Back Door or Front Door?

Feb 20, 2015 by

Back DoorIn Jennifer Torres’ article, “Breast milk and labour support: lactation consultants’ and doulas’ strategies for navigating the medical context of maternity care”, the author makes a declarative statement.  She says that both professions have filled a niche in maternity care practice that is not covered by nurses or physicians.  However, lactation consultants have been able to influence medical practice directly.  They entered through the “ front door” and have been welcomed by medical professionals, because breastfeeding is seen as a medical event.  However, doulas are not recognized as having anything meaningful to offer to medical professionals, and as such are seen as entering through the “back door”.

When the doula movement began in the late 1980’s, we were really trying to figure out how to get in through the front door.  Doulas have often read the same journals as medical professionals, and many of the doulas I know have college or advanced degrees.  We really thought that once physicians saw what we had to offer their patients we would be welcomed on the maternity care team.  However that was not what happened, and we have been relegated to the back door ever since.

One of my missions has been to do doula research that will convey the complexity of birth doula skills.  If we have enough evidence, eventually it will be too much to ignore.  But I’m also struck by the way we delegitimize ourselves.   We have had no choice but to declare our power as outsiders – we have had few opportunities to be insiders!  Having our knowledge and contributions to labor progress be ignored is seen as normal; we are used to this position.

So when I look at national certification efforts, I realize that there will be no recognition from other sources unless we do it ourselves first.  When the NAACP Image awards were televised last week, actor Laurence Fishburne made a statement along the lines of ‘we have to recognize ourselves first before expecting anyone else to see our worth.’

However I believe most strongly that the process in which national certification for birth doula efforts is absolutely vital to its success. In order to maximize its impact, it needs to:

  1. Be self sustaining from the very beginning.  No one goes into debt creating an organization.
  2. Be transparent.  There is no reason for secrecy.
  3. Incorporate the voices of experience with the voices of tomorrow.  People who have been doulas for years know a lot.  People who are new will be doing the work for years to come.  Both are needed.
  4. No existing organization should be in charge.  However, having a representative from each successful doula organization of significant standing who believes in NC should be invited to the table.
  5. National certification needs to arise organically from several different spheres involving doulas with different priorities but focused on one goal: a vital and effective national certification organization for birth doulas.
  6. Utilize current and emerging technology to create and communicate.  Its important to have a smaller working group that actually meets face to face especially in the beginning stages to outline decisions, craft a timeline, and organize projects.  But a larger ring of committed, strategically chosen doulas and invested stakeholders would be another working group.  This outer ring would be involved over time to listen and hear what the working group discussed and decided.  They would then be able to consider options and provide feedback.  They would not meet face to face, but would be involved through communications technologies.
  7. A working group needs to be experienced in a variety of areas and chosen for areas of expertise that can make progress happen.  Those not in the group needs to feel a sense of confidence in the people who will be doing the work.
  8. Obstetricians, midwives and nurses, represented individually and by their leading organizations (ACOG, AWHONN, MANA, ACNM) need to be involved from the beginning.  If we want to create an organization that “speaks” to their interests and want to be invited in the front door, this is absolutely necessary.
  9. Health care, insurance, and Medicaid consultants need to provide input to maximize the opportunity of obtaining reimbursement.
  10. Policy makers and community health education/worker industry leaders need to be consulted to discover how birth doula national certification could be bridged to be a part of CHEW programs and jobs.
  11. Health care consumers, parents who have used doula support, need to have a voice in setting priorities.
  12. Consensus decision-making, not majority rule.  With consensus you spend more time discussing, but more gets done in the long run because people are committed to the eventual decision.  Disagreements are aired.  With formal consensus, those who disagree can choose to do so but not stand in the way of action.  Or they can choose to go on record as blocking, knowing there is no compromise they can agree with.  In my 20 plus years of using consensus (I’m formally trained), only one time has someone blocked.

This is a large undertaking.  It is not a kitchen table project.  We are talking about transforming the birth doula industry from one that is totally unregulated and provides no consumer protections.  National certification may be optional, but market forces will determine if it becomes the future standard for the profession.

Many of you have written to me asking when we will get started or even when it will be completed.  My commitment was to write about national certification in a way that would expose the issues involved, and to get doulas and other people talking.  I have completed that commitment, and it was my gift to my community.  I want us to make conscious decisions about our direction and our future and that only comes from considering various points of view over time.

I do not have any plans to create a national certification organization.  There are other projects in front of me.  I would appreciate consulting with any serious efforts to organize, because I feel I could offer a rich perspective.  I still have reservations that make me doubt what is possible, or if it should be done.  If NC is part of an effort to transform maternity care, reduce disparities in birth outcomes, or increase job opportunities in urban areas, there is possible foundation money available to fund our efforts.  It will be interesting to see what happens next.

Torres, J.M.C. (2013) Breast milk and labour support: lactation consultants’ and doulas’ strategies for navigating the medical context of maternity care. Sociology of Health & Illness, 35(6), 924-938.

 

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.  Benefits of National Doula Certification

5.  Fears, Downsides, and Challenges of National Certification

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

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The Fears, Downsides, and Challenges of National Certification

Jan 7, 2015 by

rock-climbing-403484_640This post articulates the shadow side of national certification (NC).  Listening to shadows allows us to learn and become stronger from going deeper into a process.  These 13 reflections are from my notes, your emails, Facebook and blog comments.  So please be in a space of listening – and I hope you also feel heard.

1.  No guarantees of results.  Several of my hopes of what NC could do for doulas as a profession are just that – hopes.  One hope is that NC would provide an avenue of acceptance and involvement with medical professionals and hospital programs.  Another hope is that NC would substitute for each individual hospital developing their own doula approval program for independent practice (IP) doulas.  This may not happen especially if we do not involve nationally respected members of those communities to participate in shaping our competencies.  It also may not happen despite our best efforts.  We also may go through all of this work and are still unable to obtain doula specific national billing codes for birth and postpartum doula services.  It may not lead to creating a reliable third party billing and payment system.  But if we do not have NC, there is no chance.  As I see it, NC creates the opportunity.

2.  NC would lead to the continued professionalization of “caring”, which is viewed as a “natural” behavior.  People are not comfortable making a job out of behaviors they wish most human beings would display.  In this concern, there are elements of the idea that doulaing is somehow a natural, innate, human behavior; and that there is no skill involved.  Birth doula work is a highly skilled profession (Gilliland, 2012) which is why so few who take a training end up being successful at it long term.  It isn’t the business part; it’s that supporting a lot of people you don’t know in a professional manner takes “people skills” that cannot be taught in a 24 hour workshop!  Not everyone can be a successful birth doula but everyone should be able to take a training who wants to.  We need an educated population who understands why birth matters and who wants to help ensure every pregnant woman and her baby get the support they desire.

The institutionalization of doula support began when organizations were started to teach people.  Remember, the 1980’s doula movement is in response to a breakdown in the system of caring for laboring women.  In her essay on titling the “Scandanavian Journal of the Caring Sciences”, Halldordottir writes eloquently on how important it is to teach caring – and research the science and behaviors that make a person feel cared for.  Ask any doula who has been to over 50 births what she has learned about caring in that time – she could fill a book.  Caring may be innate for some people, but for most it is a learned and highly skilled behavior.  Does that mean it should be restricted to only certain individuals?  Heck no!! We all need caring skills, but not everyone will pursue them professionally.

3.  NC would lessen the power of experiential knowledge.  Birth teaches us about birth.  Mothers teach us about their needs.  Reflection and support from our birth circles improve our skills.  Education imparts knowledge and confidence.  Since this is the core of doula learning for all, how can NC denigrate it?  We must have experiential knowledge at the core of our learning, and NC competencies would incorporate it.  Similar professions, such as massage therapy and lactation consulting, also have a strong experiential learning core.

4.  “NC belittles the culture and history of doulas and disrespects the knowledge of learning passing from woman to woman.”  NC is a tool for professional doulas to use as they advance in their careers.  No one achieves that by not learning from women.  Institutionalization and traditional and/or matriarchal learning seem to be at odds with one another – I get it.  I’ve been immersing myself in these perspectives for many years, and I understand this dilemma.  We want to be recognized as the women in the village with the specialized knowledge and dedication to this life transition.  We don’t want to have to declare ourselves or compete.  Yet we live in a world where there are barriers to support, and where there is little recognition that support is even important.  We’re surrounded by institutions, many of them patriarchal.  And if we organize and certify ourselves, are we participating in the patriarchy that we wish to transform?

5.  “National licensing didn’t help midwifery.”   Doulas are not midwives.  We have a completely different history; we do not compete for market share with physicians or nurse midwives; certification is not licensing, which is a legal, government process. When you list the differences and similarities there are huge differences, which makes comparing the two professions ineffectual.   Even though we can both be found giving support in the labor room, after that the similarities end.  Doulas have more in common with lactation professionals, who have been refining their own certification processes.

6.  NC would clearly draw the line between doulas who practice according to an evidence based standard and those who do not.  NC is not for beginners; it would be a standard of achievement for people who have made a commitment to the doula profession as one of their highest priorities.  That is not to say these doulas are any better at doulaing than people who only go to a few births a year or only doula their friends and family members. In order for many women to have access to doula support, we need all kinds of doulas.  That is not going to change.  My hope is that we can continue to respect and support one another in our local communities even though the role doulaing plays in our lives is different.  Yes, NC will magnify these divisions – which already exist whether we formally acknowledge them or not.

7.  “The national certification philosophy of doula support will become the only acceptable one.”  NC would set competencies for doula behaviors and knowledge.  It would not set an exclusive philosophy for conducting those behaviors, nor would it evaluate training programs.  It is highly likely that multiple types of learning experiences would be needed to meet all competencies.  The approach of an initial program would be chosen by the individual, just like it is now. If we want a doula for every woman, that doula needs to reflect the mother’s beliefs, language, and behavioral norms.  Which means we need doulas from all communities and multiple training programs with different philosophies.

8.  “National certification would define the standards for appropriate doula behavior, and I don’t want anyone telling me what I ought to do.”  Yes, it would set standards for professional doulas and promote those expectations to consumers, medical professionals, and the general public.  NC is voluntary and it is likely not for everyone.  Some doulas are individualists – they have highly developed moral codes and are not really interested in following or scorning rules set by others.  Other doulas have a rebel or subversive identity.  They want to behave in ways that are “outside the system” or “according to their own conscience” or “tailor it to my client’s needs, not what I’m told by some organization”.  People come to doula work with a variety of mindsets and beliefs and they will use their doula path (and their client’s births) to learn and grow.  No matter what direction we choose, it will be problematic for some doulas on a philosophical level.  For years doulas have been outside the system, working to change birth by showing over and over again that mother’s emotional needs, and those of her baby and partner, are equal in importance to physical ones.  For some, it is being outsiders that is important.  Once we become like the institutions we guide our clients through, they think we lose.  Others have been waiting until there is a critical mass of doulas to set up a national certification system and welcome NC as weakening their outsider status.

9.  “I don’t want to be controlled by “the government” or “the hospital”.  This is a huge misunderstanding about who has power over who accompanies a woman laboring in a hospital.  Many people seem to think it’s the woman.  No, it is the hospital.  Once a woman consents to have a birth in a particular hospital or birth center, she submits to their rules.  Each hospital has the authority to decide who can visit a woman in labor and who she can have with her.  There are no legal patient rights or guarantees about who can accompany her (except Minnesota), but even that is nullified if someone is perceived as getting in the way of the medical care provided by the hospital or a safety concern.

Hospitals in rural areas and large cities are already forbidding doulas and setting rules about who is allowed.  If you don’t know this, you haven’t been paying attention. That’s one of the main reasons for NC now – to set up something that WE can agree on, so we aren’t barred en masse or have to succumb to rules that tell us what we have to do with our bodies, such as blood tests and vaccinations.  When it comes to licensing, doulas do not have any behaviors that would invite licensing by any governmental body at any level.  So this fear is unfounded.  The only involvement of the government with doula care has been to create a law that the hospital cannot get in the way of doula support as long as the certified doula is following the hospital’s rules for her presence (Minnesota), or to allow for third party reimbursement for services (Oregon).

10.  “Clients don’t care whether I’m certified or not.”  They don’t care because we haven’t taught them to.  Right now the client takes all the risk and places their trust in the doula.  Inexperienced parents have no idea of their own needs or all the things a doula can do to muck up their birth, their relationships with their caregivers and even with their partner.  Bad doulas do exist – its naïve to think otherwise. NC could offer optional background checks, assurance about back up doulas; and define standard industry practices (collecting fees before birth, typical letters of agreement, etc), and a grievance procedure with consequences.  NC could offer a layer of consumer protection for parents that they now do not possess at all.  Remember, parents’ primary reason for choosing a doula is whether they feel safe with her and trust her on an intuitive level.  NC may be able to make that leap of faith more secure.

11.  NC would restrict women’s access to doulas.  Right now bringing your own doula into the hospital with you is up to the hospital.  It is the hospital’s rules and women choosing to go along with them that will restrict women’s access to the doula of their choice.  If a hospital states that a doula needs to be nationally certified to or follow a NC standard of practice in order to do labor support in their facility, that is their right.  But that’s the idea: we would do a better job setting standards for ourselves than each individual hospital.  If NC is successful in helping third party reimbursement to occur and in gaining grant monies to expand doula programs, it would actually expand women’s access to doulas.

12.  “NC would restrict what I can charge, how I can charge or who I can bill.”  This is erroneous as any restrictions on fee setting or billing would be considered price fixing under U.S. labor law.  “We would have to listen to what insurance companies would want us to do or not do in developing or changing our standards.”  Since getting insurance and Medicaid reimbursement is a part of this movement, having this information would be important.  How it would be responded to is a different matter.  In some ways its true – we may only be reimbursed for two prenatal visits and not three; a company may set a reimbursement rate for a whole state, which may not be high enough in a metropolitan area.  It would be up to the individual doula whether to charge parents more than what their insurance would cover or not accept third party reimbursement at all.

13.  Is NC coming from a place of fear or a place of power?  I think it’s both.  I think doulas feel powerful enough within to organize and say, “Hey! These are our standards for ourselves.  This is the way we think professional doulas ought to behave, and what they ought to know.”  But I also think its coming from a place of fear of the existing system having ‘power over’ us.  Fear that doulas will not be allowed in hospitals unless following their rules; fear that doula support is becoming a wealthy woman’s indulgence; and fear that doulas will not be available to more women unless we do something.  The idea of national certification brings up deep fear – colluding with the system/patriarchy/institutionalization; as well as providing some solutions to the problems that we face – restricted access in hospitals; and lack of recognition for our skills, achievements and professionalism.  It has potential to shift and change the landscape for current and future doulas.

As a profession, I think we need to ask ourselves, who are we accountable to?  What is our purpose?  Does NC fulfill that purpose and accountability?  Because of the differences highlighted in this essay, doulas will arrive at different answers.  Will we end up at what serves the greater good, allowing the concerns of dissenting voices to also guide us?  Will we consciously decide to stay unorganized and live with our current fragmented system?  HOW we proceed next is just as important as WHAT we will create.

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

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.  Benefits of National Doula Certification

5.  This post:  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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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.

 

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

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

read more

Do We Want A Place At The Table?

Nov 11, 2014 by

PlaceTableOne of the possibilities offered by national certification is the ability of doulas to have an impact on public health objectives. Because of the level of intimacy we have with our clients, doulas are uniquely situated to relay information about health conditions and detect possible issues.  In 2014 alone, at the top of the perinatal agenda are initiatives to end racial disparities in perinatal outcomes, detection and prevention of birth related trauma, the CMQCC multi-level project to increase health care response to pre-eclampsia, and promoting awareness of postpartum kidney disorders related to pregnancy illness.

However, established medical groups and public health organizations repeatedly ignore birth and postpartum doulas as vital conduits of information and support.  When women have problems, they are more likely to self disclose to the doula who they trust and know intimately.   The evidence is very clear and positive.  The October 2013 Cochrane Collaboration released its fifth review of labor support, once again finding there are no negatives to continuous professional labor support provided by trained people unrelated to the family.  The American College of Obstetrics and Gynecologists (a trade organization) released a statement in February 2014 acknowledging the value of birth doula care by a non-family member to laboring mothers.  Medicare rules may allow for the reimbursement for doula care, but it is unclear on who gets reimbursed and under what circumstances.

This leads me to two very clear questions.  Do we, as professional doulas, want to be a part of solving these health care issues?  Do we, as a professional group, want to be respected for our value, compensated for our worth, and treated as having unique and valuable knowledge by perinatal professionals (nurses, family practice physicians, obstetricians, midwives) and policy makers?  Do we want to be reliably paid a living wage by insurance companies and other third party payers?  Are we willing to generate change in order for these things to happen?

If the answers are “no”, then let’s continue to go on as we have been.  Some individuals will garner respect and have additional privileges, but as a group we won’t.  If the answers are “yes”, then we need to make some changes.

First though, why don’t health care organizations and professions already include doulas in their educational and support solutions?  For one, training quality varies a great deal.  Certification is uneven at best.   There are no standards for professionalism.  Backstabbing and insults towards different organizations is common on social media.  It’s the Wild West, with almost every doula for him or herself.   New training organizations are emerging every month.  In September 2013, I located 14.  In September 2014, I stopped at 24.  New or old, they are of various levels of quality.  Most say they “certify” their participants, but often it is only a certificate of completion of a checklist.  Some small local organizations garner respect, and some larger ones dominate a particular geographic region.  So the first step is separating out training from certification.  Once it reaches a certain point, no similar profession does both – its time we respond to these growing pains.

Secondly, doulas are unorganized.  As a whole there are no centralized standards, professionalism is voluntary, and ethics are not clearly defined.  If one chooses to participate in a certification program that has this level of organization, then the burden is on that individual doula to prove herself to every hospital or perinatal professional.  There is no universal acceptance that says, “You can trust me because I’ve been vetted and endorsed by this organization”.  Medical staff can make no assumptions based on a doula’s credentials.   This leaves policy makers, grant writers, and public health programs with few mechanisms to fund doula programs.  It also means HMO’s, insurance companies, and other third party payers without a standard to pay for doula services.  Without high national standards, it isn’t going to happen.

If we want a place at the table, that would mean creating a certifying organization only.  No training, no education, just certification.  I think it needs to offer multiple levels of certification, so there is recognition of higher levels of achievement and service.  My vision is something that leaders who possess different perspectives would collaborate and create, with standards of practice that are versed in reality and a philosophy that is well explained.  With today’s technological tools, it likely will not take as long as CIMS did in the 1990’s.  But we are talking about institutionalizing our profession here.  There needs to be a universal buy-in by different stakeholders.  We will need to collaborate with organizations who we want to respect us – which means ACOG, AWHONN, as well as key policy makers.  The current ACOG leadership is more likely to be doula-friendly.  Otherwise the February statement would not have been released.

This institutionalization has already begun.  Birth doula care is a protected right in the state of Minnesota.  Medicare wants to reimburse for it, but with no national standard available to all doulas regardless of training it is very unlikely that many doulas would be able to take advantage of that.  Once there is a code, doulas can likely use that with other payers.

Based on your comments, I know many of you have a knee-jerk fear to anyone telling you what to do or how to do it.  You have a fear of doulas being co-opted by the institutions that you want to change – hospital policies, ACOG, nurses or doctors as a group, etc.  However, our profession has a history of negotiation skills, of creating opportunities for empowerment and communication.  Don’t we do that every day with our clients?  I have a very high degree of confidence that experienced doulas leading this shift will utilize those skills to create an organization that works for us AND for other professionals who want to work with us.  I encourage you to sit with your fear and let it lead you and us to wisdom and possibility, rather than shutting a door.

 

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

Posts In This Series:

1.  Social movements – The Next Step In The Doula Revolution

2.  Balancing Dynamic Tension – Respecting All Doulas 

3.  This Post:  Do We Want A Place At The Table?  National Certification and Public Health

4.  Benefits of National Certification

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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Doulas: Balancing Dynamic Tension

Oct 26, 2014 by

Downward-Facing-Dog22“National Certification will mean that I can’t…”  “I’m a traditional doula and I don’t want a national certification organization to tell me that…”  “I don’t want to go to a lot of births, will NC mean that I have to…?”  I have said it before and I will say it again, clearly, out loud:  We need all kinds of doulas.  There are all kinds of women in this world, who need a doula who they feel safe with, who they can trust, who believes the same things they do, and who supports her birth and/or postpartum vision.  No one doula can be the right doula for everyone.  Ergo, we need all kinds of doulas.

A national certification organization will not be the right fit for everyone.  However it can, if we create it in the right way, be a very effective tool for the vast majority of existing doulas.  But the real growth is in our future – to pave the way for ethical and professional behavior for people who haven’t yet become doulas.  We have an opportunity to impact doula work and the American way of birth itself.

First we have to embrace this primary task:  balancing the dynamic tension of creating a professional doula certifying organization and embracing the reality that we need all kinds of doulas.  Does that mean all doulas must achieve certification with the organization?  No, not at all.  We need to respect that doulaing is an essential task – one that exists in a professional way and one that exists in a non-professional way.  Neither way is better than another, they are just different.  Both are meeting women’s needs – the women who need one or the other are different!!!  If we are to go forward in a positive way, we need to respect one another.  Multiple ways of being in this world need to be respected by ALL of us (or at least most of us).  Otherwise we’ll end up bickering amongst ourselves and accomplish nothing on a larger agenda.  That would be pointless and a waste of energy.

What does it mean to balance dynamic tension?  In yoga there is a pose called Downward Dog.  In it, one’s body creates a triangle, with both feet and hands on the floor and one’s hips at the top of the triangle.  The goal is to elongate the spine and the legs, raising the hips to the sky while simultaneously reaching one’s heels towards the floor.  This creates tension between the legs moving in both directions simultaneously, however both directions need to be strived for in order for the position to be effective.  Back, forth, up, down, hips, heels, the body dynamically balances the tension of both muscles stretching in each direction.

Balancing dynamic tension is not a task that is completed once and then forgotten – it is a way of being in the world.  Like a yoga, this is a task we do all the time as doulas.  We support a mother in her sacred vision of her birth in a hospital that is not set up for it.  We believe in a woman when others do not, whether it is in her ability to birth or breastfeed or nurture her child.  Development of this skill – holding the space for all things to be possible – is essential for the effectiveness for ALL doulas.  I do not think it is beyond reason that we apply it to ourselves and our profession as we grow.

It is why I believe we can value all kinds of doulas and simultaneously have a strong national certification organization.  Not everyone will need it in order to practice in their area.  Not all will follow its standards of practice (for a variety of reasons) even if they are clearly evidence based.  I do not believe diversity is antagonistic to the cause of national certification.  If we gather together to create it, NC has the possibility of offering us legitimization to medical people ON OUR TERMS.  If it has the highest standards possible, it can lead to consistent compensation at a livable wage from third party payers, this will enable all women – not just wealthy ones – to access doula support.  It can offer consumers a measure of protection which they currently lack.  Consumers will make up their own minds about what kind of doula they want and what kinds of standards are important to them; that is one of the main principles of a market driven economy.  We live in a world where most people use the energy of money to compensate for products or services.  Accepting payment for an energetic exchange is not demeaning of doula service; it is how we as a society have agreed to compensate one another.  Now there are doulas who are not interested in any of those things, but there are many who are.

Those of you who might say, “Amy’s always followed DONA’s rules, so she doesn’t get it” are wrong.  I spent my first eight years as a professional birth assistant, I trained and used homeopathy for births and even learned to do vaginal exams, palpation, and listen for fetal heart tones.  So I do understand that in some practices you might want to offer those services, even though I now feel they undermine the true power of service that is the essence of doulaing. I have Been There.

We need to hold both truths simultaneously, side by side, as valid.  When doula services are ethical and the mother is placed at the center and not the doula, we are both on the same side.  Our venues are different, our clients are different, our ways are different, but our aims are the same.  We just need different tools to meet our own and our clients’ needs.

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Posts In This Series:

1.  Social movements – The Next Step In The Doula Revolution

2.  This Post: Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Doula Certification

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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The Next Step In The Doula Revolution

Oct 16, 2014 by

Steps2One of the most urgent issues facing birth doulas today is our future.  Very few doulas seem to realize this because they are focused on their own businesses.  In many ways the social revolution of birth doula support has succeeded.  According to the Listening To Mothers III survey, 6% of women had birth doula care.  ACOG recently recognized birth doula support as an effective method to lower cesarean rates.  Decades of research has shown no negative effects with the presence of a trained birth doula.  Capitalizing on the growing demand for trained labor support, many small organizations are cropping up to instruct doulas.  These groups are of varying quality, but so are individual instructors within a larger organization.

When I look back on 27 years of doulaing and 17 years of being a trainer, I feel a sense of accomplishment.  My mission was to educate women about the importance of birth in our lives and to ensure that mothers and their partners have supported, caring birth experiences.  Usually that means a doula.  Generations of people needed to “get it” in order to create cultural change and to listen compassionately to the women sitting next to them tell their birth stories.  Both missions are incredibly important if we are going to turn the tides.

From my readings on social movements, especially those similar to doula support, the next step is for doulas to become part of the established system.  Yup.  It has started in several ways – hospital based doula care, community based doulas, and doulas who work for physicians, midwives, or birth centers.  For the most part these programs are very tenuous.  They are based on the champion of one person who keeps the program continuing.  When they leave or funding dries up, the program also folds.  It is most likely to last when hospitals are competing for market share and the doula program attracts mothers to their facility.

For many years being a successful birth doula implied a willingness to work independently and to create a new path.  It necessitated some personal sacrifice to promote the cause of labor support.  Newer doulas are less likely to want to do this.  They have matured in a culture that promotes mentorship and the idea that there is an established map for success.  Younger women today act as if doulas were always around!  I don’t think this difference is entirely generational but a part of the success of birth doulas. Many older doulas feel their hold is more tenuous because they had to break ground.  So there is a turnover in attitudes because of our success, and the personality traits needed now are different.

Another change that I see coming is the institutionalization of doulas.  Almost any social movement that has become established in our society has been absorbed by the institution it desired to change.  It developed as an alternative.  Then once the concept was recognized as being a significant and positive thing, it was brought into the fold of the institution.  You can see this with home schooling.  Once an outside alternative movement that had to fight for recognition, it is now an established method of educating one’s children.  You can even purchase established curriculums from public school districts.

When I wrote about this issue last fall, several people brought up the argument that having national certification didn’t help midwifery.  Instead it brought about divisiveness.  However, midwifery and doula work have very different histories.  In addition, we don’t have the institutionalized power struggles that occurred with nurse midwives and professional midwives.  We don’t compete for market share with any other profession like physicians and midwives do.  Does that mean that we don’t have struggles?  No.  But our growing pains are not their growing pains.

What brought this to a head for me is the realization that even though ACOG wrote about doulas in February, we are still not taken very seriously.  There are several public health issues where birth and postpartum doulas could easily be part of the solution.  But we aren’t even mentioned.  Doulas can have a key role in recognizing the symptoms of perinatal anxiety disorders and postpartum depression, yet any training we get is haphazard.  If a mother spends 10 minutes actually interacting with a physician or the nursing staff at a clinic visit, and we spend 90-120 minutes at our visits, who has the better chance of viewing any symptomology?

One of the first questions we need to ask ourselves is do we want to be a part of that system?  Do we want to provide a stronger, organized social support component?  Do we want our prenatal role to be taken more seriously by other members of the health care team?

Of course there are pluses and minuses to each, which I’ll be exploring in future posts.  With less organization, doulas can continue to practice independently incorporating whatever points of view they wish into their practice.  This allows for a somewhat uneven delivery of services and an atmosphere of “let the buyer beware”.  We can vouch for ourselves but not for our doula sisters – unless we know them personally.  With a stand alone certification organization, we could allow for different types of training and practice styles while maintaining high standards for ethics.  As I have stated before, I am quite concerned that if we don’t do it ourselves, physician, nursing, or public health organizations will do it for us. Some hospitals already have rules allowing only doulas who agree to them to accompany mothers.

Legitimization and set standards for birth doula care IS going to happen.  It’s a matter of whether we’re going to be in charge of it or not.  What do we want that to look like?

 

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

Posts In This Series:

1.  This Post: Social movements

2.  Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Doula Certification

5.  Fears, Downsides, and Challenges of National Certification

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

 

read more