Why Don’t We Have The Doula Research We Need? Part I of III

Nov 3, 2017 by

070The Cochrane Collaboration updated their doula research review this year. They added four, only FOUR new studies – and none of them advanced our research conclusions in any significant way. Birth doulas have the potential to be the most influential factor in lowering negative birth outcomes and optimizing positive ones for mothers and babies. We’ve known that for over THIRTY YEARS – that’s a whole generation of people who could have benefitted but didn’t.

No one, and I’m pointing my finger at academics and medical careproviders and political women’s organizations, has bothered to do any significant research or insist that it be done. Instead the established power systems are hoping doulas will just go away. They want to keep us small and bickering amongst ourselves, which happens to any group when they experience some success. The established power structures don’t want to change and any good doula research would show that hospital systems have to change in order to get better results. I’m angry, and I rarely get angry.

Here are the research questions I expected to see answered in the past 37 years since the first (Sosa, Kennell, & Klaus et al., 1980) doula study was published:

  1. In a randomized control study or a matched pair study of people who did and didn’t have a doula, do we see consistent outcomes in perception of pain, length of labor, intervention rates, breastfeeding initiation and longevity, birth satisfaction, partner satisfaction, postpartum wellness, and the feeling that ‘my baby is better than other babies’?
  1. What factors interfere with the doula’s ability to affect obstetrical outcomes?
  1. Does partner involvement with labor support (not the birth itself) make a difference in outcomes?
  1. How do doulas benefit partners and/or have an influence on parenting relationships and partner/marital relationships?
  1. Do prenatal visits make a difference in obstetrical, birth satisfaction, maternal and infant outcomes? The way most birth doulas practice is 2-3 prenatal visits, continuous labor support at the birth, and one to two postpartum visits. But we have no data on whether that is the best way to practice or not. Are labors still shorter? Do laboring people have less pain or use less pain meds? Are people more satisfied with each other or with their doctors or midwives when they have a doula?
  1. Does having a birth doula affect a pregnant person with a perinatal anxiety or mood disorder? When someone is supported by a doula during labor are they less likely to have postpartum depression? How about with a postpartum doula?
  1. Under what circumstances does it make financial sense to fund doulas or doula programs? Rather than spending money on other labor interventions, is it more economical to pay for the doula? Along with Drs. Will Chapple and Dongmei Lee, I published a study in the Wisconsin Medical Journal exploring this question. Katy Kozhimannil co-authored a study on Medicare costs for doulas. Where are the rest?
  1. In 2010, I published a study on birth doula’s emotional support strategies. Four were the same as those in the nursing literature, but the other five were sophisticated counseling or therapy techniques. The doulas in my study were never formally taught those strategies, they arose spontaneously from the doula. Why hasn’t anyone actually observed doulas to see what they actually DO at a birth that makes a difference?
  1. Where are all the research reports on hospital based (HB) doula programs, where the doula is a paid member of the hospital staff? What are their outcomes? Who benefits from the doula program? What models are more effective at getting which outcomes? I’ve interviewed 15 HB doulas from four different programs. Why am I the only one? (Why that data is not published is in the next blog post.)
  1. Are doula programs staffed by volunteers effective?
  1. What are successful models of doulas and nurses working alongside one another that increase both job satisfaction and positive patient outcomes?
  1. There are no studies on physicians and doulas, exploring how people in each role perceives the other, how they can optimally work together, or any models of doulas working for doctors. Why not?
  1. Does continuous care matter? The only reason we know that is from two meta-analyses that are both twenty years old. Is that enough?

These are all of the things that I thought we would know in thirty years.  Each time a research review on doula support is published, I’m eager to discover any articles I might have missed. But there aren’t any.  In my next posts, I’ll explore why we don’t have the research I thought we’d have. My conclusions?  There are few doula research studies because of obstacles from medical politics; outmoded beliefs; difficulty in approvals, funding and publishing access; and yes, the priorities of the U.S. women’s movement. Look for it in your inbox in the next few days.

 

Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E.. (2013) An economic model of the benefits of professional doula labor support in Wisconsin births. Wisconsin Medical Journal, 112(2), 58-64.

Gilliland, A.L. (2011) After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada. Midwifery, 27(4), 525-531.

Kozhimannil, K.B., Hardeman, R.R., Alarid-Escudero, F., Vogelsang, C.A., Blauer-Peterson, C. & Howell, E.A. (2016a) Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth-Issues in Perinatal Care, 43(1), 20-27.

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Sosa, R., Kennell, J., Klaus, M., Robertson, S. & Urrutia, J. (1980) The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine, 303(11), 597-600.

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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 Are Paraprofessionals

May 31, 2016 by

2DoulasAreParaprofessionals (2) copyEncouraging professional behavior by doulas is one of the purposes of this blog, but it needs to be clear that the doula occupation is a paraprofession, not a profession. Community based, hospital employed, and independent practice birth doulas clearly fit dictionary and research interpretations and even the U.S. Department of Labor classification. However postpartum doula work is not such a neat fit. One of the definitions for paraprofessional is that they work alongside of or under the supervision of professionals. While they may work and make decisions independently, there is something about the nature of their work that is connected to the stronger influence of a professional.

Profession vs. Paraprofession

A profession is any type of work that needs specialized and prolonged training, a particular skill, or a high level of education; often a formal qualification or licensure is required. A defining characteristic of paraprofessional occupations is that training can be achieved with only a high school degree or its equivalent. While some programs may offer an associate’s (two year) degree, this is often done for financial aid reasons, not because it is essential for training purposes. Because there are no impediments to offering services (some people don’t even take a doula training before doing the work), we cannot define doula work as a profession.

However, that does not mean that doulaing does not require a high level of specialized skills to perform well, nor does it mean that there are lower standards for professional behavior. In fact, several papers discuss the need for paraprofessionals in the family support services field to develop a professional identity as helpers of families, and to transform who they are and how they serve others as part of a successful training process (Behnke and Hans; Hans and Korfmacher).

“Paraprofessionals frequently associate significant personal growth with their training and work experiences. They connect their training to higher self-esteem, greater personal and professional aspirations, and the ability to engage in more effective interpersonal relationships (p.10)…An emerging identity as someone who plays a valuable and valued role helping other individuals seemed to be a central experience of doula training for the women who successfully became doulas.” The women who did not complete this transformation [or become doulas] felt they gained “mostly technical knowledge” but did not feel personally changed by the experience. In fact they expressed “a resistance to change” and seeing themselves in a helping role.” –Behnke and Hans (2002)

It also does not mean that the professionals we work alongside of can effectively do our job. This is not to say that the professional person can perform the paraprofessional’s duties.   The paraprofessional has specific skills and attributes that make it possible for the professional to accomplish more complex tasks and responsibilities.

Several sources discuss that when paraprofessionals fulfill their role, they boost the effectiveness and relationship between the client and the professional. They are able do their job better because we do ours. I think this is true in the perinatal context for doulas because our core values are good communication, maternal involvement in decision making and maximizing positive memories. Even though the labor and delivery professionals we work with may not have the same values, our presence often contributes to meeting their medical goal of “healthy mom, healthy baby”.

Doula Research

The defining of doulas as paraprofessionals comes initially from research articles published in the Zero to Three journal from 2000 through 2005. Researchers at the University of Chicago were invited to participate in a community based doula program called the Chicago Doula Project (now part of Health Connect One). Examples of other paraprofessionals: paralegals who work in attorney offices; paraeducators working in school classrooms; library assistants; nursing assistants; paramedics; veterinary assistants working alongside veterinary technicians (associate’s degree) and veterinarians (doctorate degree).

Another aspect of the paraprofessional is that the person is considered a good fit based on personality characteristics and social skills they already possess. Paraprofessionals often work with the people part of a situation; they need solid interpersonal skills and to be good communicators. These skills are strengthened during the training and early supervision process. This concept is clearly defined and repeated in the articles about community based doula programs and their staff selection process.

In the only national representative survey of doulas (so far!) published in a peer reviewed journal in 2005, the title is, “Doulas As Childbirth Paraprofessionals: Results From A National Survey”. Lantz, Low and their team state “doulas have become a new type of “paraprofessional” (or someone with a lower level of training and /or credentials who works in tandem with another professional) with a specialized role and an interest in finding clients who will hire them for their services. As such, doulas (who are also called labor assistants) represent a new addition to today’s maternity care team.”

Dictionary and Wikipedia Definitions

As an English prefix, the word “para” is used “in the naming of occupational roles considered ancillary or subsidiary to roles requiring more training, or of a higher status, on such models as paramedical, and paraprofessional: paralegal, paralibrarian, parapolice.” (Dictionary.com) “A person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.” (Oxford Dictionary.com) Wikipedia, which represents the generally understood meaning of a concept, states that “paraprofessional is a job title given to persons in various occupational fields such as education, healthcare, engineering and law, who are trained to assist professionals but do not themselves have professional licensure [note – in the U.S. this is administered by state]. The paraprofessional is able to perform tasks requiring significant knowledge in the field, and may even function independently of direct professional supervision, but lacks the official authority of the professional.”

Are All Doulas Paraprofessionals?

While the definition of paraprofessional is grounded in the early literature on community based doula programs, the nature of a doula’s labor and her support behaviors do not vary substantially for independent practice and hospital based doulas. While each may have their own niche and specialty skills, the actions of support during the prenatal, labor, birth and the postpartum periods are the same. In teaching how to support emotionally and physically; offer information as needed; and prompting clients to advocate for themselves, the skills do not change. The setting changes, and the background knowledge to effectively complete the task, but the behaviors of support are transferable. For example, an independently hired postpartum doula comforting a new mother about her birth will use the same skills as a community based birth doula. Building confidence in one’s ability to birth is similar to building confidence in one’s ability to breastfeed.

One of the conflicts inherent in these definitions is that the paraprofessional works for or under a professional. We can make the case that a birth doula would not be engaged for their services if the person was not pregnant and is almost always seeing a physician or midwife for prenatal and labor care. But what about postpartum doulas? While a postpartum person may also engage a lactation consultant or be seeing a doctor for checkups, there is no connecting relationship between them and their doula.

Is Being A Doula A Vocation?

Doula work may or may not be a vocation, which is a strong feeling of suitability for a particular career or occupation. In my files, there are plenty of interviews from women who state they could not imagine not being a doula – it fulfills their purpose in life. I’ve previously written about it being a calling. However, not all doulas feel that way nor is it a requirement for effectiveness. Therefore, it is not a vocation.

United States Department Of Labor Classification

In December of 2010, the Bureau of Labor Statistics Standard Occupational Classification Policy Committee (SOCPC) added “Doula” to category 39-9099 Personal Care and Service Workers, All Other. They declared that no formal schooling was needed although most in this category had a high school diploma or equivalent. I don’t think we can disagree with that. Those of us who have advanced degrees find them helpful but they are not required to perform the tasks of doula work effectively. Other occupations in this category are Butler, House Sitter, Shoe Shiner, Valet, and Magnetic Healer. While being lumped with shoe shiners may feel frustrating or upsetting to doula readers, from the SOCPC standpoint, median wages for doula work are not high and there isn’t an educational requirement, nor are there many doulas. But also consider butlers. The Guild of Professional Butlers has 10,000 active members (35% in the U.S.) who earn $50,000 to $150,000 a year. I’d also like to point out that each of these jobs require a high level of interpersonal skill to provide good service and personal care.

DoulaDeptofLabor

 

Abramson, R., Altfeld, S. & Teibloom-Mishkin, J. (2000) The community-based doula: an emerging role in family support. Zero to Three, Oct/Nov, 11-16.

Behnke, E.F. & Hans, S. (2002) Becoming a doula. Zero to three, (November), 9-13.

Hans, S. & Korfmacher, J. (2002) The professional development of paraprofessionals. Zero to three, (November), 4-8.

Lantz, P.M., Low, L.K., Varkey, S. & Watson, R.L. (2005) Doulas as childbirth paraprofessionals: Results from a national survey. Womens Health Issues, 15(3), 109-116.

Meyer, H., Kirwan, A. & Dealy, K. (2005) Expanding the Doula Model: An Illinois Replication Story. Zero to Three, 25(5), 35-42.

 

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Fewer Blogs but More Amy

Dec 30, 2015 by

AmySmile2This year has been about serving you, committed birth and postpartum doulas, in a different way. I’ve written fewer blogs, but posts on higher impact topics like essential oils and universal certification. When I’m not blogging, it’s because I’m writing something else. This year alone I’ve had two book chapters published, one podcast, three videos, developed four new continuing education sessions, and one peer-reviewed journal article, all relevant to what YOU do. I also wrote a 350 page memoir, but that was a personal project!  Several of these resources are FREE. I’m committed to improving our profession and your experience of being a doula.

Round The Circle: Advice for New Doulas includes a chapter on the results of my research on Doulaing Friends and Family Members. Basically, it turns out well when what the laboring person expected to happen and what really happened are close to one another. If the birth or postpartum doesn’t turn out as expected, the relationship between the doula and friend or family member will change dramatically, and usually not for the good. Want more?  [Link to Amazon]

Doulas and Intimate Labor is an academic book published this month by Demeter Press. Edited by Andrea Castaneva and Julie Johnson Searcy, my chapter covers my scholarly work on Doulas as Facilitators of Transformation and Grief. As doulas we are present as the woman becomes a mother and must surrender her old self in order to become her new self (this research was done on cisgendered women). Change implies grief, which is one of the unacknowledged journeys of postpartum. In addition, this chapter covers doula’s experiences when the partner dies during pregnancy, and when the baby dies before birth (fetal demise), at birth, or in the immediate postpartum period. I’ve also turned this topic into a successful continuing education session. [Link to Amazon]

Why Do People Attend Doula Trainings? is an original solo research project. I collected data in 2010 and 2014, asking over 400 people why they were taking a doula training (before the workshop). Surprisingly, many people taking a training are not there to become doulas, but because they want a general education about birth! This topic is also a successful continuing education session. The full article is forthcoming in a 2016 issue of the Journal of Perinatal Education!

Sexuality and Birth Video and Podcast – In October, I had the opportunity to be interviewed by Penny Simkin on Sexuality, Birth and Postpartum. This eight minute video is going through approval to be recommended by Lamaze as a resource for parents and professionals. I’m thrilled that this free video, which gets at the sexual and emotional needs of people becoming parents, primarily connection and pleasure.  [Sexuality After Childbirth Youtube video]

Amy Neuhadel, of The Cord in Sweden, also interviewed me on sexuality and birth. We’ve gotten great feedback on how helpful this TEN minute interview has been for parents and for educators.  [Intimacy and Pleasure In Your Birthing Year Link]

Giving Fathers What They Really Need In Birth  – This YouTube interview conducted by Penny Simkin gave me the opportunity to summarize the research on men and fathers (male cisgendered perspective).  You’ve loved my conference sessions on this topic, so here’s a short resource you can use as a discussion starter in your classes, small groups, or just for yourself!  [The Role of Fathers YouTube video link]

Giving Birth, the birth video that I executive produced with director Suzanne Arms (it really is her baby) is now finally available on Amazon Instant Video!  It took me a year, but its now up!  Suzanne Arms sells it on DVD through her site.

Northwest Doula Conference presentation covering The Top Eight Challenges of the Birth and Postpartum Doula Professions. After two hours of listening to me and what I think, I got a standing ovation. And that’s after getting people to commit to making behavior changes to meet those challenges, not just passively listen and go on their way! I had multiple requests to turn this address into a podcast, but I’d really love to give it again live at another conference and record that. Anyone interested?

New workshop content – this year I wrote several new sessions for continuing education. Hospital Based Doulas: What’s The Difference? is based on multiple waves of research interviews with this HB doulas around the United States; Doulas as Facilitators of Transformation and Grief focuses on how to be this significant person in our client’s lives, as they shift into parenthood, face the possibility of loss, and experience grief as part of the transition into a different phase of adult life. It also gives us space to breathe as we recognize our shared responsibility for the emotional well being of our selves and each other as doing doula work changes who we are as human beings.

Communication Skills for Birth Professionals is a skill building workshop where you learn by doing – you leave with skills you didn’t have when you walked in the door! It is available in two, three, and four hour formats. Two hours focuses on listening; the third hour focuses on preparing yourself to communicate successfully; and the fourth hour adds conflict resolution skills focusing on typical situations that birth and postpartum doulas face. These sessions are not formulas, telling you what to say. They teach you how to think about a situation, so you can be authentically yourself in all of your encounters.

PTSD: How It Affects Childbirth And How To Improve Your Outcomes is the latest addition to my catalogue, which came my way because of requests from physicians and nurse groups. Yay! What most doctors and nurses don’t learn in school is how to show they care. They don’t learn the physical and emotional skills that communicate their internal feeling of caring for a patient on a personal level. In fact, for many professionals their educational experience is to have the emotional center pummeled away in order to follow good practices in medical care.  The ‘cure’ for preventing childbirth to make existing PTSD worse is authentic human connection.

If that isn’t enough for you, I also wrote a 350 page memoir of the experience of taking care of my terminally ill mother, who was misdiagnosed for the first half of her illness. Tentatively titled The Summer of Mimi, I hope to complete the second and third drafts in 2016. This was a personal goal of mine, but as I can’t stop being a doula all over my life, its has juice in it for all doulas too.

2016 promises more content and more projects!

As always, please subscribe!  [Box is on the lower left.]  Thank you for your support!

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The Essential (Oil) Dilemma

Apr 30, 2015 by

EOflowerphotoRepeatedly, doulas discuss whether or not it’s in their scope of practice to recommend or use essential oils and aromatherapy.  While that is a part of the discussion, it really isn’t the central issue.  What we need to recognize is an underlying philosophical difference between doulas.  The core issue is whether it the doula’s role to DO more to moms or just to BE present with her as the labor unfolds.  In the DO camp, people say they want to have more tools in their birth bag.  When a few simple sniffs can help with nausea, mood, or even help a woman to urinate, that is a good thing.  There are so many other interventions happening with the labor, using oils can help to counter them and bring the labor back into balance – or at least make the laboring mother feel better.

The BE group tends to feel that mothers have enough people trying to alter the course of her labor.  These doulas feel their strength is in the support they bring and the use of comfort measures to alleviate discomfort, not to change what is happening in the labor or what mother is feeling.  Being “present with” and supporting the mother 100% means not seeing her or her labor as a problem that needs to be fixed.  Doulas are usually the only ones who are not trying to will things to be different than what they are.  In a postpartum context, these issues are still present.  Is it our support that makes a difference or is it the tools we bring to help with post birth discomforts?  There is also a baby to consider, whose system may react differently than expected to scents and oils.

The BE-la vs. DO-la* debate isn’t new, but it reflects one of the philosophical differences between doulas.  I don’t think either of these approaches is wrong, but each leads us in a different direction.  As a community we haven’t formally acknowledged these two approaches. The essential oils issue brings them to the forefront, and offers an effective way to frame this discussion. If you’re a DO-la, using essential oils and/or aromatherapy makes sense.

The second issue with essential oils and aromatherapy is more practical.  Is there a potential for harm when they are used?  The answer is clearly “yes”. People can get burned and have unexpected adverse reactions (headache, migraine, nausea, allergic reactions, skin sensitization, phototoxicity, etc).[1]  For example, the desired result of calming a mother by using lavender can have the unintended effect of lessening contraction strength and frequency.  However, often these reactions are not common enough to discourage them from being sold to unwary doulas, who see themselves as trying to help mothers.  If you haven’t had an adverse reaction yourself, it’s hard to imagine that someone else might.

Essential oils are drugs.  They are processed products that are used with the intention of altering what is already occurring.   They smell nice, have fun names, and are easily available.  You can buy them at parties!  But that does not mean they are benign.  Rather they are potent substances deserving of respect and care.  Many hospitals need to chart their use in labor.  For these reasons, using essential oils as an untrained doula should be avoided.  Some would say that is enough reason for doulas to always leave them alone.

One of the core tenets for almost any doula is that the mother should be free to make her own choices, and the doula’s role is to fully support her in those choices. Including essential oils and/or aromatherapy as part of one’s practice could certainly be one of those choices, if you know what you’re doing.  It just seems so simple to pair a scent with a relaxation exercise during pregnancy to condition the mother to relax when smelling the same scent in early or active labor.  However if you want to use this powerful tool, you need to take full responsibility for it.  To me that means going over all the risks of using essential oil therapy as well as the benefits, and having your client acknowledge that in writing.

The risks to the mother if the doula isn’t fully informed are great.  They are not “safe” and any web site that makes that claim is wrong.  According to one doula, you can be liable for prosecution if there is a negative consequence, depending on how your state’s legislation is written. She suggests that the way to protect yourself and your client is to pair with a certified aromatherapist and have them make the recommendations.  The doula follows through on what the mother wants to do based on the consultation.  The risks to our profession are even higher.  Doulas are in a tentative position in many communities, and a black mark against one doula causing harm to a mother can easily spread.  I don’t want to be alarmist, but our position is precarious in some communities.  I often think that newer doulas are not considering how their actions affect everyone else.  We live in a global world now. This means you have a responsibility to other doulas and our profession once you begin to use the title of “doula”.

These days there’s really no excuse for not getting educated by completing a high quality course and engaging in ongoing discussions with others who use oils dermally and as aromatherapy.  Birth Arts International offers a self paced course specifically for doulas. (If you know of others, please put them in the comments section.)  As with all things, if the course is being offered by someone who is also selling you a specific brand of products, sales may be their primary motivator.  You may not receive objective information or even the breadth of experience you’d like in an instructor about their use during pregnancy, labor, and postpartum.

Some certifying doula organizations prohibit the use of essential oils or aromatherapy, taking the stance that they are drugs. Others advocate that doulas interested in this therapy take formal education or certification so they can be used properly and follow an aromatherapy standard of practice.  Others have no opinion on the matter. [2] This confuses the average doula who just wants to help mothers.  The better we understand what the debate is really about – philosophically, educationally, and professionally, the better we can support each other to find our own right actions.

 

 

Note:  In the interest of full disclosure, I have used essential oils on several occasions, most notably on my dog when he was dying of untreatable cancer.  I would don gloves and a facial mask twice a day and apply the oils in several places on his body.  The veterinarian, oil consultant, and I are all convinced that their application made him more comfortable, stimulating his appetite, minimizing his discomfort, and lengthening his life.  Second, my body does not respond positively to essential oils. There are very few that do not irritate my skin or cause other unpleasant symptoms, including migraine headaches. However I have close friends and midwives who have been using them in their professional practices with people and animals for a long time.  All of them have taken educational courses to gain the knowledge to use them appropriately and safely. Because of these experiences, I have a healthy respect for the power of essential oils. 

 

*Thank you to Gena Kirby and Lesley Everest who introduced me to this phrase.

[1] http://www.agoraindex.org/Frag_Dem/eosafety.html

https://www.naha.org/explore-aromatherapy/safety/

[2] At my last count, there were 26 certifying organizations in the U.S. alone, so I’m not going into detail.  Feel free to put your group’s stance in the comments section.

 

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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

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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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How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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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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Doulas! Charge What You’re Worth!

Jan 28, 2014 by

In support of the effort made by YourDoulaBag.com, I’ve decided to repost the graphic from their blog this week.  Feel free to post it on your web site to help prospective clients understand how doulas set their fees.

blog_DoulasChargeWhatYouAreWorth1

 

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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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Christine Morton On Certification and Professionalism

Dec 2, 2013 by

Agreeing with me while also challenging some of my perceptions, Christine Morton has been researching doula care for as long as I have.  Dr. Morton* writes for the Lamaze International blog, Science and Sensibility, and she is the author of the forthcoming book, Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America, (with Elayne Clift).  She is not a doula although ten years ago she trained and certified through Pacific Area Labor Support (PALS) in Seattle and attended a dozen births.  She is not a doula trainer nor a current member of any doula organization.  Her interest comes from her background and training as a sociologist.  (Note: Bold and italicized type are my additions – ALG)

In response to my recent blogs, Dr. Morton writes:

I’ve done a bit of historical research on the history of the doula role and some critical thinking about what I’ve called the “organizational diversity” of the doula training/certification landscape.  Most of that work was done several years ago and it was an issue then and (not surprisingly) continues to be an issue now.  You count 16 organizations – and I bet there are many more in local contexts that do their own version of training/certifying doulas.  I’ve identified at least five in the San Francisco Bay Area alone!

The idea of an “umbrella” or “universal” organization that would certify doulas regardless of how they were trained was a vision of the first national organization – National Association of Childbirth Assistants (NACA), headed by Claudia Lowe in Northern California from 1984-1994.  I know that DONA founders had some interactions with Ms. Lowe in the early 1990s and there was a sense that DONA could serve that universal certification function.  NACA ceased to exist in 1994, a mere two years after DONA was founded.**

I suggest that the key challenge here comes from how the doula is defined.  There is an internal contradiction in the definition of a doula – that this person is a caring, kind individual who only needs to be co-present with a laboring woman as well as a skilled provider of specialized services, the provision of which is associated with highly consequential health outcomes for the mother and baby.  It seems to me the broad community of doulas can’t have it both ways.  I think the tension in this definition is the crux of the issue of certification.

Sociologically, doulas are far from being a recognized “profession” in the sense that there are no barriers to entry to the role (anyone can say they are a doula) and there is no formalized route to training nor admittance into the role  such as accredited education programs and licensure.  There is no regulatory board which might hear grievances or complaints about a lapse in service or care.

The grassroots (primal) origin has been a fascinating and compelling feature of the doula role but you are right in pointing out that changes are on the horizon.  The train is coming down the track and doulas can either jump aboard while it’s still in the station and attempt to drive it (and fuel it) or can be run over by it.  Maternity providers face the same thing with regard to the changed landscape of quality measures in perinatal care.

Given the past history of doula (and childbirth education) organizations, I am not optimistic that doulas and their organizations will be able to overcome the definition issue, in part because of the ideological diversity in their members.  I’m part of a research group that has surveyed doulas, childbirth educators & nurses in the US and Canada on a number of issues (MaternitySupportSurvey.com), and preliminary results show that doulas hold views on the most extreme ends of attitudinal measures on childbirth practice and beliefs.  The data from that study will be informative for this and other issues facing doulas today.

The current state of doula organizational diversity reflects the historical state of childbirth education/home birth midwifery organizations in the 1960s-1980s when doulas entered the scene, and now reflects intra-group differences, driven by a number of factors, including access to power, resources and perhaps, inability of strong minded individuals with differing views to understand the importance of working together.  Without the temporizing effects of larger institutions (think: universities or colleges with established means to organize and manage education) and without the infrastructure of formal management techniques and systems, membership organizations run by doulas for doulas lack necessary access to resources and power to effectively negotiate and mediate different viewpoints. 

Unless representatives of doula organizations come together with a collective desire and will to bridge this history, and define a common goal and work to achieve it, I don’t see how it will happen.  Anyone can claim to be a doula, anyone can claim expertise to open up a training and certification enterprise, and unless the doula role is substantially redefined so that only those with access to specialized training and /or licensure can legally charge money to provide defined services, there will continue to be an open field.

Other occupations have similar dilemmas where in theory “anyone” could do the service but to provide the service as a ‘business’ and charge a fee, there are regulations — think: childcare worker, especially home based childcare providers; barbers/hair stylists; dog groomers; caterers; teachers/tutors; massage therapists; personal/career coaches; home organizers; housecleaners ….. what we are seeing is the professionalization of service providers …. (this does not make these occupations “professions”, however).

I will leave you with another thought and another route to consider.  Patient advocates. Patient navigators. There is growing recognition that all patients in US hospitals would do well to have an advocate by their side.  Hospitals are complex systems where medical errors and communication mishaps inordinately account for a large number of preventable morbidity and mortality.  Maternity does so well relatively speaking because so many of the ‘patients’ are healthy to begin with and because there is poor surveillance of health outcomes (think hemorrhage, which is known to be significantly undercoded).  A strategy that frames doulas more as patient advocates runs the risk of defining laboring women within the context of a ‘patient’ and all that means, but one thing that doulas know well is that women who enter hospitals to give birth do become ‘patients’ — that powerful institutional fact is exactly why doulas are there – to provide some counter weight to the institutionalization of birth.  But an individual is no match for an institution.

There are some strong and growing organizations devoted to patient advocacy and shared decision-making, mostly in other areas of health care (it’s ironic that childbirth, the site of the original advocacy and patient-centered care is nowhere represented in these organizations, but that is another discussion).  Perhaps doulas can partially reframe their role to align with the agendas of these groups, who are increasingly present in forums and meetings on health care services and policy.  Doing so would de-center the ‘mystical and sacred’ elements of birth but not wipe them out completely.

Christine H. Morton, PhD
Research Sociologist, California Maternal Quality Care Collaborative
Author, with Elayne Clift, Birth Ambassadors: Doulas & the Re-emergence of Woman Supported Birth in America (forthcoming, Praeclarus Press, 2014)

christine@christinemorton.com
http://www.birthambassadors.com

*I use “Dr.” not to separate ourselves from everyone else, but because as women we rarely acknowledge our accomplishments.  To use the honorific Dr. when appropriate says “Hey, you achieved something!”  Because I work at home mostly I hear “Dear” and “Mom”, not Dr.

**I was in contact with Claudia Lowe in the late 1980’s as I was a member of IH/IBP and seeking out any other birth assistants I could find in the U.S.  Claudia Lowe lived in my hometown, in fact in my old neighborhood.  What Claudia Lowe told me at the time was that NACA’s dissolution was due to her and her business partner’s change in interests and not anything to do with DONA.  (I was not involved with DONA until October 1994 – after NACA folded.)

 

 

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What It Means To Be A Professional Birth Doula

Nov 26, 2013 by

There is a line between doulas who are professionals – where this is the source of their livelihood and the mainstay of their lives next to family and self – and other women who doula occasionally.  Not all doulas are professionals nor is it a goal for all doulas.  There is a place for all kinds of doulas and we need everyone if we are to reclaim our understanding of birth as important in women’s lives.  We lost it in the last century and taking a doula training or doulaing friends and family is a way to reclaim that.

Being a professional does not diminish the spiritual value we find in our work or the fact that many of us find it to be a calling.  We would be diminished in some way if we could not be doulas.  We have the joy of being in a life situation that enables us to do work we are passionate about, change the world for another family, and create income at the same time.

In my writings, I frequently use the term “professional doula”.  It is on a lot of web sites – even in the names of international organizations.  But no one has really defined specifically how it applies to our profession.  So I analyzed data from my 60 doula interviews, sifted through what I was reading on social media, and read through several books on professionalism.  This is what I have come up with to describe the internal identity and behaviors exhibited by doulas who consider themselves professionals.  I’d also like to introduce the term “emerging professional”, to represent doulas who are growing to meet professional standards.  So what does it mean to be a professional doula today?

1.  To be a professional means that you have completed education and training to gain the necessary knowledge and skills recognized by others in your profession.  Much of doula education is self-study, reading books and completing assignments, combined with taking a workshop and using hands-on skills correctly.  Training may involve working with a mentor and on the job training without any supervision.  Improvement comes from appraising our experiences and evaluations from clients, nurses, midwives and doctors.

2.  To be a professional means you have acquired expert and specialized knowledge.  This goes beyond learning a double hip squeeze in a workshop.  It means making sense of people’s conflicting needs in the birth room; intuiting when to speak and when to keep silent; how to talk to a physician about the patient with a sexual abuse history; how to set up a lap squat with an epidural; and so forth.  Competence and confidence grow in interpersonal and labor support arenas.  Any additional service you offer to clients means that you have additional study, experience, and possibly mentorship or certification to use it appropriately.

3.  To be a professional means that you receive something in return for your services.  For many of us that is money or barter goods.  However there are doulas who receive stipends that prohibit receiving money for any services performed.  They may request a donation be made to an organization instead.  If they meet the other requirements for professionalism charging money should not be the sole criteria holding them back.

4.  To be a professional means that you market your services and seek out clients that are previously unknown to you.  You consider doulaing to be a business.

5.  To be a professional means that you hold yourself to the highest standards of conduct for your profession.  You seek to empower and not speak for your clients.  You give information but refrain from giving advice.  You make positioning and comfort measure recommendations that are in your client’s best interests.  Your emotional support is unwavering and given freely.  Your goal is to enhance communication and connection between her and her care providers.  You seek to meet your client’s best interests as she defines them.  Several doula organizations have written a code of ethics and/or scope of practice in accordance with their values.  They require any doula certifying with them to uphold them.  But signing a paper and acting in accordance with those standards are two different things.  Even the values represented by various organizations are different.  Holding yourself to the highest standards is shown by how you behave.

6.  To be a professional means that you put your client first.  When you make a commitment to be there, you’re there.  If you become ill or have a family emergency there is another professional who can seamlessly take over for you.  You keep your client’s information and history confidential.  Confidentiality means not posting anything specific or timely on any social media.  Your responsibility to their needs and not your own is a priority.

7.  To be a professional means that you cultivate positive relationships with other perinatal professionals whenever possible.  You respect their point of view even when it differs from yours.  You seek to increase your communication skills and to understand different cultural perspectives.  You keep your experiences with them confidential and private.  You learn from past mistakes.

8.  To be a professional means that you have a wide variety of birth experiences and feel confident in your ability to handle almost anything that comes along.  Other professional doulas respect you and make referrals.  Note that I did not include a number of births.  Because of life and career experiences, some doulas will arrive at this place sooner than others.

9. To be a professional means that you seek out and commit to doula certification that promotes maximum empowerment of the client, using non-clinical skills, values and promotes client-medical careprovider communication, and requires additional education before offering additional non-clinical skills.  Certification means that you are held to standards that people outside your profession can read and understand.  Not being certified means there are no set expectations for that doula’s behavior.  Some doula training organizations have very loose certification standards with no specifics behaviors listed, just general attitudes.  Certification with behavioral standards that can evaluate whether the doula acted according to those standards is important for furthering the professionalism of birth doula work outside our own individual spheres.  It means that a doula is accountable to someone outside of herself and her individual client.   (In other words, certification in the context of professionalism is not about you, but about how it affects other people’s perceptions of you AND our profession as a whole.)  Having said this, not all doulas have certification like this available to them.

10.  To be a professional means that you seek to improve your profession by serving in organizations, representing your profession at social events, and assisting novice doulas to improve their services.  You balance your own desires and needs with the actions that further the doula profession – such as certification.  You know that when you get better – increase your skills, knowledge and integrity – you make it better for all labor doulas.

11.  To be a professional means that you have personal integrity.  Integrity means that your values, what you say, and how you behave are congruent with one another.  Sullivan has written:

“Integrity is never a given, but always a quest that must be renewed and reshaped over time.  It demands considerable individual self-awareness and self-command…Integrity of vocation demands the balanced combination of individual autonomy with integration to its shared purposes.  Individual talents need to blend with the best common standards of performance, while the individual must exercise personal judgment as to the proper application of these communal standards in a responsible way.”  [p. 220] 

“Integrity can only be achieved under conditions of competing imperatives.  Unless you are torn between your lawyerly duties as a zealous advocate for your client and your communal responsibilities as an officer of the court, you cannot accomplish integrity.  Unless you are confronted with the tensions inherent in the practice of any profession, the conditions for integrity are not present:  “Integrity is not a given….” 

In a doula context, this means that when you are in the labor room trying to figure out what the right thing is to do and struggling with it, you are having a crisis of integrity.  “Do I say something to the medical careprovider (MCP) or do I keep my mouth shut?  Have the parents said anything on their own behalf?  Do I just let this happen and help them afterwards?”  What value takes precedent: empowerment of the client or allowing an intervention to occur that may affect the course of the labor?  How will each potential action change my relationship with the MCP?  Situations like these are true tests of integrity that require us to rank our values of what is most important.

Sullivan, William M. (2nd ed. 2005). Work and Integrity: The Crisis and Promise of Professionalism in America. Jossey Bass.

How does this fit with your definition of professionalism for doulas?  What parts do you agree with?  If you disagree, consider why – is it my wording or the spirit of what is written?  Let me know – let’s keep talking about this!

Here is a pdf copy of this post to print or for your doula discussion group.

 

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Their Doula Disappointment

Oct 26, 2013 by

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

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

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

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

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

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

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

 

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

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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

 

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We Need ALL Kinds of Doulas

Oct 1, 2013 by

No we don’t.  We don’t need doulas that lack integrity, who interfere with a mother  getting an epidural or a cesarean, or who say nasty things to their clients about hospitals, doctors, nurses, or midwives.  In my experience these doulas may leave damage behind but they don’t usually last very long.  We hope.

What we have is a huge variety of doulas.  Doulaing is so important and integral to the process of supporting women in their birth experiences that it is finding its way everywhere. There are doulas who work only in their own religious or ethnic communities.  There are some who only attend births for free because it is their way of giving back to the world.  There are doulas who can’t imagine getting paid for work of their heart and spirit.  There are doulas who have no problem putting a price on their caregiving skills and need to support their families.  If we’re going to have a social revolution to rehumanize birth we need all the doulas.  Friend doulas, hobby doulas, grandma doulas, and professional doulas who work for programs, hospitals, and have independent practices.  We need inclusivity to change birth.

There are doulas who live in a neighborhood and are known as the “woman who knows about birth”.  There are doulas who move to foreign countries and hold the hands of mothers whose language they don’t understand.  There are doulas who are angry about how women are treated in labor.  There are doulas who cry about the lack of recognition that the baby is a conscious being.  There are doulas who can’t imagine attending a woman they’ve never met before and don’t know intimately.  There are doulas who do that on a weekly basis.  There are doulas who receive additional training and use other skills such as acupressure, homeopathy, Reiki, or aromatherapy.  If we want all women to have doulas available, that means we need to accept all different kinds of doulas.

The dilemma is this:  If we need all kinds of doulas to humanize and change birth, we also pay the price in delaying our claim to legitimacy for our profession.  There is a difference between a professional doula and other doulas.  No other birth profession has this dilemma where the stakes are so high.  There aren’t any hobby doctors, hobby nurses, or even hobby childbirth educators.  It’s no wonder there is confusion and conflict among doulas and medical staff.  Friends acting as a mom’s doula have no allegiance to advancing our profession and no idea that their actions reflect on all doulas.  When doctors and nurses interact with a doula they have no idea whether she is a novice, a professional or somebody’s buddy.  We can look alike from the outside and seem like we’re doing the same thing.

Legitimacy is like the right of way in driving a car.  The right of way is not something you automatically receive, it is something the other driver gives you.  We can claim the space for legitimacy but it is up to other forces to recognize us as having it.  Those key forces are parents, physicians, midwives, nurses, educators, third party payers, and the general public. We need to have professional standards and educate about the differences to doctors, nurses, midwives who will work with all the doulas.  We need to tell them that their expectations can and should be different of professionals.  We need to show them there is a difference.

There are some doulas who feel that a goal of professionalism is missing the point.  Their vision is for every community or neighborhood to have their own doulas.   They would be the go-to person for pregnancy questions, education, and support during labor.  In this vision it is all about connection and creating a knowledgeable empowered female community.  This happens when people have pre-existing relationships that continue as the child grows.  While I can appreciate that vision, many of the mothers we serve don’t live in that world.  Our connections occur most often with the assistance of technology not around the back porch.  Some women feel most comfortable with intense intimacy when they purchase it – they retain control.

The doula revolution was born through social forces and will continue to form itself around existing systems.  In other words there will be all kinds of doulas everywhere – including those that break rules others hold dear.  We are fighting for two separate things – to improve birth where a mother can have the support she needs from the person she wants to serve as her doula.  We are also massing to shift the perception of us as professionals and to communicate there is a separate set of standards.  Sometimes the accomplishment of the former conflicts with the latter: when a non-professional doula acts in a way that a professional would not.  This is messy and confusing for all of us, including nurses and medical care providers.  While we may not need all kinds of doulas (see first paragraph), all kinds of doulas exist and we need to live in that world.

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We Need To Create Social Change That Values Caregiving

Aug 28, 2013 by

Recently I wrote about how we needed to increase the value of doula care in the minds of consumers, caregivers, and third party payers.  If we are to create a social revolution regarding the value of professional caregiving, doulas can do it.  Many of us are white, well educated, and have other sources of income besides doula work (Lantz et al. 2005).  Groups with these characteristics have greater influence.  For many years the majority of professional caregivers in America have been immigrants or have brown skin.  They had little social power in our country and it was better for them as individuals to be silent.  Historically and now, professional carers are our nannies, home health nursing assistants for the elderly, and aides for the developmentally disabled.

Our movement as professional doulas is tied to these other jobs, whether we like it or not.  All involve caring for others and improving their experience of living in this world.  Being young, old, or disabled are not illnesses.  But they are times of vulnerability where the family seeks trained outside help.  Nannies, CNA’s (certified nursing assistants), and aides all offer emotional, physical, and informational support.  They must get along with the medical care providers and responsible adults guiding the individuals they support.  Most importantly, their outcomes are mostly soft.  Soft outcomes consist of good memories, satisfaction, improved relationships and the ability to communicate with others.   They also put a price on their caregiving skills and must maintain standards if they are certified.

So when we are asking for our doula skills to be valued, we are asking for social change.  We are making a statement that caregiving is a skill; it is not something innate to all women (or people).  It is learned and cultivated and takes years of experience to be consistently effective.  Caregiving skills have value.  Receiving good caregiving makes a positive difference in one’s health, personal growth, life satisfaction, and social interactions with others.  In obstetric outcomes, effective caregiving by professional doulas leads to fewer interventions, less pain, increased birth satisfaction, fewer operative deliveries and cesarean surgeries.  We have quantified the influence of the human factor in labor and delivery.  We have “known” statistically for 15 years.  But still few are willing to make the change.

Why?

Using Robbie Davis-Floyd’s terminology, the technocratic model* does not value caregiving as a reliable skill in influencing the machine like movements of the body.  It cannot be used on every person and get the same outcome.  Not every person offering doula care is a good match for someone who wants to receive it.  There are human factors involved.

Inviting doulas onto the maternity team in a way that shows they are valued, means that there are influences that someone who has comparatively little training or education can have on the patient.  The doula may make a bigger difference on birth outcomes than someone with 12 years of expensive education and training.  That can be bitter to accept.  (Of course the physician needs to have a low management style with few vaginal exams and little intervention to begin with.)  Physicians may also feel that not doing anything (no continuous monitoring, no amniotomy, allowing food and drink, etc.) is the same as doing nothing.  It isn’t.  It is allowing the social-emotional-hormonal interactions of labor to bring forth the baby when it is possible.

Lastly, it is because we do not value what we do.  We do not entirely one hundred percent believe that caregiving is a quantifiable skill that makes the vulnerable experiences in life better.  We need to change.  Our caregiving is not very different from the Filipino home health aide who is gently wiping the drool off your grandfather’s chin.  It is not that different from the African American mother of ten who is soothing and changing your dying mother’s diaper.  When your Down’s syndrome son is going into a rage in the group home, it may be the twenty-year-old community college student who knows how to talk him down.

We might like to think we are better than they are because our care is specialized, because it deals with mothers and babies, because we feel it is a calling and not a job.  Because we value what we do but not what they do: “Anyone can wipe an old guy’s mouth.”  Guess what?  No one else thinks we’re that darn special either.  As the mother of a child with a disability, as someone who has changed my dying mother’s diaper, and who has sat with many a drooling elderly man as he told me a story, it is not that different.  They are all caring activities and involve many of the same birth doula skills – just applied differently.

Some of you are sitting there fuming – angry with me.  Why?  Is it because you feel I have devalued your skills?  Is it because you would not want to do those other jobs but feel compelled to help mothers and babies?  It is these feelings that I am directly addressing.  We have an internalized prejudice against caregiving and we don’t value it.  Until we do we are stuck exactly where we are.

If you start arguing with me about how different birth and postpartum doulaing is from these other jobs, you’ve missed the point.  Yes, there are subtle differences and specialized skills involved with each professional niche.  But they are all caregiving professions.  In our society few of them are valued as important, even though every one of them is essential.  We need to value all of them so that every caregiving profession is seen as important and worthy of a good wage.

 

Lantz, P.M., Low, L.K., Varkey, S. & Watson, R.L. (2005) Doulas as childbirth paraprofessionals: Results from a national survey. Womens Health Issues, 15(3), 109-116.

*Here is a simple chart of the Technocratic and Holistic Models with an exercise to use with your clients: ModelsofBirth13

* One of Robbie Davis-Floyd’s articles on the Technocratic Model of Birth.

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Should Doulas Offer Free Services Is The Wrong Question

Aug 26, 2013 by

It seems every doula with a blog has weighed in on the “no free births” debate and every doula with an opinion has expressed it on Facebook.  The debate usually goes something like this:

“If you don’t charge, you demean my services.  You make doula work appear unprofessional or not worth paying for.  By giving away your services, people are less likely to pay me for mine.  They won’t value what we do.  And since our customers usually employ us only once or twice in their lifetime, they will tell other people a free doula is as good as an expensive one.  Third party payers will continue to refuse to reimburse us because they’ll say a consumer could get the same services for free or a professional is not required.”

Beneath this argument is a current of fear.  We want our profession to be recognized as legitimate.  As birth doulas, our actions are often invisible.  They are only missed when we aren’t there.  Our fear is if those we are welcoming into our professional ranks undermine our work – even if it is out of ignorance – how can we ever rise into a position of recognition and be seen as having a unique and valuable contribution to maternity care?  Will we ever be able to earn a living wage to support our families?

We have no control over how other doulas set their fees or how they feel the calling of doula support fits into their lives.  However we do have control over ourselves.  When we examine the root of our fear, we can take action to address those issues in other ways.  We need to establish the value of our own experience and contributions.  Some doula businesses have already done this with tiered pricing based on experience and credentials.  With each successive tier, more skills are added to the list.  Parents and payers can easily see what they are paying for.  Individual doulas have added a section on their own web site:  “What I know now after 20, 40, 100 births” or “What makes my services special”.

Instead of putting our efforts into controlling the newbies – and there are thousands of them every year – those of us who have survived past the first ten births need to make a LOUD statement about what we bring to the labor room.  There are fewer of us and we’re busier and more tired, but we have lasted.  We need to value ourselves first. 

My goal with this blog is to give you tools to do just that.  You need to go forth in your own community and state loudly and clearly, “I have something to offer that benefits everyone in the labor room.  It requires training, experience, and very few people can actually be an effective birth doula.”  We must support one another in this stage of our profession’s growth by actively promoting our value to families and to care providers.  Yup.  If you’re doing it right, you make a positive difference for nurses, midwives and physicians too.

It is up to us to use research and other evidence to create change.  After 27 years in this business, I have seen it grow incredibly.  For the first ten years, I didn’t even use the word “doula” to describe what I did.  This argument about “no free births!” is a part of our growing pains.  But we have to recognize it for what it is – a response to our fear.  Once we can name what we are really scared of, we can act to change those circumstances where we do have control.  I am eager to see what we will do next.

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The Art of Labor Sitting

Jul 22, 2013 by

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

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

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

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

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

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

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

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

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

 

 

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Doulas and Informed Consent

Jul 17, 2013 by

One of our primary functions is to empower the mother and her partner to ask questions.  Many of us feel that a nudging, “Do you have any questions about that?” should get our clients more information in the labor room.  Often I can tell them what they need to know, but I don’t consider that to be my role.  It also defeats one of my main unstated purposes:  to increase communication and trust between patient and medical care provider (MCP).  The more I assist information to flow from the doctor, nurse or midwife towards my client, the more improved their relationship will be.  Mother and her partner or family member can also evaluate their MCP and whether their approaches match.  If I do the talking, those important processes don’t take place.  I know what I know so I can tell whether they are getting the information they need.

What if the mother and her family aren’t getting the information she needs?  What if an important piece is missing?  Then I ask.  Depending on the situation, a direct or indirect approach may be best.  Direct approach:  “Is timing an issue with this procedure?  Some other physicians at this hospital had mentioned that to me before?”  I recommend never mentioning that you read something somewhere – it can be interpreted that you are trying to one up the MCP – bad move!  But stating that you heard it from a MCP with equal status or that you observed it at another hospital works better.   The direct approach works best when you sincerely act curious.  You need to be really present with the thought – “Why is it being recommended this way?

If you have another agenda or predominant emotion it is likely that your subliminal behavior will reveal that and be interpreted negatively– often on an unconscious level.  So the direct approach needs to be used attentively by the doula.  Your client also gets the message from your question that there are different approaches – which the MCP may not care for.

The indirect approach can also be referred to as the Dumb Doula approach.  “Isn’t there something about…um, well…the timing, is it called, with this procedure?”   You are asking a leading question in a non-threatening voice.  This strategy is designed to solicit information from the nurse, physician or midwife without challenging them or their authority.  To be honest, I use this approach most often.  It’s been the most effective at meeting my client’s needs over the years.  Now the Dumb Doula approach is not without controversy.  It certainly doesn’t add to our professional reputation or appeal!  “Those doulas might know how to rub a back, but you’d think they’d have learned some more technical stuff by now.”  Additionally, some doulas may think it is manipulative, that we aren’t being authentic.  To me, crafting communication strategies to maximize effectiveness is what I do all over my life: with my family, my students, in mentoring situations.

Some physicians and midwives are happy to answer questions until their patient is comfortable with the recommended treatment or another decision has been reached.  Others seem to feel that asking questions is equal to challenging their authority.  They may seem brusque or annoyed.  Often it is a clash of health care philosophies.  Your client is likely to be wanted to be treated as an individual and to cooperatively make decisions with the doctor or midwife (who is likely a stranger).  However the MCP is likely to see him or herself as the knowledgeable authority whose role it is to make medical decisions.  In addition, they will have to answer not only to the patient, but their colleagues, the hospital administrator, their liability insurance company, and maybe a judge and jury.  So doing what your client wants rather their preference can be a loaded proposition for a physician or midwife.

Having said that, doulas prompting clients to ask questions and receiving answers actually helps informed consent.  When mothers and their partners receive more complete information regarding procedures and intervention, this actually helps the MCP if an action is called into question.  It also decreases the likelihood of a complaint or lawsuit.  Both patient satisfaction studies in public health journals and birth satisfaction studies in nursing and midwifery journals give the same conclusion.  Involved decision making and more complete information from MCPs leads to greater satisfaction, better long term outcomes, and fewer legal actions against physicians.

As doulas our prompts to get more information for our clients is a win/win for physicians and their patients.  The more moms know before something is done, the more satisfied they can be afterward – both immediately and weeks and months afterward.  I just wish more physicians and nurses understood that.

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Labor Support – You Mean That’s A Profession?

Jul 9, 2013 by

In my twenty-five years of offering labor support professionally, there is one persistent challenge that our profession still faces:  that of legitimacy.  While people may be more knowledgeable about what the term doula means, they are still befuddled by what we actually do.  If you asked someone who already knew what a doula was, what a doula actually did, they would be hard pressed to describe it accurately.  Most people think (even those we think should know better) that doulas pat laboring mothers on the back and tell them everything will be okay.  Our clients have learned through direct experience that birth doula support is skilled caregiving.  But even their descriptions are limited by their own birth experiences.

Doula care requires a large skill set.  It requires being able to accurately perceive the needs of people you do not know well and sensitively and contingently respond to those needs in a timely manner.  Doulas need to have many physical and emotional support skills at their disposal in order to effectively apply the correct strategy.  Effective communication skills with a wide variety of people are necessary for a doula to excel.  Birth doulas also know how to navigate the complicated obstetrical health care system in their area.  One of my main purposes of my research has been to illustrate the sophisticated nature of doula skills (Gilliland, 2011).  Caregiving is a skilled profession, and doula support is professional caregiving.

However, most people do not recognize doula care as a skill.  Even if they do, that does not mean that our caregiving has value.  There is a long history of disregarding professional caregiving in the United States.  Many of the other caregiving jobs are not well paid and are often held by people not native to the U.S.  Most Americans do not want these kinds of service jobs – they feel they are beneath them.  The fact that most doulas are white and from middle and upper classes (Lantz, 2005)  has not made us immune from this struggle to recognize the value of giving care.

Then there is the idea that all women are natural caregivers.  Besides being sexist, it is not true!  Many of us can think of women who have few caregiving skills and men who seem to possess them innately.  But perhaps the most insidious part of this idea is that if doula support is something “all women” could do if they wanted or needed to, it makes it easy to devalue.  The more common a skill is, the less it is valued. It is also a career pursued almost entirely by women, which also gives it less status.

If we bring all of these ideas together, it is easy to see why the majority of the public doesn’t value doula work.  All women could do it if they wanted, it’s a job few people want, has little status, and it does not require any special skills.  While women pregnant for the second time may have a better understanding of what a doula has to offer, they may have paid a high price for that knowledge.  If we want to be recognized by medical caregivers, insurance companies and first time parents as a necessary service, we need to increase respect for our skills.  The first twenty years has been about getting the word out – now we need to make certain people know what that word means.

(This blog entry was originally published in June 2012 in www.childbirthtoday.blogspot.com.)

Gilliland (2011), After Praise and Encouragement: Emotional Support Strategies Utilized By Birth Doulas in the United States and Canada, Midwifery, Volume 27 (4) p. 525-531

Lantz, P., Kane Low, L., Varkey, S., Watson, R. ( 2005) Doulas as paraprofessionals: Results of a National Survey. Women’s Health Issues15:109-116.

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