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

Jan 26, 2017 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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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. 

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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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The Essential (Oil) Dilemma

Apr 30, 2015 by

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

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

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

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

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

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

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

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

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

 

 

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

 

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

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

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

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

 

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A World Where We Didn’t Need Doulas

Aug 3, 2014 by

A World Where We Didn’t Need Doulas

Maybe it comes from being weaned on Star Trek reruns but I’ve often contemplated alternate universes.  The kind where if a different decision had been made the whole future course of humanity would be altered.  Recently I’ve contemplated what if we had a birth culture today where professional doulas weren’t necessary?  Going back in time, the critical point seems to be a little over one hundred years ago with women deciding to give birth in hospitals.

Like most cultural changes the reasons were multifaceted.  Pain relief was possible in a hospital setting.  At that time relief from labor pain was considered a feminist issue.  Rich women also wanted to set themselves apart from women in the lower classes so paying to go to a hospital accomplished that.  There is also the drive for modernism, to do what is new and improved which was hospital birth.  Once the wealthy had established a new norm and the physician profession benefited financially, a social movement for “safe and healthy” births in the hospital was quickly established.  Within a generation, our birth norms had altered the trajectory of our society. **

But what if something else happened instead?  What if wealthy women demanded that physicians come to their homes?  What if they asked to be attended by a midwife as well as a physician?  What if women surrounded each other with their closest friends and family members instead of strangers?  What if women retained their power by being in their own homes instead of transferring it to someone else in an unfamiliar location?  If physicians could bring their pain relieving medicines into the home or trained midwives to use them, we would have enough caregivers to provide for many laboring mothers.  Women and men would grow up with labor and birth, understanding its meaning and its risks.

As in all things there are probably some women and men who would be more drawn to helping during birth.  But they would have the opportunity to be part of a helping team from a young age and many more people would see birth as normal.  They would understand the caring skills that are necessary to see others through difficult times.  Instead of the unique skills set that doulas have now, these skills would be learned at an early age.  We would all learn to doula one another.

The paradigm of needing assistance during difficult transitions would be widespread.  Simply by growing up in a family or village group, we would learn how to care for one another.  Labor and birth would be our teachers.  Midwives, rather than being derided by physicians and seen as competitors for birth business, would be a necessary part of the paradigm.  Hospital birth would be the exception, not the norm.  With plenty of assistance from loved ones and reassurance from being in their own homes, fewer women might have needed pain relief to cope.  We would have an uninterrupted cycle of support, caring, and knowledge that spanned generations.  There would be no need for doulas because we would all be doulas.  In addition to whatever else we did in the world, doulaing would be second nature.

All the other events in the world – multiple wars, the Depression, the Atomic Age, all would have unfolded differently because we were together and cared about one another.  Touching someone’s brow when they are in pain and connecting with them on a heart level changes a person.  We see the inner power of connection and caring.  I do not think those lessons would be confined to the birth room but would be spread across the world.  Our whole social history would be different if we all learned the value and skills of caring.

So I guess I’m saying that doulaing has the power to change the world.  It shouldn’t have been confined to a select few but something all people should have experienced themselves and learned to do.  However we live in a world that has compartmentalized caring and who does and does not do it.  It has demanded that we professionalize caring in order to exist as a group in the current medical systems.  Sigh.  I think I’ll go watch another Star Trek rerun.

 

*This paragraph is a painfully brief summary.  Two good books written by historians are “Reclaiming Birth: History and Heroines of American Childbirth Reform” by Margot Edwards and Mary Waldorf (1984) and “Brought To Bed: A History of Childbearing in America” (1999) by Judith Walzer Leavitt.  There is also “Birth: The Surprising History of How We Are Born” by Tina Cassidy, a reporter.

** We know today that births in the hospital were not safer nor healthier for mother and baby.  However that was not the public perception of the time.  The propaganda circulating derided midwifery and home birth as “dirty”.   The American Medical Association was originally founded to push midwives from the market of delivering babies.

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Not Any Woman Can

Jun 30, 2014 by

One of my most hated myths about doula care is the idea that any woman can be a doula.  Just put a person born with a uterus in a labor room and she’ll be able to help effectively – with no preparation.  This is a myth that devalues what doulas do, and gets in the way of us being perceived as professionals. It also devalues the men who offer good doula care.  The myth that “any woman can” is even perpetuated by doulas, who may not realize the damage this idea does.

Effective labor support requires sophisticated emotional skills that rise to the level of a skilled counselor.  A good doula has to be able to correctly read everyone’s behavior in order to positively influence the emotional tone of the room.  She or he needs to know the mother’s need before the mother knows it.  In my published research on emotional support skills [pdf: GillilandMidwifery], it became clear that these skills take many births to master.  The components of emotional intelligence are at the heart of doula work.  Good doula support cannot be accomplished without keen self-knowledge, empathy, emotion management, and relational skills.

In addition, doulas utilize a wide variety of positioning techniques and comfort measures.  In order to establish a position correctly, the subtle placement of a shoulder, foot or ankle can make the difference between comfort and pain for days after the birth.  Having a wide variety of ideas and stamina are essential for the physical demands of labor support.

The key to understanding empowerment is knowing that a doula cannot empower anybody.  A person has to take advantage of an opportunity presented to them to state what they want and to ask questions.  Doulas create these opportunities.  But it only happens smoothly by using complex communication strategies.  Doulas need to be able to relate to everyone’s concerns:  medical care providers, nurses, the mother and her immediate family.  This begins with keen observational skills and compassion for conflicting agendas.  Her choice of words and attitude is deliberate and intentional.

These are not skills possessed by most people!  They are cultivated, practiced, and honed over years of attentive living and attending births.   Doulas go over and over each support experience they have in order to squeeze as much knowledge as possible out of it.  They learn that birth is about what the mother wants and not what the doula wants.  This is central to labor doula effectiveness.

In this post, I’ve only begun to scratch the surface of what birth doulas do.  Its necessary to establish a rapport with strangers and educate without overwhelming at prenatal visits.  Many births involve trauma prevention and navigating the landscape of past abuse.  After the birth, doulas are critical to recovery from a difficult birth or normal postpartum challenges.

We MUST establish our own value in the world.  The work of birth doulas is vitally important in people’s lives!  It cannot be done by just anybody.  When we don’t value the complexity of our carework, no other professional – nurses, doctors, or midwives – can do so either.

 

Upcoming:  How Doulas Undermine Our Own Value (it’s not money)

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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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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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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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Their Doula Disappointment

Oct 26, 2013 by

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

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

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

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

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

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

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

 

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

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A Story About Certification

Oct 10, 2013 by

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

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

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

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

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

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

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

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

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

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

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We Need ALL Kinds of Doulas

Oct 1, 2013 by

No we don’t.  We don’t need doulas that lack integrity, who interfere with a mother  getting an epidural or a cesarean, or who say nasty things to their clients about hospitals, doctors, nurses, or midwives.  In my experience these doulas may leave damage behind but they don’t usually last very long.  We hope.

What we have is a huge variety of doulas.  Doulaing is so important and integral to the process of supporting women in their birth experiences that it is finding its way everywhere. There are doulas who work only in their own religious or ethnic communities.  There are some who only attend births for free because it is their way of giving back to the world.  There are doulas who can’t imagine getting paid for work of their heart and spirit.  There are doulas who have no problem putting a price on their caregiving skills and need to support their families.  If we’re going to have a social revolution to rehumanize birth we need all the doulas.  Friend doulas, hobby doulas, grandma doulas, and professional doulas who work for programs, hospitals, and have independent practices.  We need inclusivity to change birth.

There are doulas who live in a neighborhood and are known as the “woman who knows about birth”.  There are doulas who move to foreign countries and hold the hands of mothers whose language they don’t understand.  There are doulas who are angry about how women are treated in labor.  There are doulas who cry about the lack of recognition that the baby is a conscious being.  There are doulas who can’t imagine attending a woman they’ve never met before and don’t know intimately.  There are doulas who do that on a weekly basis.  There are doulas who receive additional training and use other skills such as acupressure, homeopathy, Reiki, or aromatherapy.  If we want all women to have doulas available, that means we need to accept all different kinds of doulas.

The dilemma is this:  If we need all kinds of doulas to humanize and change birth, we also pay the price in delaying our claim to legitimacy for our profession.  There is a difference between a professional doula and other doulas.  No other birth profession has this dilemma where the stakes are so high.  There aren’t any hobby doctors, hobby nurses, or even hobby childbirth educators.  It’s no wonder there is confusion and conflict among doulas and medical staff.  Friends acting as a mom’s doula have no allegiance to advancing our profession and no idea that their actions reflect on all doulas.  When doctors and nurses interact with a doula they have no idea whether she is a novice, a professional or somebody’s buddy.  We can look alike from the outside and seem like we’re doing the same thing.

Legitimacy is like the right of way in driving a car.  The right of way is not something you automatically receive, it is something the other driver gives you.  We can claim the space for legitimacy but it is up to other forces to recognize us as having it.  Those key forces are parents, physicians, midwives, nurses, educators, third party payers, and the general public. We need to have professional standards and educate about the differences to doctors, nurses, midwives who will work with all the doulas.  We need to tell them that their expectations can and should be different of professionals.  We need to show them there is a difference.

There are some doulas who feel that a goal of professionalism is missing the point.  Their vision is for every community or neighborhood to have their own doulas.   They would be the go-to person for pregnancy questions, education, and support during labor.  In this vision it is all about connection and creating a knowledgeable empowered female community.  This happens when people have pre-existing relationships that continue as the child grows.  While I can appreciate that vision, many of the mothers we serve don’t live in that world.  Our connections occur most often with the assistance of technology not around the back porch.  Some women feel most comfortable with intense intimacy when they purchase it – they retain control.

The doula revolution was born through social forces and will continue to form itself around existing systems.  In other words there will be all kinds of doulas everywhere – including those that break rules others hold dear.  We are fighting for two separate things – to improve birth where a mother can have the support she needs from the person she wants to serve as her doula.  We are also massing to shift the perception of us as professionals and to communicate there is a separate set of standards.  Sometimes the accomplishment of the former conflicts with the latter: when a non-professional doula acts in a way that a professional would not.  This is messy and confusing for all of us, including nurses and medical care providers.  While we may not need all kinds of doulas (see first paragraph), all kinds of doulas exist and we need to live in that world.

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Why You Should Keep Your Hands To Yourself

Sep 23, 2013 by

Answer:  “Vaginal exams.”  Jeopardy question:  “What is one thing a doula does not do?”  Most of us hear these reasons in our doula trainings :  doulas are not experienced at it; it introduces germs; it is a medical diagnosis (liability); or that it “muddies the waters” between the doula’s role and that of other medical professionals.  There are doulas and other birth professionals who feel that doing vaginal exams at home in early labor is an advantage.  When I first started as a labor assistant in the mid-1980’s it was assumed that I would someday provide vaginal exams and other clinical skills.  We thought being able to offer more medical information to the mother would be empowering.  After years of personal experience and research, I now theorize that it is more empowering for the mothers and more powerful for the doulas to avoid doing vaginal exams.  Here’s why:

1.  Everyone else wants to put their fingers in her vagina.  Triage nurses, doctors, residents, midwives, midwifery residents, nursing students, you name it.  Even though I would likely be using these skills at her home to gauge when to go to the hospital, I don’t have to add my name to the list.  Doing vaginal exams doesn’t help me be a better doula. I just become another person who is entering the private spaces of her body.

2. It changes the balance of power in the client doula relationship away from an act of service. As a doula my role is to empower and support this mother one hundred percent.  If she wants something I help her to get it; if she doesn’t want something I help her to say “no”.  My role is to help her believe in herself.  As a professional doula, I have no agenda other than to support her and her loved ones. As women we are equals and I am there to serve her as she labors and births her child.

Once I put my hand inside of her we are no longer equals – she doesn’t put her hand in my vagina.  The social roles between us have shifted.  In her mind who I am symbolically has changed.  I used to be there to serve her and now I have touched her intimately and evaluated her!  This shifts the power balance between us so that I have more power than she does – I have personal private knowledge of her she does not have of me (and very likely will never have of me). Our support relationship is no longer the same.

3.  With that one act, the doula role shifts from support to evaluation.  I am judging her body.  I am giving her information about herself that we don’t believe she has any other way.  I am subtly communicating that I don’t trust her to know where she is in labor.  Her intuitive knowledge of her own body and labor isn’t good enough – we need to check the cervix just to be sure.

4.  The doula misses the opportunity to empower the mother.  When you aren’t doing the evaluating, you need to rely on the mother’s internal messages.  She lives in her own body, for goodness’ sake, which is something most people tend to forget.  You can call it intuition or receptivity to subtle nerve pathways perceived by the brain. The mother has access to what is going on in her body and as a doula I can assist her to listen to these messages. If we can help her to identify what she is experiencing and feeling, she can discern for herself what she wants to do.  When we model early on: “It’s your body, what do you feel?  What do you want to do?”, it starts a pattern that can carry on throughout her labor.

5.  Not relying on vaginal exams means that the doula hones other observational skills.  Patterns of breathing, skin color changes, cartilage and bone changes, even the usual bloody show and contraction patterns can all tell us where the mother is in labor.  Combined with her own internal messages we can present her with information so she can decide.  We can also observe signs of progressing labor, dehydration, or other concerns which might lead us to think that going to the hospital or birth center is a good idea.

As doulas, our very presence is an effort to put the mother at the center of her own birth experience.  Our role of unconditional support is special and no one else can offer what the doula does.  Rather than being a limitation, avoiding vaginal exams empowers both the mother and the doula.  Why endanger that when the price can be so high?

 

**Having said that, there are some mothers that really want at home labor support that includes vaginal exams.  That is why we have monitrices who possess both clinical skills and labor support skills and are covered by midwifery or nursing standards of care – even as students.  There are also midwives who will teach the mother’s intimate life partner to get to know her cervix during pregnancy so they can feel for labor changes.  But the expectations that are brought to the midwifery relationship and nursing relationship are different than with professional doula support. 

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If the Doula Disappeared…No One Would

Sep 5, 2013 by

Shut the door

Cover every toe with the blanket

Make sure the curtains overlap

Persevere until we find just the right spot

Remind you to ask questions

Repeat what was said to you during a contraction

Move the yukky towels from your sight and smell right away

Shut the door again

Restart the playlist

Work with your nurse, helping him or her to get to know you

Repeat your visualization with each contraction

Be calm

Be the extra pair of hands

Fetch anything you wanted

Anticipate what you need

Keep a catalog in their head of what makes you feel better

Have your comfort and well being as the #1 priority

Make sure your loved ones are informed

Know how to interpret your medical provider’s concerns in language a tired laboring brain can understand

Shut the door again

Give your partner a break and remind him or her its okay to eat

Keep the focus on you

Remind you that you are having a baby

Help the nurse

Tape your photos in the room

Understand medical procedures and explain what you might feel in advance

Believe in you and your ability to birth your baby

Remind you that you can say “no” or “not now”

Help you find your voice

Be there with you the whole time

Make sure your partner got to do what he or she wanted to

Shut the door again

Remember to fetch the baby book

Change the room temperature

Recall your deepest birth dreams and help to make them happen

Console you when they don’t

Reflect your rhythms

Take detailed notes of what people say and write down what happened

Empower you to advocate for what you want

Try other things first

Disappear when you need privacy

Understand how each pain medication may affect you and your baby

Know your birth memories and satisfaction will affect you the rest of your life

Protect the space

Keep irrelevant activities from distracting you

Offer unconditional support free from future obligations

Be your doula

 

I’ve often said that no one notices what the doula does; they only notice if she’s not there.   The professional doula often works in the background to make things run more smoothly and help people to get along.  Of course doulas do more than what is on this list but those activities (i.e. comfort measures, encouragement) can also be done by nurses and loved ones.  This list is about what we uniquely bring to the labor room.  It is based on my interviews with sixty doulas and parents about their experiences.

Use this post with your clients and other professionals!  Research articles are great but sometimes a detailed list of what we actually DO seals the deal.

For your own pdf copy of this list, click here:  If the Doula Disappeared…No One Would

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We Need To Create Social Change That Values Caregiving

Aug 28, 2013 by

Recently I wrote about how we needed to increase the value of doula care in the minds of consumers, caregivers, and third party payers.  If we are to create a social revolution regarding the value of professional caregiving, doulas can do it.  Many of us are white, well educated, and have other sources of income besides doula work (Lantz et al. 2005).  Groups with these characteristics have greater influence.  For many years the majority of professional caregivers in America have been immigrants or have brown skin.  They had little social power in our country and it was better for them as individuals to be silent.  Historically and now, professional carers are our nannies, home health nursing assistants for the elderly, and aides for the developmentally disabled.

Our movement as professional doulas is tied to these other jobs, whether we like it or not.  All involve caring for others and improving their experience of living in this world.  Being young, old, or disabled are not illnesses.  But they are times of vulnerability where the family seeks trained outside help.  Nannies, CNA’s (certified nursing assistants), and aides all offer emotional, physical, and informational support.  They must get along with the medical care providers and responsible adults guiding the individuals they support.  Most importantly, their outcomes are mostly soft.  Soft outcomes consist of good memories, satisfaction, improved relationships and the ability to communicate with others.   They also put a price on their caregiving skills and must maintain standards if they are certified.

So when we are asking for our doula skills to be valued, we are asking for social change.  We are making a statement that caregiving is a skill; it is not something innate to all women (or people).  It is learned and cultivated and takes years of experience to be consistently effective.  Caregiving skills have value.  Receiving good caregiving makes a positive difference in one’s health, personal growth, life satisfaction, and social interactions with others.  In obstetric outcomes, effective caregiving by professional doulas leads to fewer interventions, less pain, increased birth satisfaction, fewer operative deliveries and cesarean surgeries.  We have quantified the influence of the human factor in labor and delivery.  We have “known” statistically for 15 years.  But still few are willing to make the change.

Why?

Using Robbie Davis-Floyd’s terminology, the technocratic model* does not value caregiving as a reliable skill in influencing the machine like movements of the body.  It cannot be used on every person and get the same outcome.  Not every person offering doula care is a good match for someone who wants to receive it.  There are human factors involved.

Inviting doulas onto the maternity team in a way that shows they are valued, means that there are influences that someone who has comparatively little training or education can have on the patient.  The doula may make a bigger difference on birth outcomes than someone with 12 years of expensive education and training.  That can be bitter to accept.  (Of course the physician needs to have a low management style with few vaginal exams and little intervention to begin with.)  Physicians may also feel that not doing anything (no continuous monitoring, no amniotomy, allowing food and drink, etc.) is the same as doing nothing.  It isn’t.  It is allowing the social-emotional-hormonal interactions of labor to bring forth the baby when it is possible.

Lastly, it is because we do not value what we do.  We do not entirely one hundred percent believe that caregiving is a quantifiable skill that makes the vulnerable experiences in life better.  We need to change.  Our caregiving is not very different from the Filipino home health aide who is gently wiping the drool off your grandfather’s chin.  It is not that different from the African American mother of ten who is soothing and changing your dying mother’s diaper.  When your Down’s syndrome son is going into a rage in the group home, it may be the twenty-year-old community college student who knows how to talk him down.

We might like to think we are better than they are because our care is specialized, because it deals with mothers and babies, because we feel it is a calling and not a job.  Because we value what we do but not what they do: “Anyone can wipe an old guy’s mouth.”  Guess what?  No one else thinks we’re that darn special either.  As the mother of a child with a disability, as someone who has changed my dying mother’s diaper, and who has sat with many a drooling elderly man as he told me a story, it is not that different.  They are all caring activities and involve many of the same birth doula skills – just applied differently.

Some of you are sitting there fuming – angry with me.  Why?  Is it because you feel I have devalued your skills?  Is it because you would not want to do those other jobs but feel compelled to help mothers and babies?  It is these feelings that I am directly addressing.  We have an internalized prejudice against caregiving and we don’t value it.  Until we do we are stuck exactly where we are.

If you start arguing with me about how different birth and postpartum doulaing is from these other jobs, you’ve missed the point.  Yes, there are subtle differences and specialized skills involved with each professional niche.  But they are all caregiving professions.  In our society few of them are valued as important, even though every one of them is essential.  We need to value all of them so that every caregiving profession is seen as important and worthy of a good wage.

 

Lantz, P.M., Low, L.K., Varkey, S. & Watson, R.L. (2005) Doulas as childbirth paraprofessionals: Results from a national survey. Womens Health Issues, 15(3), 109-116.

*Here is a simple chart of the Technocratic and Holistic Models with an exercise to use with your clients: ModelsofBirth13

* One of Robbie Davis-Floyd’s articles on the Technocratic Model of Birth.

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Should Doulas Offer Free Services Is The Wrong Question

Aug 26, 2013 by

It seems every doula with a blog has weighed in on the “no free births” debate and every doula with an opinion has expressed it on Facebook.  The debate usually goes something like this:

“If you don’t charge, you demean my services.  You make doula work appear unprofessional or not worth paying for.  By giving away your services, people are less likely to pay me for mine.  They won’t value what we do.  And since our customers usually employ us only once or twice in their lifetime, they will tell other people a free doula is as good as an expensive one.  Third party payers will continue to refuse to reimburse us because they’ll say a consumer could get the same services for free or a professional is not required.”

Beneath this argument is a current of fear.  We want our profession to be recognized as legitimate.  As birth doulas, our actions are often invisible.  They are only missed when we aren’t there.  Our fear is if those we are welcoming into our professional ranks undermine our work – even if it is out of ignorance – how can we ever rise into a position of recognition and be seen as having a unique and valuable contribution to maternity care?  Will we ever be able to earn a living wage to support our families?

We have no control over how other doulas set their fees or how they feel the calling of doula support fits into their lives.  However we do have control over ourselves.  When we examine the root of our fear, we can take action to address those issues in other ways.  We need to establish the value of our own experience and contributions.  Some doula businesses have already done this with tiered pricing based on experience and credentials.  With each successive tier, more skills are added to the list.  Parents and payers can easily see what they are paying for.  Individual doulas have added a section on their own web site:  “What I know now after 20, 40, 100 births” or “What makes my services special”.

Instead of putting our efforts into controlling the newbies – and there are thousands of them every year – those of us who have survived past the first ten births need to make a LOUD statement about what we bring to the labor room.  There are fewer of us and we’re busier and more tired, but we have lasted.  We need to value ourselves first. 

My goal with this blog is to give you tools to do just that.  You need to go forth in your own community and state loudly and clearly, “I have something to offer that benefits everyone in the labor room.  It requires training, experience, and very few people can actually be an effective birth doula.”  We must support one another in this stage of our profession’s growth by actively promoting our value to families and to care providers.  Yup.  If you’re doing it right, you make a positive difference for nurses, midwives and physicians too.

It is up to us to use research and other evidence to create change.  After 27 years in this business, I have seen it grow incredibly.  For the first ten years, I didn’t even use the word “doula” to describe what I did.  This argument about “no free births!” is a part of our growing pains.  But we have to recognize it for what it is – a response to our fear.  Once we can name what we are really scared of, we can act to change those circumstances where we do have control.  I am eager to see what we will do next.

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“Being Whoever She Needs You To Be” – Part One: When It’s Easy

Aug 6, 2013 by

On the surface, this seems like a deceptively simple concept.  Many of us understand that different mothers have different needs.  Some women need a sister, some a mother, some a grandmother, some a new birth knowledgeable friend.  As I’ve said before, women hire you based on what they need – which is an intuitive process.  She already senses you have the potential to fulfill her needs.  What comes next is a process of adapting one’s skills and communications to best meet those needs. You can think of “being whoever she needs me to be” as a description of HOW you doula a mother.  Maybe you can relate to these two doulas’ words:

As one doula put it:  “I will match the energy in the room.  I will match their moods.  I will take on the music that they’re listening to.  I will join in the conversations that they’re discussing.  I will ask more about their life because I want to know more about them, I may pray with them.  But I don’t think I actually lose my inner self.  My inner self actually connects with their inner selves.” 

Another doula says:  “It’s taking your cues from them, picking up on the energy and just relating to them in whatever capacity they need. Sometimes I’m an information giver and I don’t do anything hands-on because they want that between them. Sometimes the dad doesn’t want to do anything hands-on, and I’m totally hands-on. And sometimes they don’t want the information because they have all the information that they believe they need in their heads. So it really depends totally on the couple.”

When I was analyzing my first few doula interviews, this concept arose spontaneously. After that, I heard almost every experienced doula describe it.  Later on, I selected passages from over 40 interviews and analyzed them, grouping similar ideas together.  From that I’ve been able to outline this process and come to understand that sometimes ‘being whoever she needs you to be’ is very satisfying, and other times it can hurt you down to your core.  Today’s post is focusing on the process and when it is easy to be the doula she needs.

Emotional support, physical support, informational support and empowerment – these are the four cornerstones of how doulas support mothers.  The doula is sensing what the mother and her partner need and being as effective as possible in providing good care. But it is the mother who is shaping the doula, who is bringing out of the doula what is inside to meet her needs.  Most of the time we enter a labor room curious about how the labor will unfold and not knowing what will be demanded of us.  We just roll with whatever comes our way.  Because we are adapting our skills to meet their needs, parents get to determine what roles we play in their lives.  We have extend ourselves in a position of service for them – and they get to choose how they wish us to serve. 

There are several roles or ways mothers need their doula to be that were fairly common.  Doulas did not struggle at all with these functions.  Here, different doulas describe roles that are common and easy to adapt to. Sometimes mothers want you to be the person who provides:

Informational Support and Empowerment:  “This mom said, “I don’t want any of this hippie-dippy stuff.  I need answers. I need someone who will help me ask the right questions and gather information.”

Forceful Guidance: “I think she needed to have a strong person who wouldn’t back down when she resisted and said, “Oh, but I’m so comfortable here.”  She needed someone who would insist that she move around and do things to make the labor more effective.”

Sometimes I’ll hear the partner in the other room say, “[The doula] said you have to get out of bed and take a shower. Because she said you’re going to feel much better.  So let’s go.”  And then two seconds later they’re in the shower and Mom’s going, “Oh, my God, I can’t believe I didn’t want to, this is so much better.”

Physical Strength:  “Right now I probably couldn’t pick up that television, but at a birth I could hold you up as long as you needed me to.  It’s amazing! I am an amazingly strong person at a birth.  I am that kind of a doula. I will sit up in a bed behind her and push with her.  I will catch her puke. I mean, I know doulas who won’t catch puke. I’ll catch her puke.  I’ll do anything.  I will do anything.”

Comforting Presence:  “As soon as I walked in the door, her husband left, went home, ‘the construction guys were coming’. It was me and the woman, and I sat there and I held her hand. She was sitting in the rocking chair, and I knelt in front of her, and basically what I did was, I staved off the people who were coming by every 20 minutes or so asking if she wanted medication, which she never did even though they gave her the pitch. She never took an epidural or any other medication. Put a sign on the door and said, “Leave us alone.” And then literally all I did was hold that woman’s hand. She would open her eyes and look at me. And she would close her eyes back, and I sat there and held her hand. And she told me afterward she could not have done it without me. Amy, all I did was hold her hand. I did nothing. I didn’t do a comfort measure. I did nothing.”

Acceptance and Humor:  “They were an Orthodox Jewish couple.  So her husband could not be there for the actual birth. But he sat behind a curtain and prayed.  At one point I said, like from the Wizard of Oz, “Pay no attention to that man behind the curtain!” And oh, I’d never say that to anyone else!”

To Let Her Lead:  “I’m thinking we’re in for a long night because she is so high need so early.  She doesn’t sound like she’s having coping related responses to what’s going on at 1-2 centimeters.  But she was not willing to relax, and she’s not going to sleep anyway no matter what I try to do positioning wise or massaging or whatever.  She’s not gonna sleep so we might as well work.  And that’s where she was at.  She did not, she did not want to relax enough to try and fall asleep which I felt would benefit her labor if she would relax and let go.”

Many of these roles or needs could not be predicted.  While we might know that we are expected to help with position changes, what we don’t know is whether she is resistant or not.  We don’t know if simply sitting with her will be all she needs or we’ll be exhausted from walking, stroking, massaging and holding her up.  While we always strive to follow the mother’s lead, there are times when sleep might be better than activity.  But we have to figure out what is more important – her being in charge or the textbook idea to rest.  How we give encouragement also shifts.  When a woman needs mothering or grandmothering, your response is different than if she is a logical and practical person.  People are very different from one another.  A good doula responds to become whoever she needs you to be.

 

Next time:  “No, I Won’t”, Hostess, Scapegoat: When “Being Who She Needs You To Be” is Difficult

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Why Not To Share Your Birth Story

Jul 31, 2013 by

A major part of our effectiveness as doulas is being authentically ourselves without revealing a lot of information about our lives.  We are most effective doulaing our clients when we can be whoever she needs us to be.  The less they know about us, the easier that is.  We are free to shape ourselves around our client and her family.  Good doulaing has much more to do with who we are being in the present moment with our clients than our lifestyle choices or personal history. 

The easiest way to start is to set good professional boundaries and not include personal details that aren’t important to your doula-client relationship.  Such as not having meetings at your home – have them either at the client’s home or a neutral place.  What your partner does or your children’s interests or even your housekeeping standards are all unrelated to your ability to be a good doula to her.  Yet, she will take that information into account in evaluating you and your abilities to assist her.  So my recommendation is to take it out of the equation.

After conducting my thesis and doctoral research, it reinforced for me that it is not a good idea to share your own pregnancy and birth stories with your clients.  None of my own clients has any idea what my births were like or the decisions I made.  It is completely irrelevant and gets in the way of her allowing me in.  As women, we can be notoriously self-judgmental.  We will compare ourselves to others to find out whether our own decisions are “better” or “worse”.  Our mothers do this – sometimes when we tell them the story or later during the labor as they make their own choices.  As doulas, our clients consider us experts – thus our choices carry more weight with them.  Many doulas have had a mother turn to them in labor and sob, “What will you think of me if I do this?”  So I keep silent about my own journey.

This can be a dilemma for doulas who are also childbirth educators (CBE).  Sharing about births in an education situation has a different purpose – “Learn from what I know”.  CBE’s are also freer to advocate for certain choices.  When the CBE is hired as a doula, she needs to be prepared to deal with this issue directly and be more aware of the potential impact on the mother during labor.  I heard this from every mother who hired her childbirth educator as a doula in my study: “I wondered what she was thinking of me”.

As a doula, when a mother asks me, “What were your births like?”  I turn it around.  For doulas who have not given birth, “What would you do?” is the same question.  “Tell me more about why you would like to know.”  It could be she is interested in getting to know me better; then it is easy to redirect to another topic to build intimacy.  It could be she is trying to figure out a dilemma.  In that instance, I can offer more information or some more emotional support.  In either case, asking about my births is often metaphorical; it is a question that indicates she is seeking care.  Her underlying needs will be better met in other ways than discussing my births.  In our own heads we need to understand that the question about our births may not be about our births at all.  It is an indicator that she has a need and isn’t sure how to express it.  Our job is to figure out what it is and how to meet it.

I’m not advocating you never say anything – there is no such thing as absolutes in the doula guidebook!  Sometimes it is very simple. “Did you have a long labor like I did?”  is just that – she wants to know if I have faced the same challenge.  “No, but I have attended a lot of women who did and helped them through it.”  Short answer plus emotional support – we aren’t dwelling on our stories, but meeting the underlying need as we perceive it.  However, we need to know that mom pretty well and sometimes we’re still wrong.  “Tell me more about why you’d like to know” can give us so much rich information about our clients!  It invites her to reflect on herself and learn something – sometimes something significant.  Rather than assuming we already know, her answer tells us so much more about how we can best meet her needs.

The really important thing is to be conscious about what you share about yourself and to make sure that information is in your and your client’s best interests.  You need to know her pretty well in order to choose what to say.  Remember this is a professional relationship, not a friendship.  You want to build intimacy and safety, but they are engaging you for a service.  Based on my research and years of experience, mothers and their families want be accepted exactly as they are – that is part of your support role.  Since people automatically compare themselves to others, you want to make sure that the information you share will soften those comparisons.

Now I know there are doulas who share their personal stories on their web sites – they feel it is honest and a significant part of the way they doula.  However it is likely that they attract clients who agree with their choices or feel attracted to the emotions expressed in their story.  This is not bad, only limiting.  People probably self select further contact based on reading the story.  It really depends on the doula, the kind of clients she wants to attract, and the kind of practice she has.  The key message I am making is to be conscious about your choices in what you share, to realize it has hidden impacts, and that mother’s questions are often not what they seem to be on the surface. 

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The Art of Labor Sitting

Jul 22, 2013 by

Labor sitting is the process of being present with a mother when she is laboring and does not require your direct attention, but needs your attentiveness.  In other words, labor is going well but there really is nothing for the doula to do but step to the outer circle and wait.  Common situations for labor sitting are early labor, the first few hours of an induction, when mother is resting with an epidural, or taking turns with another member of the birth team.

Good labor sitting means that the doula seems occupied but interruptable.  The mother does not feel pressured by your presence to be further along in labor or to be doing anything different than what she is doing.  At the same time she can feel your presence, knowing you are available if she should need you.  Often, labor sitting takes place in the same room with the mother.  Effective labor sitting is an active, not passive process.  It may seem we are sitting on the couch working on a little project.  But a good doula is much more aware of what is going on than it seems!

So how do you strike this balance?  Over the years, through trial and error – doing it wrong and by accident doing it right and then repeating it – I have found my way to effective labor sitting.  I do needlepoint.  If I am reading a book or looking at the screen on my phone, I seem occupied by what I’m doing.  My attention is focused on the book or my phone.  Someone might feel they were interrupting me if they spoke to me.  If I am just sitting there, people may feel bad because I’m just sitting in the chair not doing anything.  They might feel badly or pressured because my skills weren’t being used yet.  If I am sitting on the couch doing needlepoint*, my mind is in the room with them, yet I am happily occupied.

One time a father called me saying he and his wife were getting ready to go to the hospital.  They weren’t packed yet so he was rushing around the house.  Her contractions were 4-5 minutes apart with no bloody show.  Mom was relaxing in the bathtub and coping well.  Through our conversation I got the idea that Dad was anxious.  I surmised he wanted to go to the hospital because it would relieve his anxiety.  As we’ve all learned from TV when you go to the hospital the baby comes out.  While this is an irrational belief, it is the way our culture has trained us.

I offered to come over and help.  When I arrived, Mom had just gotten out of the tub and gave me a big smile.  My doula assessment of the labor was that it was not time to go to the hospital.  I asked her preference and she said she wasn’t ready to go (she is the decider, not me).  We talked a bit and I went to sit on the couch and got out my needlepoint.  I didn’t say anything but after a while Dad seemed to calm down.  We chatted and his furious pace of grabbing household items and putting them in the pile slowed down.  He began to pay more attention to Mom.  The message he got from my behavior was:  “Amy’s calm so there must not be any rush.”  When mom had a contraction I would stop and breathe with her, looking at her from across the room.  This visual regard is also a part of effective labor support – if she were to look at me she would see that I was watchful and available.  In due time we went to the hospital; they were both calm and made the decision they were ready.

Another time labor sitting skills come in handy is at the beginning of an induction.  There are many anxieties to soothe and many decisions that are made in those first few hours that have repercussions later.  If I am present I am able to remind them of their choices, make sure their questions are answered, and calm them down.  I create an atmosphere in the room to make it their space.  I can increase the level of connection between my client and the nurse, resident physician, and attending physician.  If I am not there, those things often do not happen.  This is another time to discuss methods of induction and parent’s concerns.  It is often easier to advocate for using the shower or tub, or having a slower, gradual Pitocin drip before any interventions are administered.  Parents may be able to get approval for a plan to go home under certain conditions.  What I have found most often is that a mother may bring up these things and then the medical care providers (MCP) explain to her why they won’t do it that way.  But in the long run, my client has explored her options to the extent she wanted to.  Plus, the MCP and my client have talked and understand each other’s concerns and preferences.  The nurse has heard the mother and she may make more suitable labor support or intervention suggestions.

Of course a discussion about options is fifteen minutes out of three hours of labor sitting.  Even if none of these discussions happen, there are still other fears and plans that are on their minds and choices to be made.  I have never found NOT being there at the beginning of an induction to gain my clients or me anything.  Sometimes with a Pitocin induction, parents want me to leave for a while.  That’s fine and we agree to check in verbally – not with a text – every hour or two.  If they want privacy with a misoprostol induction, I stay immediately outside the room or return every 15-20 minutes.  Those intense contractions can hit without warning and the partner or nurse may not be able to contact me.

Labor sitting is a creative art.  It requires an understanding of the people involved, a perception of possible futures, and an empathetic, compassionate presence.  It is not a passive process – you are not waiting for something to happen and then responding to it.  Instead, you are influencing the present moment.  You are there, caring, mindful, and available.  People take their cues from your behavior and from your presence.  Because of active compassionate labor sitting, labor often unfolds differently.

*Some doulas embroider or crochet something for the baby or make a lace cap out of a handkerchief.  Knitting needles may click which bothers some mothers.

 

 

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