Agreeing with me while also challenging some of my perceptions, Christine Morton has been researching doula care for as long as I have. Dr. Morton* writes for the Lamaze International blog, Science and Sensibility, and she is the author of the forthcoming book, Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America, (with Elayne Clift). She is not a doula although ten years ago she trained and certified through Pacific Area Labor Support (PALS) in Seattle and attended a dozen births. She is not a doula trainer nor a current member of any doula organization. Her interest comes from her background and training as a sociologist. (Note: Bold and italicized type are my additions – ALG)
In response to my recent blogs, Dr. Morton writes:
I’ve done a bit of historical research on the history of the doula role and some critical thinking about what I’ve called the “organizational diversity” of the doula training/certification landscape. Most of that work was done several years ago and it was an issue then and (not surprisingly) continues to be an issue now. You count 16 organizations – and I bet there are many more in local contexts that do their own version of training/certifying doulas. I’ve identified at least five in the San Francisco Bay Area alone!
The idea of an “umbrella” or “universal” organization that would certify doulas regardless of how they were trained was a vision of the first national organization – National Association of Childbirth Assistants (NACA), headed by Claudia Lowe in Northern California from 1984-1994. I know that DONA founders had some interactions with Ms. Lowe in the early 1990s and there was a sense that DONA could serve that universal certification function. NACA ceased to exist in 1994, a mere two years after DONA was founded.**
I suggest that the key challenge here comes from how the doula is defined. There is an internal contradiction in the definition of a doula – that this person is a caring, kind individual who only needs to be co-present with a laboring woman as well as a skilled provider of specialized services, the provision of which is associated with highly consequential health outcomes for the mother and baby. It seems to me the broad community of doulas can’t have it both ways. I think the tension in this definition is the crux of the issue of certification.
Sociologically, doulas are far from being a recognized “profession” in the sense that there are no barriers to entry to the role (anyone can say they are a doula) and there is no formalized route to training nor admittance into the role such as accredited education programs and licensure. There is no regulatory board which might hear grievances or complaints about a lapse in service or care.
The grassroots (primal) origin has been a fascinating and compelling feature of the doula role but you are right in pointing out that changes are on the horizon. The train is coming down the track and doulas can either jump aboard while it’s still in the station and attempt to drive it (and fuel it) or can be run over by it. Maternity providers face the same thing with regard to the changed landscape of quality measures in perinatal care.
Given the past history of doula (and childbirth education) organizations, I am not optimistic that doulas and their organizations will be able to overcome the definition issue, in part because of the ideological diversity in their members. I’m part of a research group that has surveyed doulas, childbirth educators & nurses in the US and Canada on a number of issues (MaternitySupportSurvey.com), and preliminary results show that doulas hold views on the most extreme ends of attitudinal measures on childbirth practice and beliefs. The data from that study will be informative for this and other issues facing doulas today.
The current state of doula organizational diversity reflects the historical state of childbirth education/home birth midwifery organizations in the 1960s-1980s when doulas entered the scene, and now reflects intra-group differences, driven by a number of factors, including access to power, resources and perhaps, inability of strong minded individuals with differing views to understand the importance of working together. Without the temporizing effects of larger institutions (think: universities or colleges with established means to organize and manage education) and without the infrastructure of formal management techniques and systems, membership organizations run by doulas for doulas lack necessary access to resources and power to effectively negotiate and mediate different viewpoints.
Unless representatives of doula organizations come together with a collective desire and will to bridge this history, and define a common goal and work to achieve it, I don’t see how it will happen. Anyone can claim to be a doula, anyone can claim expertise to open up a training and certification enterprise, and unless the doula role is substantially redefined so that only those with access to specialized training and /or licensure can legally charge money to provide defined services, there will continue to be an open field.
Other occupations have similar dilemmas where in theory “anyone” could do the service but to provide the service as a ‘business’ and charge a fee, there are regulations — think: childcare worker, especially home based childcare providers; barbers/hair stylists; dog groomers; caterers; teachers/tutors; massage therapists; personal/career coaches; home organizers; housecleaners ….. what we are seeing is the professionalization of service providers …. (this does not make these occupations “professions”, however).
I will leave you with another thought and another route to consider. Patient advocates. Patient navigators. There is growing recognition that all patients in US hospitals would do well to have an advocate by their side. Hospitals are complex systems where medical errors and communication mishaps inordinately account for a large number of preventable morbidity and mortality. Maternity does so well relatively speaking because so many of the ‘patients’ are healthy to begin with and because there is poor surveillance of health outcomes (think hemorrhage, which is known to be significantly undercoded). A strategy that frames doulas more as patient advocates runs the risk of defining laboring women within the context of a ‘patient’ and all that means, but one thing that doulas know well is that women who enter hospitals to give birth do become ‘patients’ — that powerful institutional fact is exactly why doulas are there – to provide some counter weight to the institutionalization of birth. But an individual is no match for an institution.
There are some strong and growing organizations devoted to patient advocacy and shared decision-making, mostly in other areas of health care (it’s ironic that childbirth, the site of the original advocacy and patient-centered care is nowhere represented in these organizations, but that is another discussion). Perhaps doulas can partially reframe their role to align with the agendas of these groups, who are increasingly present in forums and meetings on health care services and policy. Doing so would de-center the ‘mystical and sacred’ elements of birth but not wipe them out completely.
Christine H. Morton, PhD
Research Sociologist, California Maternal Quality Care Collaborative
Author, with Elayne Clift, Birth Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America (forthcoming, Praeclarus Press, 2014)
*I use “Dr.” not to separate ourselves from everyone else, but because as women we rarely acknowledge our accomplishments. To use the honorific Dr. when appropriate says “Hey, you achieved something!” Because I work at home mostly I hear “Dear” and “Mom”, not Dr.
**I was in contact with Claudia Lowe in the late 1980’s as I was a member of IH/IBP and seeking out any other birth assistants I could find in the U.S. Claudia Lowe lived in my hometown, in fact in my old neighborhood. What Claudia Lowe told me at the time was that NACA’s dissolution was due to her and her business partner’s change in interests and not anything to do with DONA. (I was not involved with DONA until October 1994 – after NACA folded.)