Career Minded Participants in Birth Doula Trainings

Dec 29, 2016 by

 

career-minded-doula-training-participantsIts natural to assume everyone in your birth doula training was there to become a doula. Not so! Only about half the people are there because they want to do labor support as birth doulas. What else can my research can tell us about career minded attendees? In my Journal of Perinatal Education article, “What Motivates People To Take Doula Trainings?” (Summer 2016, Vol 25, No. 3, p. 174-183), “become a professional birth doula with my own practice” ranked as the fourth most popular answer out of eighteen possibilities. In the question where people were forced to choose only their favorite five reasons, 60% included “birth doula” but only 30% chose it as their number one reason.

Hospital Based Doulas: What about “working for a hospital program”? Only 4% chose it as their top reason, but 20% selected it as one of their top five. Some participants expected to work both independently and for a hospital, as 24% chose both options. Hmmm…there are only a handful of hospital programs that employ doulas or pay them as independent contractors in North America. So this percentage made me wonder if some trainings in my sample were being conducted specifically for a hospital based program. However, these responses were not associated with a specific training, location or doula trainer.

Midwifery and Nursing Students: Another significant presence in trainings was participants desiring to become midwives. “Want to become a midwife (or am considering it)” was the number one reason for 20%, and a top five reason for 43% of participants. For the most part, the midwifery and doula bound groups had little overlap. Only about a third of people who put “birth doula” in the top five also chose “midwife”. Midwifery bound attendees are different in other ways too. They tended to be younger, not have children, and only about half had attended a birth (not their own). Interest in midwifery was confined mostly to women in their twenties. It dropped off almost entirely in the 30-39 year olds, with resurgence in the 40-49 year old group (who had all had children and attended a birth). Another contributing factor may be that 64% of all nursing students (n=42) chose “midwifery” as one of their top five reasons, and nursing students in the study tended to be younger and childless. In my experience, midwifery students have always attended doula trainings. But only in the last eight years are many midwifery schools requiring that students take a doula training before being accepted. In this way, the training serves as a screening and preparation tool to ascertain whether people understand the importance of support skills.

Nursing Students made up 9% (n=42) of total attendees and were more likely to attend to increase their birth knowledge (72%) and to explore midwifery (71%), as indicated in their top five choices. I found it very interesting that one quarter wanted to be in an atmosphere that “believed in women’s bodies and ability to birth naturally”. For the most part they were not interested in a doula career (only 7%) but many intended to volunteer their labor support services (36% of nursing students).

In comparison, “birth doula” bound attendees usually have birthed or adopted children, tend to be more evenly distributed across the age spectrum, with about the same number in their twenties and thirties. Participants in this study adopted children at twice the average rate in the United States (12% versus 6%). I don’t know what that signifies, but it’s worth mentioning! Slightly more than half have attended at least one birth (not their own) already.

Volunteering As A Doula: Birth doulas also displayed other altruistic motivations. Ten percent chose “volunteering as a doula on my own or as part of a program” as their number one (2.5%) or number two (7.5%) reason. A closer look revealed that 23% of all people in the study chose these three reasons as part of their top five: “professional birth doula with my own practice”, “volunteer as a doula”, and “make money in a profession I enjoy”. They felt that all of these things were possible as part of their doula career. In an open-ended question, participants said they intend to volunteer for specific programs for low income women, to go to foreign countries to serve, or for their own parish or mission work. Its also possible that they felt that volunteering was part of the path to gaining experience, had a lack of knowledge of how this could affect doula businesses, or thought this was an easy way to get started. Recall, these are neophytes to the doula world – these questions were asked before they had ever taken their training or likely joined a doula group on Facebook. They probably were unaware of the divisions over the “no free births” paradigm.

Making Money: What about “making money in a profession I enjoy”? Data was collected in late 2010 and again in 2013. While the two samples did not have any statistically significant differences with one another, the birth doula world itself was going through a large shift. In the early days of doula work, the idea of “making money” almost seemed exploitative, like it was breaking some kind of code of honor. How could you benefit from someone else’s labor and birth experience? It wasn’t unusual to think of doulaing as “a hobby that pays for itself”.

The next step in our professional evolution was a push to make birth doula work viable economically. It required a shift in how doula services were perceived by parents, perinatal professionals, as well as doulas themselves. I consider this period of time, from 2010 to 2015 to be a time of commodification[i] [ii] in the birth doula profession, most notably from the influence of ProDoula and their beliefs and paradigm. This shift in business professionalism has made “making money in a profession I enjoy” much more likely today. My point is that this was an emerging idea at the time of the first sample, and was much more established three years later at the time of the second sample. However there was no difference in the two time periods. Why?

First, these are not members of doula communities, but outsiders. It was fairly rare at the time to join a large doula group on Facebook before taking a training. Today, (by my own observation as a doula trainer) that is often the first place an interested person will visit. Two, commodification and the presence of doulas in the labor room are now assumed to be normal by non-doulas. Three, only DONA International trainings were sampled (2 countries; 19 states, 3 provinces; 38 trainers; 46 trainings; 467 participants; 85% response rate).  So these research findings likely only apply to trainings that also have an open focus (see “Take A Doula Training, Change The World” for more information on generalizability).

Now that I am a Research Fellow at the Center for Child and Family Well Being at the University of Wisconsin Madison, I am looking forward to interviewing a younger cohort and comparing the First Wave and Second Wave of birth doulas in future studies.

Perinatal Professionals: How about the childbirth educators? Only 14 out of 467 people identified as childbirth educators (CBE), but 63 people said they were taking the training “to enrich their childbirth education practice” as one of their top five reasons. Two things come to mind. First, people may consider the doula workshop to be part of the preparation to become an educator. Second, rather than focusing on becoming a CBE who teaches classes, their intention was to informally educate people about birth.

Ten participants were postpartum doulas and all of them wanted to become birth doulas. None were using the course to enrich their postpartum doula practice. But 14 people who were not PP doulas were taking it to enrich their future practice as postpartum doulas.

Nurses: Labor and delivery nurses made up 2% (n=10) of the sample, but nurses with no perinatal experience made up 4% (n=19) of the sample. Almost all of this latter group felt the workshop would make them more desirable candidates for labor and delivery positions, as indicated by choosing “add to my resume”. Seven chose “want to become a midwife” as their number one answer. A smaller number wanted to become birth doulas. Why weren’t there more nurses? As a doula trainer for twenty years, I can say that in the first seven years we had many OB nurses in trainings. But now nurses have other options to learn labor support skills at nursing conferences or workshops and earn CE credits. I also teach these workshops.

Non-birth professionals: Almost one fifth of participants (19%) taking trainings had no intention of becoming doulas, midwives, or labor and delivery nurses, as indicated by their top five reasons. Five percent chose “help women have better births not as a doula or birth professional” as their number one reason. Many had incidental contact with pregnant people and wanted to enrich their knowledge and support skills. They also wanted to be more informed listeners. In the open ended question, several listed their related occupation as social workers, home visitors, case managers, day care providers, or yoga instructors. This is a really important group. As I mentioned in my previous blog post [LINK], these are the outer rings of people who can pass along birth knowledge and listen attentively to birth stories. They extend our sphere of influence outward and change the conversations about childbirth to more meaningful ones, simply because they understand that support matters.

So far we’ve covered people who are in a training to advance their career aspirations, and those who want to increase their knowledge about birth and be inspired for change. In my next post I will cover a third group, who have a small but powerful influence over how a workshop actually unfolds. These are the people who are coming for healing from past births.

 

[i] Commodification is the transformation of goods, services, ideas, people, or other entities that were not previously considered goods for sale into a marketable and saleable item. It implies some standardization.

[ii] An interesting article on the commodification of women’s household labor, which has bearing on the internal and external struggles for legitimacy of the First Wave of Doulas (late 1980’s to mid 2000’s): http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1126&context=yjlf

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Hospital Agreements: An Opportunity For Engagement [Part II]

Jul 24, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (1) copyIf a doula agreement is being waved in front of you, congratulations! It means that your doula community has gotten too large to ignore and is having enough of an impact that the hospital wants to exert some control. Now the real work begins, not with clients, but with the institutions where our clients are choosing to birth. You have an opportunity to create a collaborative atmosphere even if their actions seem hostile at the moment. This is politics, system change, and social change happening in your neighborhood, and I hope to give you concrete suggestions to co-create a synergistic relationship – even if it seems impossible now.

Keep the focus on your long term goal: an open channel of communication between this hospital and the doula community. Your goal is not to get the hospital to eradicate the agreement but to build understanding and strong reliable communication channels between two groups of people. You are using the proffered agreement as an opportunity for greater connection, understanding and dialogue between the people most affected by it. It’s imperative that the doulas who are approaching this conflict negotiation realize that attacking the hospital’s solution, the agreement, is counterproductive.[1] Anytime you openly criticize something, you make that person defensive about it and more entrenched that they are right. Instead, you have to put the emphasis on the conflict and your mutual interest in resolving it. If you focus on the agreement and what’s ‘wrong’ with it, you will get into a power struggle and doulas will likely lose. If not this issue, how you handle this will set a precedent for communicating about any future conflicts. Sorry to increase the tension, but this is an influential time and needs to be recognized as such.

So what can doulas do?

  1. First, have a leadership committee of the people who have the best communication skills as well as doula experience. Prepare yourselves. Read simple books on negotiation and conflict resolution (see below), or see what community or internet resources are available for continuing education. Being prepared and having skills will give you more confidence – but don’t wait too long.
  2. Contact the people in charge and set up a meeting. Make it clear that your goal is to generate solutions to their problem, and not to deny that a problem exists. Explain your perspective is rooted in concern for the long term health of the hospital’s relationship with its future patients and future doulas, and an ongoing relationship with open communication can work to both of your benefits. Doulas are not going to disappear, and trying to exert power over the doula community without seeking to get to know them will not work in the hospital’s favor. Someone in that problem solving group knows that, but their voice may have been drowned out by others. Doulas, there are allies in that hospital, and you will need to find them. Hopefully, you will also cultivate new ones through your sincerity and focusing on the long term goals. This will be harder to do if the atmosphere is hostile or the agreement is written in a way that delegitimizes a doula’s contributions to maternal-infant health or seeks to restrict the doula’s access to a client. However it isn’t impossible. Remember, they don’t understand our values or our role and you can change this over time.
  1. Be gently persistent until you get a meeting. State that you don’t want to get rid of their agreement proposal, but seek to find additional ways for their needs to get met. Do they want someone to call and complain to? Often what people want the most, over and over again, is to feel that their concerns were heard and met with kindness and respect. If you push that aspect of the meeting – “we want to hear more about your concerns” – it will be more effective than “we have to do something about this agreement”.
  2. Use this handout Doula Information for Nurses Sheet (initially designed for a nurse and doula conflict resolution meeting in my city) or a similar one to explain why doulas do what they do and give background about the state of the profession. Make sure you are all on common ground about doula support and what doulas actually DO and don’t do. Issues may arise as you go through this sheet together.  Listen. Listen. Listen. Even if the people at that meeting are not listening to you, listen to them. Reflect back their concerns in your own language. “What I heard you say is…”
  1. Emphasize common interests. “What we both value is…[2] Do this repeatedly as needed throughout the conversation.
  2. Ask, “What other possible ways to address this problem did you come up with besides an agreement?” This is where you’ll find out whether they fully explored the initial problem or took into account the concerns of other stakeholders. It’s possible they may not have and you can initiate it at this meeting. Ideally, you’ll be able to follow up with a small group made up of multiple stakeholders (see list in Part I) who are interested in a more complete problem solving process. Resist the urge to rely on one or two people from either group to do the negotiating or attend meetings – if one person leaves their position you’re back where you started from – without an ally.
  3. If the atmosphere is hostile or untrustworthy, it is critical that you do not allow emotions to cloud your judgment. Your communication needs to be intentional, not reactive. Don’t take bait – slurs on a doula’s past actions, a doula’s motivations, etc. Let it go for now.  Frame it as “learning about the tactics of your negotiating partners”.  Recognize that establishing trust takes time and repeated interactions where people behave reliably and do what they say they are going to do. Promise what you can deliver, not what you can’t. Set reasonable deadlines and meet them. People learn the value of a doula by experiencing you doing what you do, not from reading or talking about it.
  1. Be prepared for the presenting problem to not be the true problem. In one hospital I consulted with people were angry that doula clients kept insisting on special treatment for their newborns. Administrators discovered that while there were protocols for one hour of uninterrupted skin to skin contact in place, that was not what nurses were actually doing. Unless the doula reminded the parents and both parties actively advocated for it, usually repeatedly during that first hour, parents were not getting the care that the protocols were written to encourage. Nurses didn’t like the criticism and resistance they experienced from doula attended clients, and it was labeled as a ‘doula problem.’ However, once different stakeholders were interviewed, they discovered a deeper issue. It turned out the nurse’s workloads were so high that they felt pressured to do newborn procedures even when that interfered with the one hour skin to skin mandate. So what was initially perceived as a doula conflict, was instead a conflict between policy and workloads, with parents and babies being the losers and doulas as the scapegoat. This can also work the other way, so be prepared to listen to criticism of doula behaviors. Remember, listening is the most important thing you can do at this stagethere may be years worth of resentments pouring out if you’ve never had a meeting before.
  2. Focus on the possibility of a positive outcome. You can create collaborative relationships that don’t compromise the doula’s autonomy, ability to represent and serve her clients, and satisfy the hospital staff’s needs for predictability. In doing research for these blog posts, I found examples of several birth communities who had already created collaborative long term processes. (Please add yours in the blog comments.)

Susan Martensen, a doula and trainer in Ottawa, Ontario, Canada, states that her local doula group has worked hard to be recognized as part of “The Care Team” and not as a “visitor”. The instigating situation that brought doulas and nurses together was the SARS outbreak in 2003. Hospitals sought to limit access for anyone into the hospital. Doulas in the area formed a new group to develop a standard of practice and code of ethics based on ones from their different training organizations. All doulas in the area agreed to sign the document they had created. “Two hospitals in the area agreed to regular meetings to build bridges and establish doulas as part of the Care team (and not included in the usual visitor policy),” according to Ms. Martensen. “It took several in-services to introduce, or re-introduce, the role of the doula to the nursing staff, so that we all understood the collaborative model of care. The meeting was multi-disciplinary, so there were doctors, anesthetists, pediatricians, etc, there, but not everyone and not all at the same time.”

The next step was to establish nametags for the doulas that were created by the doula group and a book at the nurse’s station that listed photos, names and contact information for the doulas. “Over time we developed a complaint process as well as establishing a system for addressing any conflicts during a labor,” adds Ms. Martensen. “It is a collaborative model that has worked well for the most part, and it is not administered by the hospitals.” They continue to have regular meetings with key personnel and doulas to provide feedback and assess their collaboration with one another. Ms. Martensen feels that the emphasis on collaboration and being seen as a valued member of the care team is what has made all the difference.

Ana Paula Markel, of BiniBirth in Los Angeles, California, USA, initially worked with a small task force at Cedars Sinai Medical Center. A rising number of conflicts was leading to a tense atmosphere, and Ms. Markel was talking to a labor and delivery nurse about it. Out of that casual conversation, a small group of interested individuals got together and outlined several steps which they have been implementing in the last year. They created a Cedars-Doula Advisory Committee made up of labor and delivery nurses, midwives, the nurse manager, and six doulas from the community who each have a different level of experience. Ms. Markel feels that having new doulas involved is crucial, since they often present a different perspective. The CDAC meets monthly, and has its own email address where people can write with questions or complaints. It is used by both doulas and nurses. Based on this feedback, they created a teach-in day for doulas, which was also attended by much of the labor and delivery staff. They did several role plays of challenging scenarios and explored the point of view of both nurses and doulas and what each thought the other “should” be doing. It was very enlightening for everyone. After attending the teach-in day, doulas received a recognition badge to wear. In this way nurses were reassured about the doula’s perspective and background knowledge.

Both the Toronto and Los Angeles doula communities were able to turn potential conflicts into opportunities for collaboration and enrichment. So, take heart! It can be done – you can create a process that benefits many stakeholders long term.  It is up to us, as doulas, to do the work and it is a task to be embraced. To have the ear of hospital leaders, even if it is coming in the guise of an untenable agreement, is what decades of doulas have been waiting for: an opportunity to create positive change in the system.

 

Here is a pdf copy of this blog post: Gilliland Hospital Agreements Engagement

[1] Fisher and Ury, Getting To Yes, p. 41 (first ed.)

[2] Fisher and Shapiro, Beyond Reason, p. 53

Fisher, R., Shapiro, D., (2006) Beyond Reason: Using Emotions As You Negotiate. Penguin Books. 

Fisher, R., Ury, W., (1981 through 2011) Getting To Yes: Negotiating Agreement Without Giving In. Penguin Books. 

Other conflict resolution, negotiation, or mediation resources may be available through a community college, university extension, adult education, or state or provincial small business support organization.

 

 

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Doulas: Why You Need To Be Nice First

Feb 17, 2014 by

A doula was complaining on Facebook in response to one of my posts about getting along with nurses.  “Why do I have to be the one to put forth the effort?  I wish some nurse would try to get along with me first.”  Here’s why it’s up to the professional birth doula:

  • You are a guest in her house.
  • Making the first move sets the tone for every communication and interaction that follows.  Why not use this opportunity to your advantage?
  • You only get one chance to make a first impression – and it takes three times as much experience with you to change someone’s mind.  Make those first minutes count.
  • You are an ambassador for all birth doulas.  Your actions reflect on all of us.
  • Social skills and emotional intelligence are a significant part of a doula’s success.
  • “Hostess” is implied in our job description.
  • Hospitals are set up for the mass production of a number of patients moving through the system.  When you ask the nurse to change what she usually does to personalize care for your client (even when it is evidence based), she may get flak from other nurses or doctors for doing so.  Therefore you need to be grateful when you hear “yes” and accept “no” graciously.  (It doesn’t mean your clients stop trying – it means you are polite.)
  • The last doula may not have behaved optimally.
  • As unfortunate as this is, a client may be treated negatively by the nurse or medical care provider for a poorly behaving doula.  I think we can all agree it is unacceptable to stress out anyone at a birth over our behavior.
  • When you make an effort, especially a big one, the “norm of reciprocity” states the nurse will naturally want to keep things in balance.  So you get what you give.

 

 

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The Doulas Have Arrived! Nurses, What Does This Mean For You?

Feb 9, 2014 by

Dear Nurse,

When doulas move into a new area, nurses are often skeptical and hesitant rather than welcoming.  This is a normal reaction to change especially when you are uncertain about how it is going to affect you – and how you do your job.  Here is a list written by an experienced doula trainer that might be helpful for you:

  1. Professional doulas want to work with you to help a laboring mother’s needs get met.  She views you as an important ally who has some of the same objectives and priorities.
  2. The doula’s goal is to remind their client to tell you and her physician or midwife what is most important to her about her birth.  She may have listed her preferences on a one page birth plan or may only state them verbally.
  3. Professional doulas do not have any agenda for a “natural” birth.  Every woman benefits from doula support – even mothers planning an epidural or cesarean section.  She and her family can benefit from the added nurturing, reminders they can discuss options, and extra hands that a professional doula can provide.  A doula birth is a supported birth.
  4. Professional doulas are familiar with the research evidence and best practices for maternal and fetal health.  Doula clients tend to also be familiar with this information – which is why they hire a doula.  Because of this, patients with a doula may make more requests than an uninformed patient.  Some of these requests may be a part of hospital protocols even though the obstetrical unit’s culture does not usually promote them.  Some examples:
  • No routine amniotomy
  • Intermittent fetal monitoring
  • Freedom to choose second stage positions outside of bed
  • Hands and knees, kneeling and semi-sitting positions with an epidural
  • Delayed cord clamping
  • Baby’s naked body on mom’s naked body immediately after birth and not removing it for 90 minutes or more
  • Delaying routine newborn procedures (not health assessments) for 90 minutes or more
  • Newborn exam on mother’s body or her bed
  • Weighing and bathing of baby in the patient’s room
  1. When patients prefer a cooperative decision making relationship with their care provider, they usually hire a doula.  The doula will help to remind them to ask questions about their care.  This interaction style may be rare in some obstetrical settings.  Rather than having their physician autocratically making decisions, these patients expect to be consulted and give explicit consent for each intervention.  With these patients, the doula may ask if the mother and her partner have any questions about a proposed intervention.  The ensuing discussion about benefits, risks, and options may be seen as an interruption or a delay.  However, involvement with decision making has been shown to increase patient satisfaction, birth satisfaction, lower anxiety, lessen the incidence of postpartum depression and prevent post traumatic stress disorder due to a traumatic birth.  This has been repeatedly shown in the nursing literature to be more important than complications, length of labor, or location of birth to short and long term maternal well being.
  2. In order to facilitate involvement in decision making, a doula may tell the patient about an unannounced intervention the physician is about to do. This way the mother may give explicit consent or ask for clarification.  This may be seen as an interruption by the nurse or physician but this is what a doula accompanied patient expects her doula to do.
  3. Despite these interruptions to the usual flow of care, the professional birth doula is your ally.  She knows the patient and can help you to get to know her too.  She will observe almost every contraction and can keep you informed of any issues the mother has or adverse symptoms shy mothers may keep to themselves.  They help mothers to stay focused.
  4. With a 60-80% epidural rate in most hospitals, nurses do not see many unmedicated labors. Doulas have been trained in normal physiologic birth, as defined by the American College of Nurse Midwives (ACNM).  Mothers without pain medication may become louder and listen to their bodies’ urges to move around as labor intensifies.  When mothers are coping well they are calm between contractions.   The doula will help the mother to continue her coping ritual – which may become louder and more intense as labor progresses.

Three Clinical Recommendations:

When you are introduced to the doula, ask her about her training and experience.   Professional doulas are usually excited to tell you about their organization and background.  If she has not taken a training, then she is the client’s friend who is doulaing her. She is not a professional, so none of the descriptions in this essay apply.  The “doula” friend may act in ways that a professional would not do, such as speaking for the mother, touching you or the physician inappropriately, arguing with you, giving medical advice or telling the mother what to do.  These are NOT in the scope of practice of a professional doula.   If she is doing these things and has been trained, she is considered a rogue doula, behaving outside the circle of professional practice and ruining our reputation.  We hope she goes away even more than you do.

New doulas may make beginner mistakes.  There are more new doulas than experienced ones.  This is a challenging profession and many promising new doulas find it is not a good lifestyle fit.  Please be patient with the beginning doula and help her to learn how to treat you.  She wants to do her best to get along with you while helping her client to have the best birth possible.  She may ask more questions about procedures and provider preferences until she becomes familiar with your facility.

Labor and birth are changing due to the doula’s influence.  But this is not necessarily a bad thing.  Nurses are learning alternative approaches in non-pharmacological pain management and positioning techniques to rotate malpositioned babies.  They are relearning the satisfaction of emotional connection to a patient that the doula helps to facilitate.  They are seeing normal physiologic birth happen in their facility (even though it may require suspension of usual interventions).  But most of all, because of nurses and doulas working together, mothers and babies are having emotionally healthy outcomes as well as physically healthy ones.

Here is a pdf copy of this post: The Doulas Have Arrived

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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 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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