Birthrape And The Doula

Apr 29, 2016 by

The (1)“At many births, while I have my hand on a woman’s arm reminding her to breathe, someone has their hand in her vagina digging around, her eyes are wide, she’s trying to get away, screaming STOP… What do I do? What do I say? How do I help make it right? I hate it. I hate it. I hate it. It seems so wrong.” [excerpt from one email among many I’ve received over the years]

Dear Doula,

I wish I could tell you that these kinds of things only happen to you, that they aren’t worldwide, that people aren’t suffering, that how one is treated during birth doesn’t traumatize a person, and that I don’t have multiple examples of this in my doula interview files. But that wouldn’t be true.

I wish I could explain what the medical careprovider is thinking or understand more deeply the processes that lead this person to conclude that what they are doing is right or that it doesn’t matter to the person in the body that they are touching. But that compassion is hard for me to come by.

What I can tell you is that the careprovider has somehow forgotten they are treating a person, not just a body. The medical detachment they learned to protect themselves has gone haywire, and so much so that they’ve forgotten that a real person is inside the body, and it is the person, not simply a medical situation they are treating. There is no detachment for the patient – and everything is experienced wholistically, meaning it affects their psyche and their spirit as well as their physical selves. Maybe the medical careprovider never learned this or maybe this knowledge has gotten buried.

But our focus needs to be on our client, on the person in the body. We are their amplifier, their voice, their conduit, when others who are caring for them aren’t listening. We are the one reminding that there is a person in the body, and that person has value. So what do you do?

  1. Be the voice. State what is happening in clear language.

“Dr. X, I hear [client’s name] saying “Stop” and “No”. Do you hear them?”

“[Client’s name], do you want Dr. X to stop?”

“Dr. X, is this an emergency or can you stop for a moment and let us all catch up with one another?”

Christine Morton and Elayne Clift, in their book Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, discuss the “interactional wedge” when doulas ask physicians to stop doing what they are doing and talk about it. It’s one of the main reasons doulas are often disliked by medical careproviders. (My opinion is this an asset for informed consent, which I discuss here). When we interrupt a physician or midwife, we are vying for power, so it must be very clear that we are doing it on behalf of our clients whose voice is not being heard even though they are expressing themselves.

  1. If the medical careprovider does not stop, appeal to the nurse.

“Nurse Y, I hear [client’s name] saying “stop” and “no”. Do you hear her too?”

“[Client’s name], do you want Nurse Y to ask Dr. X to stop?”

“Nurse Y, if this is an emergency, can you explain quickly to [client’s name] why Dr. X cannot stop? She needs to know this for her own well-being.”

Sometimes careproviders don’t stop because they think that whatever they are doing will be over quickly and just want to finish. Unless there is a medical imperative, this is selfish behavior because they are putting their own desire to be done quickly over the patient’s need for understanding and caring from them. Unfortunately, this is their prerogative as careproviders. As doulas we will experience a wide variety of responses to our clients’ needs for compassion and kindness from their physicians and midwives. Often the lack of it within a system is why we are hired as birth doulas.

  1. If the medical careprovider stops, facilitate the communication. Start with gratitude – really. Then help your client to gain information, preview what they can expect especially with bodily sensations, and encourage eye contact and affirming touch (if possible) between careprovider and client and nurse and client.

Your goals are:

  • To assist your client not to feel they are being treated like an object, and for the careprovider not to fall into the trap of treating the body as separate from the person inside of it (objectifying).
  • To assist in obtaining the information they need about what is happening and why.
  • To forecast what is going to happen and what sensations they might experience.
  • To re-establish a positive relationship with the physician or midwife and the client, and the nurse and the client, if possible.

“Thank you, Dr. X. I think [client’s name] needs a breather from all that intensity. Can you explain what is going on?”

“What sensations can [client’s name] expect?”

“What other procedures or people might we expect?”

“[Client’s name], what do you want Dr. X or Midwife Z to understand about what you were feeling or why you were feeling it?”

If the doctor or midwife seems disinterested, show it matters to you:

“[Client’s name], do you want to tell me more about what you were feeling or why you were feeling it?”

  1. What if it really is an emergency and there isn’t time for the physician or midwife to stop?

If the physician or midwife is really concentrating, we don’t want to interrupt them. So appeal to the nurse.

“Nurse Y, I can hear that [client’s name] is becoming really frightened/terrified (make sure you include an emotion) by what is happening and the pain they are in. Can you please get their attention and explain briefly why the doctor or midwife can’t stop?”

Use the Take Charge Routine from The Birth Partner to get through the painful procedure.

If the nurse is unavailable or busy, it’s up to us.

  1. What if the physician or midwife doesn’t stop, the nurse can’t help, and the situation is continuing? What do I do then?

You go further into what I call “trauma prevention mode”. You want to affirm that they are not alone in what they are experiencing, that you heard what they said, that what they wanted is not what is happening, and that you know how to help them get through it. If you can forecast any sensations or what might happen next, do so.

Get your client’s attention and look them in the eye. Grasp their hand, arm, shoulder, or side of their face firmly. Say:

“I’m right here with you and I’m not going anywhere.”

“Dr. X isn’t stopping but I hear your request and your pain.”

“Right now, let’s just get through this together.”

“This might get crampy or sharp before it goes away, but I’m right here.”

In the immediate aftermath, most careproviders and nurses will make some acknowledgement. “Sorry I couldn’t stop right then”, and then just go on to the next thing. For them, it isn’t any big deal. This is what I find the most frustrating – it’s as if they ignore the situation it doesn’t exist. I imagine that in their mind, that’s true, even if it isn’t our client’s reality. Whether to pursue a conversation at that point is up to your client, the situation, and how they like to handle conflict. We have to take our cues from them.

If you are a direct person, who is used to privilege and of having choices in your medical care, this might be very frustrating to not pursue the situation. But your client may feel that any confrontation may make things worse, or that they have to take what they get. Clients may be afraid of the consequences to them and their baby. These consequences may be very real, especially for people of color, immigrants, and those living below the poverty line. If you are white, or otherwise privileged it may be hard to believe but consequences for not being compliant exist.[i][ii][iii] This is hard because you are emotional too, but you have to keep in check what you would want to do. You will be leaving this client and their baby in a few hours, and they will have to deal with any aftermath.

In some cases where the doula is concerned about being asked or made to leave, it may be appropriate to go directly to option #5.  The doula who is in the room can offer more effective support than the one who has been restricted to the waiting area.  Use your skills to assess the situation.

Sometimes I find that clients are not interested in pursuing a conversation at any time. They just want to put the unpleasantness behind them. They may also have a different memory of what occurred, minimizing their experience. Don’t mess with this! The brain works to protect the psyche, and defense mechanisms are called that for a reason. They are defending against the negative impact of an experience. Often how a person thinks about what happened to them (cognitive appraisal) influences whether a situation is coded as traumatic or not. So, in the moment, they may make minimizing statements to try to soothe the chaos of their thinking – but whether that works in the long run remains to be seen. Increasing oxytocin flow by positive touch, eye contact, laughter, holding the baby skin to skin, etc, should be encouraged if it feels appropriate and congruent with your client’s feelings and experience of the moment. Oxytocin lowers stress hormones, which contribute to encoding memories as traumatic. After all, it’s still a birth! If the event really does become a source of anxiety and trauma, we can validate our client’s feelings at that time. Once again, we take our cues from them.

But what about us? As doulas we are often the ones left feeling raw and as if we witnessed a rape. I say that if you feel that was what you saw, then that was what you saw and you should seek counseling with that in mind. Your experience was valid even though it doesn’t jibe with what the medical careprovider, nurse, or client experienced.

If you have a positive rapport with your client’s nurse, you may want to discuss what you witnessed if you have some private and unhurried moments together. “It was really difficult for me when [client’s name] was crying out for Midwife Z to stop. My client sounded terrified, and then the midwife didn’t stop and it just continued. Can you help me to make better sense of this? What was that like for you?”

Hopefully you will get a good dose of understanding and some insight on the nurse’s perspective of these situations. You will get a snapshot of the nurse’s mindset if they feel free enough to share with you. I have found that some nurses feel exactly the same way the doula does, but they don’t know what to do either. Sometimes the discussion with the doula, who is an outsider, is the impetus for them to talk with the director of nursing about it.

Other times, the doula will hear a minimizing statement, “Oh, I knew it would be over in another minute and the mom sounded like she was overreacting.” Or, “Most patients wish Midwife Z would be gentler during that procedure but that’s just the way she does it.” If that’s the case, just thank the nurse for their insight and know that you’ve learned how they rationalize their way through these situations.

Note:  All my suggestions are based on my research, discussions with expert doulas, and conversations with medical careproviders.  I am steeped in white culture, the privileges of education, and being white. Please interpret my suggestions with that in mind – your culture and life experience may lead you to conclude that other actions are more appropriate or better than what I have written.  My goal is give doulas actions that are within their standards of practices as most define them – a beginning point to have a conversation, not to provide the last word for every doula.  

Is it rape? Aren’t you exaggerating?

Some people feel that by using the term ‘rape’, I’m overdramatizing these situations or minimizing the experience of people who have been sexually violated. But I don’t think so. The patient has given over their trust, their body, their life, to a medical careprovider who has a sacred covenant to treat that person and honor them. When they act in a manner that is dismissive, painful or coercive, they violate that trust. The careprovider is touching the most intimate parts of the body – places that may only have been touched by one or two other people besides the careprovider! They have power over the patient and are treating their body like an object. The patient is often lying down and is unable to move or get away. When the patient says, “No” and “Stop”, to me, they are voluntarily retracting their consent.

As a qualitative researcher, our ethics state that the person who is having the experience is the one who defines it. They choose their language and share with us their emotions and mindset. In recent Facebook queries with over forty responses from mothers and professionals, all of the people who felt they had experienced an assault during their labor used the term “rape” or “birthrape”.  Many had also experienced sexual assault or rape, and these people felt many links between the two experiences. The term “rape” has a visceral emotional component that grabs one’s attention in a way that “assault during labor” does not. That is what the victim or survivor wants – for us to acknowledge and see their experience as best we can through their eyes. These people didn’t feel assaulted, they felt raped.[iv]

Rape is defined as “unlawful sexual intercourse or any other sexual penetration of the vagina, sex organ, other body part, or foreign object, without the consent of the victim. An act of plunder, violent seizure or abuse; despoliation; violation. The act of seizing and carrying off by force.”[v]

If the person who had the experience describes it in terms of feeling their body was violated, that is an assault. If they say, “I feel like I was raped”, that counts. They may have signed a legal consent for treatment for a vaginal birth form upon entering the hospital. But that in no way gives medical careproviders, or anyone for that matter, consent to violate their person when they clearly state their wish for that person to stop.

The medical and nursing literature is full of research on traumatic birth and the role of physicians and nurses in creating that trauma. It is also full of the pain that medical careproviders experience when they feel they have been complicit with or damaged by the coercive tactics of their coworkers and colleagues. For more information, I would urge you to read chapter 17 in “Traumatic Childbirth” by Cheryl Tatano Beck, Jeanne Watson Driscoll, and Sue Watson, or access Beck, C.T., & Gable, R.K. (2012) Secondary Traumatic Stress In Labor and Delivery Nurses: A mixed methods study. JOGNN, 41, 747-760.

 

 

[i] Bridges, Khiara, (2013) Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization. UC Press

[ii] Oparah, Julia, & Bonaparte, Alicia (2015) Birthing Justice. Routledge.

[iii] The American Dream of Birth (2016) Video (Free and a good watch!)

[iv] If I was working with a group of medical care providers desiring to change their care practices, I probably would use the word “assault” repeatedly in discussion – it’s no good triggering their own histories of being assaulted or demeaned when the goal is lasting behavioral change. The majority of physicians have experienced bullying behaviors and mistreatment from professors and supervisors. The idea that physicians are perpetuating what they experienced as students and residents to their patients is a valid one. https://portalcontent.johnshopkins.edu/Housestaff/Uploaded%20Files/Medical_Student_Mistreatment_at_Hopkins_BRIEF.pdf

[v] http://www.dictionary.com/browse/rape

There are several good books about trauma and recovery but these are a good place to start:

The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms by Mary Beth Williams PhD LCSW CTSSoili Poijula PhD

In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter A. Levine

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others by Laura Van Dernoot Lipsky and Connie Burk

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How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

One of the neglected areas of research on doulas is their impact on physicians. Studies have shown that physicians have mixed feelings about the presence of birth doulas with younger obstetricians of both genders having the least positive attitudes (1). Commenting on this study, Klein stated:

“Perhaps most concerning, the obstetricians in the younger group were less favorable to birth plans, less likely to acknowledge the importance of the woman’s role in her own birth experience, and more likely to view cesarean surgery as “just another way to have a baby”. (2)

Klein has also stated that there is diversity among the attitudes of both obstetricians and family physicians. At least 20% had attitudes similar to midwives and doulas regarding childbirth – especially experienced and older physicians. Even though our philosophies of birth may differ that does not mean that the presence of a doula is detrimental to physicians. In my estimation there are nine benefits that a professional doula can provide for physicians. In order of relevance, these include ensuring informed consent, observing detailed progression of labor; assisting the physician to know the patient; increasing patient satisfaction with the birth experience; fewer interventions; higher percentage of fees collected; informed refusal; early labor monitoring; and mitigating socially awkward situations.

1. Increasing informed consent. When the doula encourages patient discussion with her physician about an intervention, the doula is increasing the level of disclosure. Information about risks, benefits, and alternatives is given until the patient makes a decision. When this happens, patients are able to give explicit informed consent for the procedure, which benefits the physician. It is no secret that obstetrical care providers are one of the most likely to be sued for malpractice (3). Any time discussion of a procedure can be documented, it is positive for the physician. Informed consent strengthens the physician’s position in case of a lawsuit even if it cannot protect him or her from its occurrence.

However, this discussion does not always fit smoothly into the course of a labor. As Morton explains, the doula can drive an “interactional wedge” between the patient and the physician (4). This occurs when the physician is going to conduct a procedure where the mother had not explicitly given consent. As the doula has been trained to act and engaged by the mother to do, she informs the mother of the physician’s actions before they are completed. The physician’s activity is interrupted and must interact with the patient about the procedure. If the doula were not there, this interaction would likely have proceeded without interruption or discussion between the patient and physician.

In the moment the medical care provider (MCP) may not care for the doula or the interruption to what the MCP perceives as giving good care. It is possible the MCP perceives that there is no need for discussion or consent because it has already been given when signing the “consent for vaginal delivery” form. But there can be a difference between what a physician perceives as informed consent and what a patient perceives as informed consent. When the doula knows the patient’s concerns, she or he is able to facilitate communication around those areas where the patient wants more information and more involvement in decision making. However, this interaction can be awkward and resented by the physicians – even though it is ultimately to their benefit.

2. Getting to know the patient as an individual: The majority of the time in a busy hospital the attending physician has never met the mother. Even if a recent pregnancy appointment occurred, it is quite likely that the physician has seen dozens of women since this mother’s last visit. When a doula is present, the medical care providers are urged to individualize their care for this patient. Doulas do this in subtle ways: we encourage mothers and their partners to say what they want to their nurse, to remind the doctor of their priorities, and to write a brief birth plan for their hospital record. Our very presence is a huge reminder that these parents have thought about their birth and have taken action to see that their needs are met. Evidence suggests that both patients and physicians may be unprepared for these conversations or be uncertain how to proceed (1). In these instances the presence of a doula may be valuable to both.

When providers know the mother, they are able to shift their care in a way that is aligning with this patient’s priorities – while still acting in their comfort zone. The doula is also able to explain the physician’s concerns in language familiar to the laboring mother. Without the doula, the physician has a harder time satisfying the needs of the patient and ensuring that their experience is a positive one. Once again, this depends on the physician’s style. Doctors who like to treat all patients similarly may be irritated by requests to individualize care. MCP’s who place a high priority on connecting with their patients will recognize how much easier that is when a doula is present.

3. Increasing patient satisfaction. Three of the most important factors influencing patient satisfaction during labor are the quality of the caregiver-patient relationship, involvement in decision making, and amount of support from caregivers (5). These factors are more influential than age, socioeconomic status, ethnicity, childbirth preparation, physical birth environment, pain, immobility, medical interventions, and continuity of care. Patients who feel higher levels of satisfaction are less likely to sue (6). Several studies show that continuous support by a trained doula helps to increase overall satisfaction with the birth experience (7). When the doula increases communication with the physician, assists with informed consent for interventions, and provides effective labor support, mother’s satisfaction with the birth is increased. The intervention of the doula may carryover into increased satisfaction with the physician and possibly fewer lawsuits.

4. Observing progression of labor. Undoubtedly, physicians and nurses see more labors and births than a professional doula. However, observation of those labors is intermittent. Doulas have the opportunity to be with women for the entire labor. We see the progression of labor more clearly and are attuned to subtle changes in the woman’s behavior and contraction pattern. When a physician asks the doula about the mother’s labor, the doula is able to report detailed changes. With my observations and the physician’s expertise, it is then possible to forecast more accurately. MCP’s need to make decisions about doing a cesarean on another patient, going to the clinic, or seeing their child’s recital. Physicians often do not realize that the doula is a source of information about the patient that is beneficial to their decision making.

5. Lower intervention rates and healthier outcomes: The recent Cochrane Collaboration review of over 15,000 mothers in 22 studies confirmed that mothers with a trained doula are less likely to have certain interventions (7). Thus, the complications that may occur as a result of their use do not happen. Of course, the practice style of the physician and hospital policies are influential factors that have more impact than the doula’s presence (7). However, the fewer interventions that are used, the healthier the outcomes are for both mother and child.

6. Increased profit with a standard reimbursement rate: Mothers who have doulas are less likely to use pharmacological methods of pain relief and receive fewer interventions (6). When the physician receives a preset reimbursement rate for a delivery, there may be more profit when fewer interventions are used (8,9). The same is true for hospitals that are billed and reimbursed separately from physician fees. This is only a benefit when charges are not itemized or reimbursement is an underpayment of the actual cost.

7. Informed refusal. When patients are uncooperative, the doula can be blamed for their behavior. However, it is more likely that mothers and fathers with defensive attitudes hire doulas (10). Doulas are just not influential enough to change lifelong preferences about physicians or hospitals. (This also assumes that doulas are against hospital birth – which is not true.) Those patterns of behavior and beliefs are set long before doula services have begun. The professional doula’s role is to support the mother in her decisions even if it is not what the physician or midwife would want. Because the doula is not encouraging the patient to be compliant, the doula can be seen as part of the problem.

Informed refusal is a part of informed consent and the right of every patient. However, it can appear that the patient is personally distrustful of the physician or that their actions show a lack of care for their child. Misunderstandings often occur because this is an emotionally charged event for both patient and doctor. Sometimes the doula is highly skilled at negotiating the communication so that both parties understand one another even though they disagree. No matter when it occurs, informed refusal is a risk for both doctor and patient. The doctor is being asked to practice in a way that is less than preferred and the patient may experience a drop in the physician’s good feelings towards her. The benefit for the physician to having a doula present is to facilitate communication and to realize there is a person close to the patient who can understand the physician’s legitimate concerns.

8. Early labor monitoring. When the professional doula is at home with the laboring mother, she is able to provide reassurance. Mothers may choose to stay at home until active labor is established rather than arriving too early by hospital standards.  With the new recognition of active labor commencing at 6 centimeters, early labor monitoring becomes even more important.  Because of her level of skill the professional doula is also capable of recognizing overt signs of an impending delivery or emergency that family members may miss. The doula can recommend calling the triage center for advice or emergency services when imminent help is required. The doula’s skilled observation provides an additional level of safety for the patient that may benefit the physician.

9. Mitigate socially awkward situations: Physicians are often required to get to know several patients in rapid succession. Labor often includes meeting and interacting with extended family. Not all patients or providers are socially skilled and not all situations are easy for people to get along. While the doula, nurse, midwife and physician are all professionals, influences of family structure, language, culture, exhaustion, and personality converge to create a number of challenging and awkward social situations. When the doula knows the family and the mother’s desires, she can head off or smooth over interpersonal problems for the physician. Simply introducing everyone properly may defuse tension.

Relationships between doulas and physicians can be tricky. The doula’s presence indicates a desire on the part of the patient to be involved in decision making and to receive individualized care. The doula is the only professional on the birth team who is not beholden to the physician or the hospital, but to the patient. However, this part of the doula’s role – to increase communication, understanding, and respect between physician and patient is a benefit to the doctor. Doulas increase patient satisfaction rates in a multitude of ways, which is also a benefit to physicians. When doctors understand how professional doulas benefit them and utilize their expertise, they can make the birth less stressful for all concerned.

NOTE:  Originally I wrote this post as an opinion piece for a journal.  But the feedback I got was that it was more opinion than research so it was more suited to a blog.  It’s 1400 words, which is too long for a blog post but I didn’t want to omit anything I felt was relevant.   With the release of ACOG’s statement last week, I thought it was a good time to publish this essay. 

1.  Klein, M.C., Liston, R., Fraser, W.D., Baradaran, N., Hearps, S. J., Tonkinson, J., Kaczorowsky, J., Brant, R. Attitudes of the New Generation of Canadian Obstetricians: How do they differ from their predecessors? Birth 2011;38:129-139.

2.  Klein, M.C. Many women and providers are unprepared for an evidence- based, educated conversation about birth. J Perinat Edu 2011; 20:185-187.

3.  Jena, A.B., Seabury, S., Lakdawalla, D., Chandra, A. Malpractice Risk According to Physician Specialty New Engl J Med 2011; 629-636

4. Morton, C., Clift, E. Birth Ambassadors, Praeclarus Press 2014; 4:210

5.  Hodnett, E.D. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160-72

6.  Stelfox, H.T., Gandhi, T.K., Orav, E.J., Gustafson M.L. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med, 2005; 118:126-133.

7. Hodnett, E.D., Gates, S., Hofmeyr, G.J. & Sakala, C. Continuous support for women during childbirth. Cochrane Database of Syst Rev 2013

8. Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E. An economic model of the benefits of professional doula labor support in Wisconsin births. WMJ 2013;112:58-64.

9.  Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health 2013; 103:e1-9

10. Gilliland, A.L. Nurses, doulas, and childbirth educators: Working together for common goals. J Perinat Edu 1998;7:18-24.

11.  Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

For a downloadble pdf copy of this post, click here:  How Professional Birth Doulas Benefit Doctors

 

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How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

THAT Doula is the one the nurses roll their eyes at and don’t want to see in the labor room.  The one they aren’t certain about, the one who leaves them wondering how their patient may be negatively influenced, the one they feel oversteps her boundaries and has her own agenda – not the patient’s – in mind.  I’ve done extensive research interviews with doulas and nurses, consulted with nursing unit directors and had served as a mentor doula.  To me, the vast majority of the time these concerns arise from misunderstandings and miscommunication between nurses and doulas.

So how do we counter these negative perceptions that nurses may have about a doula when we arrive at the hospital?  (Now this is much harder when the hospital staff has had experiences with a rogue doula who behaves in these ways on a regular basis.  That may require a more direct approach.)  What I am talking about here is building your own reputation as a trustworthy doula.  Often we can’t do anything about the past, we can only begin with the next birth.  Here are best practices culled from experienced doulas and labor and delivery nurses:

  1. Smile.  Smile when you meet someone, smile when they walk into the room, smile when you walk down the hall.  Be genuinely yourself, don’t fake smile.  A person’s brain perceives a smile as welcoming and automatically changes their behavior to be more receptive towards the person smiling at them.  This is unconscious.  So shifting your behavior to be welcoming by authentically smiling can use this to your advantage.
  2. Adjust your nonverbal behavior to be welcoming and acknowledge the MCP’s presence when they come into the room or closer to the laboring mother’s personal space.  A head nod, slight shift in your shoulders or body orientation can indicate your awareness of their presence.  You can do this while not taking your attention away from the mother in her laboring, or wait until the contraction passes if needed.
  3. Introduce yourself, share a little bit about yourself and what you are there to do.  “Hi, Nancy.  My name is Amy, I’ve been a doula for 20 years off and on.  I’m here with Nick and Nora to help them with comfort measures, remind her to change positions, fetch things, and to remind Nora to speak to you and Dr. X about what is most important to her about her birth.”
  4. If needed, explain what you do not do.  “I don’t do vaginal exams or anything clinical.  I don’t speak for Nora and Nick, I just remind them when it’s a good time to discuss their wants and needs with you or the doctor and midwife.”
  5. “Wonder with” and include the nurses when they are present.  “I wonder if we might try…”  “Nora seems to be tiring, maybe a position change would be good???  What are you thinking?”  “Are you noticing Nora’s cxns slow down when her mother is in the room or is it just me?”  Nurses have been to hundreds of labors and may know coping strategies that we’ve never thought of.  It is a courtesy to ask – remembering mom is the decider.
  6. Include the nurse in the mother’s coping ritual whenever you can.  Any connection you can enhance between the mother and her nurse is good for their relationship.  It also helps the mother to feel safer and cared for.  Nurses like to provide comfort measures but their other responsibilities limit their time.
  7. Acknowledge the nurse’s rank and her territory.  If you are thinking about a big change, such as laboring in the tub or walking the unit, find the nurse and ask her before you do it.  Maybe ask her in a general way an hour or two before you make your move.  “Nora wanted to try laboring in the tub today.  Is there any reason we ought to check with you first before doing that?”  Some nurses don’t need this communication, while others feel put out when their patient is doing something unexpected.  There’s nothing like going into a patient’s room and finding her not there!   If the physician calls and the nurse is out of the loop, she looks less competent.
  8. Do simple things that make the nurse’s job easier.  Pick up the dirty laundry, offer to get her something to drink when going to the kitchen.  Imagine yourself working together on the same team and building a relationship.  You are!  You are both on this mother’s birth team along with her family members.
  9. Urge Mom to speak up verbally about what she wants to each nurse and MCP.  “I really want to avoid an epidural” or “I want an epidural but Amy is going to help me to use the tub first to see if I like it.”  “Don’t tell me to ‘push, push’.”   Get mom and her partner used to speaking up.  Get their voice in early and often.
  10. Prompt mom to speak up:  “Nora, do you want to tell the resident about your approach to pain medication?” Maybe a slower, gentler approach is better: “Hmmm, Nora, I’m wondering if you want to share what’s important to you with Dr. Y since she’s going to be involved with your care.”  You want your voice to be remembered as the one who is reminding mom, not the one who is saying the words for her.
  11. If you’ve done the prompting and mom doesn’t say anything, let it go.  It is her birth and if her vision is not happening because she isn’t saying anything then you have to let it go.  A good general guideline: “I’ll stick my neck out as far as my client does, but I won’t go farther than she does.
  12. When a medical decision needs to be made invite the nurse to stay in the room.  “ Since Nick and Nora have some time to discuss what to do next, Nancy, do you want to stay in case they have any questions?”  By inviting the nurse to stay you avoid the appearance of being manipulative or unduly influencing your clients toward other approaches than the one being initially recommended.
  13. Don’t give medical information.  Help your client to solicit that information from the medical staff.  You know what you know so that you can tell if they are getting the information they need to make a good decision.  You don’t know it so that you can say it out loud to your client.  The doula’s role is to enhance connection and communication, not be the source of medical information.  It is okay to ask leading questions IF your client has indicated she wants more information but it doesn’t seem to be forthcoming.  “Isn’t there some kind of number or score about her cervix to consider when breaking her bag?  I think Nora and I were talking about that a while ago.”
  14. Know what you know and don’t claim to know what you don’t know.  If you are unfamiliar with position changes with an epidural, say so.  “I took a workshop where getting in a kneeling or hands and knees position with an epidural was helpful in preventing posterior positioning and labor dystocia.  I haven’t done it before, but Nora would like to try it if possible.  Do you think we could work together and see if that is good for Nora and the baby?”
  15. Realize that everyone present is providing what they feel is the best care for mother and baby.  Almost all physicians, midwives and nurses are making the best recommendations possible based on their knowledge and experience while taking your client’s preferences into account.  It is the rare MCP who is misogynist or disregarding the emotional importance of childbirth.  I’m not saying that it doesn’t happen.  I am saying that making that assumption without direct experience of it does a disservice to you, your clients, and the medical staff you are working with.
  16. Repeat after me:  “It’s not your birth.  It’s not your birth.  It’s not your birth.”  Tattoo this in your memory, embroider it on the inside of your birth bag.  It’s not our birth!  Our role is to follow the woman’s lead even if it seems she is doing the opposite of what she said she wanted prior to labor.  Don’t have your own agenda for this birth or this mom.  Her birth is her life experience.  Don’t cheat her out of it just because we want it to be a different way.  Our job is to support the choices she is making now even when she may not stand up for herself or what she said she wanted earlier.
  17. Your reputation precedes you and nurses will talk about you after you leave (perhaps even while you are there).  Make sure that this nurse has good things to say about you – or at least nothing specifically bad.  It may take more than one birth for positive feedback about you to circulate but it’s worth it.  Hopefully you will experience greater satisfaction in your relationships with medical staff by following these strategies too.
  18. Nurses have personalities, struggles with coworkers, worries, and families waiting for them.  In other words, they are whole people.  Show respect for them and concern for their needs.  An approach that works with Nurse Nancy won’t work with Nurse Abby.  A large factor in your success as a doula is your ability to pay attention to other’s cues and adapt your behavior to get along successfully with them.  Our job is complex because we have to do this with our client, her family, her care providers and members of the nursing staff – simultaneously!!

These are advanced communication strategies that seem deceptively simple.  It takes courage to change even when behaving in a way that is natural to us isn’t getting the results we want.   All of them are ways of being at a birth that highly effective doulas practice and that labor and delivery nurses said they appreciate.  My hope is that they will help you find increased satisfaction and harmony in this critical aspect of doulaing.

 

Here is a pdf copy of this post: How not to be THAT DOULA in a Nurse’s Mind

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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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What If ACOG Decided To Certify Doulas?

Nov 8, 2013 by

For thirty years or so, birth assistants (now doulas) have been attending mothers.  The good news is that now doulas are everywhere.  We’ve reach a critical mass where many people birthing these days have heard of doulas.  But our growth has been random and erratic, working in isolated groups, going to births and getting the word out.  For almost two decades there were about four doula organizations; last month I easily counted 14 – each with different philosophies and visions for doula supported birth.

Among physicians and nurses, doulas have a mixed reputation.  At worst doulas can be seen as interfering with patient care.  A more begrudging view is that doulas are annoyances to be tolerated.  Sometimes doulas are seen positively but that relationship is usually fragile or reserved for individual doulas.  Originally, certification was conceived to be a reassurance to medical careproviders that certain standards of ethical behavior could be expected.  However, most doulas today only view certification as a marketing tool:  “My clients don’t care whether I’m certified.”

In any case, the current certification process has failed in both reassuring medical staff and clients.  (There are exceptions to this on a local level.)  The great majority of organizations offering doula training do not have any behavioral standards for the people who complete their courses.  Even though they title course completion as “certification”, they really aren’t certifying anything except that someone completed their organization’s checklist.  According to the publicly available information on their web sites, there is no vetting of their candidate’s character, no compliance with professional ethics, nor any standards of behavior that must be adhered to.  What exactly is being certified???  While these organizations may or may not do a good job training birth doulas, they do not seem to be certifying them to any particular standard.

Let’s consider the point of view of physicians and nurses.  I think we can safely assume they would like reassurance and some control over the people calling themselves doulas who they are forced to work with in the labor room.  As a profession we have not been able to provide it.  So who can blame them if they decide to do it?

What if ACOG (American College of Obstetricians and Gynecologists) decided that the mosquito-like annoyance of birth doulas needed dealing with?  Swatting at the occasional bug has not been working.  What if they set up their own registry or certification process and promoted it to their patients?  They may not be able to get rid of birth doulas but they sure can influence and frame the discourse about doulas with their patients and the general public.  What they want us to do and what we want to do in our current standards of practice may be very different.  Even if they follow evidence-based guidelines by the Cochrane Collaboration, it doesn’t say anything about birth plans or empowerment or client involvement in medical choices.  We don’t have that evidence.

But ACOG does not need a lot of evidence; they have money, power, and access to patients.  With only one (somewhat flawed) study they changed medical practice regarding breech birth in one year!  The same is true of VBAC.  Even with a potent consumer movement, we have been unable to create strong social change influencing the rate of VBAC in our countries.  Only now that we have careproviders reexamining their own practices is there any possibility for change.

I do not like to act from a place of fear.  I prefer to plan and be proactive rather than react.  My concern is that we are far too complacent about our own place in the birth world.  Right now it is dependent on being ignored by the people with all the power.  Birthing women and medical consumers do not have the power; large groups of doctors and hospital administrators do.  If we do not provide an answer to their “doula problem” that is on our terms, they will take action and dictate the terms.  We have to solve our own problem regarding certification and we have to solve it soon.

Is it time for an independent certifying organization? As an independent group, it would be divorced from training issues and philosophical issues that exist within a particular organization.  It could employ a robust complaint and grievance process.  It could actively promote birth doula standards of practice and spend money to explain these standards to health professionals. It could offer different levels of certification that reflected achievement in the profession.  It could build on existing certifications set by organizations who have them.  The only purpose would be to certify birth doulas, provide ethical guidance, and to set and ensure standards of behavior.  This organization could actively work to cultivate the trust of physicians, nurses, and midwives.

On the positive side, this would mean that doulas who trained with an organization that only offers certificates of completion would be able to obtain certification that reflects real ethical standards.  If promoted well, this certification could reassure medical people by defining professional behavior.  It would let everyone know what to expect.  Consumers could discover what appropriate norms are for professionals.  As doulas we get to choose what those standards are.  If we are a large group who earns a reputation of being trustworthy, we may be able to negotiate for doulas with a certain level of certification to remain while patients receive epidurals or to get into the operating room.  We could be viewed as the professionals we are.

On the negative side, it means surrendering a rebel image (if you have one).  It would mean distinguishing the difference between professional and non-professional doulas without judging someone for being a hobby doula or a friend doula.  (As I’ve stated previously if we want every woman to have a doula who wants one, that means we need to accept all kinds of doulas.)  The challenge will be to remain inclusive and nonjudgmental while maintaining there are different standards of behavior.  It means realizing that the organizational model of offering training, support and certification in one place is no longer working from an expanded system standpoint.  Most people are shopping for doula training based on location, price, or teaching method (workshop, correspondence).  They are not considering any of the certification or profession issues discussed on this blog.

A big fear that has been around since we first started attending births professionally is that birth doula care will be co-opted by “The System”.  “Doulas need to be outside the hospital system not a part of it.”  Well, that depends on what you value about birth doula support.  What I value is a supported birth as the mom sees it – no matter what her birth philosophy, caregiver, or place of birth.  I think that if we want doulas to be widely available to every woman who wants one, that means that doula support will take many forms.  This fear says, “If we have a separate certifying organization that appeals to physicians and nurses then it would be reflecting the values of the hospital system – which we usually view as disempowering to mothers.  So wouldn’t we be colluding with this philosophy?”

That depends.

This will only work if we understand the situation we are in and commit to this process.  It must be a consensus process and one that involves asking all stakeholders what they envision for doula certification.  Yes, that means asking nurses, doctors, mothers, consumers, administrators, insurance companies, and most importantly ourselves, what we want this to look like.  What do we want certification to do?  What do other stakeholders want certification to do?  A lot of professions go through growing pains.  I think that we have reached a point in our growth where we have to assess our current status and actively chart our future.  For 35 years it’s been about getting known and people understanding the importance of what we bring to the perinatal period.  We’ve done that.

While I would like things to go along as they have been, there are a lot of unhappy people out there when it comes to certification – many of them working doulas.  Until two months ago when I started listening to them, I really had no idea just how fractured our current system was.  I don’t know exactly what a certification organization might look like at the end of a conscious consensus process.  It’s kind of like looking at adolescence; I really don’t really want to have the experience of going through it but I really want the benefits of being on the other side.

Right now we can be in charge of our own destiny.  If ACOG or a similar organization decides what our behavior and standards should be, they have the power to restrict doulas from the labor room.  When I consider that alternative, I feel more compelled to consider conscious action.

 

 

 

 

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Their Doula Disappointment

Oct 26, 2013 by

Recently these two news stories came across my desktop.  “My Doula Disappointment” outlines one woman’s story with her birth and postpartum doulas. The second is a petition which is a response to North Florida Regional Medical Center’s recent move to create a registry of birth doulas who are “allowed” to attend women in labor at their hospital.  What do these stories have to do with the current discussion of certification?  Plenty.

In the first issue, the woman noted that the doula she hired had twenty years experience and was highly recommended but not certified.  The mother disregarded the doula’s lack of certification, remarking that since she came highly recommended, certification was not necessary.  Now that she is not satisfied with her experience, she realizes that there is no one to complain to nor to mediate her dispute (or even to listen to her feelings).  While I know nothing about the circumstances or doula’s perception of what happened, that isn’t relevant.  My point is that the mother bemoans the fact that there is no one with any authority who will listen to her concerns, so she is forced to air her concerns on the internet – for all to read.  If there was a certifying body, the story she shares might be different.

In the second instance, NFRMC is reportedly instituting a doula registry in order to clear doulas who will be allowed into the hospital in a doula role.  [This is unverified as the only mention I have found online is the petition.]  Undoubtedly, they have encountered unprofessional behavior and are doing what they can to provide a “reasonable” working environment for their staff and providers.  Part of the problem is that doctors and nurses deal with novice doulas, hobby doulas, friends of mothers calling themselves doulas, and rogue doulas*Very few of these people feel any allegiance to other doulas or the professional standards most of us hold dear.  They can’t tell them apart from the professional doulas – we’re all the same to them.  We use the same title and there is no visual distinction between us.  Every doula gets blamed when one person calling herself a doula acts in a way that medical professionals do not care for.

Even though we are not part of the medical culture, it behooves us to structure our profession in a way that garners their respect.  We can either control and patrol ourselves or hospitals will do it for us.  As someone who has consulted with hospitals regarding their conflicts with birth doulas, I am not surprised by NFRMC’s purported action.  It makes perfect sense to me when I consider the bigger picture of their possible doula experiences.

On the other hand I hear doulas rejecting certification because it interferes with their freedom to offer services to their client.  What is it you want to do for your client that is outside the doula’s scope of practice as defined by DONA, CAPPA, and similar standards?  This “I want to follow my own conscience” does NOT work for doctors, accountants, or even personal trainers.  No one is protected by an “anything goes” attitude.  According to DONA and CAPPA SOPs you are welcome to use aromatherapy, therapeutic touch, even massage, homeopathy, and herbal remedies IF you have additional education or certification.  Counseling that these alternatives are available is certainly within your SOP.  Giving your mom a recipe for an herbal tea to start labor is too IF you are a trained herbalist and her MCP of choice is consulted.  Herbs, homeopathy, and essential oils are drugs!  They have effects on the body; that is why we use them.  The same goes for acupressure.  To think that these effects are always benevolent is deluding yourself.  States and provinces even require massage therapists to be licensed.  But many alternative remedies have been classified as supplements which means they are available over the counter.  But OTC does not = benign.  Both of these SOPs state that if the mother is considering doing something to her body that may have a deleterious effect, even if it is a rare occurrence, that she discuss it with her care provider of choice first.  Some doulas interpret this as asking for permission; I see it as consulting.  The mother hired her MCP for their expertise on her physical health.  If she is considering taking a drug or having a treatment that may affect her health, it is important for her to get their opinion and for her medical record to be complete.  It is the mother’s choice to make; we only counsel her to do so.

We live in a society where few people take personal responsibility.  You may think your client will never blame you or a technique you recommended for a poor outcome.  Just ask the doula who has had 100 clients – she’ll set you straight.  According to my own research participants and the hundreds of  doulas I’ve known over the years, scapegoating occurs in both small and large ways.  The limits for the doula’s standards of practice and condition that the client consult her medical care provider PROTECT you and your client.  If you really want to prescribe rather than support (or in addition to it), get the education and credentials to do so.  No one is stopping you.

But remember that the doula’s magic is her ability to support unconditionally and be present with a woman when she is vulnerable, uncertain, and challenged on every level.  It is believing in her ability to find her own voice.  It is not being another voice telling her what to do.  That is what the research evidence supports.  If prescribing, diagnosing, and treating are important to you, then perhaps your path is not to be a doula.  There are many other roles where these desires can be accommodated – just don’t do them and call yourself a doula.  Be fair to the rest of us – the choices you make individually do not end with you – they affect all doulas.

 

*rogue doulas:  A doula who willfully behaves in a way that is dishonest, unethical or against established standards for doula behavior.

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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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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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The Art of Labor Sitting

Jul 22, 2013 by

Labor sitting is the process of being present with a mother when she is laboring and does not require your direct attention, but needs your attentiveness.  In other words, labor is going well but there really is nothing for the doula to do but step to the outer circle and wait.  Common situations for labor sitting are early labor, the first few hours of an induction, when mother is resting with an epidural, or taking turns with another member of the birth team.

Good labor sitting means that the doula seems occupied but interruptable.  The mother does not feel pressured by your presence to be further along in labor or to be doing anything different than what she is doing.  At the same time she can feel your presence, knowing you are available if she should need you.  Often, labor sitting takes place in the same room with the mother.  Effective labor sitting is an active, not passive process.  It may seem we are sitting on the couch working on a little project.  But a good doula is much more aware of what is going on than it seems!

So how do you strike this balance?  Over the years, through trial and error – doing it wrong and by accident doing it right and then repeating it – I have found my way to effective labor sitting.  I do needlepoint.  If I am reading a book or looking at the screen on my phone, I seem occupied by what I’m doing.  My attention is focused on the book or my phone.  Someone might feel they were interrupting me if they spoke to me.  If I am just sitting there, people may feel bad because I’m just sitting in the chair not doing anything.  They might feel badly or pressured because my skills weren’t being used yet.  If I am sitting on the couch doing needlepoint*, my mind is in the room with them, yet I am happily occupied.

One time a father called me saying he and his wife were getting ready to go to the hospital.  They weren’t packed yet so he was rushing around the house.  Her contractions were 4-5 minutes apart with no bloody show.  Mom was relaxing in the bathtub and coping well.  Through our conversation I got the idea that Dad was anxious.  I surmised he wanted to go to the hospital because it would relieve his anxiety.  As we’ve all learned from TV when you go to the hospital the baby comes out.  While this is an irrational belief, it is the way our culture has trained us.

I offered to come over and help.  When I arrived, Mom had just gotten out of the tub and gave me a big smile.  My doula assessment of the labor was that it was not time to go to the hospital.  I asked her preference and she said she wasn’t ready to go (she is the decider, not me).  We talked a bit and I went to sit on the couch and got out my needlepoint.  I didn’t say anything but after a while Dad seemed to calm down.  We chatted and his furious pace of grabbing household items and putting them in the pile slowed down.  He began to pay more attention to Mom.  The message he got from my behavior was:  “Amy’s calm so there must not be any rush.”  When mom had a contraction I would stop and breathe with her, looking at her from across the room.  This visual regard is also a part of effective labor support – if she were to look at me she would see that I was watchful and available.  In due time we went to the hospital; they were both calm and made the decision they were ready.

Another time labor sitting skills come in handy is at the beginning of an induction.  There are many anxieties to soothe and many decisions that are made in those first few hours that have repercussions later.  If I am present I am able to remind them of their choices, make sure their questions are answered, and calm them down.  I create an atmosphere in the room to make it their space.  I can increase the level of connection between my client and the nurse, resident physician, and attending physician.  If I am not there, those things often do not happen.  This is another time to discuss methods of induction and parent’s concerns.  It is often easier to advocate for using the shower or tub, or having a slower, gradual Pitocin drip before any interventions are administered.  Parents may be able to get approval for a plan to go home under certain conditions.  What I have found most often is that a mother may bring up these things and then the medical care providers (MCP) explain to her why they won’t do it that way.  But in the long run, my client has explored her options to the extent she wanted to.  Plus, the MCP and my client have talked and understand each other’s concerns and preferences.  The nurse has heard the mother and she may make more suitable labor support or intervention suggestions.

Of course a discussion about options is fifteen minutes out of three hours of labor sitting.  Even if none of these discussions happen, there are still other fears and plans that are on their minds and choices to be made.  I have never found NOT being there at the beginning of an induction to gain my clients or me anything.  Sometimes with a Pitocin induction, parents want me to leave for a while.  That’s fine and we agree to check in verbally – not with a text – every hour or two.  If they want privacy with a misoprostol induction, I stay immediately outside the room or return every 15-20 minutes.  Those intense contractions can hit without warning and the partner or nurse may not be able to contact me.

Labor sitting is a creative art.  It requires an understanding of the people involved, a perception of possible futures, and an empathetic, compassionate presence.  It is not a passive process – you are not waiting for something to happen and then responding to it.  Instead, you are influencing the present moment.  You are there, caring, mindful, and available.  People take their cues from your behavior and from your presence.  Because of active compassionate labor sitting, labor often unfolds differently.

*Some doulas embroider or crochet something for the baby or make a lace cap out of a handkerchief.  Knitting needles may click which bothers some mothers.

 

 

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