Hospital Agreements: An Opportunity For Engagement [Part II]

Jul 24, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (1) copyIf a doula agreement is being waved in front of you, congratulations! It means that your doula community has gotten too large to ignore and is having enough of an impact that the hospital wants to exert some control. Now the real work begins, not with clients, but with the institutions where our clients are choosing to birth. You have an opportunity to create a collaborative atmosphere even if their actions seem hostile at the moment. This is politics, system change, and social change happening in your neighborhood, and I hope to give you concrete suggestions to co-create a synergistic relationship – even if it seems impossible now.

Keep the focus on your long term goal: an open channel of communication between this hospital and the doula community. Your goal is not to get the hospital to eradicate the agreement but to build understanding and strong reliable communication channels between two groups of people. You are using the proffered agreement as an opportunity for greater connection, understanding and dialogue between the people most affected by it. It’s imperative that the doulas who are approaching this conflict negotiation realize that attacking the hospital’s solution, the agreement, is counterproductive.[1] Anytime you openly criticize something, you make that person defensive about it and more entrenched that they are right. Instead, you have to put the emphasis on the conflict and your mutual interest in resolving it. If you focus on the agreement and what’s ‘wrong’ with it, you will get into a power struggle and doulas will likely lose. If not this issue, how you handle this will set a precedent for communicating about any future conflicts. Sorry to increase the tension, but this is an influential time and needs to be recognized as such.

So what can doulas do?

  1. First, have a leadership committee of the people who have the best communication skills as well as doula experience. Prepare yourselves. Read simple books on negotiation and conflict resolution (see below), or see what community or internet resources are available for continuing education. Being prepared and having skills will give you more confidence – but don’t wait too long.
  2. Contact the people in charge and set up a meeting. Make it clear that your goal is to generate solutions to their problem, and not to deny that a problem exists. Explain your perspective is rooted in concern for the long term health of the hospital’s relationship with its future patients and future doulas, and an ongoing relationship with open communication can work to both of your benefits. Doulas are not going to disappear, and trying to exert power over the doula community without seeking to get to know them will not work in the hospital’s favor. Someone in that problem solving group knows that, but their voice may have been drowned out by others. Doulas, there are allies in that hospital, and you will need to find them. Hopefully, you will also cultivate new ones through your sincerity and focusing on the long term goals. This will be harder to do if the atmosphere is hostile or the agreement is written in a way that delegitimizes a doula’s contributions to maternal-infant health or seeks to restrict the doula’s access to a client. However it isn’t impossible. Remember, they don’t understand our values or our role and you can change this over time.
  1. Be gently persistent until you get a meeting. State that you don’t want to get rid of their agreement proposal, but seek to find additional ways for their needs to get met. Do they want someone to call and complain to? Often what people want the most, over and over again, is to feel that their concerns were heard and met with kindness and respect. If you push that aspect of the meeting – “we want to hear more about your concerns” – it will be more effective than “we have to do something about this agreement”.
  2. Use this handout Doula Information for Nurses Sheet (initially designed for a nurse and doula conflict resolution meeting in my city) or a similar one to explain why doulas do what they do and give background about the state of the profession. Make sure you are all on common ground about doula support and what doulas actually DO and don’t do. Issues may arise as you go through this sheet together.  Listen. Listen. Listen. Even if the people at that meeting are not listening to you, listen to them. Reflect back their concerns in your own language. “What I heard you say is…”
  1. Emphasize common interests. “What we both value is…[2] Do this repeatedly as needed throughout the conversation.
  2. Ask, “What other possible ways to address this problem did you come up with besides an agreement?” This is where you’ll find out whether they fully explored the initial problem or took into account the concerns of other stakeholders. It’s possible they may not have and you can initiate it at this meeting. Ideally, you’ll be able to follow up with a small group made up of multiple stakeholders (see list in Part I) who are interested in a more complete problem solving process. Resist the urge to rely on one or two people from either group to do the negotiating or attend meetings – if one person leaves their position you’re back where you started from – without an ally.
  3. If the atmosphere is hostile or untrustworthy, it is critical that you do not allow emotions to cloud your judgment. Your communication needs to be intentional, not reactive. Don’t take bait – slurs on a doula’s past actions, a doula’s motivations, etc. Let it go for now.  Frame it as “learning about the tactics of your negotiating partners”.  Recognize that establishing trust takes time and repeated interactions where people behave reliably and do what they say they are going to do. Promise what you can deliver, not what you can’t. Set reasonable deadlines and meet them. People learn the value of a doula by experiencing you doing what you do, not from reading or talking about it.
  1. Be prepared for the presenting problem to not be the true problem. In one hospital I consulted with people were angry that doula clients kept insisting on special treatment for their newborns. Administrators discovered that while there were protocols for one hour of uninterrupted skin to skin contact in place, that was not what nurses were actually doing. Unless the doula reminded the parents and both parties actively advocated for it, usually repeatedly during that first hour, parents were not getting the care that the protocols were written to encourage. Nurses didn’t like the criticism and resistance they experienced from doula attended clients, and it was labeled as a ‘doula problem.’ However, once different stakeholders were interviewed, they discovered a deeper issue. It turned out the nurse’s workloads were so high that they felt pressured to do newborn procedures even when that interfered with the one hour skin to skin mandate. So what was initially perceived as a doula conflict, was instead a conflict between policy and workloads, with parents and babies being the losers and doulas as the scapegoat. This can also work the other way, so be prepared to listen to criticism of doula behaviors. Remember, listening is the most important thing you can do at this stagethere may be years worth of resentments pouring out if you’ve never had a meeting before.
  2. Focus on the possibility of a positive outcome. You can create collaborative relationships that don’t compromise the doula’s autonomy, ability to represent and serve her clients, and satisfy the hospital staff’s needs for predictability. In doing research for these blog posts, I found examples of several birth communities who had already created collaborative long term processes. (Please add yours in the blog comments.)

Susan Martensen, a doula and trainer in Ottawa, Ontario, Canada, states that her local doula group has worked hard to be recognized as part of “The Care Team” and not as a “visitor”. The instigating situation that brought doulas and nurses together was the SARS outbreak in 2003. Hospitals sought to limit access for anyone into the hospital. Doulas in the area formed a new group to develop a standard of practice and code of ethics based on ones from their different training organizations. All doulas in the area agreed to sign the document they had created. “Two hospitals in the area agreed to regular meetings to build bridges and establish doulas as part of the Care team (and not included in the usual visitor policy),” according to Ms. Martensen. “It took several in-services to introduce, or re-introduce, the role of the doula to the nursing staff, so that we all understood the collaborative model of care. The meeting was multi-disciplinary, so there were doctors, anesthetists, pediatricians, etc, there, but not everyone and not all at the same time.”

The next step was to establish nametags for the doulas that were created by the doula group and a book at the nurse’s station that listed photos, names and contact information for the doulas. “Over time we developed a complaint process as well as establishing a system for addressing any conflicts during a labor,” adds Ms. Martensen. “It is a collaborative model that has worked well for the most part, and it is not administered by the hospitals.” They continue to have regular meetings with key personnel and doulas to provide feedback and assess their collaboration with one another. Ms. Martensen feels that the emphasis on collaboration and being seen as a valued member of the care team is what has made all the difference.

Ana Paula Markel, of BiniBirth in Los Angeles, California, USA, initially worked with a small task force at Cedars Sinai Medical Center. A rising number of conflicts was leading to a tense atmosphere, and Ms. Markel was talking to a labor and delivery nurse about it. Out of that casual conversation, a small group of interested individuals got together and outlined several steps which they have been implementing in the last year. They created a Cedars-Doula Advisory Committee made up of labor and delivery nurses, midwives, the nurse manager, and six doulas from the community who each have a different level of experience. Ms. Markel feels that having new doulas involved is crucial, since they often present a different perspective. The CDAC meets monthly, and has its own email address where people can write with questions or complaints. It is used by both doulas and nurses. Based on this feedback, they created a teach-in day for doulas, which was also attended by much of the labor and delivery staff. They did several role plays of challenging scenarios and explored the point of view of both nurses and doulas and what each thought the other “should” be doing. It was very enlightening for everyone. After attending the teach-in day, doulas received a recognition badge to wear. In this way nurses were reassured about the doula’s perspective and background knowledge.

Both the Toronto and Los Angeles doula communities were able to turn potential conflicts into opportunities for collaboration and enrichment. So, take heart! It can be done – you can create a process that benefits many stakeholders long term.  It is up to us, as doulas, to do the work and it is a task to be embraced. To have the ear of hospital leaders, even if it is coming in the guise of an untenable agreement, is what decades of doulas have been waiting for: an opportunity to create positive change in the system.

 

Here is a pdf copy of this blog post: Gilliland Hospital Agreements Engagement

[1] Fisher and Ury, Getting To Yes, p. 41 (first ed.)

[2] Fisher and Shapiro, Beyond Reason, p. 53

Fisher, R., Shapiro, D., (2006) Beyond Reason: Using Emotions As You Negotiate. Penguin Books. 

Fisher, R., Ury, W., (1981 through 2011) Getting To Yes: Negotiating Agreement Without Giving In. Penguin Books. 

Other conflict resolution, negotiation, or mediation resources may be available through a community college, university extension, adult education, or state or provincial small business support organization.

 

 

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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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Are There Enough Clients For All Of Us?

Feb 6, 2016 by

Are There Enough Clients For All Of Us-Do you feel that you are competing with every other doula for clients? “There’s not enough for me and for everyone else. If someone else gets a client, that’s one I don’t have.”  And then you try to work harder to compete and get ahead. (Or you give up.) Fearing there isn’t enough to go around means believing in scarcity.

Let’s break down that idea – Are there enough clients to go around?

From a rational perspective, the answer is clearly “yes”. According to the Listening To Mothers III survey, 6% of people in the sample had a birth doula but 27% of them wanted one. That’s a huge gap between demand and supply. Granted not all of those people may be willing to pay a doula a sustainable fee. But the doula’s biggest market is second time parents! They are more aware of the doula’s value and will pay money not to repeat their first experience. Unfortunately they did not report on postpartum doulas in the survey, but many people have had postpartum experiences they don’t want to repeat either.

From a marketing perspective, the answer is also “yes”. By profiling and targeting your ideal client, you learn that the best person for you to work with isn’t “everybody who is pregnant”. No matter how wonderful you are, you are not everyone’s best doula. It really is a select group. When you compare your ideal client to those of other doulas, you realize that you are after different markets. Of course there will be some overlap and not all of your clients will fit the ideal profile, but many will be close to the target. I find that reassuring – we’re not all after the same person but different kinds of pregnant people.

From a personal perspective, the answer is always “yes”. People choose their doula based on who they feel safe with in their gut, not on how good your welcome packet looks. (The welcome packet opens the door and introduces you.) We have no control over that decision except to be our authentic selves.

For my nineteen years as a doula trainer, I have been preaching that it never makes sense for doulas to compete with each other, no matter what organization they trained with. There’s no economic reason to do that because the market isn’t saturated. When one doula gets a client, it generates interest in the market among other potential buyers of our services. The more people we serve, the more interest grows, and more our potential market grows. Every nine months there is a complete turnover. So our best strategy to grow the profession is to support each other while also pursuing our own individual goals. Abundance is out there. The more we work for success together, the more there will be for all of us.

Every doula I have trained understands this. There are plenty of potential clients and the more we work together to educate the public and careproviders, the more paying clients we will all get. The doula leaders in our region (past and present) also reflect this attitude, and because of it we have a more collegial and supportive atmosphere in our state than in many of the places I visit across the U.S.

When we choose scarcity, we choose fear. Fear that there won’t be enough. Fear that someone else will get the good stuff first. Fear that if someone else does well, that means we’ll do poorly. There isn’t enough cake for everyone to have a piece even if we slice it small! Our bodies end up feeling tight and tense and we worry about what we can do to get more and to get it for ourselves.

Rather than thinking “not enough”, think “there is enough”. It doesn’t cost you anything to shift from a mindset of scarcity to one of abundance, except your level of personal responsibility. With a scarcity mindset, all of your problems are “out there”. The locus of control is outside of you and thus uncontrollable. But when you believe that abundance exists, your attention becomes focused on how to tap into it. You have an internal locus of control – “what I do and how I do it influences my circumstances”.

As this process advances, you’ll become more optimistic – the best is yet to come! You’re more willing to take risks and share your self and resources with colleagues. You can learn from your competitors because you are all in this together. As your relationships with other doulas grow, you can ask for feedback and help without it feeling like a threat. Babies will continue to be conceived and people will keep recognizing that their emotional needs are not being met by current medical systems. That isn’t going to change anytime soon.

What about not having enough time?

My worst tendency towards scarcity is about time. I fear there will never be enough time to get everything done; that I won’t achieve my dreams much less what’s on my daily ‘to do’ list. “There just isn’t enough time!!” Sound familiar? I’m not competing with other people for time – its not like if I get more someone else gets less. I’m really competing with myself – and I never win.

The funny thing is that it’s not true. I do have enough time. Sometimes it takes me until Wednesday to get through Monday’s to do list, but it does get done. The small tasks and the big projects do get completed, for the most part. So what’s going on here? It’s all in my attitude. Being anxious that I don’t have enough time doesn’t get me more time, nor does it make me more creative or efficient. It just makes me jittery and unpleasant. So, what’s my alternative?

I decided to change my thought. “Time expands to meet my needs.” Whenever I begin to have the impending feeling of doom – “there will never be enough” – I realize it’s all in my head. Whatever really needs to happen will and I will have enough time to accomplish it. It’s been four months now, and I have accomplished everything I needed to do.   Some things got postponed, true, but it was mostly because the time wasn’t right – and even I can’t do everything at once. In some instances my priorities changed. But what was really different was my compassion for myself and my anxieties.

Our approach to life is up to us. We choose how we want to think about life. I prefer to choose abundance.

Many thanks to Jessica English of Heart Soul Business for inspiring this post. 

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

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Doula Entrepreneurs and Birth Visionaries Conference

Mar 26, 2014 by

A conference grounded in the business of being a doula and  making your work profitable.  I won’t be there but I trust Patty Brennan immensely!!

Doula Conf copy

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Doulas! Charge What You’re Worth!

Jan 28, 2014 by

In support of the effort made by YourDoulaBag.com, I’ve decided to repost the graphic from their blog this week.  Feel free to post it on your web site to help prospective clients understand how doulas set their fees.

blog_DoulasChargeWhatYouAreWorth1

 

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What It Means To Be A Professional Birth Doula

Nov 26, 2013 by

There is a line between doulas who are professionals – where this is the source of their livelihood and the mainstay of their lives next to family and self – and other women who doula occasionally.  Not all doulas are professionals nor is it a goal for all doulas.  There is a place for all kinds of doulas and we need everyone if we are to reclaim our understanding of birth as important in women’s lives.  We lost it in the last century and taking a doula training or doulaing friends and family is a way to reclaim that.

Being a professional does not diminish the spiritual value we find in our work or the fact that many of us find it to be a calling.  We would be diminished in some way if we could not be doulas.  We have the joy of being in a life situation that enables us to do work we are passionate about, change the world for another family, and create income at the same time.

In my writings, I frequently use the term “professional doula”.  It is on a lot of web sites – even in the names of international organizations.  But no one has really defined specifically how it applies to our profession.  So I analyzed data from my 60 doula interviews, sifted through what I was reading on social media, and read through several books on professionalism.  This is what I have come up with to describe the internal identity and behaviors exhibited by doulas who consider themselves professionals.  I’d also like to introduce the term “emerging professional”, to represent doulas who are growing to meet professional standards.  So what does it mean to be a professional doula today?

1.  To be a professional means that you have completed education and training to gain the necessary knowledge and skills recognized by others in your profession.  Much of doula education is self-study, reading books and completing assignments, combined with taking a workshop and using hands-on skills correctly.  Training may involve working with a mentor and on the job training without any supervision.  Improvement comes from appraising our experiences and evaluations from clients, nurses, midwives and doctors.

2.  To be a professional means you have acquired expert and specialized knowledge.  This goes beyond learning a double hip squeeze in a workshop.  It means making sense of people’s conflicting needs in the birth room; intuiting when to speak and when to keep silent; how to talk to a physician about the patient with a sexual abuse history; how to set up a lap squat with an epidural; and so forth.  Competence and confidence grow in interpersonal and labor support arenas.  Any additional service you offer to clients means that you have additional study, experience, and possibly mentorship or certification to use it appropriately.

3.  To be a professional means that you receive something in return for your services.  For many of us that is money or barter goods.  However there are doulas who receive stipends that prohibit receiving money for any services performed.  They may request a donation be made to an organization instead.  If they meet the other requirements for professionalism charging money should not be the sole criteria holding them back.

4.  To be a professional means that you market your services and seek out clients that are previously unknown to you.  You consider doulaing to be a business.

5.  To be a professional means that you hold yourself to the highest standards of conduct for your profession.  You seek to empower and not speak for your clients.  You give information but refrain from giving advice.  You make positioning and comfort measure recommendations that are in your client’s best interests.  Your emotional support is unwavering and given freely.  Your goal is to enhance communication and connection between her and her care providers.  You seek to meet your client’s best interests as she defines them.  Several doula organizations have written a code of ethics and/or scope of practice in accordance with their values.  They require any doula certifying with them to uphold them.  But signing a paper and acting in accordance with those standards are two different things.  Even the values represented by various organizations are different.  Holding yourself to the highest standards is shown by how you behave.

6.  To be a professional means that you put your client first.  When you make a commitment to be there, you’re there.  If you become ill or have a family emergency there is another professional who can seamlessly take over for you.  You keep your client’s information and history confidential.  Confidentiality means not posting anything specific or timely on any social media.  Your responsibility to their needs and not your own is a priority.

7.  To be a professional means that you cultivate positive relationships with other perinatal professionals whenever possible.  You respect their point of view even when it differs from yours.  You seek to increase your communication skills and to understand different cultural perspectives.  You keep your experiences with them confidential and private.  You learn from past mistakes.

8.  To be a professional means that you have a wide variety of birth experiences and feel confident in your ability to handle almost anything that comes along.  Other professional doulas respect you and make referrals.  Note that I did not include a number of births.  Because of life and career experiences, some doulas will arrive at this place sooner than others.

9. To be a professional means that you seek out and commit to doula certification that promotes maximum empowerment of the client, using non-clinical skills, values and promotes client-medical careprovider communication, and requires additional education before offering additional non-clinical skills.  Certification means that you are held to standards that people outside your profession can read and understand.  Not being certified means there are no set expectations for that doula’s behavior.  Some doula training organizations have very loose certification standards with no specifics behaviors listed, just general attitudes.  Certification with behavioral standards that can evaluate whether the doula acted according to those standards is important for furthering the professionalism of birth doula work outside our own individual spheres.  It means that a doula is accountable to someone outside of herself and her individual client.   (In other words, certification in the context of professionalism is not about you, but about how it affects other people’s perceptions of you AND our profession as a whole.)  Having said this, not all doulas have certification like this available to them.

10.  To be a professional means that you seek to improve your profession by serving in organizations, representing your profession at social events, and assisting novice doulas to improve their services.  You balance your own desires and needs with the actions that further the doula profession – such as certification.  You know that when you get better – increase your skills, knowledge and integrity – you make it better for all labor doulas.

11.  To be a professional means that you have personal integrity.  Integrity means that your values, what you say, and how you behave are congruent with one another.  Sullivan has written:

“Integrity is never a given, but always a quest that must be renewed and reshaped over time.  It demands considerable individual self-awareness and self-command…Integrity of vocation demands the balanced combination of individual autonomy with integration to its shared purposes.  Individual talents need to blend with the best common standards of performance, while the individual must exercise personal judgment as to the proper application of these communal standards in a responsible way.”  [p. 220] 

“Integrity can only be achieved under conditions of competing imperatives.  Unless you are torn between your lawyerly duties as a zealous advocate for your client and your communal responsibilities as an officer of the court, you cannot accomplish integrity.  Unless you are confronted with the tensions inherent in the practice of any profession, the conditions for integrity are not present:  “Integrity is not a given….” 

In a doula context, this means that when you are in the labor room trying to figure out what the right thing is to do and struggling with it, you are having a crisis of integrity.  “Do I say something to the medical careprovider (MCP) or do I keep my mouth shut?  Have the parents said anything on their own behalf?  Do I just let this happen and help them afterwards?”  What value takes precedent: empowerment of the client or allowing an intervention to occur that may affect the course of the labor?  How will each potential action change my relationship with the MCP?  Situations like these are true tests of integrity that require us to rank our values of what is most important.

Sullivan, William M. (2nd ed. 2005). Work and Integrity: The Crisis and Promise of Professionalism in America. Jossey Bass.

How does this fit with your definition of professionalism for doulas?  What parts do you agree with?  If you disagree, consider why – is it my wording or the spirit of what is written?  Let me know – let’s keep talking about this!

Here is a pdf copy of this post to print or for your doula discussion group.

 

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A Story About Certification

Oct 10, 2013 by

Once upon a time, there was a pregnant mother who wanted the support of another woman during her labor.  While she loved her husband, she knew they both needed something more.  Through her childbirth educator this mother got the name of a woman who might be able to help.  Once they met, they went for long walks together and the three of them chatted over tea.  The mother and father felt reassured by her presence and grew in their trust that the labor and birth could go smoothly.

When the time came they called their new birth friend.  They spent a few calm hours together before they all went to the hospital.  The triage nurse isolated the couple until their room was ready.  The mother was agitated and afraid but once reunited the three of them worked together to restore calm.  The new nurse was admiring but questioning at the same time.  She challenged their friend, “Who are you? What is your role?”

Their birth friend replied, “I am their doula. I’ve taken some classes and been to a few other births.  I–”.  But the nurse cut her off, uncertain of this doula person’s status and whether she would interfere with what the nurse needed to do.  The labor proceeded smoothly with the nurse and doula side by side caring for the mother.  The baby was born, fed, and procedures accomplished.  As she neared the end of her shift, the nurse told the doula, “I wish there was some way to know whether people like you would act like you do.  We get all kinds of people in here doing all kinds of things and we don’t know how to tell them apart. They all say they’re doulas, too.”

Thus the idea for certification was born.  Could there be some way to reassure medical people of certain standards of behavior?  There was also a need for doulas to bond together and promote the idea of doula support.  Could those two purposes actually be part of the same organization?

We all know the answer to that.  Informed Homebirth/Informed Birth and Parenting (IH/IBP) and DONA International were the first national organizations, followed a few years later by CAPPA International, Childbirth International (CBI), and Birth Arts International (BAI).  Now there are at least 14 organizations in the United States alone offering a variety of standards for birth doula certification. But let’s go back to the reason why it was invented in the first place.

Certification was created to offer doulas legitimacy and to give us control over setting our own standards.  For those unfamiliar with doula support, it gives them reassurance that there are standards for a doula’s actions.  In the medical culture where certification and licensure have great meaning, it shows respect for their way of doing things.  As doulas we are guides from our client’s culture to the hospital culture.  We are effective because we are not of that culture but we understand it and can explain its rituals, tools and language to our clients. But the flip side is that to be effective long term that culture needs to respect our presence.

In some hospitals a mother is not allowed to accompanied by a doula unless she is certified by an organization whose standards match those of DONA and CAPPA.  Mothers are supplied with the doula policy when they register to birth at the hospital.  Doulas are given a copy of the hospital’s policy and expectations about the doula’s role.  Many of these policies are not problematic for most birth doulas – no vaginal exams, no interpretation of monitor strips, the mother decides what she wants not the doula.   But these policies arise from “doulas” doing these things – they do not arise out of nowhere.  Every nurse manager I spoke with who had a doula policy in place cited several examples of conflict because the doula acted outside of the role that the hospital assumed was true for her.

Certification has opened the door for all doulas whether they individually choose to be certified or not.  In fact it is almost a back door for doulas who set their own personal standards for behavior.  Hospital staff and medical careproviders make assumptions about doula behavior based on the two main organization’s certification standards.  (There is more to the individual certification decision that I will outline in a companion post.  My objective in this post is to take a system perspective that goes beyond the individual – and I am not advocating pro or con, just observing what has occurred and why.)  Because of this, most newly trained doulas are able to accompany a mother without being given a compliance policy to sign.

Of course there is conflict with the autonomy of the mother to have whoever she wants with her during her birth experience.  But hospitals have retained the right to restrict birth companions if they feel it interferes with or has the potential to interfere with patient or employee safety or medical care.

There is something to be said for setting our own standards for our profession.  Personally I would rather prefer those standards be set by people who do what I do and share a similar philosophy.  The alternative is for people who don’t understand or respect a doula’s value to set those standards.

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Doulaing With A Disability

Sep 16, 2013 by

Often becoming a professional doula is an achievable goal.  But for others becoming or continuing as a doula with its physical demands is extremely difficult.  In my thirty years of doing labor support I have met several doulas who were able to maintain their careers.  After thirty years, I have had to make adaptations myself.  As my colleague Cory Silverberg once said, “If you live long enough you will end up with a disability.”  Here are some helpful steps if you receive a diagnosis that will significantly change your abilities.

  1. Feel your feelings.  Anything that is significant enough that you will have to adapt your life around it will bring up a mix of feelings.  Relief, fear, anger, anxiety, sadness, and other emotions are all important.  Take some time to grieve – your body and your life are no longer the same.  It is when you push away your emotions that they control you.
  2. Adjust to the diagnosis.  Will any medications or health care regimens have unknown affects?  Are there any procedures that need to be planned for?  Remember you are a person with an illness or disability, not the disability.   Utilize your doula skills:  seek out resources, confide in those your trust, enlist others in your support circle, and advocate for your own needs.
  3. Be realistic about your circumstances.  How does your condition affect your ability to fulfill the doula’s responsibilities?  How do your changed circumstances affect your client and her labor support experience? How do they affect you?  Examples:  If you have a joint ailment, you may not be able to support a larger mother in her positioning or while walking or dancing.  As a cancer survivor, you may tire more easily.  With multiple sclerosis, you may have a flare that requires a cane or wheelchair.  Perhaps an endocrine condition requires at least five hours of sleep each night.  A benign tremor may mean your pictures are usually out of focus.  As a postpartum doula, arthritis may mean it is unwieldy to pick up a baby.
  4. Brainstorm possible solutions.  You might not be able to pick up the baby, but you’re fine if someone hands you the baby.  Maybe it is time for you to take on an apprentice doula who can do the more physical tasks.  Perhaps attending births together or in overlapping shifts with a doula partner would work for you.  Maybe you just don’t take photos.  When you look at your solutions, which ones would you need to choose and which might be up to your client?  For example, maybe your client would get to choose the second doula from three you like to work with.
  5. Readjust your marketing. You want to emphasize the positive while not misleading potential clients.  On your web site show a photo of you holding a client’s baby at a postpartum visit with your cane on the chair. At the introductory visit, state the adjustments that are required and how you intend to address them.  Focus on what you uniquely offer and don’t apologize for yourself!  Emphasize that prenatal planning affects birth outcomes tremendously and is not affected by your disability.  Maybe instead of three prenatal visits, you offer four.  Maybe you can turn a problem into an opportunity –  offer an incentive for a particular birth photographer which benefits both businesses.  It may be that if you work with an apprentice or a partner, no explanation is needed.  Your potential clients will choose based on your business model and feelings of safety with you.  Depending on what you are asking of clients and how open they are to your solutions, business may stay the same or even pick up.  “Two experienced doulas for the price of one – that’s great!”
  6. What if my business drops off?  Birth and postpartum doula support are market driven businesses and also relationship based businesses.  It may be that potential clients prefer not to make adjustments to work with you.  May be your confidence has declined or your grief over these changes is coming across.  Mothers may decide you are not the best fit because of your disability.  It always feels bad to be rejected  – and this may be your worst fear.  Less or no business may stimulate the grief process all over again – which is entirely appropriate.  In thirty years there have been many times I could not attend births even though I wanted to.  This was due mainly to my life circumstances and needs of my children. But eventually it was due to a health condition.  I swore a lot and then went through the process I have outlined here.
  7. Shifting your doula energy.  Maybe you can’t attend client’s births or postpartums anymore.  Notice I did not say, “can’t be a doula anymore”.  You’ll always be a doula – it is a way of being in the world.  Maybe you’ll open a mentor doula business:  attending a few births with novice doulas, and have monthly educational and support meetings.  There is a huge need for this type of additional education and support for emerging doulas.  Some birth doulas become postpartum doulas.  Some become childbirth educators, birth activists, support group leaders, parenting educators, home visitors, or run doula programs.  Some go back to school and get certificates and degrees that enable them to affect birth in a positive way.  There is still a place for you at the table it just has a different setting.
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Should Doulas Offer Free Services Is The Wrong Question

Aug 26, 2013 by

It seems every doula with a blog has weighed in on the “no free births” debate and every doula with an opinion has expressed it on Facebook.  The debate usually goes something like this:

“If you don’t charge, you demean my services.  You make doula work appear unprofessional or not worth paying for.  By giving away your services, people are less likely to pay me for mine.  They won’t value what we do.  And since our customers usually employ us only once or twice in their lifetime, they will tell other people a free doula is as good as an expensive one.  Third party payers will continue to refuse to reimburse us because they’ll say a consumer could get the same services for free or a professional is not required.”

Beneath this argument is a current of fear.  We want our profession to be recognized as legitimate.  As birth doulas, our actions are often invisible.  They are only missed when we aren’t there.  Our fear is if those we are welcoming into our professional ranks undermine our work – even if it is out of ignorance – how can we ever rise into a position of recognition and be seen as having a unique and valuable contribution to maternity care?  Will we ever be able to earn a living wage to support our families?

We have no control over how other doulas set their fees or how they feel the calling of doula support fits into their lives.  However we do have control over ourselves.  When we examine the root of our fear, we can take action to address those issues in other ways.  We need to establish the value of our own experience and contributions.  Some doula businesses have already done this with tiered pricing based on experience and credentials.  With each successive tier, more skills are added to the list.  Parents and payers can easily see what they are paying for.  Individual doulas have added a section on their own web site:  “What I know now after 20, 40, 100 births” or “What makes my services special”.

Instead of putting our efforts into controlling the newbies – and there are thousands of them every year – those of us who have survived past the first ten births need to make a LOUD statement about what we bring to the labor room.  There are fewer of us and we’re busier and more tired, but we have lasted.  We need to value ourselves first. 

My goal with this blog is to give you tools to do just that.  You need to go forth in your own community and state loudly and clearly, “I have something to offer that benefits everyone in the labor room.  It requires training, experience, and very few people can actually be an effective birth doula.”  We must support one another in this stage of our profession’s growth by actively promoting our value to families and to care providers.  Yup.  If you’re doing it right, you make a positive difference for nurses, midwives and physicians too.

It is up to us to use research and other evidence to create change.  After 27 years in this business, I have seen it grow incredibly.  For the first ten years, I didn’t even use the word “doula” to describe what I did.  This argument about “no free births!” is a part of our growing pains.  But we have to recognize it for what it is – a response to our fear.  Once we can name what we are really scared of, we can act to change those circumstances where we do have control.  I am eager to see what we will do next.

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Why Mothers Choose A Particular Doula

Jul 13, 2013 by

Let’s say you have a problem where you need some advice.  Explaining the situation will require some self-disclosure and revealing personal information.  You are in a meeting for the day with women you have never met before.  The advice you need can’t wait so you’ll need to choose to reveal your problem to one of the women present.  As the day goes on you have the opportunity to observe and interact with everyone.  When you make your choice, what are you likely to base it on?  Is it the intellectual qualities or resume of the person?  Or the woman you feel comfortable enough to disclose your feelings and your dilemma?  If you’re like most women, it will be the person you feel safest with.

The same thing is true about how a mother chooses her doula.  It is based on her gut feeling – who she can be naked with – because she will be.  Who she senses can accept her fears and her lifestyle – because that is our role.  All of these attributes are due to who the mom is:  what she intuits as right for her, which we as doulas cannot influence at all.  A woman’s gut feeling about which doula is right for her has more to do with who that woman is than who we are.

That mom may need a mother, a sister, or a new friend who knows a lot about birth.  She may need someone she can say “no” to safely.  But whatever it is she needs, choosing a doula is an emotional decision not an intellectual one.  Mothers say, “It just felt right.”  “I felt safe with her.”  “I just knew she was the one.”  “I was leaning towards another doula but wasn’t sure.  Then I met our doula and something clicked.”  “Even though she didn’t look as good as the others on paper, we just connected and that was it.”

Effective doulas are nurturers and good listeners.  In an initial interaction, these are the qualities that attract someone to you.  After that, it is all about anticipating and meeting the mother’s needs – and we don’t yet know what they are.  She may not even be able to put them into words, but that doesn’t mean that her brain isn’t communicating them on some level.  Often the brain sends emotional information to the nerve endings in the digestive system.[1]  Her gut feeling about who is right for her is just that.

I often find myself reassuring new doulas about getting clients.  It isn’t about the best web site or the number of workshops you’ve attended.  It doesn’t matter whether you have given birth yourself.  Parents choose doulas based on a number of criteria.  Yes, cost and experience do count.  Some parents enjoy cool websites with professional photos.  But mothers are often looking for someone they can have an intimate relationship with.

Which is why I think competition between doulas is unnecessary.  It is more important to be yourself and work on developing your interpersonal skills and a nonjudgmental attitude.  When we compete with other doulas in our community we may diminish the opportunities for all of us to get clients.  When we band together to promote doula support and have inclusive “Meet The Doula” events, we send a positive cooperative message to other birth professionals and prospective clients.


[1] http://www.scientificamerican.com/article.cfm?id=gut-second-brain

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