Responses to “What If ACOG Certified Doulas?” Post
It is difficult to pose these hard questions and I’ve enjoyed reading your responses and thinking together more deeply about these issues. In many cases we’ve ended up with more questions, but that is a good thing. Doulas brought up both practical and philosophical considerations. To begin with there is little doubt among you that a medical organization could decide on a uniformly enforceable and restrictive doula policy. No one liked this idea. Several of you brought up childbirth education and lactation consultants to illustrate what happens when independent professions get co-opted by hospital systems.
- Overall people are pretty positive about the idea of an organization that would recognize doulas with different types of training and offer universal certification. Doulas with work experience in other careers view this as inevitable progress and reflecting the maturity of the doula movement. The group that feels most positively is already affected by hospital or MCP restrictions. They are experiencing what I predict will spread across our countries. Some doulas have local organizations that have negotiated successfully with their hospitals. In listening to these stories success is dependent on an individual in the hospital who wants doula support available. In a lot of cases, these people move on and the agreement weakens or momentum crumbles altogether. I do believe in the power of the local model, but it seems to be unusual for it to be sustainable long term. In addition, a local approach isn’t viable in many places nor does it solve other issues.
- Some discussions centered on whether a voluntary registry rather than a certification process would be sufficient. I understand the appeal of a registry – we could do it quickly and people could sign that they agree with what was presented. However, a registry has no teeth; there is no consumer protection, no vetting of doulas, everything is between a doula and her own conscience. It doesn’t solve the issues before us.
- When I consider a certifying organization I would absolutely hate to see the division that has occurred among midwives occur among doulas. This fear was a part of several conversations. Doulas are not the same as midwives. We don’t compete with physicians for business. Our social and political histories are different and so is our future. It is dependent on holding our leadership accountable and creating systems and communities that lessen the possibility of divisiveness. In midwifery, it was the leadership of different organizations that caused the current fracture. I am adamant that we intentionally continue to create an environment where all doulas are welcome. We need our family doulas, the doulas who only do four births a year, the ones who do doula work as their way of changing the world and reversing disparity. However, we also need professional standards and a way to teach and enforce those standards for doulas who want them. We can create unity while still acknowledging differences in goals, approach, and the women we serve. If anyone can do it, doulas can. Yes, there will be differences between professional and non-professional doulas. But there is room for us all and we need each other – if we forget that, we’re already lost.
- Additionally, there were doulas who stated “we serve the mothers, not the doctors”. This is true. Others were concerned that the “spirit or soul of doulaing” would be tainted by universal certification standards. Yes, the sacred nature of our service is our connection to a woman and creating the space for her birth to unfold as she wishes it. It demands that we give of ourselves, of our essential nature, of what we cherish. We are changed by the work we do. When done in honor and service to the mother, it has the potential to heal. Simultaneously, many doulas work in environments where they interact with physicians and nurses. Can we create a system that honors the true nature of doula carework and has a good possibility of being respected by medical staff? I think we can. However it would be voluntary. If this certification process doesn’t fit your paradigm of doulaing, then don’t do it.
- There is a lot of diversity among doulas. That is because there is a lot of diversity among women. We all need different things and no one is everyone’s best doula. Some concerns were raised about whether all philosophies could truly be respected. Can someone who views pregnancy and birth as one of the most sacred acts in life be equally honored as someone who sees them as mostly physiological processes? Our strength is that we’re doulas – we’re accepting and empowering of the mother at all times. We create opportunities for her to find her own way. Can we not use those same skills with one another in this co-creative process? Maybe I’m idealistic. But I trust us.
- The medical system most of our clients give birth in and that we interact with is imperfect. It isn’t optimal for mothers, babies, nurses, doctors, or midwives. Some doulas asked, “If we choose to participate in the systematic ritual of certification, aren’t we just embracing and internalizing this broken (or patriarchal or classist) system?” We want to use this system to our advantage without being tainted by it. The paradox is that we don’t want to perpetuate this broken system but we want to be recognized by it to gain legitimacy, power, and privileges. “Isn’t the very existence of doulas a bandage on this broken system?” Of course it is. To me, this is the dilemma of our times. We face a version of these conflicts in education, our food supply, human rights, almost anyplace you bring conscious awareness. If this issue has meaning to you, you will need to use your own values to weigh what is gained and lost by participating.
- Others said, “I don’t want to be like providers; I want to us to be ourselves!” What needs to be repeated is that I don’t think we are going to be allowed to continue the way we have been. And I mean “allowed”. We don’t have power and once the people that do decide they want to do something, it is too late. We can only react. Just ask the doulas who are already operating in areas where the hospitals have restrictive doula policies. Some are in rural areas and some are in large cities – but each is finding its own solution to their “doula problem”.
- “Certification doesn’t make me a better doula.” I have a few responses to this. One, the certification process we’re discussing doesn’t have to look like anything we’ve seen before. What would we dream of having, being, doing? At what stage in their career do we envision people going through this process? Could we offer mentoring groups? Right this minute now my husband is Skyping with his certification mentor to meet his supervision requirement for sex therapy. We have different technological tools, years of experiences, and vivid imaginations. There is a new generation of doulas who can contribute to crafting a different process. We could devise a system that could make you a better doula. My second response is that maybe certification isn’t about making you a better doula. Maybe it is about legitimizing what you do and what we all do. Maybe it is about offering consumers some protection and recourse. Maybe it is about making a statement to medical careproviders that we take our role seriously and that we are professionals. Third, we have the opportunity to define the meaning of certification and why it is preferable for parents to choose a certified doula. We can create a system that has benefits to other stakeholders as well as ourselves and market that.
- Looking ahead, those who are positive about this system have also posed other possibilities. According to a research project I am in the midst of, almost every woman who wants to be a professional doula or a midwife also “wants to make money in a profession I enjoy”. With the current system that is not possible unless you have clients that are paying out of pocket. Even so doulas are not charging what their services are worth. They charge what the market will pay. The new health care legislation will no longer allow for doula support to be paid out of flexible health care accounts. If we want to be paid a wage by third parties that supports our families, universally recognized certification will be the minimum requirement. (IBCLCs created their own certification years ago, and are now pursuing state licensure in order to ensure insurance and Medicare reimbursement and recognition.) If we can get our services covered by health insurers, the market for our services could expand exponentially. But we can’t lobby for that without a universal standard for certification and professionalism.
We would not even be having this discussion without the path carved in the last 20 years by PALS, DONA International, CAPPA International, and ALACE with their certification programs. They have led the way. Doulaing another woman is an essential experience of existence for many of us. It fulfills what it means to be a woman and it is ancient; coded in our DNA. In some ways, the idea of codifying how it has to be done is upsetting. If there were no external forces pushing the issue, I am pretty sure we could stay with the situation the way it is. But I don’t want us to lose what we have and we don’t know when the window of opportunity will close. With universal certification standards and a centralized organization, we are shaping the future of our profession for decades to come. If we centralize our power we may gain more than what we lose.
Author’s Note: When I started my inquiry about certification issues I had no idea it would lead me to this place. I’ve learned over the years that my voice is pretty direct and provocative. I say things I see out loud. What I’ve learned in 20 years is not to rush and to include lots of voices. I value process. When the process of listening, hearing concerns, and building consensus works, the path to creating what you wish falls into place. So let’s all reflect, talk, ponder, ruminate, observe and wonder. Let’s engage with one another about the issues I’ve brought up in the last five posts. Thanks to those who have already sent me proposals. Email me with your thoughts – there’s no time limit. Then let’s see what happens.
If you want some provocative questions, here is a list to help get started.