Responses to “What If ACOG Certified Doulas?” Post

Nov 18, 2013 by

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.

  1. 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.
  2. 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.
  3.  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.
  4. 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.
  5.  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.
  6.  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.
  7.  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”.
  8. “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.
  9. 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.


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  1. I’m certainly not opposed to a certification process that includes us all and links us to the same code of ethics but I wonder about how we would navigate the cost of it. Currently I am working toward certification with DONA but have toyed majorly with the idea of telling my future clients that I follow the same code but not keeping the certification current. So far I have spent over $600 on certification alone…plus the cost of my supplies and have made only $360 and attended 5 births in as many years only 2 of which count toward my certification (my heart is in this profession but my husbands job requires us to move a lot and it takes time to build my business in each location)…. so for a doula like me would certification cause me to drop out because of cost, or could we find a way to make the cost of certification reflect the number of births a doula has or will have attended? Or make it super cheap but cost time or resources or something other than money to make it more about the love of the work than about they width of a persons wallet?

  2. Lesley Everest

    Who are our allies in this process?
    While I do not believe any one certifying organization should create and sanctify a standard of ethics/scope of practice, etc., I do feel we would be remiss in not looking seriously at what the large organizations like DONA and CAPPA have done to promote doula work. Some stuff I don’t agree with, but much of it I do. Whether I do or not, though, we have to respect and appreciate the amazing amount of work these organizations have done. It takes talent and insight to be on the map in this way, and these leaders are important voices and serve as powerful mentors. I also believe our allies are health care providers. While they shall NOT dictate what we are to accomplish as doulas, having honest dialogue is crucial. We do this in our area. My small organization is asked frequently to provide education to health care providers about not only what we do as doulas, but to give them tips. I have taught hands on doula skills workshops to nurses and invite medical residents to our monthly apprentice gatherings to have honest conversations and air out concerns. It is IMPORTANT to be able to receive criticism and hear concerns about our work. If we are to work in the same room with physicians and nurses, it behooves us to have good relations. Our allies are also organizations like CIMS and White Ribbon Alliance.

    Who provides critical feedback that assists us in shaping this process?
    Health care providers, as well as clients we work with. Every doula enjoys whipping out the old Klaus and Kennel stats, or the Cochrane Review which provide evidence for the efficacy of the doula. Many of these studies are medically based. They do us a solid. The more we engage in open communication, the better.

    What do we want to keep in the way things have been done and what would we like to

    I believe a universally accepted scope of practice and code of ethics is something that will serve as a nourishing container, if it can suit most doulas needs. Ideally, it would support many paths to doula work. Everyone with a calling to the work will have different desires in terms of how long they want to train, how much they want to pay, where they want to focus their attention. As long as there are an agreed upon amount of hours that cover agreed upon essential doula knowledge, the courses can be shaped by the expertise of those providing them. Many trainers have strong back grounds and certifications in other areas that are far more involved in terms of study than the comparatively simple one of becoming a doula., and these naturally contribute to and shape training approaches.

    What can we learn from other organizations who have pursued similar aims? (Such as
    CIMS and the mother-friendly hospital designation process.)
    These guys are dong great work. We can achieve this as a doula organization, as well as in partnership with groups such as this.

    What are the components for other professions in their certification processes? What
    about ones that aren’t in perinatal health care?
    There are generally standard tests. As a certified practitioner in many methods of bodywork, much of the learning I’ve experienced is dedicated to codes of ethics and communication. These are not bad things. Yes, the criticism is that they can be limiting. I believe there has to be room for some lay person, common sense approach to things. I think of Susun Weed’s approach to healing, and she goes from step 0 (do nothing), 1(engage energy), and I believe three is nourish and tonify. I feel doulas stay within this range, even in using homeopathy or herbs (unless certified in those things…they can go much farther). If you go into “diagnosing” or “treating”, this is far beyond the scope of doula work. But to provide resources about nutritive,remedies, encouraging clients to research and decide for themselves if this might be of interest of use to them, there can be room for this..

    How much do they cost?
    Way more than doula trainings, that’s for sure. What other jobs can you train for in which in just a couple of paying gigs you can entirely make back your training investment?! Yes, doula work is from the heart, but one still needs to invest in education to realize that calling. Doula training is comparatively SO inexpensive. I cannot even count how many thousands of dollars I have spent in other avenues of training over the years. Even though these skill sets are far more in depth and “recognized” than what I’ve learned in doula training, I never expected immediate return. As “professionals” I feel considering how many hours doulas put in, the fact that the longer you work and strain yourself the LESS you make, etc., payment for the work is not great, but given the small amount of education, some would say it’s not that bad. However, I’m all for good pay for the amount of energy we put out and let’s face it, crap we sometime have to put up with. For the doula who needs the work to feed her family, and this is the life skill set she has trained for, she risks burnout and has a higher risk of overlap (unless she works in a group with excellent backups clients have met).

    What about an ethical requirement? Ethical dilemmas are by their very nature complex
    and without easy answers. They require discussion and consultation with trusted others
    to sort out appropriate responses. How do other professions do this?
    Non biased third party grievance protocols would be a good idea.

    How is the history of birth doulas similar and different from that of midwifery?
    It is similar in that many doulas struggle to be autonomous professionals and have many diverse backtgrounds and approaches which often prevent them from seeking unity with those different from them, but different in that we do not have to deal with the red tape surrounding clinical care (thank goodness…it’s why I’m a doula and not a midwife).

    If we’re considering creating a system that would exclude some doulas, how can we
    remain inclusive and honor each doula’s wisdom in our communities?
    The same way you honour any human being. You just do. Everyone has the right to practice how they want. The repercussions are on their shoulders if they act in ways that are generally considered un-doula-ly. With more standards, consumer would also become more knowledgeable about.what is universally recognized as standard doula care. And if parents want to choose the doula outside of that universal standard, more power to ’em. It is their prerogative. My desire is for parents to make INFORMED choices. If doulas from other organizations want to come to an apprentice gathering for connection with our sisterhood and for storytellling, they are welcome. But I might not hire them if they don’t meet my levels of expectation of what I feel are strong boundaries around a scope of practice.and code of ethics. Also, as the work grows, these standards must evolve. We all learn as we go along, (as people and as organizations) make mistakes, and hopefully have enough ability for soul searching to redouble our efforts to offer the best service. That must always be our priority.

    Thanks, Amy, for continuing to ask the hard but really necessary questions.

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