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

Nov 29, 2017 by

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

Graduate Student Researchers

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

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

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

Funding

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

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

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

Planning The Study and IRB Approvals

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

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

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

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

What Journals Will Publish Your Doula Study?

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

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

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

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

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

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

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

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

Nov 6, 2017 by

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

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

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

Politics and Power:

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

Outmoded Beliefs:

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

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

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

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

 

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

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

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

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

Nov 3, 2017 by

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

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

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

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

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

 

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

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

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

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

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

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What U.S. Birth Professionals Need to Understand About ICWA

Oct 13, 2016 by

icwa-alex-garland-photo-copyThe Indian Child Welfare Act – why is that relevant to my practice? The laws concerning children’s rights changed earlier this year. Although standards vary among the 544 tribal nations recognized by the United States government, some tribes consider a person with one drop of Native American blood as a member.  While only slightly over five million people have full or partial Native American heritage, the growth rate within the population is more than double that of other racial groups. At 26.7%, birth rates between 2000 and 2010 were almost triple that of the nation as a whole at 9.7% (U.S. Census, 2012). The average age of a Native American is 29 years old, compared to 37 years for all Americans (U.S. Census, 2012). This means most of the indigenous U.S. population is in their childbearing years – when they are most likely to be utilizing our health care services.

Why should we care? Recognition of tribal status is important to the individual, the family, and for the continuation of the tribe. The child may qualify for different social programs because of their heritage, but the most significant impact occurs if they enter a Child Protective Services (CPS) system.

Tribal status begins with correct information on the birth certificate. Even misspelling a name can interfere with identification. (The infamous Veronica case went all the way to the Supreme Court in 2013, which was caused in part by an error in spelling the absent father’s name on the birth registration form. Even though he was registered with his tribe, his misspelled name did not show up in a search. So the child was legally adopted by a White family until the father contested.) Since hospital staff are filling out the forms, it is important that parents and their support team ensure that correct names and demographic information appear on the birth certificate. In a recent briefing session, Oklahoma CPS social workers explained, “Even though we have a higher than average population of Native Americans in our state (Oklahoma), nurses still look at the baby to discern race and ethnicity. If the baby looks white or black, they check that off without ever asking the parents.”

Parents may also not realize why it is important to categorize their child’s heritage correctly from the very beginning. It is difficult, but not impossible, to get that changed at a later date – but it must be done with a court order by a judge.

Doulas can explain to families how ICWA affects their child’s rights, their ability to receive assistance or scholarships, and placement in the welfare system if those services are ever needed.

How does a person become recognized as a tribal member? Heritage is not established by clicking a box; the person must be recognized by the tribe. Each tribe has their own standards and they are not the same. After applying, the first step will be genealogical research on the child’s relative, who may or may not be a recognized tribal member. Most tribes keep complex family trees. Some records are online and easily searched, while others have paper records kept in file folders. If the relative is already recognized, establishing heritage may be fairly easy.

Why does this status change how a child is treated in protective services?  Native Americans are dual citizens, and each tribe has the right to be self-governing as a sovereign nation over its own lands and properties. That means that most large nations have their own child welfare services. They work cooperatively with the state or county CPS agency. Anytime a child needs to be removed from the home and a biological relative cannot be found, the child needs an emergency placement. This could happen if there was an auto accident that hospitalized the parents and it took time to notify relatives, or when abuse or neglect is suspected.

It is considered ideal for a Native American (NA) child to be placed with a NA family rather than a non-NA family, preferably within the tribe. The majority of families who take in emergency placements or foster children in the U.S are White. ICWA is designed so that children will be preferentially placed in a qualifying NA home when a biological relative is unavailable – even if that placement is farther away, even hundreds of miles away, from the child’s school or home community. This is the controversy of ICWA: it states that the child’s status as a tribal member is more important to nurture than the child’s emotional or developmental ties with an existing family or community.

Here is how it gets problematic: Let’s say five year old Melinda needs a temporary foster family. She is not listed as having tribal blood on her birth certificate. As her relatives are contacted, one of her paternal aunts mentions that she is a tribal member so her niece is too. Rather than getting the best possible placement from the start, Melinda would be put in a temporary home while her records are investigated. Since placements with a tribal family are harder to come by, she would likely be placed initially with White or Black foster parents. It may take several weeks or months – if all records are in order – before Melinda’s initial placement is confirmed or she is moved to a new tribal foster family. If she is confirmed as a tribal member, she will be moved, with no exceptions. So, what most of us are wondering is, “Why aren’t they thinking about Melinda and putting her needs first?”

In their own way, they are.

So, the individual child’s welfare is considered secondary to the cultural preservation of the tribe? Yes, that is one way to look at it. But the goal is for both to be important. If records are properly kept from the very beginning, many of the heartaches shown in the popular news can be avoided. The world is seen differently by many tribal peoples and this influences their definitions of health, harmony, and balance. The more we can step back and understand the world from that point of view, the more ICWA’s policies make sense from that perspective. In this informative essay, Clark explains that most western European or American thought is linear, and Native peoples tend to think in relational terms. “In the linear view, the person owns or is the problem. In the relational view, the problem is circumstantial and resides in the relationship between factors. The person is not said to have a problem but to be out of harmony. Once harmony is restored, the problem is gone. In the linear model, we are taught to treat the person, and in the relational model, we are taught to treat the balance.” So ICWA helps to bring their world back into balance.

How is this affected by past racist policies to assimilate Native people into White culture? Between 1790 and 1920, it was considered good domestic policy by the U.S. government to bring as many Native peoples as possible into White culture. By 1890, that meant separating children into residential schools where they would not learn their tribal language or beliefs or participate in events and ceremonies. Children would be effectively cut them off from their past and their people. Adoption became a negative thing because it was used as a method to separate NA children from their culture and families of origin. The goal was not to place the child back in their home, but to find whatever possible reason to keep them from returning. This went on for over fifty years, leading to multiple generations of tribal peoples feeling angry, lost and without a sense of belonging. Many of the social problems that Native peoples face today have their roots in U.S. government policies of assimilation. So part of what is happening with ICWA in 2016 is a response to the damage done by assimilation policies of the past – and to bring indigenous peoples back together and into harmony.

 

For more information about the Indian Child Welfare Act:

http://www.adoptuskids.org/adoption-and-foster-care/overview/who-can-adopt-foster/families-for-native-children

http://www.nicwa.org/what_we_do/documents/NICWA%20FAQ.pdf

https://www.childwelfare.gov/topics/systemwide/diverse-populations/americanindian/icwa/

Photo ©Alex Garland This photo has been altered to highlight the mother and child. https://www.flickr.com/photos/backbone_campaign/27186540216

 

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Hospital Agreements: An Opportunity For Engagement [Part II]

Jul 24, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (1) copyIf a doula agreement is being waved in front of you, congratulations! It means that your doula community has gotten too large to ignore and is having enough of an impact that the hospital wants to exert some control. Now the real work begins, not with clients, but with the institutions where our clients are choosing to birth. You have an opportunity to create a collaborative atmosphere even if their actions seem hostile at the moment. This is politics, system change, and social change happening in your neighborhood, and I hope to give you concrete suggestions to co-create a synergistic relationship – even if it seems impossible now.

Keep the focus on your long term goal: an open channel of communication between this hospital and the doula community. Your goal is not to get the hospital to eradicate the agreement but to build understanding and strong reliable communication channels between two groups of people. You are using the proffered agreement as an opportunity for greater connection, understanding and dialogue between the people most affected by it. It’s imperative that the doulas who are approaching this conflict negotiation realize that attacking the hospital’s solution, the agreement, is counterproductive.[1] Anytime you openly criticize something, you make that person defensive about it and more entrenched that they are right. Instead, you have to put the emphasis on the conflict and your mutual interest in resolving it. If you focus on the agreement and what’s ‘wrong’ with it, you will get into a power struggle and doulas will likely lose. If not this issue, how you handle this will set a precedent for communicating about any future conflicts. Sorry to increase the tension, but this is an influential time and needs to be recognized as such.

So what can doulas do?

  1. First, have a leadership committee of the people who have the best communication skills as well as doula experience. Prepare yourselves. Read simple books on negotiation and conflict resolution (see below), or see what community or internet resources are available for continuing education. Being prepared and having skills will give you more confidence – but don’t wait too long.
  2. Contact the people in charge and set up a meeting. Make it clear that your goal is to generate solutions to their problem, and not to deny that a problem exists. Explain your perspective is rooted in concern for the long term health of the hospital’s relationship with its future patients and future doulas, and an ongoing relationship with open communication can work to both of your benefits. Doulas are not going to disappear, and trying to exert power over the doula community without seeking to get to know them will not work in the hospital’s favor. Someone in that problem solving group knows that, but their voice may have been drowned out by others. Doulas, there are allies in that hospital, and you will need to find them. Hopefully, you will also cultivate new ones through your sincerity and focusing on the long term goals. This will be harder to do if the atmosphere is hostile or the agreement is written in a way that delegitimizes a doula’s contributions to maternal-infant health or seeks to restrict the doula’s access to a client. However it isn’t impossible. Remember, they don’t understand our values or our role and you can change this over time.
  1. Be gently persistent until you get a meeting. State that you don’t want to get rid of their agreement proposal, but seek to find additional ways for their needs to get met. Do they want someone to call and complain to? Often what people want the most, over and over again, is to feel that their concerns were heard and met with kindness and respect. If you push that aspect of the meeting – “we want to hear more about your concerns” – it will be more effective than “we have to do something about this agreement”.
  2. Use this handout Doula Information for Nurses Sheet (initially designed for a nurse and doula conflict resolution meeting in my city) or a similar one to explain why doulas do what they do and give background about the state of the profession. Make sure you are all on common ground about doula support and what doulas actually DO and don’t do. Issues may arise as you go through this sheet together.  Listen. Listen. Listen. Even if the people at that meeting are not listening to you, listen to them. Reflect back their concerns in your own language. “What I heard you say is…”
  1. Emphasize common interests. “What we both value is…[2] Do this repeatedly as needed throughout the conversation.
  2. Ask, “What other possible ways to address this problem did you come up with besides an agreement?” This is where you’ll find out whether they fully explored the initial problem or took into account the concerns of other stakeholders. It’s possible they may not have and you can initiate it at this meeting. Ideally, you’ll be able to follow up with a small group made up of multiple stakeholders (see list in Part I) who are interested in a more complete problem solving process. Resist the urge to rely on one or two people from either group to do the negotiating or attend meetings – if one person leaves their position you’re back where you started from – without an ally.
  3. If the atmosphere is hostile or untrustworthy, it is critical that you do not allow emotions to cloud your judgment. Your communication needs to be intentional, not reactive. Don’t take bait – slurs on a doula’s past actions, a doula’s motivations, etc. Let it go for now.  Frame it as “learning about the tactics of your negotiating partners”.  Recognize that establishing trust takes time and repeated interactions where people behave reliably and do what they say they are going to do. Promise what you can deliver, not what you can’t. Set reasonable deadlines and meet them. People learn the value of a doula by experiencing you doing what you do, not from reading or talking about it.
  1. Be prepared for the presenting problem to not be the true problem. In one hospital I consulted with people were angry that doula clients kept insisting on special treatment for their newborns. Administrators discovered that while there were protocols for one hour of uninterrupted skin to skin contact in place, that was not what nurses were actually doing. Unless the doula reminded the parents and both parties actively advocated for it, usually repeatedly during that first hour, parents were not getting the care that the protocols were written to encourage. Nurses didn’t like the criticism and resistance they experienced from doula attended clients, and it was labeled as a ‘doula problem.’ However, once different stakeholders were interviewed, they discovered a deeper issue. It turned out the nurse’s workloads were so high that they felt pressured to do newborn procedures even when that interfered with the one hour skin to skin mandate. So what was initially perceived as a doula conflict, was instead a conflict between policy and workloads, with parents and babies being the losers and doulas as the scapegoat. This can also work the other way, so be prepared to listen to criticism of doula behaviors. Remember, listening is the most important thing you can do at this stagethere may be years worth of resentments pouring out if you’ve never had a meeting before.
  2. Focus on the possibility of a positive outcome. You can create collaborative relationships that don’t compromise the doula’s autonomy, ability to represent and serve her clients, and satisfy the hospital staff’s needs for predictability. In doing research for these blog posts, I found examples of several birth communities who had already created collaborative long term processes. (Please add yours in the blog comments.)

Susan Martensen, a doula and trainer in Ottawa, Ontario, Canada, states that her local doula group has worked hard to be recognized as part of “The Care Team” and not as a “visitor”. The instigating situation that brought doulas and nurses together was the SARS outbreak in 2003. Hospitals sought to limit access for anyone into the hospital. Doulas in the area formed a new group to develop a standard of practice and code of ethics based on ones from their different training organizations. All doulas in the area agreed to sign the document they had created. “Two hospitals in the area agreed to regular meetings to build bridges and establish doulas as part of the Care team (and not included in the usual visitor policy),” according to Ms. Martensen. “It took several in-services to introduce, or re-introduce, the role of the doula to the nursing staff, so that we all understood the collaborative model of care. The meeting was multi-disciplinary, so there were doctors, anesthetists, pediatricians, etc, there, but not everyone and not all at the same time.”

The next step was to establish nametags for the doulas that were created by the doula group and a book at the nurse’s station that listed photos, names and contact information for the doulas. “Over time we developed a complaint process as well as establishing a system for addressing any conflicts during a labor,” adds Ms. Martensen. “It is a collaborative model that has worked well for the most part, and it is not administered by the hospitals.” They continue to have regular meetings with key personnel and doulas to provide feedback and assess their collaboration with one another. Ms. Martensen feels that the emphasis on collaboration and being seen as a valued member of the care team is what has made all the difference.

Ana Paula Markel, of BiniBirth in Los Angeles, California, USA, initially worked with a small task force at Cedars Sinai Medical Center. A rising number of conflicts was leading to a tense atmosphere, and Ms. Markel was talking to a labor and delivery nurse about it. Out of that casual conversation, a small group of interested individuals got together and outlined several steps which they have been implementing in the last year. They created a Cedars-Doula Advisory Committee made up of labor and delivery nurses, midwives, the nurse manager, and six doulas from the community who each have a different level of experience. Ms. Markel feels that having new doulas involved is crucial, since they often present a different perspective. The CDAC meets monthly, and has its own email address where people can write with questions or complaints. It is used by both doulas and nurses. Based on this feedback, they created a teach-in day for doulas, which was also attended by much of the labor and delivery staff. They did several role plays of challenging scenarios and explored the point of view of both nurses and doulas and what each thought the other “should” be doing. It was very enlightening for everyone. After attending the teach-in day, doulas received a recognition badge to wear. In this way nurses were reassured about the doula’s perspective and background knowledge.

Both the Toronto and Los Angeles doula communities were able to turn potential conflicts into opportunities for collaboration and enrichment. So, take heart! It can be done – you can create a process that benefits many stakeholders long term.  It is up to us, as doulas, to do the work and it is a task to be embraced. To have the ear of hospital leaders, even if it is coming in the guise of an untenable agreement, is what decades of doulas have been waiting for: an opportunity to create positive change in the system.

 

Here is a pdf copy of this blog post: Gilliland Hospital Agreements Engagement

[1] Fisher and Ury, Getting To Yes, p. 41 (first ed.)

[2] Fisher and Shapiro, Beyond Reason, p. 53

Fisher, R., Shapiro, D., (2006) Beyond Reason: Using Emotions As You Negotiate. Penguin Books. 

Fisher, R., Ury, W., (1981 through 2011) Getting To Yes: Negotiating Agreement Without Giving In. Penguin Books. 

Other conflict resolution, negotiation, or mediation resources may be available through a community college, university extension, adult education, or state or provincial small business support organization.

 

 

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Hospital Agreements: The Wrong Solution for the Right Problem

Jun 27, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (3)Birth doulas are concerned about hospitals requiring signed agreements in order for them to practice their livelihood on the facility’s grounds. Some agreements outline scope of practice behaviors and even have vaccination requirements. My concern is that these agreements are seen by hospital leaders as an easy solution, without realizing that agreements without prior negotiation lead to greater conflict and tension, thus worsening the situation for their staff rather than alleviating it. They seek to save institutional energy and time, sidestepping the processes of defining the problem well or evaluating other possible solutions.

It’s also possible hospital leaders do not understand the doula’s role. A few months ago a very experienced labor and delivery nurse asked me about a doula who “just sat on the couch” most of the birth, only “getting up to help them change positions or go to the bathroom”. Her perspective was that the doula’s role was to tell the mother what to do to make her labor more efficient. This also represents a clash in values. In the hospital system, members have been socialized to believe that their primary value is in doing something. Our emphasis is on presence, a state of being that helps to create a safe space where oxytocin can flourish, the laboring person’s body can open up and use it’s own wisdom to get the baby born.

As someone who does frequent workshops and trainings for labor and delivery nurses, I can say that nurses gain their knowledge about birth from different sources; and often they do not know what doulas know. Nurses reading this blog very likely do, but they may not be the people in charge of solving the ‘doula problem’. Doulas read different research literature and have different conclusions. It is risky for doulas to assume that others understand our role or why we place value on physiologic birth[1]. When people don’t understand the doula’s approach to enhancing labor, they misunderstand our actions and motives as well.

To me, the agreements and many doula communities’ reaction to them, are representative of a clash in values, misunderstandings about each person’s role, and short sightedness about the long term relationships that need to exist between birth doulas and hospital staff and administrators. Part of my reasoning comes from the hospitals and doula communities who have effectively worked through their conflicts and found solutions that work. Each group took the time to appreciate the other’s contributions, and develop a long term perspective that included a multifaceted communication network. In my next post, I’ll outline their achievements and share strategies to help get to that point in your own community.

If an agreement is being proffered by your hospital, this means that you have a sparkling opportunity to engage with administrators to resolve conflicts and outline your working relationship. This is a critical time to define your relationship with one another as it has the potential to influence all future interactions. In a way congratulations are in order – the doulas in your area are being seen as a big enough force that they can no longer be ignored. You’ve got their attention and can use it to create positive change in the system that benefits you, your clients, as well as the hospital. The hospital staff just doesn’t know it yet!

Let’s focus on some key questions that we need to ask:

First, has the problem been defined well? Agreements are seen as a solution to a problem that people belonging to the hospital are having. Usually it seems the doulas in the area are often in the dark about what the problem actually is. From what I’ve learned about people and medical systems, a solution can be latched on to without ever really defining the problem well. “I read on the internet that Hospital X was having a doula problem so they developed an agreement. We could do that too.” Having latched on to a solution, the group then moves forward without fully defining the problem first.

Problems that agreements may be seen as solving:

  • Doulas who are using clinical skills while in the hospital.
  • Doulas misinforming the person in labor about their progress.
  • Doulas who are not being collaborative in their labor support strategies with nurses.
  • Doulas who ignore nurse’s experience or expertise in support skills.
  • Doulas who criticize a medical careprovider’s approaches.
  • Doulas who give medical information that the hospital feels should come from their representative.
  • Doulas who are blamed for their client’s strategies to delay or avoid interventions.
  • New doulas who need mentoring, and the nurse doesn’t feel that is their role (the agreement serves a gatekeeping function, keeping newbies away).

Besides the first one, the rest of these problems are relational. In other words, they aren’t easy to define and will depend on the personalities and communication skills of the people involved. That is what makes the agreements so problematic – they really can’t define appropriate behaviors in an accurate way. For example, if an agreement states, “The doula will not openly criticize the medical care being offered to a patient”, what does that mean? What is considered “criticism” and “open”? Is asking about BRAND[2] seen as criticism? Is bringing up alternatives critical? Is reminding a mother about her pre-labor priorities critical? How do doulas know? How do nurses know?

Second, are the perspectives of multiple stakeholders (nurses, physicians (all kinds including anesthesiologists), midwives, administrators, mothers, fathers, babies, laboring patients, family members, lactation professionals, doulas, social workers, etc) being taken into account? Having defined the presenting problem, who else is affected by it? What are their considerations that need to be taken into account? Have they been asked or consulted?

Third, what are all of the possible solutions to the problem? Are there other issues that have come up during this exploration period? What are the short and long term gains of each solution? What if instead of forcing all doulas to sign an agreement, we had twice yearly orientations for new doulas? What if the hospital sponsored events that covered the allowed safe discussion of most annoying behaviors of doulas in nurse’s eyes, and vice versa? What if nurses were free to ask questions about why doulas do things a particular way, without negative repercussions? What if doulas could seek to understand the nurse’s perspective without animosity?

In this way, hospital-doula agreements can be shortsighted. We don’t know what the goals of the hospital or the doula community are or whether they overlap.

Agreements that are created without communication between the negotiating parties will create tension and conflict. An agreement works best when it has been negotiated after a effective communication and conflict resolution process has been established. The agreement is the outcome of a negotiation. When it is handed down with authority as a “power over” move, it is doomed to create tension, defensiveness, and an anxious and tense work environment.

 

 

[1]  Supporting Healthy And Normal Physiologic Childbirth: A Concensus Statement by ACNM, MANA, and NACPM (pdf file) 

[2] Acronym for Benefits, Risks, Alternatives, do Nothing, Decision (after establishing that this is not an emergency)

For a doula’s insights on being handed an agreement, read: https://birthanarchy.com/hospital-doula-agreement/

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Birthrape And The Doula

Apr 29, 2016 by

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

Dear Doula,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Your goals are:

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

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

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

“What other procedures or people might we expect?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is it rape? Aren’t you exaggerating?

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

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

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

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

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

 

 

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

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

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

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

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

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

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

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

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

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The Time To Ask About Past Abuse or Assault is Never

Apr 6, 2016 by

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

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

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

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

You can also offer examples:

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

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

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

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

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

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

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

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

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

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

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

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

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

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When Midwives Don’t Recommend Doulas

Jun 17, 2015 by

MWBlogphotoSo your local midwife told a prospective client of yours that she didn’t need a doula.  You feel surprised, even betrayed, at her lack of support.  What’s going on?

First, the midwife is right.  No one is compelled to have a professional doula.  Some women have friends or relatives who can serve in that role.  Some midwives have an assistant or student who s/he prefers to doula her client.  Women and their families have needs in labor that a professional doula is trained to meet.  But there are other people who can serve in those support and communication roles.

Second, the midwife is wrong.  Midwives may feel that their role is to support the woman in labor as well as provide expert medical care.  Since they are there continuously as a doula would, they think they can fulfill both roles.  That can be true depending on the midwife, her assistants, and the events and length of the labor.  If a birth becomes medical, there are two patients to care for – the mother and her baby.  Unless there is a third person whose priority is the mother’s emotional wellbeing, those needs go unmet.  You cannot adequately address emotional wellbeing, especially in a medical crisis, if you are monitoring and conducting lifesaving measures on a mother, baby, or both.  You just can’t.

In addition, just because a mother may trust her midwife with her medical care, that doesn’t mean she is the ideal person to meet her emotional needs.  There are many times I have been hired as a doula at a home birth for just that reason. Sometimes the mother feels fine with the midwife but is concerned about her partner’s needs.  With a lengthy labor, having a third knowledgeable person with a professional attitude can be an asset to a midwife and his or her assistant.  All of us are less tired, we can nap more frequently, and think creatively about positions and comfort measures to try.  We are all on the same team, chosen by the mother and her partner(s) to be their support.

However, it’s also not that simple.  Doulas often have strong emotional reactions when this happens.  Doulas often imagine that since midwives and doulas are both professional birth workers, we would naturally support one another.  We recommend midwifery care.  We’re kin, right?  Yes and no.

There are some very emotionally supportive, hands on midwives. These ladies and men give a lot of emotional support and are instrumental in suggesting comfort measures.  Others sit and knit, quietly observing, and only get involved to do monitoring and the eventual birth and aftercare.  Most midwives are somewhere in between – and it may also depend on the clients they are working with.

Some midwives may feel a sense of competition with a doula; as if we are infringing on her territory or passing a judgment on her abilities.  They may even have begun as doulas and feel they can continue in both roles.  They may like the doula role and be unwilling to give that up.

Our histories are also different.  For over six hundred years, midwives have been maligned, persecuted, misunderstood, and demeaned. Lies were told about the abilities of Black Midwives in the American South in order for physicians to get their business.  The worst kinds of discrimination and injustice against women have occurred in midwifery history.  A legacy of this oppression is that they fight among themselves about what kind of midwifery philosophy and training is best.

Doulas, beginning as birth assistants or labor assistants, have been around in a structured way for about thirty-five years*.  I contend that our whole profession would not exist if there was universal access to supportive midwifery care that treated the whole woman.  We exist to fill a gap in the medical system and the American way of doing birth.  While doulas are begrudgingly accepted (sometimes enthusiastically), we do not face the same obstacles that midwives do.  Midwives compete directly with physicians for business, while doulas do not.

There are a lot more birth doulas than midwives in North America today, and with a lot less training and dedication than it takes to become a midwife.  Midwives may witness a revolving door of doulas in her community, and only want to work with certain ones.  After all, a labor can be a long commitment and in the intimacy of a home or birth center environment, the midwife may want to control who is there in a professional capacity.  Perhaps its not all doulas that are being discouraged, but its just sounds nicer to phrase it that way.

What if the midwife is in a hospital setting and still doesn’t recommend doulas? 

Does the midwife feel that the nursing staff is able to support and adequately provide for mothers?  Is there a history of negative experiences with a particular doula or a rotation of mostly novice doulas?  Maybe this midwife doesn’t recognize the emotional needs of mothers the same way most doulas do, or feels that they are adequately met by the way birth is done in their facility.

At other times, midwives see themselves as working towards the same goals as doulas.  Rather than feeling competitive, they realize there are multiple ways for an individual woman to get the support she’ll need for her birth.  They want women to have births they feel good about, which lead to strong mothering and optimal outcomes, but don’t necessarily have to be the provider.  These midwives usually recommend doulas.

So when you’re surprised by your local midwife’s remark, take a moment to consider these multiple perspectives.  Hopefully they will help to explain why she or he might make that statement.  What’s the best reply?  As always, the best doula reply is to turn it around and ask the mom!  “Why do you think the midwife would say that?” and follow her lead.

 

*Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean, by Nancy Wainer-Cohen and Lois J. Estner, published in 1983, was the first book to recommend a labor assistant. They cite a lecture from 1981 (p. 225-227).

 

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The Essential (Oil) Dilemma

Apr 30, 2015 by

EOflowerphotoRepeatedly, doulas discuss whether or not it’s in their scope of practice to recommend or use essential oils and aromatherapy.  While that is a part of the discussion, it really isn’t the central issue.  What we need to recognize is an underlying philosophical difference between doulas.  The core issue is whether it the doula’s role to DO more to moms or just to BE present with her as the labor unfolds.  In the DO camp, people say they want to have more tools in their birth bag.  When a few simple sniffs can help with nausea, mood, or even help a woman to urinate, that is a good thing.  There are so many other interventions happening with the labor, using oils can help to counter them and bring the labor back into balance – or at least make the laboring mother feel better.

The BE group tends to feel that mothers have enough people trying to alter the course of her labor.  These doulas feel their strength is in the support they bring and the use of comfort measures to alleviate discomfort, not to change what is happening in the labor or what mother is feeling.  Being “present with” and supporting the mother 100% means not seeing her or her labor as a problem that needs to be fixed.  Doulas are usually the only ones who are not trying to will things to be different than what they are.  In a postpartum context, these issues are still present.  Is it our support that makes a difference or is it the tools we bring to help with post birth discomforts?  There is also a baby to consider, whose system may react differently than expected to scents and oils.

The BE-la vs. DO-la* debate isn’t new, but it reflects one of the philosophical differences between doulas.  I don’t think either of these approaches is wrong, but each leads us in a different direction.  As a community we haven’t formally acknowledged these two approaches. The essential oils issue brings them to the forefront, and offers an effective way to frame this discussion. If you’re a DO-la, using essential oils and/or aromatherapy makes sense.

The second issue with essential oils and aromatherapy is more practical.  Is there a potential for harm when they are used?  The answer is clearly “yes”. People can get burned and have unexpected adverse reactions (headache, migraine, nausea, allergic reactions, skin sensitization, phototoxicity, etc).[1]  For example, the desired result of calming a mother by using lavender can have the unintended effect of lessening contraction strength and frequency.  However, often these reactions are not common enough to discourage them from being sold to unwary doulas, who see themselves as trying to help mothers.  If you haven’t had an adverse reaction yourself, it’s hard to imagine that someone else might.

Essential oils are drugs.  They are processed products that are used with the intention of altering what is already occurring.   They smell nice, have fun names, and are easily available.  You can buy them at parties!  But that does not mean they are benign.  Rather they are potent substances deserving of respect and care.  Many hospitals need to chart their use in labor.  For these reasons, using essential oils as an untrained doula should be avoided.  Some would say that is enough reason for doulas to always leave them alone.

One of the core tenets for almost any doula is that the mother should be free to make her own choices, and the doula’s role is to fully support her in those choices. Including essential oils and/or aromatherapy as part of one’s practice could certainly be one of those choices, if you know what you’re doing.  It just seems so simple to pair a scent with a relaxation exercise during pregnancy to condition the mother to relax when smelling the same scent in early or active labor.  However if you want to use this powerful tool, you need to take full responsibility for it.  To me that means going over all the risks of using essential oil therapy as well as the benefits, and having your client acknowledge that in writing.

The risks to the mother if the doula isn’t fully informed are great.  They are not “safe” and any web site that makes that claim is wrong.  According to one doula, you can be liable for prosecution if there is a negative consequence, depending on how your state’s legislation is written. She suggests that the way to protect yourself and your client is to pair with a certified aromatherapist and have them make the recommendations.  The doula follows through on what the mother wants to do based on the consultation.  The risks to our profession are even higher.  Doulas are in a tentative position in many communities, and a black mark against one doula causing harm to a mother can easily spread.  I don’t want to be alarmist, but our position is precarious in some communities.  I often think that newer doulas are not considering how their actions affect everyone else.  We live in a global world now. This means you have a responsibility to other doulas and our profession once you begin to use the title of “doula”.

These days there’s really no excuse for not getting educated by completing a high quality course and engaging in ongoing discussions with others who use oils dermally and as aromatherapy.  Birth Arts International offers a self paced course specifically for doulas. (If you know of others, please put them in the comments section.)  As with all things, if the course is being offered by someone who is also selling you a specific brand of products, sales may be their primary motivator.  You may not receive objective information or even the breadth of experience you’d like in an instructor about their use during pregnancy, labor, and postpartum.

Some certifying doula organizations prohibit the use of essential oils or aromatherapy, taking the stance that they are drugs. Others advocate that doulas interested in this therapy take formal education or certification so they can be used properly and follow an aromatherapy standard of practice.  Others have no opinion on the matter. [2] This confuses the average doula who just wants to help mothers.  The better we understand what the debate is really about – philosophically, educationally, and professionally, the better we can support each other to find our own right actions.

 

 

Note:  In the interest of full disclosure, I have used essential oils on several occasions, most notably on my dog when he was dying of untreatable cancer.  I would don gloves and a facial mask twice a day and apply the oils in several places on his body.  The veterinarian, oil consultant, and I are all convinced that their application made him more comfortable, stimulating his appetite, minimizing his discomfort, and lengthening his life.  Second, my body does not respond positively to essential oils. There are very few that do not irritate my skin or cause other unpleasant symptoms, including migraine headaches. However I have close friends and midwives who have been using them in their professional practices with people and animals for a long time.  All of them have taken educational courses to gain the knowledge to use them appropriately and safely. Because of these experiences, I have a healthy respect for the power of essential oils. 

 

*Thank you to Gena Kirby and Lesley Everest who introduced me to this phrase.

[1] http://www.agoraindex.org/Frag_Dem/eosafety.html

https://www.naha.org/explore-aromatherapy/safety/

[2] At my last count, there were 26 certifying organizations in the U.S. alone, so I’m not going into detail.  Feel free to put your group’s stance in the comments section.

 

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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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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.

 

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Posts In This Series:

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

2.   Balancing Dynamic Tension – Respecting All Doulas 

3.  Do We Want A Place At The Table?  National Certification and Public Health

4.  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.

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.  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?

 

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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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How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

One of the neglected areas of research on doulas is their impact on physicians. Studies have shown that physicians have mixed feelings about the presence of birth doulas with younger obstetricians of both genders having the least positive attitudes (1). Commenting on this study, Klein stated:

“Perhaps most concerning, the obstetricians in the younger group were less favorable to birth plans, less likely to acknowledge the importance of the woman’s role in her own birth experience, and more likely to view cesarean surgery as “just another way to have a baby”. (2)

Klein has also stated that there is diversity among the attitudes of both obstetricians and family physicians. At least 20% had attitudes similar to midwives and doulas regarding childbirth – especially experienced and older physicians. Even though our philosophies of birth may differ that does not mean that the presence of a doula is detrimental to physicians. In my estimation there are nine benefits that a professional doula can provide for physicians. In order of relevance, these include ensuring informed consent, observing detailed progression of labor; assisting the physician to know the patient; increasing patient satisfaction with the birth experience; fewer interventions; higher percentage of fees collected; informed refusal; early labor monitoring; and mitigating socially awkward situations.

1. Increasing informed consent. When the doula encourages patient discussion with her physician about an intervention, the doula is increasing the level of disclosure. Information about risks, benefits, and alternatives is given until the patient makes a decision. When this happens, patients are able to give explicit informed consent for the procedure, which benefits the physician. It is no secret that obstetrical care providers are one of the most likely to be sued for malpractice (3). Any time discussion of a procedure can be documented, it is positive for the physician. Informed consent strengthens the physician’s position in case of a lawsuit even if it cannot protect him or her from its occurrence.

However, this discussion does not always fit smoothly into the course of a labor. As Morton explains, the doula can drive an “interactional wedge” between the patient and the physician (4). This occurs when the physician is going to conduct a procedure where the mother had not explicitly given consent. As the doula has been trained to act and engaged by the mother to do, she informs the mother of the physician’s actions before they are completed. The physician’s activity is interrupted and must interact with the patient about the procedure. If the doula were not there, this interaction would likely have proceeded without interruption or discussion between the patient and physician.

In the moment the medical care provider (MCP) may not care for the doula or the interruption to what the MCP perceives as giving good care. It is possible the MCP perceives that there is no need for discussion or consent because it has already been given when signing the “consent for vaginal delivery” form. But there can be a difference between what a physician perceives as informed consent and what a patient perceives as informed consent. When the doula knows the patient’s concerns, she or he is able to facilitate communication around those areas where the patient wants more information and more involvement in decision making. However, this interaction can be awkward and resented by the physicians – even though it is ultimately to their benefit.

2. Getting to know the patient as an individual: The majority of the time in a busy hospital the attending physician has never met the mother. Even if a recent pregnancy appointment occurred, it is quite likely that the physician has seen dozens of women since this mother’s last visit. When a doula is present, the medical care providers are urged to individualize their care for this patient. Doulas do this in subtle ways: we encourage mothers and their partners to say what they want to their nurse, to remind the doctor of their priorities, and to write a brief birth plan for their hospital record. Our very presence is a huge reminder that these parents have thought about their birth and have taken action to see that their needs are met. Evidence suggests that both patients and physicians may be unprepared for these conversations or be uncertain how to proceed (1). In these instances the presence of a doula may be valuable to both.

When providers know the mother, they are able to shift their care in a way that is aligning with this patient’s priorities – while still acting in their comfort zone. The doula is also able to explain the physician’s concerns in language familiar to the laboring mother. Without the doula, the physician has a harder time satisfying the needs of the patient and ensuring that their experience is a positive one. Once again, this depends on the physician’s style. Doctors who like to treat all patients similarly may be irritated by requests to individualize care. MCP’s who place a high priority on connecting with their patients will recognize how much easier that is when a doula is present.

3. Increasing patient satisfaction. Three of the most important factors influencing patient satisfaction during labor are the quality of the caregiver-patient relationship, involvement in decision making, and amount of support from caregivers (5). These factors are more influential than age, socioeconomic status, ethnicity, childbirth preparation, physical birth environment, pain, immobility, medical interventions, and continuity of care. Patients who feel higher levels of satisfaction are less likely to sue (6). Several studies show that continuous support by a trained doula helps to increase overall satisfaction with the birth experience (7). When the doula increases communication with the physician, assists with informed consent for interventions, and provides effective labor support, mother’s satisfaction with the birth is increased. The intervention of the doula may carryover into increased satisfaction with the physician and possibly fewer lawsuits.

4. Observing progression of labor. Undoubtedly, physicians and nurses see more labors and births than a professional doula. However, observation of those labors is intermittent. Doulas have the opportunity to be with women for the entire labor. We see the progression of labor more clearly and are attuned to subtle changes in the woman’s behavior and contraction pattern. When a physician asks the doula about the mother’s labor, the doula is able to report detailed changes. With my observations and the physician’s expertise, it is then possible to forecast more accurately. MCP’s need to make decisions about doing a cesarean on another patient, going to the clinic, or seeing their child’s recital. Physicians often do not realize that the doula is a source of information about the patient that is beneficial to their decision making.

5. Lower intervention rates and healthier outcomes: The recent Cochrane Collaboration review of over 15,000 mothers in 22 studies confirmed that mothers with a trained doula are less likely to have certain interventions (7). Thus, the complications that may occur as a result of their use do not happen. Of course, the practice style of the physician and hospital policies are influential factors that have more impact than the doula’s presence (7). However, the fewer interventions that are used, the healthier the outcomes are for both mother and child.

6. Increased profit with a standard reimbursement rate: Mothers who have doulas are less likely to use pharmacological methods of pain relief and receive fewer interventions (6). When the physician receives a preset reimbursement rate for a delivery, there may be more profit when fewer interventions are used (8,9). The same is true for hospitals that are billed and reimbursed separately from physician fees. This is only a benefit when charges are not itemized or reimbursement is an underpayment of the actual cost.

7. Informed refusal. When patients are uncooperative, the doula can be blamed for their behavior. However, it is more likely that mothers and fathers with defensive attitudes hire doulas (10). Doulas are just not influential enough to change lifelong preferences about physicians or hospitals. (This also assumes that doulas are against hospital birth – which is not true.) Those patterns of behavior and beliefs are set long before doula services have begun. The professional doula’s role is to support the mother in her decisions even if it is not what the physician or midwife would want. Because the doula is not encouraging the patient to be compliant, the doula can be seen as part of the problem.

Informed refusal is a part of informed consent and the right of every patient. However, it can appear that the patient is personally distrustful of the physician or that their actions show a lack of care for their child. Misunderstandings often occur because this is an emotionally charged event for both patient and doctor. Sometimes the doula is highly skilled at negotiating the communication so that both parties understand one another even though they disagree. No matter when it occurs, informed refusal is a risk for both doctor and patient. The doctor is being asked to practice in a way that is less than preferred and the patient may experience a drop in the physician’s good feelings towards her. The benefit for the physician to having a doula present is to facilitate communication and to realize there is a person close to the patient who can understand the physician’s legitimate concerns.

8. Early labor monitoring. When the professional doula is at home with the laboring mother, she is able to provide reassurance. Mothers may choose to stay at home until active labor is established rather than arriving too early by hospital standards.  With the new recognition of active labor commencing at 6 centimeters, early labor monitoring becomes even more important.  Because of her level of skill the professional doula is also capable of recognizing overt signs of an impending delivery or emergency that family members may miss. The doula can recommend calling the triage center for advice or emergency services when imminent help is required. The doula’s skilled observation provides an additional level of safety for the patient that may benefit the physician.

9. Mitigate socially awkward situations: Physicians are often required to get to know several patients in rapid succession. Labor often includes meeting and interacting with extended family. Not all patients or providers are socially skilled and not all situations are easy for people to get along. While the doula, nurse, midwife and physician are all professionals, influences of family structure, language, culture, exhaustion, and personality converge to create a number of challenging and awkward social situations. When the doula knows the family and the mother’s desires, she can head off or smooth over interpersonal problems for the physician. Simply introducing everyone properly may defuse tension.

Relationships between doulas and physicians can be tricky. The doula’s presence indicates a desire on the part of the patient to be involved in decision making and to receive individualized care. The doula is the only professional on the birth team who is not beholden to the physician or the hospital, but to the patient. However, this part of the doula’s role – to increase communication, understanding, and respect between physician and patient is a benefit to the doctor. Doulas increase patient satisfaction rates in a multitude of ways, which is also a benefit to physicians. When doctors understand how professional doulas benefit them and utilize their expertise, they can make the birth less stressful for all concerned.

NOTE:  Originally I wrote this post as an opinion piece for a journal.  But the feedback I got was that it was more opinion than research so it was more suited to a blog.  It’s 1400 words, which is too long for a blog post but I didn’t want to omit anything I felt was relevant.   With the release of ACOG’s statement last week, I thought it was a good time to publish this essay. 

1.  Klein, M.C., Liston, R., Fraser, W.D., Baradaran, N., Hearps, S. J., Tonkinson, J., Kaczorowsky, J., Brant, R. Attitudes of the New Generation of Canadian Obstetricians: How do they differ from their predecessors? Birth 2011;38:129-139.

2.  Klein, M.C. Many women and providers are unprepared for an evidence- based, educated conversation about birth. J Perinat Edu 2011; 20:185-187.

3.  Jena, A.B., Seabury, S., Lakdawalla, D., Chandra, A. Malpractice Risk According to Physician Specialty New Engl J Med 2011; 629-636

4. Morton, C., Clift, E. Birth Ambassadors, Praeclarus Press 2014; 4:210

5.  Hodnett, E.D. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160-72

6.  Stelfox, H.T., Gandhi, T.K., Orav, E.J., Gustafson M.L. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med, 2005; 118:126-133.

7. Hodnett, E.D., Gates, S., Hofmeyr, G.J. & Sakala, C. Continuous support for women during childbirth. Cochrane Database of Syst Rev 2013

8. Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E. An economic model of the benefits of professional doula labor support in Wisconsin births. WMJ 2013;112:58-64.

9.  Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health 2013; 103:e1-9

10. Gilliland, A.L. Nurses, doulas, and childbirth educators: Working together for common goals. J Perinat Edu 1998;7:18-24.

11.  Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

For a downloadble pdf copy of this post, click here:  How Professional Birth Doulas Benefit Doctors

 

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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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The Brouhaha Over Certification

Oct 19, 2013 by

One of the purposes of this blog is to offer an analysis of current issues of importance to the doula profession.  One of the issues that have lingered over the years is certification.  It used to be viewed fairly simply: certification was an individual decision.  While that is still true, it seems that along with our profession the issues of certification have grown in depth and complexity. Certification dilemmas exist on system, organization, and personal levels.

What set me on the path of examining certification was another post about what it means to be a professional.  Putting on my researcher’s hat, I set out to gather data relevant to certification issues. Data collection consisted of the following methods:  1.  In eight different doula groups on Facebook, I searched for the keyword “certification” in past conversations going back about 9-12 months.  2.  I wrote to several people who identified themselves on FB as having “private” opinions, asking them to elaborate on their thoughts on certification.  3.  I read blog entries doulas had written on certification.  All responses I read were from women.  I stopped when I reached “saturation”, meaning that I stopped hearing anything new.  So I can’t tell you how many people have a particular opinion, but I can tell you that opinion exists.  From my examination I’ve been able to isolate several key questions or issues.

System level questions:

  1. What is the meaning of certification?  What does it mean to certain stakeholders?  Does it have value to these different stakeholders?  Why or why not?  Stakeholders are identified as an individual doula, doulas as a group, certified doulas, third party payers, clients (mothers), client’s family members, physicians, midwives, nurses, and hospital administrators.
  2. What is the process of certification?  Does it provide value for the doula seeking it?  Does it provide value for the organization that is granting it?  Are there built in mechanisms that soothe feelings of frustration and increase feelings of accomplishment throughout the process?
  3. What is the purpose and value of recertification?  Why do some organizations grant certification in perpetuity, and not recertification?  What are the assumptions underlying the necessity of recertification? What are the assumptions made by organizations that do not see recertification as necessary?
  4. What levels of certification are there?  Does it still have meaning if some groups offer certification to a person completing a correspondence course when there are no standards of behavior to observe or maintain by being certified?  When it is left to what each individual thinks is right to her own conscience, is that valuable?  How does that affect the profession as a whole? (See question 1.)

Organization level questions:

  1. As the system is currently set up, certification is linked to an individual organization.  When women choose a training, they are connected to that organization.  However the organization has values and support products that are separate from their certification process.  Are trainers communicating the values of the organization before people spend money on the training?  How significant is this conflict in a person’s certification decision?
  2. There are now at least 16 organizations in the United States and Canada offering birth/labor doula trainings (that I am aware of).  Many have different standards for certification or offer a certificate of completion that is stated as certification.  Does it have any meaning when there are so many different standards?
  3. Is there any value to separating certification from the multiple organizations offering doula training, education and mentoring?  Is there any advantage for some stakeholders if certification is achieved through an independent organization?
  4. Is each organization’s certification process following best practices for experiential and independent learning?  Are there built in mechanisms that soothe feelings of frustration and increase feelings of accomplishment throughout the process?

Personal level questions:

  1. Many doulas think certification isn’t important because potential clients don’t weigh certification heavily in their selection of a doula.  Because certification isn’t bringing them business it is not seen as necessary.  Do clients perceive certification as a benefit at a later time in their relationship to their doula?  Would a non-certified doula be privy to this realization on their client’s part?
  2. What other advantages does certification have?  Doulas responded with these answers:  1. For your peers – when you know they are certified, you know what to expect.  2. A third party payer will only reimburse if you’re certified; 3. When the patient sues all the lawyers breathe more easily; 4. It is a plus when you want to get a job, put it on a resume or curriculum vita or school application.
  3. There is another theme reflecting a doula’s personality traits (“I see myself as a rebel”) or issues around control (“I don’t like anyone telling me what I can or can’t do with a client to meet their needs.”)
  4. One of the themes is that certification is seen as being restrictive and not allowing the doula to follow her own conscience about what behavior is appropriate.  My thoughts:  What behaviors does a doula want to enact that are outside those standards?  Would other doulas agree as a group that they want someone calling herself a “doula” to behave in that way?
  5. Can people’s individual conscience be enough?  (Comment:  Any other profession says “no”, which is why there are professional standards that are protective of the client and the industry.)

Pondering those questions led me to these questions

  1. Is disregarding certification as important related to the idea that carework does not have value and thus professional standards are irrelevant?  A human being can possess both of these conflicting attitudes, such as “our work has value” and “I don’t want my behavior to be regulated”.  What are the implications of those attitudes for that individual and for other stakeholders?
  2. Does not having uniform behavioral standards and a goal of certification for all doulas make certain stakeholders take us less seriously and lessen our perceived value?  Many doulas stated that certification had little personal value because most clients considered it irrelevant.  However, the implications of this attitude may be limited in focus – not seeing beyond one’s self to see how this decision may affect others and the profession.

In essence, the issue that is identified as “certification” has multiple levels and symbolic meanings for different people.  When certification is discussed on social media, not everyone is talking about the same thing.  The number of factors to consider in her decision often overwhelms the original person posing a question about certification on Facebook.

Within each of these questions are a number of responses and possibilities.  To me, the fact that we have the opportunity to take in this information and be reflective about it is significant.  It allows us to make choices about how we want our profession to proceed.  My goal is to explore these issues in more depth in future posts.

If you have a comment about any of these questions, or feel there is an additional issue I have not listed, please email me at amylgilliland@charter.net

Gilliland, A. (2009) “From Novice To Expert: A Series of Five Articles”, International Doula, publication of DONA International (feature articles) Autumn 2007-Winter 2008; reprinted as e-book, June 2009; currently available here

 

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