The Brouhaha Over Certification

Oct 19, 2013 by

One of the purposes of this blog is to offer an analysis of current issues of importance to the doula profession.  One of the issues that have lingered over the years is certification.  It used to be viewed fairly simply: certification was an individual decision.  While that is still true, it seems that along with our profession the issues of certification have grown in depth and complexity. Certification dilemmas exist on system, organization, and personal levels.

What set me on the path of examining certification was another post about what it means to be a professional.  Putting on my researcher’s hat, I set out to gather data relevant to certification issues. Data collection consisted of the following methods:  1.  In eight different doula groups on Facebook, I searched for the keyword “certification” in past conversations going back about 9-12 months.  2.  I wrote to several people who identified themselves on FB as having “private” opinions, asking them to elaborate on their thoughts on certification.  3.  I read blog entries doulas had written on certification.  All responses I read were from women.  I stopped when I reached “saturation”, meaning that I stopped hearing anything new.  So I can’t tell you how many people have a particular opinion, but I can tell you that opinion exists.  From my examination I’ve been able to isolate several key questions or issues.

System level questions:

  1. What is the meaning of certification?  What does it mean to certain stakeholders?  Does it have value to these different stakeholders?  Why or why not?  Stakeholders are identified as an individual doula, doulas as a group, certified doulas, third party payers, clients (mothers), client’s family members, physicians, midwives, nurses, and hospital administrators.
  2. What is the process of certification?  Does it provide value for the doula seeking it?  Does it provide value for the organization that is granting it?  Are there built in mechanisms that soothe feelings of frustration and increase feelings of accomplishment throughout the process?
  3. What is the purpose and value of recertification?  Why do some organizations grant certification in perpetuity, and not recertification?  What are the assumptions underlying the necessity of recertification? What are the assumptions made by organizations that do not see recertification as necessary?
  4. What levels of certification are there?  Does it still have meaning if some groups offer certification to a person completing a correspondence course when there are no standards of behavior to observe or maintain by being certified?  When it is left to what each individual thinks is right to her own conscience, is that valuable?  How does that affect the profession as a whole? (See question 1.)

Organization level questions:

  1. As the system is currently set up, certification is linked to an individual organization.  When women choose a training, they are connected to that organization.  However the organization has values and support products that are separate from their certification process.  Are trainers communicating the values of the organization before people spend money on the training?  How significant is this conflict in a person’s certification decision?
  2. There are now at least 16 organizations in the United States and Canada offering birth/labor doula trainings (that I am aware of).  Many have different standards for certification or offer a certificate of completion that is stated as certification.  Does it have any meaning when there are so many different standards?
  3. Is there any value to separating certification from the multiple organizations offering doula training, education and mentoring?  Is there any advantage for some stakeholders if certification is achieved through an independent organization?
  4. Is each organization’s certification process following best practices for experiential and independent learning?  Are there built in mechanisms that soothe feelings of frustration and increase feelings of accomplishment throughout the process?

Personal level questions:

  1. Many doulas think certification isn’t important because potential clients don’t weigh certification heavily in their selection of a doula.  Because certification isn’t bringing them business it is not seen as necessary.  Do clients perceive certification as a benefit at a later time in their relationship to their doula?  Would a non-certified doula be privy to this realization on their client’s part?
  2. What other advantages does certification have?  Doulas responded with these answers:  1. For your peers – when you know they are certified, you know what to expect.  2. A third party payer will only reimburse if you’re certified; 3. When the patient sues all the lawyers breathe more easily; 4. It is a plus when you want to get a job, put it on a resume or curriculum vita or school application.
  3. There is another theme reflecting a doula’s personality traits (“I see myself as a rebel”) or issues around control (“I don’t like anyone telling me what I can or can’t do with a client to meet their needs.”)
  4. One of the themes is that certification is seen as being restrictive and not allowing the doula to follow her own conscience about what behavior is appropriate.  My thoughts:  What behaviors does a doula want to enact that are outside those standards?  Would other doulas agree as a group that they want someone calling herself a “doula” to behave in that way?
  5. Can people’s individual conscience be enough?  (Comment:  Any other profession says “no”, which is why there are professional standards that are protective of the client and the industry.)

Pondering those questions led me to these questions

  1. Is disregarding certification as important related to the idea that carework does not have value and thus professional standards are irrelevant?  A human being can possess both of these conflicting attitudes, such as “our work has value” and “I don’t want my behavior to be regulated”.  What are the implications of those attitudes for that individual and for other stakeholders?
  2. Does not having uniform behavioral standards and a goal of certification for all doulas make certain stakeholders take us less seriously and lessen our perceived value?  Many doulas stated that certification had little personal value because most clients considered it irrelevant.  However, the implications of this attitude may be limited in focus – not seeing beyond one’s self to see how this decision may affect others and the profession.

In essence, the issue that is identified as “certification” has multiple levels and symbolic meanings for different people.  When certification is discussed on social media, not everyone is talking about the same thing.  The number of factors to consider in her decision often overwhelms the original person posing a question about certification on Facebook.

Within each of these questions are a number of responses and possibilities.  To me, the fact that we have the opportunity to take in this information and be reflective about it is significant.  It allows us to make choices about how we want our profession to proceed.  My goal is to explore these issues in more depth in future posts.

If you have a comment about any of these questions, or feel there is an additional issue I have not listed, please email me at amylgilliland@charter.net

Gilliland, A. (2009) “From Novice To Expert: A Series of Five Articles”, International Doula, publication of DONA International (feature articles) Autumn 2007-Winter 2008; reprinted as e-book, June 2009; currently available here

 

read more

Hard Research: Birth Doulas Save Insurers and Hospitals Money

Jul 17, 2013 by

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

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

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

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

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

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

HOW TO USE THIS RESEARCH:

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

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

 

 

read more