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

Sep 16, 2017 by

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

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

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

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

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

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

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

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

 

Facts About Me That People Find Interesting:

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

Apr 3, 2017 by

AmyConf1993

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

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

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

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

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

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

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

What is your community’s story of change?

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

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

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

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

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

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

 

Resources:

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

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

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Career Minded Participants in Birth Doula Trainings

Dec 29, 2016 by

 

career-minded-doula-training-participantsIts natural to assume everyone in your birth doula training was there to become a doula. Not so! Only about half the people are there because they want to do labor support as birth doulas. What else can my research can tell us about career minded attendees? In my Journal of Perinatal Education article, “What Motivates People To Take Doula Trainings?” (Summer 2016, Vol 25, No. 3, p. 174-183), “become a professional birth doula with my own practice” ranked as the fourth most popular answer out of eighteen possibilities. In the question where people were forced to choose only their favorite five reasons, 60% included “birth doula” but only 30% chose it as their number one reason.

Hospital Based Doulas: What about “working for a hospital program”? Only 4% chose it as their top reason, but 20% selected it as one of their top five. Some participants expected to work both independently and for a hospital, as 24% chose both options. Hmmm…there are only a handful of hospital programs that employ doulas or pay them as independent contractors in North America. So this percentage made me wonder if some trainings in my sample were being conducted specifically for a hospital based program. However, these responses were not associated with a specific training, location or doula trainer.

Midwifery and Nursing Students: Another significant presence in trainings was participants desiring to become midwives. “Want to become a midwife (or am considering it)” was the number one reason for 20%, and a top five reason for 43% of participants. For the most part, the midwifery and doula bound groups had little overlap. Only about a third of people who put “birth doula” in the top five also chose “midwife”. Midwifery bound attendees are different in other ways too. They tended to be younger, not have children, and only about half had attended a birth (not their own). Interest in midwifery was confined mostly to women in their twenties. It dropped off almost entirely in the 30-39 year olds, with resurgence in the 40-49 year old group (who had all had children and attended a birth). Another contributing factor may be that 64% of all nursing students (n=42) chose “midwifery” as one of their top five reasons, and nursing students in the study tended to be younger and childless. In my experience, midwifery students have always attended doula trainings. But only in the last eight years are many midwifery schools requiring that students take a doula training before being accepted. In this way, the training serves as a screening and preparation tool to ascertain whether people understand the importance of support skills.

Nursing Students made up 9% (n=42) of total attendees and were more likely to attend to increase their birth knowledge (72%) and to explore midwifery (71%), as indicated in their top five choices. I found it very interesting that one quarter wanted to be in an atmosphere that “believed in women’s bodies and ability to birth naturally”. For the most part they were not interested in a doula career (only 7%) but many intended to volunteer their labor support services (36% of nursing students).

In comparison, “birth doula” bound attendees usually have birthed or adopted children, tend to be more evenly distributed across the age spectrum, with about the same number in their twenties and thirties. Participants in this study adopted children at twice the average rate in the United States (12% versus 6%). I don’t know what that signifies, but it’s worth mentioning! Slightly more than half have attended at least one birth (not their own) already.

Volunteering As A Doula: Birth doulas also displayed other altruistic motivations. Ten percent chose “volunteering as a doula on my own or as part of a program” as their number one (2.5%) or number two (7.5%) reason. A closer look revealed that 23% of all people in the study chose these three reasons as part of their top five: “professional birth doula with my own practice”, “volunteer as a doula”, and “make money in a profession I enjoy”. They felt that all of these things were possible as part of their doula career. In an open-ended question, participants said they intend to volunteer for specific programs for low income women, to go to foreign countries to serve, or for their own parish or mission work. Its also possible that they felt that volunteering was part of the path to gaining experience, had a lack of knowledge of how this could affect doula businesses, or thought this was an easy way to get started. Recall, these are neophytes to the doula world – these questions were asked before they had ever taken their training or likely joined a doula group on Facebook. They probably were unaware of the divisions over the “no free births” paradigm.

Making Money: What about “making money in a profession I enjoy”? Data was collected in late 2010 and again in 2013. While the two samples did not have any statistically significant differences with one another, the birth doula world itself was going through a large shift. In the early days of doula work, the idea of “making money” almost seemed exploitative, like it was breaking some kind of code of honor. How could you benefit from someone else’s labor and birth experience? It wasn’t unusual to think of doulaing as “a hobby that pays for itself”.

The next step in our professional evolution was a push to make birth doula work viable economically. It required a shift in how doula services were perceived by parents, perinatal professionals, as well as doulas themselves. I consider this period of time, from 2010 to 2015 to be a time of commodification[i] [ii] in the birth doula profession, most notably from the influence of ProDoula and their beliefs and paradigm. This shift in business professionalism has made “making money in a profession I enjoy” much more likely today. My point is that this was an emerging idea at the time of the first sample, and was much more established three years later at the time of the second sample. However there was no difference in the two time periods. Why?

First, these are not members of doula communities, but outsiders. It was fairly rare at the time to join a large doula group on Facebook before taking a training. Today, (by my own observation as a doula trainer) that is often the first place an interested person will visit. Two, commodification and the presence of doulas in the labor room are now assumed to be normal by non-doulas. Three, only DONA International trainings were sampled (2 countries; 19 states, 3 provinces; 38 trainers; 46 trainings; 467 participants; 85% response rate).  So these research findings likely only apply to trainings that also have an open focus (see “Take A Doula Training, Change The World” for more information on generalizability).

Now that I am a Research Fellow at the Center for Child and Family Well Being at the University of Wisconsin Madison, I am looking forward to interviewing a younger cohort and comparing the First Wave and Second Wave of birth doulas in future studies.

Perinatal Professionals: How about the childbirth educators? Only 14 out of 467 people identified as childbirth educators (CBE), but 63 people said they were taking the training “to enrich their childbirth education practice” as one of their top five reasons. Two things come to mind. First, people may consider the doula workshop to be part of the preparation to become an educator. Second, rather than focusing on becoming a CBE who teaches classes, their intention was to informally educate people about birth.

Ten participants were postpartum doulas and all of them wanted to become birth doulas. None were using the course to enrich their postpartum doula practice. But 14 people who were not PP doulas were taking it to enrich their future practice as postpartum doulas.

Nurses: Labor and delivery nurses made up 2% (n=10) of the sample, but nurses with no perinatal experience made up 4% (n=19) of the sample. Almost all of this latter group felt the workshop would make them more desirable candidates for labor and delivery positions, as indicated by choosing “add to my resume”. Seven chose “want to become a midwife” as their number one answer. A smaller number wanted to become birth doulas. Why weren’t there more nurses? As a doula trainer for twenty years, I can say that in the first seven years we had many OB nurses in trainings. But now nurses have other options to learn labor support skills at nursing conferences or workshops and earn CE credits. I also teach these workshops.

Non-birth professionals: Almost one fifth of participants (19%) taking trainings had no intention of becoming doulas, midwives, or labor and delivery nurses, as indicated by their top five reasons. Five percent chose “help women have better births not as a doula or birth professional” as their number one reason. Many had incidental contact with pregnant people and wanted to enrich their knowledge and support skills. They also wanted to be more informed listeners. In the open ended question, several listed their related occupation as social workers, home visitors, case managers, day care providers, or yoga instructors. This is a really important group. As I mentioned in my previous blog post [LINK], these are the outer rings of people who can pass along birth knowledge and listen attentively to birth stories. They extend our sphere of influence outward and change the conversations about childbirth to more meaningful ones, simply because they understand that support matters.

So far we’ve covered people who are in a training to advance their career aspirations, and those who want to increase their knowledge about birth and be inspired for change. In my next post I will cover a third group, who have a small but powerful influence over how a workshop actually unfolds. These are the people who are coming for healing from past births.

 

[i] Commodification is the transformation of goods, services, ideas, people, or other entities that were not previously considered goods for sale into a marketable and saleable item. It implies some standardization.

[ii] An interesting article on the commodification of women’s household labor, which has bearing on the internal and external struggles for legitimacy of the First Wave of Doulas (late 1980’s to mid 2000’s): http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1126&context=yjlf

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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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Doulaing For Friend’s Births

Feb 25, 2016 by

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

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

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

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

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

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

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

So what’s a doula to do?

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

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

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

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Are There Enough Clients For All Of Us?

Feb 6, 2016 by

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

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

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

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

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

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

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

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

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

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

What about not having enough time?

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

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

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

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

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

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

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Fewer Blogs but More Amy

Dec 30, 2015 by

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

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

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

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

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

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

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

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

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

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

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

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

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

2016 promises more content and more projects!

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

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Busting The Myth of Privacy in Hospital Birth

Sep 18, 2015 by

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

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

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

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

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

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

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

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

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

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

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

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

 

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Showing Up

Aug 20, 2015 by

The Road Goes On Forever, And The Party Never EndsOne of the doula research interviews that influenced me profoundly happened at a 2004 conference.  That morning a birth colleague, Sophie*, came striding in to my hotel room with coffee and her breakfast on a plate.  We’d met in 1988 at a retreat for birth professionals.

“I didn’t think you‘d mind if I ate while we talked,” she said as her plate clunked down on the glass table.  When I transcribed the interview later, I could hear her chewing and cutting her lox and bagel with a knife and fork on the recording.  It was so like Sophie to assume my loving acceptance of her quirks; just like she would about mine.

I turned on the recorder.  With her first story, Sophie said, “Amy, the most important thing you do isn’t a double hip squeeze. It’s not whether she gets drugs.  It’s showing up. Showing up is 50% of what we do as doulas.”

As the interview progressed, she told more stories and reflected on what she’d learned.  Sophie said, “I change that!  Showing up is 75 % of what we do as doulas!”

By the end of the two hour interview, she changed her mind again.

“It’s 99% of what we do as doulas!  The rest is just fluff.  Showing up for her, that is what counts.”

Showing up is an approach of non-judgment and a series of continuing actions over time that support the mother wholeheartedly even when others are unable to accept or support the mother’s needs (Gilliland, 2004).

In my research, doulas who had been to a hundred or more births usually told stories about this deep level of acceptance, or what Sophie called “showing up”, being the most important and most significant service that the doula can offer.  Many proficient and expert doulas mentioned the need to accept mothers whatever they are feeling or doing, and to believe them when they say they want something, even if it is different from their stated wishes prior to labor.  Here’s the excerpt from my original interview with Sophie:

“In my life there is always compromise, always negotiation, always other people in mind.  I have to take everybody else into consideration.  So I think when someone shows up for me one hundred percent, supports me one hundred percent, hears everything I have to say and amplifies it, that’s what I mean by showing up.  That to me is the greatest gift.  That’s it.  I think that’s 99%.  I’m going up to ninety-nine. [laughs heartily] I think that’s huge. I really do. Because I think very few women get to have that.”

Women have to compromise for everyone in their life.  They have to compromise for their partners, for their kids, for their pets, for their parents, bosses, and on and on.  Women shouldn’t have to compromise for their doula at their own birth!  Instead our role is to be present and mindful in the moment, and do that for hours and hours. answering her needs so she is free to labor.  What she says she wants, even if it’s surprising, isn’t there to be challenged.  Explored and confirmed, yes, not challenged.  Additionally, when women feel that whatever they do or say or behave will be acceptable to their doula, they will feel free to enter fully into their experience of birthing their baby.

What does that look like?  Let’s say I’m at a birth, with a mom who had previously been adamant about not using pain medication.  She looks at me and for whatever reason, says, “I think I want an epidural.”  The doula’s “showing up” thought process prompts me to consider the mom and ask, “What can I do to best support her in this moment?”  The attitude of the doula has to be one of caring detachment.  If we get caught up in our clients doing things a certain way or having certain things happen, the experience becomes about us and not about them.  Effective doulas need to find a way to be caring and loving of the woman and her intimate family, without being attached to what she does, how she makes decisions, or what choices she makes.  It’s essential for our own mental health, but also for our effectiveness as labor support.

What do I say to that mom?  “Would you like to talk about it more or try something first, or do you want me to get the nurse?”  If she says to get the nurse, then that’s it.  I’m there to support the woman in labor, not her birth plan.

But the reality for us is that we WANT things for our clients, we WANT them to have great births, we DO get attached.  What helps me is understanding that the birth is her journey; she is the leader, she tells me the route.  If I think she’s making a “wrong” turn, that is me comparing her journey with some idealized one I have in my head.   I know birth influences the course of women’s lives forevermore.  So who am I to judge what’s best?  I don’t know her path.  When I can say that inside of me and really own it, I am much freer to support a wide variety of women making a wide variety of choices, and to truly show up for them.

 

*her name has been changed                “Just Show Up” image courtesy of Edward Tufte.  http://www.edwardtufte.com

 

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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).

 

Did I miss something?  Want to comment?  Please do!  

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Want To Change Birth Tomorrow?

Mar 16, 2015 by

TeenPhotoTalk to the teens in your life today.  From what I can see, the decision about where to give birth and how to cope with labor is made long before conception.  Unlike previous generations, teens today are exposed to media misrepresentations of labor and birth on multiple television shows (Elson, 2009).  Based on a recent literature search (Toohill, 2014), it seems that more young women and men today are afraid of birth than at any previous time.  While the issue is multifaceted (Laursen, 2008; Saisto, 2001) the simultaneous rise in birth “reality” shows and studies of birth fear doesn’t feel coincidental.

Developmentally, girls aged 12-14 begin to ponder their adult future and consider what it means to get pregnant and give birth.  So naturally they turn to TV and to Youtube.  While many home videos are intended to show the raw power and coping potential of women, to an unknowing teen they can be downright scary.  Even videos posted to humor (Two Men Watch  Childbirth For The First Time] – can validate the fears that young people of all genders may have.

As birth professionals, we know the truth.  Given the right circumstances, labor can be coped with.  For the most part, labor is boring, with not much happening for hours at a time.  So TV producers create drama with music, narration, and selective editing.  Women’s bodies know how to create and grow a human being and get them out.  The more we interfere with that process, and that includes TV cameras and lights, the harder it can be on the mom.  Like any major undertaking, including moving house or completing a science project, labor and birth requires planning and support to do in a satisfying way.

Teens need our messages about the real nature of birth and manufactured depictions they see on TV and some uploaded videos.  They need to be engaged with, not talked at.  Even twelve year olds have critical thinking skills and despise being treated as if they are only passive consumers.

So how do you have a conversation with a teen about birth?  Make sure you are having a discussion, not a lecture.  Listen to their answers, and build upon what they share with you.  If possible, let them lead the discussion.  If teens are shy or used to being talked at, your conversation starters may be met with silence.  Use your doula skills to observe their “nonverbal leakage”; people don’t always need words to communicate!

You can start a conversation by responding to a family walking by with a baby, seeing a pregnant woman in a magazine, or even without any reason to at all.  Let your passion give you courage, and proceed from there.  “Hey, you know I’m a doula, right?  Do you know what I do?  Do you know why I do it?”

Another approach is to build on teachable moments.  “Remember that birth scene in ——-?  Did that seem realistic to you?” Build on what was valid in their comment or the scene, but don’t bash if their answer is “yes”.  Say, “I’m concerned when people see that, they’ll think that’s what labor is really like.  Because it scares people/makes birth seem dangerous/makes it seem like its painful for hours without ending.  That’s not the way that I experience it.”  Be REAL – so many people tell teens what they ought to think or do, rather than realizing they are thinking human beings making important life altering decisions almost every day.

Make sure to emphasize that both men and women need support in birth.  This is absolutely critical.  We place a disproportionate burden on men to do labor support and deny their own feelings and the developmental processes of fatherhood.  This is in the process of changing, but only if we continue to hammer home the message that men matter too.

Offer to speak to Girl Scouts (Cadettes, Seniors, and Ambassadors may have health badges), Boys and Girls Clubs, and church teen meetings.  Using the first fifteen minutes of Vicki Elson’s video, Laboring Under An Illusion, can be a great conversation starter.  It’s engaging, to the point, and it will make them laugh.  People remember more when they laugh and that helps to break the ice with groups of adolescents.

Keep your message basic, simple, and repetitive.  Labor and birth aren’t scary.  Ninety-five percent of births are normal and nothing bad happens.  Some people see birth as so safe and normal, they give birth at home and in birth centers.  Pregnancy and birth are wellness conditions, not illnesses.  Given enough support, women’s bodies function well and coping with labor is possible without resorting to medications and interventions.

Young adults will often do what feels right to them and that depends on what perspectives they’ve been exposed to previously.  If we want more informed consumers, we need to start at the most impressionable time: in adolescence when they first see themselves as potential mothers and fathers.

Like what you read?  Please subscribe!  The box is below on your right. Thanks!

Elson, Vicki (2009) Laboring Under An Illusion. DVD, BirthMedia.com 

Laursen, M., Hedegaard, M., Johansen, C. (2008) Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort, BJOG, 115 (3), 354-360

Saisto TSalmela-Aro KNurmi JEHalmesmaki E. (2001) Psychosocial characteristics of women and their partners fearing vaginal childbirthBJOG 108:4928.

Toohill, J., Fenwick, J., Creedy, D., (2014) Prevalence of childbirth fear in an Australian sample of pregnant women. BMC Pregnancy Childbirth. 2014 Aug 14:14:275

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Doulaing At Midlife

Oct 2, 2014 by

flowersmall“When my 60 year old mother insisted she was middle aged and I wasn’t, I replied, “Mom, how many 120 year old women do you know?”    -paraphrased from Postcards From The Edge by Carrie Fisher

I went to my first birth when I was 20 and my first birth as a professional at 24.  Most of my clients were older than I was, some by more than a decade.  As I aged it seemed that my clientele youthed.  At first I was their hip, knowledgeable young friend.  Then a sister, then a companion, and now their mother.  My experience is respected and my perspective has changed.  Overall, I am more patient and more understanding of the stresses on medical care providers.  Obstetrical trends have come and gone and returned again.

Doulaing at midlife is precious and different than at any other age.  Among my research participants and friends there seem to be a few common markers.  Rather than seeing ourselves giving birth, we see our children or nieces and nephews reflected in our clients.  This shift in perspective is subtle but one day you realize it’s not your generation in the bed anymore.

For those of us in female bodies, once menopause is assured, the passing of our fertility comes home to us neon loud at a birth.  There was a time when each of us decided that our family was complete and that we would have no (or no more) babies.  But there’s a difference between the inner feeling of “I’m not going to do that (again)” and “I will never in my lifetime be able to have that experience (again)”.  It is a bittersweet moment, like losing an appendage you didn’t know you had.   The surprise is almost as challenging as the grief – haven’t we traversed that terrain already?

It’s a moment unique to perinatal professionals, but more poignant to doulas.  We’ve got nothing to distract us when we’re at the bedside.  We’re there to feel, to relate, to be sensitive to everyone else’s needs.  So the surge of grief, of personal realization may catch us by surprise.  This moment may be harder if our menopause arrived early or was the result of a medical condition.  If we have lived in service of women’s reproductive bodies, why didn’t our own work perfectly?

Another common experience is acknowledging our physical limitations.  Our bodies are not quite as cooperative adopting odd labor positions.  We don’t recover as quickly from a long birth.  Some of us develop health issues that have to be accommodated.  This means our practices have to change, taking on partners and mentee doulas to help share the load.  But first we have to sit with the emotions that come with those realizations.  We are aging in a culture that spotlights only the drawbacks of growing older.

We have a huge store of knowledge to draw upon – having seen generations of children come into the world.  We’ve seen doctors come and go, inductions rates plummet and surge, and believe in the power of VBACing women.  The third marker is recognizing our own value.  If our majority culture does not see our wisdom, we must see it in each other and in ourselves.  The doctors, nurses, and midwives may be much younger and eager to dismiss us.  We have perspective and history – the lines on our face garner respect if we know how to use them.  This challenge is in acknowledging what we know – and what we don’t. While young women are the future of birth culture, we have already learned many lessons the hard way and can spare them much pain.

With our clients we know that this time is unique and scary and full of growth.  We can say, “Yes, its not what you expected.  But you know, it never really is.”  From a midlife maternal perspective, many firsts have come and gone: first baby, first child in kindergarten, first night your child doesn’t call, and the first one leaving home.  It never really feels how we expect it to – the fulfillment or the angst.  We can join our kin doulas without children in appreciating our clients as pseudo-daughters, dispersing wisdom and reassurance while not replacing their own mothers.

This is also a time of introspection and reorganization.  If they haven’t already, many doulas at this life stage become leaders in their communities.  They may move to parallel careers that are less demanding.  We need growth but we also need rest.  Rest does not mean stagnation.  Indeed periods of rest and introspection are often followed by frenzied creativity.  We give birth to books, to workshops, to programs, to businesses, and to new doulas.

So midlife doula kin, there are similar signposts on our individual journeys.  Look in the mirror and see your value.  I do.

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When A Past Client Dies

Jun 20, 2014 by

In my 30 years of doulaing, I have faced the death of a past client a half dozen times. Doulaing is intimate work and caring for mothers and partners creates a unique bond between us.  Each of the situations I faced was different but each time I started out feeling sad, uncertain and confused. I took the time to figure out the right course of action, one that I could feel good about long term. My hope is to guide you to the same peace.

This is not a time for immediate action. So if you find out on Facebook, you don’t need to type something right away. Think of anything online as permanent – even ten to sixty minutes of careful thought can modulate what you might write. Instead start with some important questions.

  1. Does this require an immediate response from me or do I have a few days? Unless the death occurs in the first few months after the birth, you have some time to figure out the right thing for you to do.
  2. What do I feel? Spend some time writing in a journal or talking with yourself or a close friend. It is normal to have many different and conflicting feelings such as shock, sadness, anger, ambiguity, dread, relief, fear, and so forth. It may bring on your own fears of death or vulnerability. We may not feel very close or identified with this family and feel badly that our own emotional response isn’t stronger. All of this is normal. The important thing is to figure it out before acting.
  1. What do I want to do? You could do nothing, write a note, send a card, go to the service, do a favor, make a meal, provide photos or a display, send flowers, or make a donation. What you decide to do will depend on the depth of your feelings, how recently your relationship ended, your own responsibilities and budget, and how close they live. Carefully consider what you need and what the family might need. If you’ve sorted through your feelings it will be easier to figure out what is supportive of the family. So often people’s actions at this time have more to do with what they need than what is best for the bereaved family!  It can be avoided by taking time to evaluate your own feelings and possible actions first.
  1. If you need some assistance in writing a condolence note, here are some suggestions. Include your feelings of sadness or sorrow, a quality or two that you admired and a personal anecdote about the person who died. The family members may treasure special memories of prenatal appointments or something that was said or done during the birth. Taking the time to write these details shows that you care. Make sure to mention your relationship as the doula; the person who is opening and cataloguing correspondence for the family may not know who you are. Sometimes the remaining parent may not read notes for months after the death. But it is nice to know who wrote. A note is more personal than a sympathy card and it can be challenging to find a prewritten card that expresses your feelings and matches their point of view. It gets even more problematic if you don’t know the circumstances of the death or their religious faith. Nice stationary or a blank card can work just fine. If they have moved, you can send the note to the funeral home.
  1. Posting on social media: Why? Carefully consider what your motivation is. Is this sensational news that will get attention? Do you need support? Make sure that whatever you write is something you would want to read if you were the bereaved parent. This is a time to put your best doula self forward. I wouldn’t recommend: “One of my old clients just died! Isn’t this the weirdest thing ever?” Instead try, “One of my past clients from a few years ago just passed away. I’m feeling bewildered and sad. Anyone have any suggestions or support?”

Here are some of my experiences and how I chose to respond:

Toby* was killed by random gun violence seven years after the birth of his third child. I wrote his wife and children a letter describing my most vivid and loving memories of our visits and the birth.  Nick* died of a drug overdose after a messy divorce and custody battle (5 years after being their doula). I kept quiet after hearing of his death because I really did not know how his ex-wife was dealing with it all. We hadn’t had any contact after the first birthday. Writing her felt like an intrusion into her personal business.  Karl* was a very loving father who passed away unexpectedly during a short hospitalization 16 months after their fifth child’s birth. I had kept in touch on Facebook. For this family, I made a montage of birth photos into a poster and had it sent (prepaid) to a Walgreen’s in their hometown. It was a treasured display at the memorial service.  When Lenora* died in a car crash four years after her last birth, I went to her service. Her husband recognized me but couldn’t place me – even though we had spent 20 hours together. That’s the nature of grief. But my presence let him know that she had affected my life enough for me to attend. I signed the guest book as their doula.

In my research interviews, one doula told me this story. “I had this great couple, they were a joy to work with. He came to every prenatal appointment full of questions and they wanted to work together at their birth. Very loving couple, so excited for their first baby. He was a family practice doctor, so he was learning not only for himself but for his future patients. I had a blast at their birth it was all so easy. He was in love with his baby girl. About four months later he died in a car crash. Right away, it was a huge fireball, horrible thing, just horrible. I went to the funeral and the mom turned to me and said the most important thing. She said that their baby girl would never know what a great man her father was and how much he wanted her except for my birth story. The story I wrote will be her memory of him. I totally broke down and cried. It was so horrible, such a tragedy.” Since hearing her talk, every birth story I write has that idea in mind.

I don’t think many of us get into this work thinking it will make us face death and develop adult skills. We love babies and empowering women! We want to build strong families through facilitating connection at birth! When we open our hearts, we grow and sometimes it hurts. We learn how to manage our emotions successfully and write condolence cards, too.

 

 *All of the names have been changed.

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Top Ten Questions For Choosing A Doula Training

Apr 21, 2014 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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Why It’s a Calling

Mar 17, 2014 by

Doula work is hard!  It is physically challenging, emotionally draining and requires a personal connection that leaves life long impressions.  Doulas sacrifice to be there for their clients.  They prioritize other people’s birth memories above the needs of their own families.  They get paid less than what they are worth – often wages are barely above the poverty line.  There is a limit to how many clients one can physically and psychically manage.  Yet, this work is something that so many of us cannot imagine not doing.  It fulfills some part of who we are – it expresses our life essence.  To help another woman through childbirth – as she is physically going through the process of giving life to another human being – is what we feel we are called to do.

A calling is often referred to in religious terms because that is our most familiar cultural reference.  But a calling means that there is a purpose within us to connect to others and improve their lives.  We want to ensure that another person’s journey is eased by our presence.  What we give is not only a skill or a service, but the essence of our own humanity.  Doulas in my study said it was a passion, a priority, without doulaing they would feel that a part of them was missing.

Ten of the sixty doulas in my study described or mentioned the word “calling”.  Tracy said, “Being a doula is a part of who you are.  You can’t try to be a doula…you either have it in you or you don’t.“  Nancy shared, “It’s my passion and it tests my compassion.  In my real life, I’m a banker!  But that’s a career and this is a passion.”  Sadie said, “It was in my heart.  For so long before I took my workshop I knew it was in my heart and I’ve never been happier even though it’s been so hard.”

The calling of birth doula work often comes at great cost.  I’m not talking about the missed birthday parties or band recitals, although those certainly matter.  It cost us when we sit holding hands of a woman who is being victimized by her own choices, or who is not respected because she is young, not white, or doesn’t speak English.  When we SEE that infants are whole human beings with a full consciousness and no one else acts in a way that acknowledges it, it costs us.  When we know a physician feels he cannot trust the system and acts in a way that is self-protective rather than letting labor continue without interference, it costs us.  When we trust birth but no one else in the system we are working in does, it costs us.

We don’t do this work because we are martyrs.  We do this work because we are willing to pay the price.  We know it makes a difference to this mother, this baby, this family.  We know that our presence will reassure nurses and doctors to allow this mother to labor another hour because she is cared for.  We know that the price we pay is a drop in the bucket to what is gained by everyone else by our presence.  We do birth doula work because we are called to make a difference in the world.

Our spirit yearning for expression in the world says, “Yes!”

This is your role.

Be of service.

Make a difference.

Hold the spirit alive.

Like a soft spring breeze it whispers, “Doula this world –it needs you.”

 

 

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Doulas: Why You Need To Be Nice First

Feb 17, 2014 by

A doula was complaining on Facebook in response to one of my posts about getting along with nurses.  “Why do I have to be the one to put forth the effort?  I wish some nurse would try to get along with me first.”  Here’s why it’s up to the professional birth doula:

  • You are a guest in her house.
  • Making the first move sets the tone for every communication and interaction that follows.  Why not use this opportunity to your advantage?
  • You only get one chance to make a first impression – and it takes three times as much experience with you to change someone’s mind.  Make those first minutes count.
  • You are an ambassador for all birth doulas.  Your actions reflect on all of us.
  • Social skills and emotional intelligence are a significant part of a doula’s success.
  • “Hostess” is implied in our job description.
  • Hospitals are set up for the mass production of a number of patients moving through the system.  When you ask the nurse to change what she usually does to personalize care for your client (even when it is evidence based), she may get flak from other nurses or doctors for doing so.  Therefore you need to be grateful when you hear “yes” and accept “no” graciously.  (It doesn’t mean your clients stop trying – it means you are polite.)
  • The last doula may not have behaved optimally.
  • As unfortunate as this is, a client may be treated negatively by the nurse or medical care provider for a poorly behaving doula.  I think we can all agree it is unacceptable to stress out anyone at a birth over our behavior.
  • When you make an effort, especially a big one, the “norm of reciprocity” states the nurse will naturally want to keep things in balance.  So you get what you give.

 

 

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The Doulas Have Arrived! Nurses, What Does This Mean For You?

Feb 9, 2014 by

Dear Nurse,

When doulas move into a new area, nurses are often skeptical and hesitant rather than welcoming.  This is a normal reaction to change especially when you are uncertain about how it is going to affect you – and how you do your job.  Here is a list written by an experienced doula trainer that might be helpful for you:

  1. Professional doulas want to work with you to help a laboring mother’s needs get met.  She views you as an important ally who has some of the same objectives and priorities.
  2. The doula’s goal is to remind their client to tell you and her physician or midwife what is most important to her about her birth.  She may have listed her preferences on a one page birth plan or may only state them verbally.
  3. Professional doulas do not have any agenda for a “natural” birth.  Every woman benefits from doula support – even mothers planning an epidural or cesarean section.  She and her family can benefit from the added nurturing, reminders they can discuss options, and extra hands that a professional doula can provide.  A doula birth is a supported birth.
  4. Professional doulas are familiar with the research evidence and best practices for maternal and fetal health.  Doula clients tend to also be familiar with this information – which is why they hire a doula.  Because of this, patients with a doula may make more requests than an uninformed patient.  Some of these requests may be a part of hospital protocols even though the obstetrical unit’s culture does not usually promote them.  Some examples:
  • No routine amniotomy
  • Intermittent fetal monitoring
  • Freedom to choose second stage positions outside of bed
  • Hands and knees, kneeling and semi-sitting positions with an epidural
  • Delayed cord clamping
  • Baby’s naked body on mom’s naked body immediately after birth and not removing it for 90 minutes or more
  • Delaying routine newborn procedures (not health assessments) for 90 minutes or more
  • Newborn exam on mother’s body or her bed
  • Weighing and bathing of baby in the patient’s room
  1. When patients prefer a cooperative decision making relationship with their care provider, they usually hire a doula.  The doula will help to remind them to ask questions about their care.  This interaction style may be rare in some obstetrical settings.  Rather than having their physician autocratically making decisions, these patients expect to be consulted and give explicit consent for each intervention.  With these patients, the doula may ask if the mother and her partner have any questions about a proposed intervention.  The ensuing discussion about benefits, risks, and options may be seen as an interruption or a delay.  However, involvement with decision making has been shown to increase patient satisfaction, birth satisfaction, lower anxiety, lessen the incidence of postpartum depression and prevent post traumatic stress disorder due to a traumatic birth.  This has been repeatedly shown in the nursing literature to be more important than complications, length of labor, or location of birth to short and long term maternal well being.
  2. In order to facilitate involvement in decision making, a doula may tell the patient about an unannounced intervention the physician is about to do. This way the mother may give explicit consent or ask for clarification.  This may be seen as an interruption by the nurse or physician but this is what a doula accompanied patient expects her doula to do.
  3. Despite these interruptions to the usual flow of care, the professional birth doula is your ally.  She knows the patient and can help you to get to know her too.  She will observe almost every contraction and can keep you informed of any issues the mother has or adverse symptoms shy mothers may keep to themselves.  They help mothers to stay focused.
  4. With a 60-80% epidural rate in most hospitals, nurses do not see many unmedicated labors. Doulas have been trained in normal physiologic birth, as defined by the American College of Nurse Midwives (ACNM).  Mothers without pain medication may become louder and listen to their bodies’ urges to move around as labor intensifies.  When mothers are coping well they are calm between contractions.   The doula will help the mother to continue her coping ritual – which may become louder and more intense as labor progresses.

Three Clinical Recommendations:

When you are introduced to the doula, ask her about her training and experience.   Professional doulas are usually excited to tell you about their organization and background.  If she has not taken a training, then she is the client’s friend who is doulaing her. She is not a professional, so none of the descriptions in this essay apply.  The “doula” friend may act in ways that a professional would not do, such as speaking for the mother, touching you or the physician inappropriately, arguing with you, giving medical advice or telling the mother what to do.  These are NOT in the scope of practice of a professional doula.   If she is doing these things and has been trained, she is considered a rogue doula, behaving outside the circle of professional practice and ruining our reputation.  We hope she goes away even more than you do.

New doulas may make beginner mistakes.  There are more new doulas than experienced ones.  This is a challenging profession and many promising new doulas find it is not a good lifestyle fit.  Please be patient with the beginning doula and help her to learn how to treat you.  She wants to do her best to get along with you while helping her client to have the best birth possible.  She may ask more questions about procedures and provider preferences until she becomes familiar with your facility.

Labor and birth are changing due to the doula’s influence.  But this is not necessarily a bad thing.  Nurses are learning alternative approaches in non-pharmacological pain management and positioning techniques to rotate malpositioned babies.  They are relearning the satisfaction of emotional connection to a patient that the doula helps to facilitate.  They are seeing normal physiologic birth happen in their facility (even though it may require suspension of usual interventions).  But most of all, because of nurses and doulas working together, mothers and babies are having emotionally healthy outcomes as well as physically healthy ones.

Here is a pdf copy of this post: The Doulas Have Arrived

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Doulas! Charge What You’re Worth!

Jan 28, 2014 by

In support of the effort made by YourDoulaBag.com, I’ve decided to repost the graphic from their blog this week.  Feel free to post it on your web site to help prospective clients understand how doulas set their fees.

blog_DoulasChargeWhatYouAreWorth1

 

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The BFF You Need To Meet: Pelvic Floor Physical Therapists

Jan 20, 2014 by

You’ve never heard of a pelvic floor physical therapist?  You are not alone. Obstetricians and gynecologists are often unaware of the help PFPTs can offer their patients.  As a sexuality and birth professional pelvic PT’s are one of the most important referrals I make.  Women should not have to suffer sexual, urinary, rectal, or pelvic discomfort or pain!  A legacy of shame about our genitals may keep women from discussing postpartum and sexual problems.  When she does seek help, a woman may also be told nothing can be done, it is in her head, or just a part of having a baby.  Because of the easy intimacy of our relationship, clients are likely to discuss pelvic discomfort or pain issues with their birth or postpartum doula.   We are an important link in offering women information about pelvic PT.

When is a referral to a pelvic floor PT a good idea?  If your client mentions she…

Wets her pants when she coughs, laughs, or sneezes

Has to pee every half hour

Has to run to the bathroom frequently or daily

Can’t use a tampon because it hurts

Dreads sexual touching or intercourse because it is no longer enjoyable and is actually painful

Experiences pelvic pain when picking up her baby or with common daily movements

Things “just don’t feel right down there”

Has orthopedic problems with the pelvis/sacrum/lower back/feet have not improved with traditional treatment

While most of us might think that too “loose” or laxity in the pelvic muscles and ligaments is often the problem, too much “tightness” or stability of the muscles is an equal problem.  The muscles and ligaments of the pelvis work together as a dynamic system, which may need treatment postpartum to perform optimally.  When you recommend Kegel exercises to your clients, make sure they are spending equal time deliberately tightening and relaxing their vaginal muscles. 

Pelvic PT’s specialize in maximizing the function and remedying the dysfunction of the muscles, ligaments, and soft tissue areas of the pelvis.  They work with both men and women although the keyword “women’s health” is often used when searching for this specialty.  Common referrals to pelvic PT’s are urinary, fecal and flatus (gas) incontinence, getting up at night often to void, constipation, pelvic pain after childbirth, nerve damage, abdominal muscle separation, internal or external cesarean scar pain, and pain with urination, bowel movements, or sexual intercourse.  Somatic pain (pain with no known physical cause) that may be the result of emotional, sexual or physical trauma can also be successfully treated.  A woman who feels her childbirth was traumatic – even one without obvious physical trauma – may feel somatic pelvic pain.  PPT’s may also specialize in sexual problems such as severe genital or pelvic pain and muscle spasms that prevent sexual pleasure and intercourse.   Anything less than a feeling of wellness and optimal function in these areas may benefit from evaluation and treatment by a qualified pelvic physical therapist.  Even after years with a particular problem, pelvic PT may help.

While we might think that women with lengthy or problematic labors are more likely to have problems postpartum, this would be misleading.  Even women with ideal pregnancies and normal labors may have problems postpartum.  In my practice I make it a point as my two or three month check in to ask about these issues.  “Is everything in your pelvic area back to normal?  Are you peeing and pooping okay?  Other than needing lubricants when breastfeeding, is your body functioning so that you are without pain or discomfort?  If it isn’t, I have some recommendations for you.”   Sometimes I just send a “thinking about you” email or letter with local PT information.  If my client had any complications whatsoever – cesarean delivery, operative delivery, lengthy second stage, posterior presentation, epidural, episiotomy, or 2nd degree or greater tear, I will inquire specifically and directly about pelvic problems.   Every one of my clients who received PPT found out about it through me.

What can a person expect from an evaluation and treatment from a pelvic floor physical therapist?  The PT will take a complete history including any pregnancy issues, birth events and feelings, and past or present sexual, urinary and continence problems.  The PT will likely do an internal pelvic exam when the patient is ready.  This may be at the first visit or several visits later.  Understanding exactly where the pain is, pelvic tone and response to different exercises can help the PT focus on the correct therapy.

PFPT’s utilize a variety of therapies depending on the patient’s issues.  For postpartum patients, therapy may include exercises, recommendations for changes in daily movements, abdominal binders, TENS units, and education about positioning and posture.  If there are issues from an operative delivery (vacuum extraction or forceps), there may be nerve damage.  Manual (hands on) therapy techniques can address myofascial restrictions of the pelvic floor and remodeling of scar tissue.  PT’s also use biofeedback to help clients become more aware of sensations and to develop controlled responses.  For sexual problems, education about optimal sexual functioning and maximizing pleasure and arousal can also be helpful.

As doulas, we are in a place to encourage women to seek high quality and compassionate treatment.  We may need to gently coach clients that they not accept pain or altered circumstances as part of having a child.  This is not normal.  Our reassurance that their condition can be treated by specialists can make a vital difference in the quality of women’s lives for years to come.  We can also learn a lot about the pelvis and birth from PFPT’s.  When you add your local PPT to your referral list, ask them to make a presentation to your local birth group too.

Resources:

Good first stop:  The Pelvic Guru Explains What PPT Is

 Case history example with diet

Pelvic Pain and Rehab on pudendal nerve entrapment

 Managing Pregnancy and Delivery in Women with Sexual Pain Disorders

Physical Therapists As Sexual Health Professionals

Find a Pelvic PT  (choose women’s health even though PPTs work with men too)

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Another Reason Why Birth Is Sacred

Jan 1, 2014 by

Long ago I learned that rescuing people from their own actions is often a trap, one that ensnares us as well as the person we are trying to help.  When it comes to my client’s birth it can be really hard as she makes decisions that are not going to take her in the direction she previously desired.  As a doula I want to grab her and say, “No! Nooo….No!”  The more attached I am to her personally the harder it is…until I shift my thinking.  Once I remind myself to respect the transformation and challenges of pregnancy and birth as a sacred path it becomes much easier to support and serve this mother.

Several decades ago there was a lot of interest in vision quests* and understanding the deeper spiritual nature of existence.  These journeys of challenge and hardship were entered into to discover one’s strengths, weaknesses, inner nature, and relationship to the Divine.  For some groups it also involved the risk of death.  Joseph Campbell wrote extensively about the “hero’s journey” and the meaning and interpretations of this myth in contemporary society.  (Today we have Frodo and Harry Potter.)

Early on in my path as a doula, I saw the potential of birth to hold these same meanings for today’s women.  Women faced these same challenges by gestating, giving birth, and nursing – they didn’t always need a vision quest in the wilderness.  While our culture has not adopted the idea of a ritualized journey, the experience of childbirth still holds this potential for women.

If we appreciate a woman’s birth story as her own personal myth it has the potential to reveal to her deep truth and knowing about herself.  It can be a mirror of who she is.  Within her birth story is how she deals with challenge, how she deals with authority, how she supports herself, what strengths she brings forth that she didn’t know she had.  It reveals her relationship to what is unknowable and undefinable in human existence.  She must give herself over to a process that may be unknown to her that she is not in control of.  How does she respond?  What allies does she call upon?  When the crisis comes, what does she do?  How does she deal with her deep fear as it faces her in the mirror?  How does she experience pain and what does she want to do about it and what does she do about it?  How does this mother see the world?  How does she see her place in it?

To me, every laboring woman I am with is traversing this terrain.  My role is to guide her to finding her own way not to show her which way is right.  There is no way I can know her inner experience or how her history has shaped her to act in these moments.  I don’t need to know – I just need to trust that this journey is unfolding as it should for her.  Women have taught me to trust them to find their own truth.

This doesn’t mean it’s easy.  This doesn’t mean I don’t speak up; it means I trust her to let me know she wants me to.  It means I have developed an automatic questioning in response to my “No! No!”: “Is it about me or about her?”    It means I trust that when she whispers, “I think I want an epidural.”  I whisper back, “Do you want to talk about it some or do you know that’s what you want?”  If she nods “yes”, I get the nurse.  I believe she KNOWS and I do not rob her of that power of choice.  To dither about her birth plan is to diminish her as being able to know what is best for her in that moment.  My service is to trust her unconditionally as the heroine on her own quest.  She will find herself whether she wants to or not.

In my decades of doulaing I have found that many women come back to me and say that their birth taught them so much about themselves.   They learned who they were.  They faced their fears and lived the consequences of their choices.  When a woman has support, true support without an agenda, she finds her voice.  We amplify it so others can hear it too.

Women change their lives based on their births.  They end bad relationships, become fiercer mothers, move across the country, yell at their obstetricians, yell at their midwives, hug and cry with their obstetricians and their midwives, grieve for not knowing.  They grieve for the woman they left behind and embrace the woman they now are.  Who am I to know what is best for that woman in the midst of her birth?  I know nothing!

This acknowledgement of the deep spiritual nature of birth and the risks it contains for crisis and change, keeps me humble.  It also frees me.  I am a chosen companion for the journey, an ally who will respond as needed. Sometimes offering wisdom but always offering patience and calm.  I follow her lead because this is Her Story, the myth she is living and creating with each breath.  I trust Her and I trust my service to her, which is why birth and the path of doulaing when practiced this way is sacred.

 

“It is by going down into the abyss that we recover the treasures of life.  Where you stumble, there lies your treasure.”   -Joseph Campbell

 

* The term “vision quest” has different historical and cultural meanings in Native American or First People cultures.  I’m using a popular culture definition of the term.

 

If you wish to explore these ideas further:

The Women’s Wheel of Life, Elizabeth Davis* and Carol Leonard, Penguin/Arkana, 1996     (*midwife and author of the midwifery textbook, Heart and Hands)

The Wholistic Stages of Labor by Whapio Diane Bartlett    http://www.thematrona.com/apps/blog/the-holistic-stages-of-labor-by-whapio

The Woman Who Runs With The Wolves: Myths and Stories of the Wild Woman Archetype by Clarissa Pinkola Estes, Ballantine Books (1993)

Joseph Campbell and the Power of Myth DVD Documentary, PBS, 1988, 2013

Transformation Through Birth, Claudia Panuthos, Bergin and Garvey, 1984 (still being published!)

Birthing From Within, Pam England, Partera Press, 1998

 

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How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

THAT Doula is the one the nurses roll their eyes at and don’t want to see in the labor room.  The one they aren’t certain about, the one who leaves them wondering how their patient may be negatively influenced, the one they feel oversteps her boundaries and has her own agenda – not the patient’s – in mind.  I’ve done extensive research interviews with doulas and nurses, consulted with nursing unit directors and had served as a mentor doula.  To me, the vast majority of the time these concerns arise from misunderstandings and miscommunication between nurses and doulas.

So how do we counter these negative perceptions that nurses may have about a doula when we arrive at the hospital?  (Now this is much harder when the hospital staff has had experiences with a rogue doula who behaves in these ways on a regular basis.  That may require a more direct approach.)  What I am talking about here is building your own reputation as a trustworthy doula.  Often we can’t do anything about the past, we can only begin with the next birth.  Here are best practices culled from experienced doulas and labor and delivery nurses:

  1. Smile.  Smile when you meet someone, smile when they walk into the room, smile when you walk down the hall.  Be genuinely yourself, don’t fake smile.  A person’s brain perceives a smile as welcoming and automatically changes their behavior to be more receptive towards the person smiling at them.  This is unconscious.  So shifting your behavior to be welcoming by authentically smiling can use this to your advantage.
  2. Adjust your nonverbal behavior to be welcoming and acknowledge the MCP’s presence when they come into the room or closer to the laboring mother’s personal space.  A head nod, slight shift in your shoulders or body orientation can indicate your awareness of their presence.  You can do this while not taking your attention away from the mother in her laboring, or wait until the contraction passes if needed.
  3. Introduce yourself, share a little bit about yourself and what you are there to do.  “Hi, Nancy.  My name is Amy, I’ve been a doula for 20 years off and on.  I’m here with Nick and Nora to help them with comfort measures, remind her to change positions, fetch things, and to remind Nora to speak to you and Dr. X about what is most important to her about her birth.”
  4. If needed, explain what you do not do.  “I don’t do vaginal exams or anything clinical.  I don’t speak for Nora and Nick, I just remind them when it’s a good time to discuss their wants and needs with you or the doctor and midwife.”
  5. “Wonder with” and include the nurses when they are present.  “I wonder if we might try…”  “Nora seems to be tiring, maybe a position change would be good???  What are you thinking?”  “Are you noticing Nora’s cxns slow down when her mother is in the room or is it just me?”  Nurses have been to hundreds of labors and may know coping strategies that we’ve never thought of.  It is a courtesy to ask – remembering mom is the decider.
  6. Include the nurse in the mother’s coping ritual whenever you can.  Any connection you can enhance between the mother and her nurse is good for their relationship.  It also helps the mother to feel safer and cared for.  Nurses like to provide comfort measures but their other responsibilities limit their time.
  7. Acknowledge the nurse’s rank and her territory.  If you are thinking about a big change, such as laboring in the tub or walking the unit, find the nurse and ask her before you do it.  Maybe ask her in a general way an hour or two before you make your move.  “Nora wanted to try laboring in the tub today.  Is there any reason we ought to check with you first before doing that?”  Some nurses don’t need this communication, while others feel put out when their patient is doing something unexpected.  There’s nothing like going into a patient’s room and finding her not there!   If the physician calls and the nurse is out of the loop, she looks less competent.
  8. Do simple things that make the nurse’s job easier.  Pick up the dirty laundry, offer to get her something to drink when going to the kitchen.  Imagine yourself working together on the same team and building a relationship.  You are!  You are both on this mother’s birth team along with her family members.
  9. Urge Mom to speak up verbally about what she wants to each nurse and MCP.  “I really want to avoid an epidural” or “I want an epidural but Amy is going to help me to use the tub first to see if I like it.”  “Don’t tell me to ‘push, push’.”   Get mom and her partner used to speaking up.  Get their voice in early and often.
  10. Prompt mom to speak up:  “Nora, do you want to tell the resident about your approach to pain medication?” Maybe a slower, gentler approach is better: “Hmmm, Nora, I’m wondering if you want to share what’s important to you with Dr. Y since she’s going to be involved with your care.”  You want your voice to be remembered as the one who is reminding mom, not the one who is saying the words for her.
  11. If you’ve done the prompting and mom doesn’t say anything, let it go.  It is her birth and if her vision is not happening because she isn’t saying anything then you have to let it go.  A good general guideline: “I’ll stick my neck out as far as my client does, but I won’t go farther than she does.
  12. When a medical decision needs to be made invite the nurse to stay in the room.  “ Since Nick and Nora have some time to discuss what to do next, Nancy, do you want to stay in case they have any questions?”  By inviting the nurse to stay you avoid the appearance of being manipulative or unduly influencing your clients toward other approaches than the one being initially recommended.
  13. Don’t give medical information.  Help your client to solicit that information from the medical staff.  You know what you know so that you can tell if they are getting the information they need to make a good decision.  You don’t know it so that you can say it out loud to your client.  The doula’s role is to enhance connection and communication, not be the source of medical information.  It is okay to ask leading questions IF your client has indicated she wants more information but it doesn’t seem to be forthcoming.  “Isn’t there some kind of number or score about her cervix to consider when breaking her bag?  I think Nora and I were talking about that a while ago.”
  14. Know what you know and don’t claim to know what you don’t know.  If you are unfamiliar with position changes with an epidural, say so.  “I took a workshop where getting in a kneeling or hands and knees position with an epidural was helpful in preventing posterior positioning and labor dystocia.  I haven’t done it before, but Nora would like to try it if possible.  Do you think we could work together and see if that is good for Nora and the baby?”
  15. Realize that everyone present is providing what they feel is the best care for mother and baby.  Almost all physicians, midwives and nurses are making the best recommendations possible based on their knowledge and experience while taking your client’s preferences into account.  It is the rare MCP who is misogynist or disregarding the emotional importance of childbirth.  I’m not saying that it doesn’t happen.  I am saying that making that assumption without direct experience of it does a disservice to you, your clients, and the medical staff you are working with.
  16. Repeat after me:  “It’s not your birth.  It’s not your birth.  It’s not your birth.”  Tattoo this in your memory, embroider it on the inside of your birth bag.  It’s not our birth!  Our role is to follow the woman’s lead even if it seems she is doing the opposite of what she said she wanted prior to labor.  Don’t have your own agenda for this birth or this mom.  Her birth is her life experience.  Don’t cheat her out of it just because we want it to be a different way.  Our job is to support the choices she is making now even when she may not stand up for herself or what she said she wanted earlier.
  17. Your reputation precedes you and nurses will talk about you after you leave (perhaps even while you are there).  Make sure that this nurse has good things to say about you – or at least nothing specifically bad.  It may take more than one birth for positive feedback about you to circulate but it’s worth it.  Hopefully you will experience greater satisfaction in your relationships with medical staff by following these strategies too.
  18. Nurses have personalities, struggles with coworkers, worries, and families waiting for them.  In other words, they are whole people.  Show respect for them and concern for their needs.  An approach that works with Nurse Nancy won’t work with Nurse Abby.  A large factor in your success as a doula is your ability to pay attention to other’s cues and adapt your behavior to get along successfully with them.  Our job is complex because we have to do this with our client, her family, her care providers and members of the nursing staff – simultaneously!!

These are advanced communication strategies that seem deceptively simple.  It takes courage to change even when behaving in a way that is natural to us isn’t getting the results we want.   All of them are ways of being at a birth that highly effective doulas practice and that labor and delivery nurses said they appreciate.  My hope is that they will help you find increased satisfaction and harmony in this critical aspect of doulaing.

 

Here is a pdf copy of this post: How not to be THAT DOULA in a Nurse’s Mind

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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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