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. 

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Benefits of National Doula Certification

Dec 3, 2014 by

CleanPlusFadeNational certification is a tool to enable professional doulas to move in a particular direction.  What benefits could a program with strong behavior centered standards of practice offer?

1.  Respect from and engagement with physicians, midwives and nurses at every hospital because they have a clear understanding of the accepted standards of practice of nationally certified doulas.  They could ask one question and know what to expect:  Are you nationally certified?

National standards means a group of doulas in a community could negotiate with a hospital to gain privileges and respect for their knowledge.  Possibilities include getting into the OR reliably, being consulted about their client’s progress, sharing knowledge at educational meetings, and discussing conflicts in an arena of professionalism.  Both birth and postpartum doulas could be considered part of the team rather than adjunct or isolated from their client’s care.  Some doulas already have this situation.  But out of the tens of thousands of hospitals and hundreds of thousands of medical staff, I can count those places on my fingers.  Wouldn’t it be great if we all had that negotiating power?

2.  We get to define the standards for appropriate doula behavior, not each individual hospital.

3.  Respect and easy establishment of credentials when moving from one area to another.

4.  Consumers (parents) would have clear understanding of national, evidence based standards of practice and materials that explain “What to expect from a nationally certified doula”.  They would have an established outline of what to do when those expectations are not met, someone objective to listen to their concerns, and an organized grievance procedure.

5.  National behavior centered competencies would outline uniformity in services offered so a unique, standard billing code can be used with Medicaid and other insurers.  There is no guarantee of this, but scientific evidence plus strong standards equal a greater likelihood of this occurring.  I cannot see it happening without it.

6.  The opportunity to participate in public health initiatives based on doula credentials, not on academic or nursing credentials or having someone vouch for you.  Doula support is a key part of the solution for many maternity issues.  But we are not included (or taken seriously) because there are no strong national standards.  Initiatives cannot plan to include doulas because they have no easy way to say who will be eligible to fill the doula’s role unless they do all the training and certifying themselves – which is an initiative all on its own and beyond the scope of the funding they are applying for.  So doulas are left out.  These are missed opportunities for jobs, influence on the maternity care system, and better care for mothers and families.

7.  Doulas are seen as a luxury rather than a necessity for birth and postpartum families.  But for maximum health and well being, there is no substitute for the one on one care a doula provides.  Done well, national standards allow our profession to grow so that not just wealthier families or women lucky enough to live in areas with community-based programs get this service.

8.  Right now, there is no system that recognizes achievement as a doula.  One of the possible reasons we have so many training programs is because the role of “trainer” is the only one achievable after “doula” or “certified doula” in a particular group.  Recognizing levels of achievement and leadership within the profession would meet this very human need to strive for something and be recognized for it.

9.  Separation of training and certification.  A national certification organization would set competencies to be met.  The applicant’s responsibility would be to meet those competencies – likely from a variety of sources and beyond the initial two or three day training workshop or correspondence course.  The term “competencies” is used in many professions especially those that involve education and caring at their core.  Competencies state an area of expertise and specific behaviors that demonstrate that ability.  In your comments to me many of you have mentioned that you deal with competencies in order to be certified as massage therapists, realtors, respiratory therapists, and certified nursing assistants.  For an example of how a competency based system works, go to this home visitor organization web site, and click on the “gold” list.

The next question is, “Who sets the competencies?” and “Who provides the training for these competencies?”  The answer is we do.  This system allows for a natural progression of training that focuses on obtaining the skills that ensure doula success but cannot be taught in an initial 16 to 24 hour basic course.  Interpersonal skills such as listening, relationship closure, debriefing, minimizing trauma, and conflict management come immediately to mind.

10.  National certification with competencies and behavioral standards would allow for expansion of the doula role into other fields.  Community health education workers and home visitors could easily include doula work into their own job descriptions, or permanently include doulas into their programs.  While this is occurring in a few places (Illinois’ the Ounce), it is most often haphazard and dependent on a single person or limited time grant.  Even though the evidence is available and there is a program to replicate, other stakeholders outside the program also need to be convinced.  Funders may also not be able to give money for initiatives where workers do not have established competencies.  Evidence based national certification standards set by doulas makes it more difficult to minimize our effectiveness or brush our contributions aside.

11. National certification available to all shows that we take ourselves seriously, have professional competencies that define our role, and makes that statement to the world.  We are not just hippies, hipsters, yuppies, hobbyists, bored at home parents, soccer moms/dads, frustrated midwives, or trying to exert power over someone’s else life experience.  The market demand for our services shows that we have a part on the team to play, we are here to stay, and we believe that what we have to offer makes a positive difference in the quality of health care and the emotional lives and memories of the families we serve.

12.  Being a part of other health related professions would expand doula employability, wages, and the number of mothers who could receive doula services.  It would also enable more people to become doulas and hopefully at a wage that would support their families.  Many trained and effective doulas are not cut out to be independent business owners.  But this is the only choice for many.  Respect for and expansion of the doula’s role would allow for different models of employment, such as working for social programs, agencies, HMO’s, physician and midwife groups, and collectives.  We don’t have this now because there are no strong standards for employing doulas on staff or for third party reimbursement for their services (see #5).

In sum, national certification offers us legitimacy and opportunities to move our profession forward.  Some of those directions are dependent on interaction with others, however once we start taking our work seriously it will positively influence how we are perceived.  Most likely it will open doors that cannot be imagined today.

 

Note:  What’s the difference between accreditation or certification?  Certification verifies that a person has attained a level of competence and met requirements to practice in a certain discipline.  Accreditation evaluates institutions and programs and ensures they have met standards.  Click here for more.

 

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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.  Do We Want A Place At The Table?  National Certification and Public Health

4.  This post: Benefits of National Certification for Doulas

5.   Fears, Downsides, and Challenges of National Certification

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

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Top Ten Questions For Choosing A Doula Training

Apr 21, 2014 by

Top Ten QuestionsTo AskWhen ChoosingADoula Training (1)I hear a lot on Facebook, “If I’d only known that before I took my training…”  The market for doula training has changed incredibly, especially in the last 5 years.  There are now at least two dozen doula training organizations with programs of varying quality.  The onus is now on the prospective doula to figure out which trainer and organization is the best fit for their personal and perinatal career goals.  My hope is that doulas will circulate this post to help our future colleagues make their best choice.  I’m a firm believer that the best match for you might not be the best match for your best friend.  I’ve specialized in adult education for over twenty years and as a doula trainer, I’ve done over 80 beginning and advanced workshops – and loved every single one!  Educating adults is my passion and I feel that the more people understand the deeper meaning of birth, the more we will change the world.

Here are some important questions to consider when choosing a training:

  1. Why do you want to attend?
  2. Does this trainer have knowledge of your local birth scene? 
  3. Where were the doulas in your area trained?
  4. How do you learn best? 
  5. What are the trainer’s qualifications, experience, and philosophy of teaching?
  6. What is included in the curriculum? 
  7. What are the certification requirements of the organization?
  8. How do the certification processes of the different workshops you’re considering compare?
  9. What is your budget for doula career training? 
  10. What other knowledge will you need to gather in order to be successful? 

Why do you want to attend?  A recent study I’m preparing for publication identified 17 unique reasons women attend doula trainings.  They fit into four major areas.  One, advancing the career they already had.  Two, gaining education for a future career goal in nursing or midwifery.  Three, becoming a volunteer, hospital-based, or independent practice doula.  Lastly, personal reasons that included making sense of their past births and/or preparing for future pregnancies, or attending the births of family members.  Being clear on exactly why you want to attend can help you ascertain what training is best suited to meet those goals.

Does this trainer have knowledge of your local birth scene?  Is this important?  If you live in a rural area or disenfranchised community, having a trainer who understands and can help you with your unique challenges can be critical to your success.  If she knows the staff and preferences of the local hospitals that can be a real plus.  You can learn the behavioral norms, expectations, and attitudes about doulas in the workshop rather than trial and error on your own.  This may be less important if these answers are easy to discover or where there are many hospitals with a large staff.

Where were the doulas in your area trained? Are they open to doulas from other organizations?  I’ve spent many years combatting cliquishness in doula circles.  My attitude is that there’s no need to compete with other doulas because mothers choose whom they feel safe with in their gut. This has nothing to do with the doula and everything to do with the mother.  When we promote the doula profession together, we create a market.  However, my attitude is not shared universally!  Do some investigative work on the Internet and/or go to a Meet The Doulas event or doula meeting (ask them if its alright).  Find out where they got their training.  Ask them what trainers/organizations they respect and what topics they wish had been included in their workshop.  I’m not advocating going against your heart.  But if you are going to practice in an area, it can be easier to get along with others and get referrals when people know that you’ve had training similar to theirs. (Unfortunate but true.)

How do you learn best?  Do you prefer hands-on instruction, one on one attention, reading or hearing information?  Do you like to move at your own pace over a longer length of time or a challenging intensive experience?  To me, effective doula training is career preparation as well as a personal examination of one’s perspectives.  Choosing the right environment to optimize learning can be a critical factor in your success.  As a face-to-face [F2F] educator, I recently challenged myself to train as an online instructor.  It made me realize that for some people and situations, online learning can be equally effective with a dedicated instructor utilizing high quality resources.

Who is the trainer?  What are her qualifications, experience, and philosophy of teaching?  What are the testimonials and ratings on her web site?  What is her reputation among the doulas in your area?  The trainer makes a HUGE difference in your experience – they vary a great deal in their teaching ability and emphasis on what they consider important.  If they don’t have testimonials on their site, ask for references.  Make sure their teaching is a good match to your learning style. If you are serious about doula work, putting forth some additional money and time is an investment in your future career and self-confidence.  You may need to travel or wait a few more months for your best workshop.  Your doula workshop should change your life!

What is the curriculum?  What will you be taught?  What does she emphasize in the workshop?  Each trainer in an organization likely has a personalized curriculum.  If this is not listed on the web site or given in response to your inquiry, ask for a schedule and list of educational objectives.  Is this what you want to learn?  For example, while DONA has a core curriculum, all DONA trainers can add to that curriculum as they see fit (it must be approved).  Mine is an 8 additional hours and 114 additional pages in the manual than what is required – and I am not unique.

In addition, people have different levels of education, experience and career goals.  The person who has been to 10 births and knows they want a doula business has different learning needs than the woman just hired by a community based agency to work with Early Head Start clients.  While both need ethics training, one needs doula business planning and the other needs to know how to work with clients with few medical care options.

Each workshop also has its own mood.  I adapt my material for nurses, nursing students, midwifery students as well as open workshops.  I’ve done workshops in hospitals, birth centers, and my living room.  Each group has unique needs and to be respected and inspired.  It’s the same material but I do it differently. Do the materials give you a classroom feeling or a Red Tent feeling?  The group influences the trainer, but the trainer sets the tone.  Is that tone a good fit for you?

What are the certification requirements of the organization?  Do they offer certification with a variety of educational and experiential requirements and where your references will be checked?  Are they certifying that you as an individual are qualified to do this work?  Are you required to follow behavioral standards that protect you, your clients, and thus the reputation of the doula profession from misconduct?  Or is there a certificate of completion of the organization’s requirements that they are calling “certification”?

Of the trainings you are considering, how do their certification processes compare?  Do you understand them?  Which ones do you agree with?  Certification is an issue that may become critical to your career.  With changes in health care, third party reimbursement may only be possible to doulas with a certification process as already described.  Hospitals may bar access to doulas who do not have certification from an organization they recognize.  Disgruntled consumers are blogging on the Internet about how they didn’t understand the meaning of certification.  If you don’t agree with the behavioral conduct outlined by certification process, be clear with yourself about why.  Discuss this with other practicing doulas and both of the trainers you’re considering.  Since this is a decision that may define the future direction of your doula career, become clear on your stance and options now.

What is your budget for doula career training?  What does this workshop cost?  What other costs are there besides the workshop? If you want to be a professional doula, it is highly likely that you will put more money into your education and initial business plan in the first years than you will make in income.  However, training is an investment.  Spending an extra $200 or $300 for an educational experience that meets your needs will be cheaper in the long run.  You’ll feel more confident and be more likely to follow through with getting new clients and integrating into your new peer group (thus getting referrals).  If money is an issue, contact the potential trainer and ask for options.  There are several who don’t advertise it, but have full or partial scholarships or payment plans.

What other knowledge will I need to gather in order to be successful?  Are there other low-cost resources available?  Many doulas don’t approach birth or postpartum doula work as a business or as a significant lifestyle change.  In many areas, colleges and universities offers inexpensive short courses in beginning a small business that are applicable to doula work.  Some hospital staff will be appreciative if you take their volunteer training to learn how their system works.  This will usually cost you a few hours a month volunteering but can offer valuable knowledge and familiarity with a medical setting.  Can I volunteer my services and gain experience? Will what training I take matter?

The first step in making an informed decision is knowing what you need to be informed about!  Asking these key questions will hopefully help potential doulas find the best fit rather than the cheapest training or the one that is currently trending.  A good doula training strongly influences your career path.  While you can take a second workshop if you didn’t like the first one, that’s an expensive option.  By doing your research now, you will feel more committed to your decision because you know its right for you.

 

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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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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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We Need To Create Social Change That Values Caregiving

Aug 28, 2013 by

Recently I wrote about how we needed to increase the value of doula care in the minds of consumers, caregivers, and third party payers.  If we are to create a social revolution regarding the value of professional caregiving, doulas can do it.  Many of us are white, well educated, and have other sources of income besides doula work (Lantz et al. 2005).  Groups with these characteristics have greater influence.  For many years the majority of professional caregivers in America have been immigrants or have brown skin.  They had little social power in our country and it was better for them as individuals to be silent.  Historically and now, professional carers are our nannies, home health nursing assistants for the elderly, and aides for the developmentally disabled.

Our movement as professional doulas is tied to these other jobs, whether we like it or not.  All involve caring for others and improving their experience of living in this world.  Being young, old, or disabled are not illnesses.  But they are times of vulnerability where the family seeks trained outside help.  Nannies, CNA’s (certified nursing assistants), and aides all offer emotional, physical, and informational support.  They must get along with the medical care providers and responsible adults guiding the individuals they support.  Most importantly, their outcomes are mostly soft.  Soft outcomes consist of good memories, satisfaction, improved relationships and the ability to communicate with others.   They also put a price on their caregiving skills and must maintain standards if they are certified.

So when we are asking for our doula skills to be valued, we are asking for social change.  We are making a statement that caregiving is a skill; it is not something innate to all women (or people).  It is learned and cultivated and takes years of experience to be consistently effective.  Caregiving skills have value.  Receiving good caregiving makes a positive difference in one’s health, personal growth, life satisfaction, and social interactions with others.  In obstetric outcomes, effective caregiving by professional doulas leads to fewer interventions, less pain, increased birth satisfaction, fewer operative deliveries and cesarean surgeries.  We have quantified the influence of the human factor in labor and delivery.  We have “known” statistically for 15 years.  But still few are willing to make the change.

Why?

Using Robbie Davis-Floyd’s terminology, the technocratic model* does not value caregiving as a reliable skill in influencing the machine like movements of the body.  It cannot be used on every person and get the same outcome.  Not every person offering doula care is a good match for someone who wants to receive it.  There are human factors involved.

Inviting doulas onto the maternity team in a way that shows they are valued, means that there are influences that someone who has comparatively little training or education can have on the patient.  The doula may make a bigger difference on birth outcomes than someone with 12 years of expensive education and training.  That can be bitter to accept.  (Of course the physician needs to have a low management style with few vaginal exams and little intervention to begin with.)  Physicians may also feel that not doing anything (no continuous monitoring, no amniotomy, allowing food and drink, etc.) is the same as doing nothing.  It isn’t.  It is allowing the social-emotional-hormonal interactions of labor to bring forth the baby when it is possible.

Lastly, it is because we do not value what we do.  We do not entirely one hundred percent believe that caregiving is a quantifiable skill that makes the vulnerable experiences in life better.  We need to change.  Our caregiving is not very different from the Filipino home health aide who is gently wiping the drool off your grandfather’s chin.  It is not that different from the African American mother of ten who is soothing and changing your dying mother’s diaper.  When your Down’s syndrome son is going into a rage in the group home, it may be the twenty-year-old community college student who knows how to talk him down.

We might like to think we are better than they are because our care is specialized, because it deals with mothers and babies, because we feel it is a calling and not a job.  Because we value what we do but not what they do: “Anyone can wipe an old guy’s mouth.”  Guess what?  No one else thinks we’re that darn special either.  As the mother of a child with a disability, as someone who has changed my dying mother’s diaper, and who has sat with many a drooling elderly man as he told me a story, it is not that different.  They are all caring activities and involve many of the same birth doula skills – just applied differently.

Some of you are sitting there fuming – angry with me.  Why?  Is it because you feel I have devalued your skills?  Is it because you would not want to do those other jobs but feel compelled to help mothers and babies?  It is these feelings that I am directly addressing.  We have an internalized prejudice against caregiving and we don’t value it.  Until we do we are stuck exactly where we are.

If you start arguing with me about how different birth and postpartum doulaing is from these other jobs, you’ve missed the point.  Yes, there are subtle differences and specialized skills involved with each professional niche.  But they are all caregiving professions.  In our society few of them are valued as important, even though every one of them is essential.  We need to value all of them so that every caregiving profession is seen as important and worthy of a good wage.

 

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.

*Here is a simple chart of the Technocratic and Holistic Models with an exercise to use with your clients: ModelsofBirth13

* One of Robbie Davis-Floyd’s articles on the Technocratic Model of Birth.

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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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Hard Research: Birth Doulas Save Insurers and Hospitals Money

Jul 17, 2013 by

I am absolutely THRILLED to beWMJcovergin my new blog with my latest journal article, published in the Wisconsin Medical Journal.  In this collaboration, our team estimated the immediate cost savings per delivery with in-hospital professional doula support in Wisconsin.  This article strives to fill the gap regarding the financial impact of doula care based on the assumption that certain interventions and procedures would be avoided due to the doula’s presence.  We actually quantified how much money is saved when a birth doula is present to attend a low risk laboring mother.  To download a pdf copy, click An Economic Model of the Benefits of Professional Doula Labor Support in Wisconsin Births.

BOTTOM LINE:  There is an estimated $29 million savings if every low-risk birth was attended in-hospital by a professional doula in Wisconsin in 2010.   A professional doula providing only in-hospital labor support would yield an estimated cost-savings of $424.14 per delivery or $530.89 per low-risk delivery.  That does not include paying the doula for her services.  So, if the doula is paid $300, the cost-savings would be $230.89 for a low risk delivery.  This is due solely to the doula’s emotional and physical support at an advanced beginner level, not any advocacy she may do or advanced level skills she may acquire over time.  I can state that with confidence because the doula studies we gathered our statistics from used primarily inexperienced doulas.

COMMENTS: Of course there is no way to estimate the financial cost of improved emotional well-being for mothers and fathers. Hopefully this study will inspire others to do more doula research on those outcomes.  Early drafts included an estimate on the impact of labor doula care on breastfeeding.  But we didn’t have any hard data on the influence of doula labor support on breastfeeding rates (in other words, no randomized trials).

This is a conservative estimate of cost savings, it is likely that other (minor) procedures would also be avoided.  Hospitals often find labor and delivery to be income generating departments. They also expect future business from the families they treat.  For this reason private hospitals are often not interested in doulas to lower the number of epidurals and cesareans.  On the other hand, public hospitals that serve low income patients are interested in lowering their health care costs because the reimbursement rate can be so low.  Insurance companies and PPO/HMO’s are more interested in lowering health care costs than hospitals.  Private hospitals that have paid doula programs are usually located in cities where mothers have the choice of several hospitals to birth.  The doula program can give them a marketing edge.

Keep in mind, there are many influences on epidural and cesarean rates beyond the doula’s care.  Many of them are outside the scope of what we can influence by our presence and labor support skills.

This article does not mention the mechanism why doula care has such an impact.  For my perspective, you’ll need to read my dissertation or attend one of my presentations on the Attachment Needs of the Laboring Mother!  (All are on my main website.)

HOW TO USE THIS RESEARCH:

  1. If you are writing a grant or asking for funding for your doula program, it may increase the legitimacy of your application.  Even if cost savings is not the main reason for the program, having the data can provide a broader context for the value of birth doula support.
  2. This article increases the power and value of doula care.  The services we provide are not just “nice”.  They make a quantifiable difference in the quality of health care received by mothers.
  3. If you have a doula program or are trying to start one in your community, this provides more evidence why professional doula labor support is a significant and positive addition to your community.
  4. This article provides financial data on the relationship between what a doula is paid and cost savings.  We deserve a living wage for what we do.
  5. Are you billing an insurance company for your services?  Include this article with your denial appeal.  This could be especially helpful if your client avoided one or more of the procedures listed in the article.
  6. As a companion to other doula studies that show increased patient satisfaction, lower incidence of postpartum depression, decreased perception of pain, and higher breastfeeding rates, this completes the circle.  “Look, they save money too!”  Let’s hope lots more doula programs receive funding in the next few years.
  7. As a birth activist, are you trying to get doula services reimbursed by an insurance company?  Are you trying to get doula services offered by your HMO or PPO?  This article could be what turns the tides.  The formulas are now available in the article.  With your state or region’s statistics, you can compile your own statistics.  Find a graduate student with statistical expertise and ask for assistance.  (Heck, they’d probably think it was fun – or you can co-author your own report and they can list it on their vitae.)

Please let me know how you’ve used this article and how it impacted you.  Thanks!

 

 

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