“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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Career Minded Participants in Birth Doula Trainings

Dec 29, 2016 by

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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Take a Doula Training, Change the World

Nov 9, 2016 by

take-a-doulatrainingchange-theworldAlmost ten years ago I noticed many happy participants at the end of trainings but few people actually went on to become doulas. Being a researcher I decided to do a study, which was recently published as “What Motivates People To Take Birth Doula Trainings?” in the Journal of Perinatal Education, Summer 2016, Vol 25, No. 3. While I can’t repeat what was written for JPE because of copyright restrictions, the blog allows me to explore the findings of this research project in a more intimate way. This first post covers people’s desire for social change by taking open birth doula trainings; part two will focus on professional motivations; and part three will focus on personal reasons.

From 1997 to 2007, most people came to my workshops to become doulas. They traveled hundreds of miles and most people set up practices or attended births in some way. Sprinkled in were attendees who’d had difficult births or were from related occupations. By 2008 I was convinced there was something else going on – why did it feel that fewer people were headed down a doula path?

So, for three trainings I used my own participants for a pilot study. I had people brainstorm all the reasons why they were there until I stopped reading anything new. There were 18 unique reasons. Dang! Now, I wondered how popular each one was, and if this trend was happening outside Wisconsin. I tested on my own workshops again by making a survey to complete before the workshop began. I did that for a year, refined the survey, and then decided a wider investigation was possible.

Next dilemma: Who would volunteer to distribute the survey, and be committed enough to do it correctly? How could I get a diverse enough group in order to generalize any findings? I turned to other DONA International doula trainers, who were willing to implement my persnickety procedures so that everyone was doing the same thing. I am grateful to the many trainers who helped. In the end, the survey was answered by 473 people who took one of 46 DONA birth doula workshops offered by 38 different trainers in 18 U.S. states and 3 Canadian provinces. Data was collected in Oct-Dec or Jan in 2010/11 and 2013.

What I suspected all along was true: people were attending for many reasons and career advancement was clearly important to most attendees. But the proportion is what surprised me. No matter which statistic I cite from the study, what emerged is that only about half the people in those trainings were there with the intention of becoming a birth doula with their own independent practice. And only an additional small percentage intended to become a doula in another setting, such as volunteering or working for a hospital or other program. Remember, this is for trainings where registration is open to anyone[i]. I thought it would be about 70%, but here it was at less than 50%.

The Survey: First I had people choose ALL their reasons for attending from the list of 18 reasons (ALL). Next, they had to choose their top five reasons and rank them in order. Then I could compare what reasons were popular with ones that remained important. “Becoming a birth doula” only ranked for about half the people whether I was looking at all the reasons (tied for third place), the top 5 reason, two 2 or even #1. So why else were people there?

By far the main reason all people were taking a doula training was for social enrichment, not for any professional or personal reasons. “Increase my birth knowledge” was chosen by 74% in ALL, was in the top 5 for 65% and the top 2 for 37% of attendees. This means it was the prime motivating factor.

So what, Amy? Duh. That was my first reaction.

However, when I examined this issue more deeply its significance became clear. It means people are seeking out real knowledge about birth – learned knowledge from those who have been sitting with birthing people during their whole labors, over and over again. People gave up two to three days of their lives to acquire it! This means doulas’ views of birth are spreading. Birth doula workshops are often accessible, welcoming and oxytocin inspiring. Pregnancy and birth are powerful and meaningful to us. We’re attracting people who want this knowledge, and whether or not they actually use it doesn’t matter. Why? Because it changes the conversation about birth in the general public. The doula training has become a medium for transmitting a powerful vision of birth as a laboring person-centered and/or woman-centered one that deserves support.

This interpretation was strengthened by the popularity of two other reasons: “knowledgeably discuss birth issues with all women” (tied for #3 with becoming a birth doula in ALL motivations, and ranking 6th in people’s top 5 reasons), and “want to be around women who believe in women’s bodies and ability to birth” (#2 in ALL motivations, and #4 in the top 5).

This strong desire for inspiration and enrichment was not focused on the individual, but to “help women have better births (not as a doula or birth professional) (#10 in ALL, and #11 in the top 5). In other words, when analyzed as a separate group people who didn’t want to become birth doulas wanted to understand birth more comprehensively and from a perspective they couldn’t get from a book. They wanted hands-on learning but also to comprehend birth by focusing on the needs of the individual persons who are laboring and being born. Doulas put the persons at the center, not the process of birthing, and this is very different from other perspectives in our society. Even midwives need to pay equal attention to both.

Every birth is a symphony of social forces: majority culture values, neighborhood influences, family needs, the home/hospital atmosphere, the effectiveness of the body’s processes, and the individual wholistic needs of the laboring parent and the child. Through open doula trainings, we export the message that caring is a skill, it is not innate or inborn simply because of gender, and it is a skill that can be learned. We also emphasize meeting the needs of the individual over the system the person is birthing in, which is contrary to institutional values.

These messages are revolutionary and have already created social change simply by being enacted by doulas for the last thirty years. As more people grow to see birth the way doulas do, the demands they make on our institutions to humanize and be more rewarding and supportive places for staff to work will change, along with positive results for mothers and babies. The change has to be comprehensive – not just for patients but also for those who care for them. Doula trainings have become another significant medium in our modern society for the message that caring for individuals needs to be placed front and center in our birthing institutions.

 

[i] These results likely apply to other face to face trainings where general knowledge is emphasized. However they probably do not apply to workshops where a substantial part of the curriculum is devoted to a specific interest, especially if that is the reason people sign up. (Ex: shared religious beliefs about birth, a particular method of labor coping, or a desire to build a financially successful doula business).

This is Part One in a three part series about what motivates people to attend birth doula trainings.

 

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Doulas Are Paraprofessionals

May 31, 2016 by

2DoulasAreParaprofessionals (2) copyEncouraging professional behavior by doulas is one of the purposes of this blog, but it needs to be clear that the doula occupation is a paraprofession, not a profession. Community based, hospital employed, and independent practice birth doulas clearly fit dictionary and research interpretations and even the U.S. Department of Labor classification. However postpartum doula work is not such a neat fit. One of the definitions for paraprofessional is that they work alongside of or under the supervision of professionals. While they may work and make decisions independently, there is something about the nature of their work that is connected to the stronger influence of a professional.

Profession vs. Paraprofession

A profession is any type of work that needs specialized and prolonged training, a particular skill, or a high level of education; often a formal qualification or licensure is required. A defining characteristic of paraprofessional occupations is that training can be achieved with only a high school degree or its equivalent. While some programs may offer an associate’s (two year) degree, this is often done for financial aid reasons, not because it is essential for training purposes. Because there are no impediments to offering services (some people don’t even take a doula training before doing the work), we cannot define doula work as a profession.

However, that does not mean that doulaing does not require a high level of specialized skills to perform well, nor does it mean that there are lower standards for professional behavior. In fact, several papers discuss the need for paraprofessionals in the family support services field to develop a professional identity as helpers of families, and to transform who they are and how they serve others as part of a successful training process (Behnke and Hans; Hans and Korfmacher).

“Paraprofessionals frequently associate significant personal growth with their training and work experiences. They connect their training to higher self-esteem, greater personal and professional aspirations, and the ability to engage in more effective interpersonal relationships (p.10)…An emerging identity as someone who plays a valuable and valued role helping other individuals seemed to be a central experience of doula training for the women who successfully became doulas.” The women who did not complete this transformation [or become doulas] felt they gained “mostly technical knowledge” but did not feel personally changed by the experience. In fact they expressed “a resistance to change” and seeing themselves in a helping role.” –Behnke and Hans (2002)

It also does not mean that the professionals we work alongside of can effectively do our job. This is not to say that the professional person can perform the paraprofessional’s duties.   The paraprofessional has specific skills and attributes that make it possible for the professional to accomplish more complex tasks and responsibilities.

Several sources discuss that when paraprofessionals fulfill their role, they boost the effectiveness and relationship between the client and the professional. They are able do their job better because we do ours. I think this is true in the perinatal context for doulas because our core values are good communication, maternal involvement in decision making and maximizing positive memories. Even though the labor and delivery professionals we work with may not have the same values, our presence often contributes to meeting their medical goal of “healthy mom, healthy baby”.

Doula Research

The defining of doulas as paraprofessionals comes initially from research articles published in the Zero to Three journal from 2000 through 2005. Researchers at the University of Chicago were invited to participate in a community based doula program called the Chicago Doula Project (now part of Health Connect One). Examples of other paraprofessionals: paralegals who work in attorney offices; paraeducators working in school classrooms; library assistants; nursing assistants; paramedics; veterinary assistants working alongside veterinary technicians (associate’s degree) and veterinarians (doctorate degree).

Another aspect of the paraprofessional is that the person is considered a good fit based on personality characteristics and social skills they already possess. Paraprofessionals often work with the people part of a situation; they need solid interpersonal skills and to be good communicators. These skills are strengthened during the training and early supervision process. This concept is clearly defined and repeated in the articles about community based doula programs and their staff selection process.

In the only national representative survey of doulas (so far!) published in a peer reviewed journal in 2005, the title is, “Doulas As Childbirth Paraprofessionals: Results From A National Survey”. Lantz, Low and their team state “doulas have become a new type of “paraprofessional” (or someone with a lower level of training and /or credentials who works in tandem with another professional) with a specialized role and an interest in finding clients who will hire them for their services. As such, doulas (who are also called labor assistants) represent a new addition to today’s maternity care team.”

Dictionary and Wikipedia Definitions

As an English prefix, the word “para” is used “in the naming of occupational roles considered ancillary or subsidiary to roles requiring more training, or of a higher status, on such models as paramedical, and paraprofessional: paralegal, paralibrarian, parapolice.” (Dictionary.com) “A person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.” (Oxford Dictionary.com) Wikipedia, which represents the generally understood meaning of a concept, states that “paraprofessional is a job title given to persons in various occupational fields such as education, healthcare, engineering and law, who are trained to assist professionals but do not themselves have professional licensure [note – in the U.S. this is administered by state]. The paraprofessional is able to perform tasks requiring significant knowledge in the field, and may even function independently of direct professional supervision, but lacks the official authority of the professional.”

Are All Doulas Paraprofessionals?

While the definition of paraprofessional is grounded in the early literature on community based doula programs, the nature of a doula’s labor and her support behaviors do not vary substantially for independent practice and hospital based doulas. While each may have their own niche and specialty skills, the actions of support during the prenatal, labor, birth and the postpartum periods are the same. In teaching how to support emotionally and physically; offer information as needed; and prompting clients to advocate for themselves, the skills do not change. The setting changes, and the background knowledge to effectively complete the task, but the behaviors of support are transferable. For example, an independently hired postpartum doula comforting a new mother about her birth will use the same skills as a community based birth doula. Building confidence in one’s ability to birth is similar to building confidence in one’s ability to breastfeed.

One of the conflicts inherent in these definitions is that the paraprofessional works for or under a professional. We can make the case that a birth doula would not be engaged for their services if the person was not pregnant and is almost always seeing a physician or midwife for prenatal and labor care. But what about postpartum doulas? While a postpartum person may also engage a lactation consultant or be seeing a doctor for checkups, there is no connecting relationship between them and their doula.

Is Being A Doula A Vocation?

Doula work may or may not be a vocation, which is a strong feeling of suitability for a particular career or occupation. In my files, there are plenty of interviews from women who state they could not imagine not being a doula – it fulfills their purpose in life. I’ve previously written about it being a calling. However, not all doulas feel that way nor is it a requirement for effectiveness. Therefore, it is not a vocation.

United States Department Of Labor Classification

In December of 2010, the Bureau of Labor Statistics Standard Occupational Classification Policy Committee (SOCPC) added “Doula” to category 39-9099 Personal Care and Service Workers, All Other. They declared that no formal schooling was needed although most in this category had a high school diploma or equivalent. I don’t think we can disagree with that. Those of us who have advanced degrees find them helpful but they are not required to perform the tasks of doula work effectively. Other occupations in this category are Butler, House Sitter, Shoe Shiner, Valet, and Magnetic Healer. While being lumped with shoe shiners may feel frustrating or upsetting to doula readers, from the SOCPC standpoint, median wages for doula work are not high and there isn’t an educational requirement, nor are there many doulas. But also consider butlers. The Guild of Professional Butlers has 10,000 active members (35% in the U.S.) who earn $50,000 to $150,000 a year. I’d also like to point out that each of these jobs require a high level of interpersonal skill to provide good service and personal care.

DoulaDeptofLabor

 

Abramson, R., Altfeld, S. & Teibloom-Mishkin, J. (2000) The community-based doula: an emerging role in family support. Zero to Three, Oct/Nov, 11-16.

Behnke, E.F. & Hans, S. (2002) Becoming a doula. Zero to three, (November), 9-13.

Hans, S. & Korfmacher, J. (2002) The professional development of paraprofessionals. Zero to three, (November), 4-8.

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.

Meyer, H., Kirwan, A. & Dealy, K. (2005) Expanding the Doula Model: An Illinois Replication Story. Zero to Three, 25(5), 35-42.

 

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Fewer Blogs but More Amy

Dec 30, 2015 by

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

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

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

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

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

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

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

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

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

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

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

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

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

2016 promises more content and more projects!

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

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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

 

Like what you read?     Sign up to get “doula’ed”!       Link is on the right side column, you may need to scroll down   ———————>

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

Jul 9, 2014 by

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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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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How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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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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The Brouhaha Over Certification

Oct 19, 2013 by

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

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

System level questions:

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

Organization level questions:

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

Personal level questions:

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

Pondering those questions led me to these questions

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

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

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

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

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

 

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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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“Being Who She Needs You To Be” Part Two: When It’s Difficult

Aug 12, 2013 by

Most of us are concerned about mothers not being able to use the bathtub, take a fetal monitor break, delay cord clamping, or get a VBAC.  Beneath all of this is the fundamental truth of doula work:  we enter a woman’s life being a guide as she finds her way through one of her life’s most challenging journeys.  For our clients, birth can be physically, psychologically, mentally, and spiritually challenging.  It may be full of anxiety and conflicting messages from family members and medical caregivers.  We have agreed to provide support that is unencumbered by past history or future expectations.  We desire little but that she be true to herself – as she defines it.  That is what doula work is all about.

Some clients keep us at a distance.  Others bring us into their drama and thrust us into playing a part we would not have chosen for ourselves.  We become what they need to get through labor.  This can sometimes be awkward, unexpected, and challenging.  Have you ever been to a birth and wondered, “What is going on here?  What does she expect me to do?  I’m not sure how to handle this or what to say.”  Odds are you are being thrust into a role where ‘being who she needs you to be’ is uncomfortable.  Sometimes it is painful the way some situations turn out – especially when the doula hasn’t done anything wrong.  This can happen to all doulas no matter what their experience level, if they have prenatal visits or meet their clients in labor.  It is the laboring mother who chooses the depth of the contact and meaning of her doula in her life.

I came to these conclusions after analyzing dozens of formal research interviews and then checking out my ideas informally with other doulas.  Here doulas describe some situations where meeting the mother’s needs was difficult.

Family Member:  “She told me at the beginning that I reminded her of the sister that she never had.  Meanwhile she does have a sister so I don’t know what it was.  I think she just took me on as the role of a family member.  She saw me more of a friend than as a doula.  I was invited to her birthday party and she’d just stop by my house.  ‘I was just seeing if you were home’, kind of thing.”

This doula was cast in the role of family member during her client’s pregnancy.  This situation can be awkward and uncomfortable.  The doula needed to figure out where the boundaries needed to be but also needed to understand whether her client was lonely and what was going on. It is really hard to set a boundary after its already been breached especially if the mother is emotionally fragile or needy.  Figuring out the appropriate response requires good observation on the doula’s part plus sophisticated communication skills.  Another possibility is that the doula likes the mother too and wants to become friends.  But if they became friends could she be a good doula?  With friends one is emotionally involved and there are future expectations.

Hostess Mom:  “My client says, “Did you all have a good time at my birth?”  And I said, “A good time at your birth?  What would it be to have a good time at your birth?”  She says, “Well, did you all eat anything?  Did you have fun?”  Then I kind of thought, ‘Hmm, did she want to hostess?  Did she want us to have a party and have a good time?’  So I said, “When you were laboring in that other room, we were in here having a slumber party.  It was like a group of girls having this wonderful slumber party.”  And the delight came out.  “Oh!  I’m so glad, I so wanted you to have fun at my birth!”

Although the Hostess mom is rare, I have run into her a few times. She may have difficulty getting into her labor.  She wants to make sure the people she cares about are settled and enjoying themselves.  Do they have food? Something to do?  Will they nap?  She may have packed food for the hospital to please everyone else.  Instead of focusing inward, she becomes overly concerned with what’s going on in her environment.  This mom requires patience, reassurance about her loved ones and doula’s state of being, and refocusing on laboring.  She may be overly quiet because she doesn’t want to disturb someone else (part of her “be a good girl” upbringing).

Permission Giving:  “There are a lot of people who kind of just need someone to tell them that getting some kind of help or accepting some intervention or pain medication is not a sign of weakness.  For someone to say, “You know what? A really strong person does whatever needs to be done to get the job done.  And I understand how you didn’t want an epidural, but I’m wondering if you are at your limit and feel bad saying so.”

Sometimes a mother refuses pain medication when she is obviously suffering because she is holding on to some ideal.  She does not give herself permission to shift from the vision she set for herself of how she was going to respond in labor. Often we reassure, validate feelings, and reframe.  We subtly try to help the mother to find her own truth and make her own choice.  But sometimes what she really wants is her doula telling her it’s okay with us.  This can be uncomfortable for the doula because we don’t want that kind of power.  Remember it is the mother who looks to the doula for permission – not the doula who feels she is in the position of giving it.  It has been assigned to us – we did not seek it out.

Scapegoat:  “Second stage was very confusing.  At one point, she had said something like my mom should leave.  I looked at her and said, “Do you want your mom to go now or do you want her to stay?”  And she said, “Well I think she ought to go.” I said, “We can have the nurse say something.”  I looked at the dad and said, “You heard her.  Do you want to talk with the nurse?” So the nurse comes over and they tell her quietly.  I didn’t say anything.  The nurse said to the grandmother, “Why don’t we all kind of chill out and you go get some drinks or something to eat.”  So she missed the birth.  Then at the postpartum visit, the mom says, “I never said I wanted my mother to leave. I wished you hadn’t told the nurse to tell her to go.”  There was another doula there too and she was shocked.  After trying to explain what happened from my perspective, I realized I should just shut up and apologize.  Basically in order for her and her husband and the mother to all come out okay with one another they had to blame it on me.”

Unfortunately I have heard more than one version of this story.  It is much easier to blame the doula than it is to take personal responsibility.  We all know people who don’t take responsibility for their own behavior.  People don’t stop being who they are just because they are in labor.  As doulas we have very little power.  We are also leaving that family’s life.  So scapegoating the doula can be a mechanism for making the family members feel safe with one another again.  Other scapegoating examples:  The partner remained uninvolved with labor support no matter what strategies the doula used to involve him or her.  The partner showed no initiative and resisted the doula’s overtures.  Then the doula gets blamed for the partner not behaving as desired.  In another case, an intervention does not turn out favorably.  The doula may hear:  “Why didn’t you make sure I knew that could happen?” or “You should have told me not to do it – that’s why I hired you.”

Someone she can say “no” to:  No matter what you suggest, she says “no”.  As in, “No, I don’t want to ask any more questions.  No, I don’t want to move.  No, I don’t want to drink anything.  No, I don’t like the way you’re touching me.”  As doulas we sometimes feel frustrated because of the mother’s contrariness and our inability to please someone.  Sometimes, this mom is testing your support or begging for acceptance.  She wants to know that no matter how obstinate or uncooperative she is, you will be there for her.  Perhaps she has been let down in the past and really needs the experience of unconditional support.

Another possibility is this mom feels she has little power in her everyday life.  She may have to compromise for everyone else and do what others want.  However, in labor this mom has permission to say “no”.  But she may only be able to do that to someone who has no authority and where will be no consequences afterwards.  In effect, she engaged your services in order to be able to use you to meet her psychological needs.  Which in this case is to have some power over somebody else – even if her choices are not leading her to the kind of birth experience she previously said she wanted.

People are complicated psychological creatures.  When we enter into this path of service for them, we are entering into a relationship where the mother has control.  This is necessary in order for us to be effective as doulas and to individualize the care she needs.  But it doesn’t always feel good to be in the role where mom has cast us.  Sometimes it feels icky or that we’ve been misunderstood or betrayed in some way.  We may end up not liking this birth very much.

This is usually a shock for newer doulas.  Often they haven’t heard these kinds of stories or never really believed them.  A new doula may think, “If I only doulaed correctly, then I would not feel inadequate or be blamed.”  She is not likely to say anything to her doula friends because she thinks there is something wrong with her. But that isn’t true here.  In this way our discussion about doula work needs to shift.  This is caregiving work that can involve a deep intimacy with our clients and their psychological needs.  We become mirrors for their deepest selves.  But when they don’t like what they see, we may be told it is us that is wrong.

For more information about the concept of “Being Who She Needs You To Be”, read Part One.

Note:  I’d love to hear your comments about your own experiences and with what you think about this part of doula work.

 

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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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Hard Research: Birth Doulas Save Insurers and Hospitals Money

Jul 17, 2013 by

I am absolutely THRILLED to beWMJcovergin my new blog with my latest journal article, published in the Wisconsin Medical Journal.  In this collaboration, our team estimated the immediate cost savings per delivery with in-hospital professional doula support in Wisconsin.  This article strives to fill the gap regarding the financial impact of doula care based on the assumption that certain interventions and procedures would be avoided due to the doula’s presence.  We actually quantified how much money is saved when a birth doula is present to attend a low risk laboring mother.  To download a pdf copy, click An Economic Model of the Benefits of Professional Doula Labor Support in Wisconsin Births.

BOTTOM LINE:  There is an estimated $29 million savings if every low-risk birth was attended in-hospital by a professional doula in Wisconsin in 2010.   A professional doula providing only in-hospital labor support would yield an estimated cost-savings of $424.14 per delivery or $530.89 per low-risk delivery.  That does not include paying the doula for her services.  So, if the doula is paid $300, the cost-savings would be $230.89 for a low risk delivery.  This is due solely to the doula’s emotional and physical support at an advanced beginner level, not any advocacy she may do or advanced level skills she may acquire over time.  I can state that with confidence because the doula studies we gathered our statistics from used primarily inexperienced doulas.

COMMENTS: Of course there is no way to estimate the financial cost of improved emotional well-being for mothers and fathers. Hopefully this study will inspire others to do more doula research on those outcomes.  Early drafts included an estimate on the impact of labor doula care on breastfeeding.  But we didn’t have any hard data on the influence of doula labor support on breastfeeding rates (in other words, no randomized trials).

This is a conservative estimate of cost savings, it is likely that other (minor) procedures would also be avoided.  Hospitals often find labor and delivery to be income generating departments. They also expect future business from the families they treat.  For this reason private hospitals are often not interested in doulas to lower the number of epidurals and cesareans.  On the other hand, public hospitals that serve low income patients are interested in lowering their health care costs because the reimbursement rate can be so low.  Insurance companies and PPO/HMO’s are more interested in lowering health care costs than hospitals.  Private hospitals that have paid doula programs are usually located in cities where mothers have the choice of several hospitals to birth.  The doula program can give them a marketing edge.

Keep in mind, there are many influences on epidural and cesarean rates beyond the doula’s care.  Many of them are outside the scope of what we can influence by our presence and labor support skills.

This article does not mention the mechanism why doula care has such an impact.  For my perspective, you’ll need to read my dissertation or attend one of my presentations on the Attachment Needs of the Laboring Mother!  (All are on my main website.)

HOW TO USE THIS RESEARCH:

  1. If you are writing a grant or asking for funding for your doula program, it may increase the legitimacy of your application.  Even if cost savings is not the main reason for the program, having the data can provide a broader context for the value of birth doula support.
  2. This article increases the power and value of doula care.  The services we provide are not just “nice”.  They make a quantifiable difference in the quality of health care received by mothers.
  3. If you have a doula program or are trying to start one in your community, this provides more evidence why professional doula labor support is a significant and positive addition to your community.
  4. This article provides financial data on the relationship between what a doula is paid and cost savings.  We deserve a living wage for what we do.
  5. Are you billing an insurance company for your services?  Include this article with your denial appeal.  This could be especially helpful if your client avoided one or more of the procedures listed in the article.
  6. As a companion to other doula studies that show increased patient satisfaction, lower incidence of postpartum depression, decreased perception of pain, and higher breastfeeding rates, this completes the circle.  “Look, they save money too!”  Let’s hope lots more doula programs receive funding in the next few years.
  7. As a birth activist, are you trying to get doula services reimbursed by an insurance company?  Are you trying to get doula services offered by your HMO or PPO?  This article could be what turns the tides.  The formulas are now available in the article.  With your state or region’s statistics, you can compile your own statistics.  Find a graduate student with statistical expertise and ask for assistance.  (Heck, they’d probably think it was fun – or you can co-author your own report and they can list it on their vitae.)

Please let me know how you’ve used this article and how it impacted you.  Thanks!

 

 

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