Do We Want A Place At The Table?

Nov 11, 2014 by

PlaceTableOne of the possibilities offered by national certification is the ability of doulas to have an impact on public health objectives. Because of the level of intimacy we have with our clients, doulas are uniquely situated to relay information about health conditions and detect possible issues.  In 2014 alone, at the top of the perinatal agenda are initiatives to end racial disparities in perinatal outcomes, detection and prevention of birth related trauma, the CMQCC multi-level project to increase health care response to pre-eclampsia, and promoting awareness of postpartum kidney disorders related to pregnancy illness.

However, established medical groups and public health organizations repeatedly ignore birth and postpartum doulas as vital conduits of information and support.  When women have problems, they are more likely to self disclose to the doula who they trust and know intimately.   The evidence is very clear and positive.  The October 2013 Cochrane Collaboration released its fifth review of labor support, once again finding there are no negatives to continuous professional labor support provided by trained people unrelated to the family.  The American College of Obstetrics and Gynecologists (a trade organization) released a statement in February 2014 acknowledging the value of birth doula care by a non-family member to laboring mothers.  Medicare rules may allow for the reimbursement for doula care, but it is unclear on who gets reimbursed and under what circumstances.

This leads me to two very clear questions.  Do we, as professional doulas, want to be a part of solving these health care issues?  Do we, as a professional group, want to be respected for our value, compensated for our worth, and treated as having unique and valuable knowledge by perinatal professionals (nurses, family practice physicians, obstetricians, midwives) and policy makers?  Do we want to be reliably paid a living wage by insurance companies and other third party payers?  Are we willing to generate change in order for these things to happen?

If the answers are “no”, then let’s continue to go on as we have been.  Some individuals will garner respect and have additional privileges, but as a group we won’t.  If the answers are “yes”, then we need to make some changes.

First though, why don’t health care organizations and professions already include doulas in their educational and support solutions?  For one, training quality varies a great deal.  Certification is uneven at best.   There are no standards for professionalism.  Backstabbing and insults towards different organizations is common on social media.  It’s the Wild West, with almost every doula for him or herself.   New training organizations are emerging every month.  In September 2013, I located 14.  In September 2014, I stopped at 24.  New or old, they are of various levels of quality.  Most say they “certify” their participants, but often it is only a certificate of completion of a checklist.  Some small local organizations garner respect, and some larger ones dominate a particular geographic region.  So the first step is separating out training from certification.  Once it reaches a certain point, no similar profession does both – its time we respond to these growing pains.

Secondly, doulas are unorganized.  As a whole there are no centralized standards, professionalism is voluntary, and ethics are not clearly defined.  If one chooses to participate in a certification program that has this level of organization, then the burden is on that individual doula to prove herself to every hospital or perinatal professional.  There is no universal acceptance that says, “You can trust me because I’ve been vetted and endorsed by this organization”.  Medical staff can make no assumptions based on a doula’s credentials.   This leaves policy makers, grant writers, and public health programs with few mechanisms to fund doula programs.  It also means HMO’s, insurance companies, and other third party payers without a standard to pay for doula services.  Without high national standards, it isn’t going to happen.

If we want a place at the table, that would mean creating a certifying organization only.  No training, no education, just certification.  I think it needs to offer multiple levels of certification, so there is recognition of higher levels of achievement and service.  My vision is something that leaders who possess different perspectives would collaborate and create, with standards of practice that are versed in reality and a philosophy that is well explained.  With today’s technological tools, it likely will not take as long as CIMS did in the 1990’s.  But we are talking about institutionalizing our profession here.  There needs to be a universal buy-in by different stakeholders.  We will need to collaborate with organizations who we want to respect us – which means ACOG, AWHONN, as well as key policy makers.  The current ACOG leadership is more likely to be doula-friendly.  Otherwise the February statement would not have been released.

This institutionalization has already begun.  Birth doula care is a protected right in the state of Minnesota.  Medicare wants to reimburse for it, but with no national standard available to all doulas regardless of training it is very unlikely that many doulas would be able to take advantage of that.  Once there is a code, doulas can likely use that with other payers.

Based on your comments, I know many of you have a knee-jerk fear to anyone telling you what to do or how to do it.  You have a fear of doulas being co-opted by the institutions that you want to change – hospital policies, ACOG, nurses or doctors as a group, etc.  However, our profession has a history of negotiation skills, of creating opportunities for empowerment and communication.  Don’t we do that every day with our clients?  I have a very high degree of confidence that experienced doulas leading this shift will utilize those skills to create an organization that works for us AND for other professionals who want to work with us.  I encourage you to sit with your fear and let it lead you and us to wisdom and possibility, rather than shutting a door.

 

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Posts In This Series:

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

2.  Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Certification

5.   Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

 

 

7 Comments

  1. I agree that a nationally recognized certification would be beneficial to doulas in the movement of change but what concerns me remains very much the same. .. what about the majority of us who are young mothers ourselves who choose this career for the love of birth and good outcomes but also because it did not require years of college, high cost of training and we could step into the field quickly unlike other fields that similarly started and now the only way in is through a Vo – tech program and spending big bucks getting the training only to have low chances of getting hired because of the volume of people training for that same thing (I.e. massage therapy) or burn out before even starting?
    I don’t think you have addressed how this would affect the personal lives of the doulas it will touch, which is at least for me a very large concern. My priority list is wife, mother, home school teacher, doula… and I line up the number of clients I have according to that list. Once a client is booked it changes significantly to put that client first but the majority of my life is not on the field it is in my home. So how can we assure that people like me who are passionate about the work they do but are not out to make a living on it are not pushed with force out of the field entirely?

  2. I am following this conversation even when I don’t post. I am not opposed to national certification, but I am approaching it cautiously. I agree that it is a topic that requires time and careful thought. I definitely see the benefits of the accreditation/certification. I personally agree and also think that doulas as a body WANT to impact birth and WANT to see birth practices improved and more evidence based, more than they can do on an individual basis. I also definitely agree that it would be beneficial to have one standard by which an individual doula could be assessed…. pass the test, you met the standard and therefor there is a basis of trust formed already. It is interesting to know that Minnesota has created a doula registry and begun to set a standard.

    Susan Lane has made some interesting suggestions about how that exam might look…. I could go for those ideas. I think that it addresses some of my concerns as to various levels of intellectual prowess doulas have. The profession, after all , does not require a higher education degree to take training. So we don’t want to make the exam one that weeds out those who are less educationally privileged, or who aren’t “book smart’ because doulas need to be “heart smart” or “service smart” ( I don’t know what the multiple intelligence people call this). If we want community doula programs (doulas serving their own cultural group) to get their ladies certified we would have to have an exam that they could pass- no offense intended- Similar to the very successful WIC peer counselor program breastfeeding support is given by WIC participants to WIC participants- not all WIC moms are undereducated or unintelligent but you don’t have to be super smart to learn enough about breastfeeding to give good support and you don’t have to be super smart to truly care.

    It’s interesting to consider multiple levels of certification. My husband is nationally certified in human resources. There are 3 levels: Professional in Human Resources (PHR), Senior Professional in Human Resources (SPHR) and Global Professional in Human Resources (GPHR). He has the middle level. So a person has a degree in HR or doesn’t but works in HR- they can take the exam ( a 4 hour one). After they pass, all levels need to make 60 general HR CEU’s every 3 years but the higher levels also add an additional amount based on their level of cert. Each cert level has differing responsibility expectations- the basic level is a generalist, the middle level has experience as a strategist ( 20 extra CEU’s in strategy) and the highest has experience with global companies (more & different CEU”S). In its basic form this model seems like it could apply to us.
    Do you have a vision or an idea about what these differing levels of certification might be?

    I agree that the creation of the exam should include leaders in the doula field regardless of association with particular organizations- preferably including some from all. Perhaps at early discussions also including other leaders in the birth field so that we get a perspective from them about what types of standards would make them feel secure. I am not a mover and a shaker- I just work in my little nook- but there are others who are well traveled and talk to many from other areas who know their own areas well. These leaders hopefully would have a broader perspective and bring much to the table. Also doulas who have been doing this work for 30 years certainly have experience and knowledge but some newer doulas may have unique perspectives and see the profession from current views and also have much to offer.

    “creating a certifying organization only. No training, no education, just certification.” YES!
    From Susan: “… an independent organization to offer and monitor,… professionals who can write exams that are culturally unbiased and effectively demonstrate the skills needed by the profession.” YES!

    I don’t know how other people do things and when Amy poses the question ” what would national certification look like?” I don’t immediately get a practical picture. It seems big and scarey and difficult but like with most big projects and big changes it’s easier if we break them down into smaller parts. Were I to want to make or create something that I didn’t know how to already do I would look at what others have done… not just one other but many others to get an idea, or many ideas, to get a good general idea of how others have made the same kind of thing. Which Is why I keep looking at the certifications that I know of, professions that I understand; to create a base from which to begin. I would look at the parts that work for me, perhaps modify some aspects of some parts, take what I like from many others’ models and apply what I know I want mine to specifically look like or needs to be like, and then create it. Trying not to put the cart before the horse but still if a crystal clear idea comes along that’s probably a middle part – keep it but don’t work on it just yet.

    So asking lots of questions, I think, helps clarify the goals. Really looking at the risks and benefits at each step. Keep going AMY!

  3. I could NOT agree more with everything you said, Amy! I said as much at the DONA/Lamaze confluence, too. There is no hope of improving birth outcomes by standing on the fringes, and everything you stated is why that’s the case.

    I do think accreditation is the way to go. I actually think that it doesn’t really matter if you call it accreditation versus certification, although the verbiage does help separate the two processes. Certainly there are some models, such as the accreditation process for child care, that could be used as a road map for the process for doulas. I do think there needs to be better outreach to the medical community to get wider use.

    Bravo, and thanks for taking the time to bring up this very difficult, but very needed, topic.

  4. Susan Lane

    I believe we need to distinguish in this discussion between training, certifications as now offered by DONA, CAPPA, ICEA and dozens of other organizations, and accreditation, which no certification has now. Doulas should be able to practice with or without certification, regardless of training as they are in Minnesota now. But for those who wish public reimbursement via Medicaid or private 3rd party reimbursement, a higher level of accountability is going to be necessary. We slid by in Minnesota getting 3rd party because we limited by law the organizations that can certifiy doulas for our state registry ($150 for 3 years requires proof of certification by one of the organizations and a criminal background check to be on the registry.) But that law is weak and could be contested by other certifying organizations.
    The only way to maintain a uniform standard is with an accredited national exam such as midwives have in the NARM and such as Lamaze has chosen to pursue for its members. But this IS a complex task which will require a couple of years to achieve and an independent organization to offer and monitor, along with start up money- probably a grant – and yes, the sustaining funding of those who take the exam. If I were the Goddess of Accreditation (there will never be poetry written about that position :) ) I would hire the professionals who can write exams that are culturally unbiased and effectively demonstrate the skills needed by the profession. I would then have that exam available orally on line, I would have a small committee made up of advanced doulas from every major cultural group regularly reviewing the presentation and accessibility of the exam , and I would work hard to keep the fees reasonable. I visualize an exam of fewer than one hundred questions, a large segment of which address relationship skills along with the usual comfort measures, understanding of scope of practice, and the basics of childbirth education,pre- and postnatal health, and breastfeeding.
    Everyone should also know that as with everything involving health care, each state will make its own special regulations. But the Minnesota model of a registry rather than licensing, of medical association but not supervision for Medicaid payment, of a womens’ legal right to a doula of her choice, are proving to be effective. All we need is a uniform standard of achievement that matches a uniform standard of practice. The eight largest training organizations nationally all have a very similar standard of practice for doulas, so that is a small issue. Writing an exam and establishing the mechanism/organization to administer it – that is the large task before us.
    I believe it is wholly unnecessary to involve the medical community in this process, although I do think there is a PR job to be done with every successful interaction between doula and primary caregiver at every birth. We did not attempt to persuade the medical community regarding doula care – the evidence was there and the articles in the ACOG journal dating back to 2008 so they knew and chose to disregard. Rather we approached the public health community, the legislators who write the health laws and the departments of health/human services who recommend to legislators what good preventive, evidence-based care is. The lobbyists for ACOG told us it would never happen – 3rd party payment. We smiled, ignored them as a group, worked professionally and cooperatively with them in our practices, and that has been the key. Of course, we had the support of much of the midwifery community, increasingly of nurses just because we followed scope on the whole and worked with them professionally and respectfully birth by birth. We formed doula groups around the state and communicated with and supported each other. We practiced non-competitively at first and most still do, encouraging women to meet several doulas and hire the doula best for them. That is how you build a field, by cooperation rather than competition.
    Even so, we have many challenges, but the idea is exactly as you said, Amy, to be professionals, to profess what we do, to extend the best possible service to the most women. If we do nothing but quietly practice with the few women we now are able to serve, ultimately it will be easy to undermine the practice. It will go away or be driven away as home birth has been in some states.
    So again, being too long winded – I believe that accreditation is the only answer to promote long term stability of the occupation of doula. No matter who trains, no matter who offers a certificate of training, there needs to be a single, respected, meaningful, accessible accreditation process available nationwide, in my opinion. Then there will be more demand, more 3rd party payment, more work for doulas, and most importantly of all, better birth for many, many more women, babies and families. I hope many will join this process as many are needed. It’s an exciting time if we hang together and work for common goals.

  5. Jamie swann

    I agree with you, Amy. I work in case management for an MCO, working with Medicaid recipients. Certification /licensing is a huge issue. I believe that if there were a national certification, we could get some headway in getting doulas covered by these MCO’S that serve the undeserved population.

  6. Judith Nylander

    Hi Amy,
    Judith Nylander here – we have spoken since you came her several years ago for advanced doula training. I just finished my term as president of the Childbirth Collective. I also do legislative work with Susan Lane for the Better Birth Coalition.
    You are reading my mind! Susan and I chew on this topic all the time. I know she has spoken to the DONA leadership and I surely hope they will get on board with this agenda – they bill themselves(and I am DONA trained and certified) as the premier doula organization and I am waiting to see them live up to that. Our struggle here in Minnesota to change the Patient’s Bill of Rights, to establish a doula registry in the Board of Health and to pass legislation to allow medicaid mamas to access doula care has been a labor of love for the last decade.
    It is time to rally our community to this cause. I look forward to working towards this goal with DONA and you. Let’s chat some time.
    Stay warm,
    Judith

    • Amy Gilliland

      Hi Judith! I think that national certification needs to arise outside of any existing organization, more of a separate organic movement of its own. I think that is a better way to make it more inclusive of diverse viewpoints and learn from the wisdom of many training organizations. Lactation consultants recently went through this whole process; massage therapists have; we can learn from their models too.
      Glad to know that I am spurring discussion in so many corners! We need to have these conversations and take time with it.

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