media, and read through several books on professionalism.  This is what I have come up with to describe the internal identity and behaviors exhibited by doulas who consider themselves professionals.  I’d also like to introduce the term “emerging professional”, to represent doulas who are growing to meet professional standards.  So what does it mean to be a professional doula today?

1.  To be a professional means that you have completed education and training to gain the necessary knowledge and skills recognized by others in your profession.  Much of doula education is self-study, reading books and completing assignments, combined with taking a workshop and using hands-on skills correctly.  Training may involve working with a mentor and on the job training without any supervision.  Improvement comes from appraising our experiences and evaluations from clients, nurses, midwives and doctors.

2.  To be a professional means you have acquired expert and specialized knowledge.  This goes beyond learning a double hip squeeze in a workshop.  It means making sense of people’s conflicting needs in the birth room; intuiting when to speak and when to keep silent; how to talk to a physician about the patient with a sexual abuse history; how to set up a lap squat with an epidural; and so forth.  Competence and confidence grow in interpersonal and labor support arenas.  Any additional service you offer to clients means that you have additional study, experience, and possibly mentorship or certification to use it appropriately.

3.  To be a professional means that you receive something in return for your services.  For many of us that is money or barter goods.  However there are doulas who receive stipends that prohibit receiving money for any services performed.  They may request a donation be made to an organization instead.  If they meet the other requirements for professionalism charging money should not be the sole criteria holding them back.

4.  To be a professional means that you market your services and seek out clients that are previously unknown to you.  You consider doulaing to be a business.

5.  To be a professional means that you hold yourself to the highest standards of conduct for your profession.  You seek to empower and not speak for your clients.  You give information but refrain from giving advice.  You make positioning and comfort measure recommendations that are in your client’s best interests.  Your emotional support is unwavering and given freely.  Your goal is to enhance communication and connection between her and her care providers.  You seek to meet your client’s best interests as she defines them.  Several doula organizations have written a code of ethics and/or scope of practice in accordance with their values.  They require any doula certifying with them to uphold them.  But signing a paper and acting in accordance with those standards are two different things.  Even the values represented by various organizations are different.  Holding yourself to the highest standards is shown by how you behave.

6.  To be a professional means that you put your client first.  When you make a commitment to be there, you’re there.  If you become ill or have a family emergency there is another professional who can seamlessly take over for you.  You keep your client’s information and history confidential.  Confidentiality means not posting anything specific or timely on any social media.  Your responsibility to their needs and not your own is a priority.

7.  To be a professional means that you cultivate positive relationships with other perinatal professionals whenever possible.  You respect their point of view even when it differs from yours.  You seek to increase your communication skills and to understand different cultural perspectives.  You keep your experiences with them confidential and private.  You learn from past mistakes.

8.  To be a professional means that you have a wide variety of birth experiences and feel confident in your ability to handle almost anything that comes along.  Other professional doulas respect you and make referrals.  Note that I did not include a number of births.  Because of life and career experiences, some doulas will arrive at this place sooner than others.

9. To be a professional means that you seek out and commit to doula certification that promotes maximum empowerment of the client, using non-clinical skills, values and promotes client-medical careprovider communication, and requires additional education before offering additional non-clinical skills.  Certification means that you are held to standards that people outside your profession can read and understand.  Not being certified means there are no set expectations for that doula’s behavior.  Some doula training organizations have very loose certification standards with no specifics behaviors listed, just general attitudes.  Certification with behavioral standards that can evaluate whether the doula acted according to those standards is important for furthering the professionalism of birth doula work outside our own individual spheres.  It means that a doula is accountable to someone outside of herself and her individual client.   (In other words, certification in the context of professionalism is not about you, but about how it affects other people’s perceptions of you AND our profession as a whole.)  Having said this, not all doulas have certification like this available to them.

10.  To be a professional means that you seek to improve your profession by serving in organizations, representing your profession at social events, and assisting novice doulas to improve their services.  You balance your own desires and needs with the actions that further the doula profession – such as certification.  You know that when you get better – increase your skills, knowledge and integrity – you make it better for all labor doulas.

11.  To be a professional means that you have personal integrity.  Integrity means that your values, what you say, and how you behave are congruent with one another.  Sullivan has written:

“Integrity is never a given, but always a quest that must be renewed and reshaped over time.  It demands considerable individual self-awareness and self-command…Integrity of vocation demands the balanced combination of individual autonomy with integration to its shared purposes.  Individual talents need to blend with the best common standards of performance, while the individual must exercise personal judgment as to the proper application of these communal standards in a responsible way.”  [p. 220] 

“Integrity can only be achieved under conditions of competing imperatives.  Unless you are torn between your lawyerly duties as a zealous advocate for your client and your communal responsibilities as an officer of the court, you cannot accomplish integrity.  Unless you are confronted with the tensions inherent in the practice of any profession, the conditions for integrity are not present:  “Integrity is not a given….” 

In a doula context, this means that when you are in the labor room trying to figure out what the right thing is to do and struggling with it, you are having a crisis of integrity.  “Do I say something to the medical careprovider (MCP) or do I keep my mouth shut?  Have the parents said anything on their own behalf?  Do I just let this happen and help them afterwards?”  What value takes precedent: empowerment of the client or allowing an intervention to occur that may affect the course of the labor?  How will each potential action change my relationship with the MCP?  Situations like these are true tests of integrity that require us to rank our values of what is most important.

Sullivan, William M. (2nd ed. 2005). Work and Integrity: The Crisis and Promise of Professionalism in America. Jossey Bass.

How does this fit with your definition of professionalism for doulas?  What parts do you agree with?  If you disagree, consider why – is it my wording or the spirit of what is written?  Let me know – let’s keep talking about this!

Here is a pdf copy of this post to print or for your doula discussion group.

 

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Responses to “What If ACOG Certified Doulas?” Post

Nov 18, 2013 by

It is difficult to pose these hard questions and I’ve enjoyed reading your responses and thinking together more deeply about these issues.  In many cases we’ve ended up with more questions, but that is a good thing.  Doulas brought up both practical and philosophical considerations. To begin with there is little doubt among you that a medical organization could decide on a uniformly enforceable and restrictive doula policy.  No one liked this idea.  Several of you brought up childbirth education and lactation consultants to illustrate what happens when independent professions get co-opted by hospital systems.

  1. Overall people are pretty positive about the idea of an organization that would recognize doulas with different types of training and offer universal certification.  Doulas with work experience in other careers view this as inevitable progress and reflecting the maturity of the doula movement.  The group that feels most positively is already affected by hospital or MCP restrictions.  They are experiencing what I predict will spread across our countries.  Some doulas have local organizations that have negotiated successfully with their hospitals.  In listening to these stories success is dependent on an individual in the hospital who wants doula support available. In a lot of cases, these people move on and the agreement weakens or momentum crumbles altogether.  I do believe in the power of the local model, but it seems to be unusual for it to be sustainable long term.  In addition, a local approach isn’t viable in many places nor does it solve other issues.
  2. Some discussions centered on whether a voluntary registry rather than a certification process would be sufficient.  I understand the appeal of a registry – we could do it quickly and people could sign that they agree with what was presented.  However, a registry has no teeth; there is no consumer protection, no vetting of doulas, everything is between a doula and her own conscience.  It doesn’t solve the issues before us.
  3.  When I consider a certifying organization I would absolutely hate to see the division that has occurred among midwives occur among doulas.  This fear was a part of several conversations.  Doulas are not the same as midwives.  We don’t compete with physicians for business.  Our social and political histories are different and so is our future.  It is dependent on holding our leadership accountable and creating systems and communities that lessen the possibility of divisiveness.  In midwifery, it was the leadership of different organizations that caused the current fracture.  I am adamant that we intentionally continue to create an environment where all doulas are welcome.  We need our family doulas, the doulas who only do four births a year, the ones who do doula work as their way of changing the world and reversing disparity.  However, we also need professional standards and a way to teach and enforce those standards for doulas who want them.  We can create unity while still acknowledging differences in goals, approach, and the women we serve.  If anyone can do it, doulas can.  Yes, there will be differences between professional and non-professional doulas.  But there is room for us all and we need each other – if we forget that, we’re already lost.
  4. Additionally, there were doulas who stated “we serve the mothers, not the doctors”.  This is true.  Others were concerned that the “spirit or soul of doulaing” would be tainted by universal certification standards.  Yes, the sacred nature of our service is our connection to a woman and creating the space for her birth to unfold as she wishes it.  It demands that we give of ourselves, of our essential nature, of what we cherish.  We are changed by the work we do.  When done in honor and service to the mother, it has the potential to heal.  Simultaneously, many doulas work in environments where they interact with physicians and nurses.  Can we create a system that honors the true nature of doula carework and has a good possibility of being respected by medical staff?  I think we can.  However it would be voluntary.  If this certification process doesn’t fit your paradigm of doulaing, then don’t do it.
  5.  There is a lot of diversity among doulas.  That is because there is a lot of diversity among women.  We all need different things and no one is everyone’s best doula.  Some concerns were raised about whether all philosophies could truly be respected.  Can someone who views pregnancy and birth as one of the most sacred acts in life be equally honored as someone who sees them as mostly physiological processes?  Our strength is that we’re doulas – we’re accepting and empowering of the mother at all times.  We create opportunities for her to find her own way.  Can we not use those same skills with one another in this co-creative process?  Maybe I’m idealistic.  But I trust us.
  6.  The medical system most of our clients give birth in and that we interact with is imperfect.  It isn’t optimal for mothers, babies, nurses, doctors, or midwives.  Some doulas asked, “If we choose to participate in the systematic ritual of certification, aren’t we just embracing and internalizing this broken (or patriarchal or classist) system?”  We want to use this system to our advantage without being tainted by it. The paradox is that we don’t want to perpetuate this broken system but we want to be recognized by it to gain legitimacy, power, and privileges.  “Isn’t the very existence of doulas a bandage on this broken system?”  Of course it is.  To me, this is the dilemma of our times.  We face a version of these conflicts in education, our food supply, human rights, almost anyplace you bring conscious awareness.  If this issue has meaning to you, you will need to use your own values to weigh what is gained and lost by participating.
  7.  Others said, “I don’t want to be like providers; I want to us to be ourselves!”  What needs to be repeated is that I don’t think we are going to be allowed to continue the way we have been.  And I mean “allowed”.  We don’t have power and once the people that do decide they want to do something, it is too late.  We can only react.  Just ask the doulas who are already operating in areas where the hospitals have restrictive doula policies.  Some are in rural areas and some are in large cities – but each is finding its own solution to their “doula problem”.
  8. “Certification doesn’t make me a better doula.”  I have a few responses to this.  One, the certification process we’re discussing doesn’t have to look like anything we’ve seen before.  What would we dream of having, being, doing?  At what stage in their career do we envision people going through this process?  Could we offer mentoring groups?  Right this minute now my husband is Skyping with his certification mentor to meet his supervision requirement for sex therapy.  We have different technological tools, years of experiences, and vivid imaginations.  There is a new generation of doulas who can contribute to crafting a different process.  We could devise a system that could make you a better doula.  My second response is that maybe certification isn’t about making you a better doula.  Maybe it is about legitimizing what you do and what we all do.  Maybe it is about offering consumers some protection and recourse.  Maybe it is about making a statement to medical careproviders that we take our role seriously and that we are professionals.  Third, we have the opportunity to define the meaning of certification and why it is preferable for parents to choose a certified doula.  We can create a system that has benefits to other stakeholders as well as ourselves and market that.
  9. Looking ahead, those who are positive about this system have also posed other possibilities.  According to a research project I am in the midst of, almost every woman who wants to be a professional doula or a midwife also “wants to make money in a profession I enjoy”.  With the current system that is not possible unless you have clients that are paying out of pocket.  Even so doulas are not charging what their services are worth.  They charge what the market will pay.  The new health care legislation will no longer allow for doula support to be paid out of flexible health care accounts.  If we want to be paid a wage by third parties that supports our families, universally recognized certification will be the minimum requirement.  (IBCLCs created their own certification years ago, and are now pursuing state licensure in order to ensure insurance and Medicare reimbursement and recognition.)  If we can get our services covered by health insurers, the market for our services could expand exponentially.  But we can’t lobby for that without a universal standard for certification and professionalism.

We would not even be having this discussion without the path carved in the last 20 years by PALS, DONA International, CAPPA International, and ALACE with their certification programs.  They have led the way.  Doulaing another woman is an essential experience of existence for many of us.  It fulfills what it means to be a woman and it is ancient; coded in our DNA.  In some ways, the idea of codifying how it has to be done is upsetting.  If there were no external forces pushing the issue, I am pretty sure we could stay with the situation the way it is.  But I don’t want us to lose what we have and we don’t know when the window of opportunity will close.  With universal certification standards and a centralized organization, we are shaping the future of our profession for decades to come.  If we centralize our power we may gain more than what we lose.

 

Author’s Note:  When I started my inquiry about certification issues I had no idea it would lead me to this place. I’ve learned over the years that my voice is pretty direct and provocative.  I say things I see out loud.  What I’ve learned in 20 years is not to rush and to include lots of voices.  I value process. When the process of listening, hearing concerns, and building consensus works, the path to creating what you wish falls into place.  So let’s all reflect, talk, ponder, ruminate, observe and wonder.  Let’s engage with one another about the issues I’ve brought up in the last five posts.  Thanks to those who have already sent me proposals.  Email me with your thoughts – there’s no time limit.  Then let’s see what happens. 

If you want some provocative questions, here is a list to help get started.

 

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What If ACOG Decided To Certify Doulas?

Nov 8, 2013 by

For thirty years or so, birth assistants (now doulas) have been attending mothers.  The good news is that now doulas are everywhere.  We’ve reach a critical mass where many people birthing these days have heard of doulas.  But our growth has been random and erratic, working in isolated groups, going to births and getting the word out.  For almost two decades there were about four doula organizations; last month I easily counted 14 – each with different philosophies and visions for doula supported birth.

Among physicians and nurses, doulas have a mixed reputation.  At worst doulas can be seen as interfering with patient care.  A more begrudging view is that doulas are annoyances to be tolerated.  Sometimes doulas are seen positively but that relationship is usually fragile or reserved for individual doulas.  Originally, certification was conceived to be a reassurance to medical careproviders that certain standards of ethical behavior could be expected.  However, most doulas today only view certification as a marketing tool:  “My clients don’t care whether I’m certified.”

In any case, the current certification process has failed in both reassuring medical staff and clients.  (There are exceptions to this on a local level.)  The great majority of organizations offering doula training do not have any behavioral standards for the people who complete their courses.  Even though they title course completion as “certification”, they really aren’t certifying anything except that someone completed their organization’s checklist.  According to the publicly available information on their web sites, there is no vetting of their candidate’s character, no compliance with professional ethics, nor any standards of behavior that must be adhered to.  What exactly is being certified???  While these organizations may or may not do a good job training birth doulas, they do not seem to be certifying them to any particular standard.

Let’s consider the point of view of physicians and nurses.  I think we can safely assume they would like reassurance and some control over the people calling themselves doulas who they are forced to work with in the labor room.  As a profession we have not been able to provide it.  So who can blame them if they decide to do it?

What if ACOG (American College of Obstetricians and Gynecologists) decided that the mosquito-like annoyance of birth doulas needed dealing with?  Swatting at the occasional bug has not been working.  What if they set up their own registry or certification process and promoted it to their patients?  They may not be able to get rid of birth doulas but they sure can influence and frame the discourse about doulas with their patients and the general public.  What they want us to do and what we want to do in our current standards of practice may be very different.  Even if they follow evidence-based guidelines by the Cochrane Collaboration, it doesn’t say anything about birth plans or empowerment or client involvement in medical choices.  We don’t have that evidence.

But ACOG does not need a lot of evidence; they have money, power, and access to patients.  With only one (somewhat flawed) study they changed medical practice regarding breech birth in one year!  The same is true of VBAC.  Even with a potent consumer movement, we have been unable to create strong social change influencing the rate of VBAC in our countries.  Only now that we have careproviders reexamining their own practices is there any possibility for change.

I do not like to act from a place of fear.  I prefer to plan and be proactive rather than react.  My concern is that we are far too complacent about our own place in the birth world.  Right now it is dependent on being ignored by the people with all the power.  Birthing women and medical consumers do not have the power; large groups of doctors and hospital administrators do.  If we do not provide an answer to their “doula problem” that is on our terms, they will take action and dictate the terms.  We have to solve our own problem regarding certification and we have to solve it soon.

Is it time for an independent certifying organization? As an independent group, it would be divorced from training issues and philosophical issues that exist within a particular organization.  It could employ a robust complaint and grievance process.  It could actively promote birth doula standards of practice and spend money to explain these standards to health professionals. It could offer different levels of certification that reflected achievement in the profession.  It could build on existing certifications set by organizations who have them.  The only purpose would be to certify birth doulas, provide ethical guidance, and to set and ensure standards of behavior.  This organization could actively work to cultivate the trust of physicians, nurses, and midwives.

On the positive side, this would mean that doulas who trained with an organization that only offers certificates of completion would be able to obtain certification that reflects real ethical standards.  If promoted well, this certification could reassure medical people by defining professional behavior.  It would let everyone know what to expect.  Consumers could discover what appropriate norms are for professionals.  As doulas we get to choose what those standards are.  If we are a large group who earns a reputation of being trustworthy, we may be able to negotiate for doulas with a certain level of certification to remain while patients receive epidurals or to get into the operating room.  We could be viewed as the professionals we are.

On the negative side, it means surrendering a rebel image (if you have one).  It would mean distinguishing the difference between professional and non-professional doulas without judging someone for being a hobby doula or a friend doula.  (As I’ve stated previously if we want every woman to have a doula who wants one, that means we need to accept all kinds of doulas.)  The challenge will be to remain inclusive and nonjudgmental while maintaining there are different standards of behavior.  It means realizing that the organizational model of offering training, support and certification in one place is no longer working from an expanded system standpoint.  Most people are shopping for doula training based on location, price, or teaching method (workshop, correspondence).  They are not considering any of the certification or profession issues discussed on this blog.

A big fear that has been around since we first started attending births professionally is that birth doula care will be co-opted by “The System”.  “Doulas need to be outside the hospital system not a part of it.”  Well, that depends on what you value about birth doula support.  What I value is a supported birth as the mom sees it – no matter what her birth philosophy, caregiver, or place of birth.  I think that if we want doulas to be widely available to every woman who wants one, that means that doula support will take many forms.  This fear says, “If we have a separate certifying organization that appeals to physicians and nurses then it would be reflecting the values of the hospital system – which we usually view as disempowering to mothers.  So wouldn’t we be colluding with this philosophy?”

That depends.

This will only work if we understand the situation we are in and commit to this process.  It must be a consensus process and one that involves asking all stakeholders what they envision for doula certification.  Yes, that means asking nurses, doctors, mothers, consumers, administrators, insurance companies, and most importantly ourselves, what we want this to look like.  What do we want certification to do?  What do other stakeholders want certification to do?  A lot of professions go through growing pains.  I think that we have reached a point in our growth where we have to assess our current status and actively chart our future.  For 35 years it’s been about getting known and people understanding the importance of what we bring to the perinatal period.  We’ve done that.

While I would like things to go along as they have been, there are a lot of unhappy people out there when it comes to certification – many of them working doulas.  Until two months ago when I started listening to them, I really had no idea just how fractured our current system was.  I don’t know exactly what a certification organization might look like at the end of a conscious consensus process.  It’s kind of like looking at adolescence; I really don’t really want to have the experience of going through it but I really want the benefits of being on the other side.

Right now we can be in charge of our own destiny.  If ACOG or a similar organization decides what our behavior and standards should be, they have the power to restrict doulas from the labor room.  When I consider that alternative, I feel more compelled to consider conscious action.

 

 

 

 

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Their Doula Disappointment

Oct 26, 2013 by

Recently these two news stories came across my desktop.  “My Doula Disappointment” outlines one woman’s story with her birth and postpartum doulas. The second is a petition which is a response to North Florida Regional Medical Center’s recent move to create a registry of birth doulas who are “allowed” to attend women in labor at their hospital.  What do these stories have to do with the current discussion of certification?  Plenty.

In the first issue, the woman noted that the doula she hired had twenty years experience and was highly recommended but not certified.  The mother disregarded the doula’s lack of certification, remarking that since she came highly recommended, certification was not necessary.  Now that she is not satisfied with her experience, she realizes that there is no one to complain to nor to mediate her dispute (or even to listen to her feelings).  While I know nothing about the circumstances or doula’s perception of what happened, that isn’t relevant.  My point is that the mother bemoans the fact that there is no one with any authority who will listen to her concerns, so she is forced to air her concerns on the internet – for all to read.  If there was a certifying body, the story she shares might be different.

In the second instance, NFRMC is reportedly instituting a doula registry in order to clear doulas who will be allowed into the hospital in a doula role.  [This is unverified as the only mention I have found online is the petition.]  Undoubtedly, they have encountered unprofessional behavior and are doing what they can to provide a “reasonable” working environment for their staff and providers.  Part of the problem is that doctors and nurses deal with novice doulas, hobby doulas, friends of mothers calling themselves doulas, and rogue doulas*Very few of these people feel any allegiance to other doulas or the professional standards most of us hold dear.  They can’t tell them apart from the professional doulas – we’re all the same to them.  We use the same title and there is no visual distinction between us.  Every doula gets blamed when one person calling herself a doula acts in a way that medical professionals do not care for.

Even though we are not part of the medical culture, it behooves us to structure our profession in a way that garners their respect.  We can either control and patrol ourselves or hospitals will do it for us.  As someone who has consulted with hospitals regarding their conflicts with birth doulas, I am not surprised by NFRMC’s purported action.  It makes perfect sense to me when I consider the bigger picture of their possible doula experiences.

On the other hand I hear doulas rejecting certification because it interferes with their freedom to offer services to their client.  What is it you want to do for your client that is outside the doula’s scope of practice as defined by DONA, CAPPA, and similar standards?  This “I want to follow my own conscience” does NOT work for doctors, accountants, or even personal trainers.  No one is protected by an “anything goes” attitude.  According to DONA and CAPPA SOPs you are welcome to use aromatherapy, therapeutic touch, even massage, homeopathy, and herbal remedies IF you have additional education or certification.  Counseling that these alternatives are available is certainly within your SOP.  Giving your mom a recipe for an herbal tea to start labor is too IF you are a trained herbalist and her MCP of choice is consulted.  Herbs, homeopathy, and essential oils are drugs!  They have effects on the body; that is why we use them.  The same goes for acupressure.  To think that these effects are always benevolent is deluding yourself.  States and provinces even require massage therapists to be licensed.  But many alternative remedies have been classified as supplements which means they are available over the counter.  But OTC does not = benign.  Both of these SOPs state that if the mother is considering doing something to her body that may have a deleterious effect, even if it is a rare occurrence, that she discuss it with her care provider of choice first.  Some doulas interpret this as asking for permission; I see it as consulting.  The mother hired her MCP for their expertise on her physical health.  If she is considering taking a drug or having a treatment that may affect her health, it is important for her to get their opinion and for her medical record to be complete.  It is the mother’s choice to make; we only counsel her to do so.

We live in a society where few people take personal responsibility.  You may think your client will never blame you or a technique you recommended for a poor outcome.  Just ask the doula who has had 100 clients – she’ll set you straight.  According to my own research participants and the hundreds of  doulas I’ve known over the years, scapegoating occurs in both small and large ways.  The limits for the doula’s standards of practice and condition that the client consult her medical care provider PROTECT you and your client.  If you really want to prescribe rather than support (or in addition to it), get the education and credentials to do so.  No one is stopping you.

But remember that the doula’s magic is her ability to support unconditionally and be present with a woman when she is vulnerable, uncertain, and challenged on every level.  It is believing in her ability to find her own voice.  It is not being another voice telling her what to do.  That is what the research evidence supports.  If prescribing, diagnosing, and treating are important to you, then perhaps your path is not to be a doula.  There are many other roles where these desires can be accommodated – just don’t do them and call yourself a doula.  Be fair to the rest of us – the choices you make individually do not end with you – they affect all doulas.

 

*rogue doulas:  A doula who willfully behaves in a way that is dishonest, unethical or against established standards for doula behavior.

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A Story About Certification

Oct 10, 2013 by

Once upon a time, there was a pregnant mother who wanted the support of another woman during her labor.  While she loved her husband, she knew they both needed something more.  Through her childbirth educator this mother got the name of a woman who might be able to help.  Once they met, they went for long walks together and the three of them chatted over tea.  The mother and father felt reassured by her presence and grew in their trust that the labor and birth could go smoothly.

When the time came they called their new birth friend.  They spent a few calm hours together before they all went to the hospital.  The triage nurse isolated the couple until their room was ready.  The mother was agitated and afraid but once reunited the three of them worked together to restore calm.  The new nurse was admiring but questioning at the same time.  She challenged their friend, “Who are you? What is your role?”

Their birth friend replied, “I am their doula. I’ve taken some classes and been to a few other births.  I–”.  But the nurse cut her off, uncertain of this doula person’s status and whether she would interfere with what the nurse needed to do.  The labor proceeded smoothly with the nurse and doula side by side caring for the mother.  The baby was born, fed, and procedures accomplished.  As she neared the end of her shift, the nurse told the doula, “I wish there was some way to know whether people like you would act like you do.  We get all kinds of people in here doing all kinds of things and we don’t know how to tell them apart. They all say they’re doulas, too.”

Thus the idea for certification was born.  Could there be some way to reassure medical people of certain standards of behavior?  There was also a need for doulas to bond together and promote the idea of doula support.  Could those two purposes actually be part of the same organization?

We all know the answer to that.  Informed Homebirth/Informed Birth and Parenting (IH/IBP) and DONA International were the first national organizations, followed a few years later by CAPPA International, Childbirth International (CBI), and Birth Arts International (BAI).  Now there are at least 14 organizations in the United States alone offering a variety of standards for birth doula certification. But let’s go back to the reason why it was invented in the first place.

Certification was created to offer doulas legitimacy and to give us control over setting our own standards.  For those unfamiliar with doula support, it gives them reassurance that there are standards for a doula’s actions.  In the medical culture where certification and licensure have great meaning, it shows respect for their way of doing things.  As doulas we are guides from our client’s culture to the hospital culture.  We are effective because we are not of that culture but we understand it and can explain its rituals, tools and language to our clients. But the flip side is that to be effective long term that culture needs to respect our presence.

In some hospitals a mother is not allowed to accompanied by a doula unless she is certified by an organization whose standards match those of DONA and CAPPA.  Mothers are supplied with the doula policy when they register to birth at the hospital.  Doulas are given a copy of the hospital’s policy and expectations about the doula’s role.  Many of these policies are not problematic for most birth doulas – no vaginal exams, no interpretation of monitor strips, the mother decides what she wants not the doula.   But these policies arise from “doulas” doing these things – they do not arise out of nowhere.  Every nurse manager I spoke with who had a doula policy in place cited several examples of conflict because the doula acted outside of the role that the hospital assumed was true for her.

Certification has opened the door for all doulas whether they individually choose to be certified or not.  In fact it is almost a back door for doulas who set their own personal standards for behavior.  Hospital staff and medical careproviders make assumptions about doula behavior based on the two main organization’s certification standards.  (There is more to the individual certification decision that I will outline in a companion post.  My objective in this post is to take a system perspective that goes beyond the individual – and I am not advocating pro or con, just observing what has occurred and why.)  Because of this, most newly trained doulas are able to accompany a mother without being given a compliance policy to sign.

Of course there is conflict with the autonomy of the mother to have whoever she wants with her during her birth experience.  But hospitals have retained the right to restrict birth companions if they feel it interferes with or has the potential to interfere with patient or employee safety or medical care.

There is something to be said for setting our own standards for our profession.  Personally I would rather prefer those standards be set by people who do what I do and share a similar philosophy.  The alternative is for people who don’t understand or respect a doula’s value to set those standards.

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