Do We Want A Place At The Table?
One of the possibilities offered by national certification is the ability of doulas to have an impact on public health objectives. Because of the level of intimacy we have with our clients, doulas are uniquely situated to relay information about health conditions and detect possible issues. In 2014 alone, at the top of the perinatal agenda are initiatives to end racial disparities in perinatal outcomes, detection and prevention of birth related trauma, the CMQCC multi-level project to increase health care response to pre-eclampsia, and promoting awareness of postpartum kidney disorders related to pregnancy illness.
However, established medical groups and public health organizations repeatedly ignore birth and postpartum doulas as vital conduits of information and support. When women have problems, they are more likely to self disclose to the doula who they trust and know intimately. The evidence is very clear and positive. The October 2013 Cochrane Collaboration released its fifth review of labor support, once again finding there are no negatives to continuous professional labor support provided by trained people unrelated to the family. The American College of Obstetrics and Gynecologists (a trade organization) released a statement in February 2014 acknowledging the value of birth doula care by a non-family member to laboring mothers. Medicare rules may allow for the reimbursement for doula care, but it is unclear on who gets reimbursed and under what circumstances.
This leads me to two very clear questions. Do we, as professional doulas, want to be a part of solving these health care issues? Do we, as a professional group, want to be respected for our value, compensated for our worth, and treated as having unique and valuable knowledge by perinatal professionals (nurses, family practice physicians, obstetricians, midwives) and policy makers? Do we want to be reliably paid a living wage by insurance companies and other third party payers? Are we willing to generate change in order for these things to happen?
If the answers are “no”, then let’s continue to go on as we have been. Some individuals will garner respect and have additional privileges, but as a group we won’t. If the answers are “yes”, then we need to make some changes.
First though, why don’t health care organizations and professions already include doulas in their educational and support solutions? For one, training quality varies a great deal. Certification is uneven at best. There are no standards for professionalism. Backstabbing and insults towards different organizations is common on social media. It’s the Wild West, with almost every doula for him or herself. New training organizations are emerging every month. In September 2013, I located 14. In September 2014, I stopped at 24. New or old, they are of various levels of quality. Most say they “certify” their participants, but often it is only a certificate of completion of a checklist. Some small local organizations garner respect, and some larger ones dominate a particular geographic region. So the first step is separating out training from certification. Once it reaches a certain point, no similar profession does both – its time we respond to these growing pains.
Secondly, doulas are unorganized. As a whole there are no centralized standards, professionalism is voluntary, and ethics are not clearly defined. If one chooses to participate in a certification program that has this level of organization, then the burden is on that individual doula to prove herself to every hospital or perinatal professional. There is no universal acceptance that says, “You can trust me because I’ve been vetted and endorsed by this organization”. Medical staff can make no assumptions based on a doula’s credentials. This leaves policy makers, grant writers, and public health programs with few mechanisms to fund doula programs. It also means HMO’s, insurance companies, and other third party payers without a standard to pay for doula services. Without high national standards, it isn’t going to happen.
If we want a place at the table, that would mean creating a certifying organization only. No training, no education, just certification. I think it needs to offer multiple levels of certification, so there is recognition of higher levels of achievement and service. My vision is something that leaders who possess different perspectives would collaborate and create, with standards of practice that are versed in reality and a philosophy that is well explained. With today’s technological tools, it likely will not take as long as CIMS did in the 1990’s. But we are talking about institutionalizing our profession here. There needs to be a universal buy-in by different stakeholders. We will need to collaborate with organizations who we want to respect us – which means ACOG, AWHONN, as well as key policy makers. The current ACOG leadership is more likely to be doula-friendly. Otherwise the February statement would not have been released.
This institutionalization has already begun. Birth doula care is a protected right in the state of Minnesota. Medicare wants to reimburse for it, but with no national standard available to all doulas regardless of training it is very unlikely that many doulas would be able to take advantage of that. Once there is a code, doulas can likely use that with other payers.
Based on your comments, I know many of you have a knee-jerk fear to anyone telling you what to do or how to do it. You have a fear of doulas being co-opted by the institutions that you want to change – hospital policies, ACOG, nurses or doctors as a group, etc. However, our profession has a history of negotiation skills, of creating opportunities for empowerment and communication. Don’t we do that every day with our clients? I have a very high degree of confidence that experienced doulas leading this shift will utilize those skills to create an organization that works for us AND for other professionals who want to work with us. I encourage you to sit with your fear and let it lead you and us to wisdom and possibility, rather than shutting a door.
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Posts In This Series:
1. Social movements – The Next Step In The Doula Revolution
3. This Post: Do We Want A Place At The Table? National Certification and Public Health