Why The Doula Research We Need Doesn’t Exist: Part II – Medical Politics and Practices

Nov 6, 2017 by

DSC03787As a young woman, I naively thought that the evidence was so overwhelming that we’d steadily see doula research in major medical journals. Nursing and medical students working on research degrees would pair with their professors and community members to answer these pressing questions. The fact that our answers could impact future generations would provide enough incentive. We could stop women’s bodies from being permanently damaged by outmoded obstetric practices and facilitate trust and communication between client and caregiver. We could help mothers and babies have the best possible connection from the very beginning. We could increase physician and nurse sense of connection to patients and colleagues thus positively impacting their mental health outcomes. Doulas do this by offering two commodities that are scarce in the hospital system: time and a listening ear.

I am no longer young. Anyone wanting to study doulas from a medical perspective has been shushed or shut down – that’s my only explanation. They’ve been quietly steered to other topics that would be more acceptable to medical or nursing professors serving on the approval or review board committees. While there are plenty of theses and dissertations on doula topics, very few of them actually add to our understanding of doula support. They are almost exclusively from the social sciences not a medical field. Most focus on the way labor support is experienced by parents or doulas because that aspect is accessible.

My conclusion is there are few doula research studies because of obstacles from medical politics and outmoded beliefs which I explore here. Part III will cover difficulty in research approvals, funding and publishing access; and the feminist political agenda of the U.S. women’s movement.

Politics and Power:

  • Doulas represent the laboring person. They don’t want to maintain the system as it is, they exist to disrupt the system from offering impersonal care. Their very existence demands that the hospital see the patient as an individual, with their own particular needs. Anyone who has a vested interest in maintaining the status quo will actively resist any research on birth doula support.
  • Doulas are unpredictable. Because they make a stand for the primacy of their client’s interests, no one is quite sure what they will do. Ask for the squatting bar? Even wanting a spontaneous labor to take as long as it needs to rather than following a predictable timeline is heresy in some labor and delivery units. Doulas actually interrupt physicians from doing interventions so they can be discussed with the patient first.
  • Doulas disrupt the power imbalance in the labor room. Doulas insist that power be shared with the laboring person (patient) and that medical careproviders discuss benefits, risks, and alternatives. Doulas assist their clients to develop a collaborative relationship with their doctors, even when that is not the wish of the physician. Many doctors are used to making autocratic decisions and not having their opinions questioned. They do not see the benefit to the patient or to themselves, even though it leads to charting of the conversation that benefits the physician if there is need for a review or inquiry.
  • Doulas empower women. Current western society is still built on the premise that women are not equal to men. These patriarchal beliefs are woven into our majority culture along with white supremacy, colonialism, and racism. Anytime an oppressed group exceeds their allotted power in the system, the fear grows that it will spread to other groups. The existing system sees sharing power as a loss rather than a gain. Since doulas are basically disruptive to the status quo they cannot be empowered in any way including research funding or internal review board project approvals.
  • There’s no clear way for hospitals or medical systems to make money exploiting doula support. Although there’s a lot of controversy about the unpredictability of maternity care billing here and here, as a general rule the current system pays more money for a birth when more interventions are used. Since doulas have been shown to reduce the need or use of those interventions, and doulas cost money, there’s no financial incentive to explore labor support. Until the billing and funding systems change there will remain no financial reason to explore doula care except for Medicaid patients.
  • The only medical systems that employ doulas do so because it solves their other problems not because it primarily benefits women or babies. That’s why these systems haven’t published on positive obstetrical outcomes, because there aren’t many. In my own observations, these programs only exist when they help the hospital to attract customers or when the doulas solve other problems in the labor and delivery unit. They don’t exist to get better outcomes, lower complications from interventions, or empower patients in the medical system.

Outmoded Beliefs:

Our medical systems don’t value individual people very much. This is ironic because our medical system is supposed to help people, but when it comes to how obstetrics is practiced people are damaged as well as helped. This is true for physicians, midwives, and nurses as much as it is doulas and patients. No one personally benefits from our current system of labor and delivery care. Only the system itself does. We have to remember that the hospital system of obstetric care was founded on several beliefs:

  • Babies don’t feel pain or remember what happens to them so whatever you do to them doesn’t matter.
  • Women’s bodies are mechanical in nature, so treating the body as a machine with technical difficulties is the right approach. The fact that there is a person inside the body influencing how the body functions was not a part of that original thinking.
  • Physicians function best when divorced from their own lives and feelings and practice in a vacuum, focusing solely on the mechanics of the body and objective data.
  • Nurses are there to be the physician’s hands and eyes, not to have a voice or their own unique knowledge and contributions.
  • A mechanized system of medical care delivery, based on a factory model, provides the best results for the majority of people and the system itself.

We can see how toxic each of these beliefs are. Yet they are still present in how labor and delivery units are designed and how people do their jobs. Acting as if those beliefs are wrong is heresy! Yet that is exactly what doulas do. So no wonder no one wants to pay money or spend time to do research on birth doulas unless they are also invested in changing the way medicine is practiced. Think about it. The changes that many wish to see in the way obstetrics or hospital midwifery is performed challenge one or more of those founding beliefs. My cynical side says that they have no reason to worry as it takes 17 years for the best evidence to actually become medical practice.

In Part III of this series, I’ll explore the obstacles inherent in the research process as well as the lack of any kind of childbirth right agenda from U.S. mainstream feminist organizations.  Part I covers the doula research I thought we’d have in the 37 years since the first doula study was published.

 

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).

Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine104(12), 510–520. http://doi.org/10.1258/jrsm.2011.110180

Free SlideShare Presentation on Why It Takes 17 years  (See Slide 7):  https://www.slideshare.net/iHT2/health-it-summit-san-diego-2015-panel-research-evidence-and-clinical-realities

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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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Who Are You And Why Should I Listen To What You Have To Say?

Sep 16, 2017 by

AmyGilliland-5Demands for transparency in science and accountability for potential bias in researchers are relevant to doulas because so much of what we do is research driven. People want to know who is generating knowledge and how their backgrounds inform their findings. Since I’m about to embark on some rather provocative blog posts I wanted to share information that I think is relevant for my readers to know.

I was twenty years old when I unexpectedly went to my first birth and ended up doing all the labor support. I knew very little so I left with lots of questions. My curiosity led me to have a midwife attended birth myself a few years later, and I became a childbirth educator and professional birth assistant at age twenty four. That was over thirty years ago and I’ve never stopped being a doula or involved in birth work. Throughout the years I’ve been a La Leche League Leader, an Informed Homebirth/Informed Birth and Parenting and ALACE Certified Childbirth Educator and Birth Assistant, a DONA approved Birth Doula Trainer, Advanced DONA Birth Doula, and an AASECT Certified Sexuality Educator. I served on the boards of DONA (’95-99), Wisconsin Association for Perinatal Care (’12-present), and have given general session presentations at international conferences including DONA, CAPPA, ProDoula, and Lamaze. My full CV, listing presentations and work published in peer reviewed journals, is here.

That’s what looks good on paper. But what about me personally? I became a doula when my adult identity was cementing. I’ve never not been a doula or surrounded by doulas. For my research studies, including my master’s thesis and doctoral dissertation, I interviewed over sixty doulas and forty parents about their experiences with labor support. My goal is to increase the legitimacy, understanding and professional respect for the doula professions. A secondary goal is to empower laboring people and careproviders to create a respectful, cooperative system of perinatal care that allows for differences in philosophy and practice.

For fourteen years I’ve taught university level courses in the psychology of human relationships, human sexuality, introduction to psychology, and public speaking. I have a graduate certificate in prenatal and perinatal psychology and believe the newborn is conscious human being capable of complete sensation and the creation of memory before birth. I believe in the empowerment of people in labor, no matter what their gender or sex, and the individualization of care towards that person. I believe the medical system is toxic for most nurses, midwives and physicians and that system change is possible when we are all willing to subvert the existing power structure. However I’m not an activist or an agitator. Those roles are necessary and valuable for social change, but it’s not my gift.

Instead, I’ve noticed that lasting change comes when people are open and you can make an individual connection. So I teach. I facilitate. I lead. My workshops are grounded in research – it is what we know and trust as a society – as well as teaching the skills of connection and communication. Those ‘soft’ processes are the ones that bring differences in neonatal and obstetrical outcomes at a birth. After all my years of research and reading, that is my theory. Doulas make a difference because they are able to meet a laboring person’s attachment needs.

Others have described me as a thought leader and visionary in the doula world. I spend a lot of my time thinking, pondering, considering, ruminating, and gestating my ideas. This blog is a culmination of much of that effort. Many of these essays have been worked on for four months or more before they are posted. For those of you who are still reading, I am constantly trying to answer the question, “What are the influences on this situation? Why are things the way they are?” My research interests have landed me a postdoctoral fellowship at the University of Wisconsin Madison School of Human Ecology’s Center for Child and Family Well-Being. This enables me to access the university’s resources to continue researching and publishing my studies on labor support and doula care.

People have criticized me for being too detached, not emotionally involved enough, or not having a strong enough opinion. As a trained scientist I really strive to be aware of my own biases and to include them when they are an influence on my conclusions. This detachment may come across as uncaring in my writing.  On a personal level, I’d been attending births for a decade before I called myself a “doula”. I didn’t really care for the word – I was a professional birth assistant – but it was the word the market chose for what I did. I rationalized that it took up less space on my business card. Birth trends have changed, what mothers want has changed, who is birthing has changed, men’s roles in society and parenting have changed, and so have public attitudes about childbirth. Having lived and adapted my practices to accommodate all these changes, I just don’t get as emotionally invested anymore. I’m not uncaring, I’m just more protective about what I allow to make me angry or upset. When I wrote the Birthrape blog for example, it wasn’t going to help anyone if I ranted. What doulas really wanted was solutions – a recipe of what to do and some understanding of why medical careproviders ignore the protests and cries of their patients during a painful procedure.

Anyone who knows me knows that I care deeply about doulas, about how people birth and are born on this planet, and creating lasting social change that honors our brains, psyches, and bodies. Otherwise I would not have dedicated my life to it.

 

Facts About Me That People Find Interesting:

  • “Giving Birth The Movie” – (2006, 2000) I executive produced this DVD documentary with director/producer Suzanne Arms   – available for viewing on Amazon.com for $2.99!
  • I have a research chapter called “Doulas As Facilitators of Transformation and Grief”, (2016), in the first academic book about doulas, Doulas and Intimate Labour: Boundaries, Bodies, and Birth, edited by Angela Castaneda and Julie Johnson Searcy.
  • I have a research chapter in Julie Brill’s book called “Attending the Births of Friends”, Round The Circle: Doulas Share Their Experiences, by Julie Brill (2015).
  • In 2002/2003 I lost 100 pounds and have kept 90 pounds off for fifteen years.
  • I married my fourth husband in 2013 and am the happiest I have ever been.
  • I birthed three children out of hospital with midwives, and am stepmother to a fourth.
  • I grew up in a family with only women and went to all girl’s school and camp.
  • I have no cousins, aunts, uncles, or siblings. My family of origin has all passed away.
  • I have done end of life care for several people who I have loved.
  • I am committed to being the best multicultural birth doula trainer I can be and actively work at uncovering my own internalized racism from living in a racist society. Towards this end, I have an accountability group and take workshops on a regular basis.
  • Like many women, I have survived sexual abuse, sexual assaults, marital rape, interpersonal violence, and stalking. I moved to Wisconsin to get away from the stalker. I believe we have to share this herstory otherwise victims/survivors feel isolated or ashamed. It was not our fault.
  • My areas of privilege are socio-economic, education, cisgendered, white, and the ability to pass in most other areas where I do not possess societal privileges.
  • Since I was born I’ve never lived without a cat.
  • I hiked for eight hours on an erupting volcano. Yes, it was dangerous!
  • I grew up on a rural California cattle ranch, a Napa historical home, and in the cities of San Jose and San Francisco. I can ride a horse, ski down a mountain, and swim in the ocean.
  • The Wisconsin State Journal published two articles about me and I’ve been featured in a regional women’s magazine (as a doula) and Florida and Wisconsin regional home magazines.
  • I’ve rehabilitated or extensively remodeled five homes and planned and pulled off six weddings. I love being inspired by the potential in homes and people to be their best.
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Career Minded Participants in Birth Doula Trainings

Dec 29, 2016 by

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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Take a Doula Training, Change the World

Nov 9, 2016 by

take-a-doulatrainingchange-theworldAlmost ten years ago I noticed many happy participants at the end of trainings but few people actually went on to become doulas. Being a researcher I decided to do a study, which was recently published as “What Motivates People To Take Birth Doula Trainings?” in the Journal of Perinatal Education, Summer 2016, Vol 25, No. 3. While I can’t repeat what was written for JPE because of copyright restrictions, the blog allows me to explore the findings of this research project in a more intimate way. This first post covers people’s desire for social change by taking open birth doula trainings; part two will focus on professional motivations; and part three will focus on personal reasons.

From 1997 to 2007, most people came to my workshops to become doulas. They traveled hundreds of miles and most people set up practices or attended births in some way. Sprinkled in were attendees who’d had difficult births or were from related occupations. By 2008 I was convinced there was something else going on – why did it feel that fewer people were headed down a doula path?

So, for three trainings I used my own participants for a pilot study. I had people brainstorm all the reasons why they were there until I stopped reading anything new. There were 18 unique reasons. Dang! Now, I wondered how popular each one was, and if this trend was happening outside Wisconsin. I tested on my own workshops again by making a survey to complete before the workshop began. I did that for a year, refined the survey, and then decided a wider investigation was possible.

Next dilemma: Who would volunteer to distribute the survey, and be committed enough to do it correctly? How could I get a diverse enough group in order to generalize any findings? I turned to other DONA International doula trainers, who were willing to implement my persnickety procedures so that everyone was doing the same thing. I am grateful to the many trainers who helped. In the end, the survey was answered by 473 people who took one of 46 DONA birth doula workshops offered by 38 different trainers in 18 U.S. states and 3 Canadian provinces. Data was collected in Oct-Dec or Jan in 2010/11 and 2013.

What I suspected all along was true: people were attending for many reasons and career advancement was clearly important to most attendees. But the proportion is what surprised me. No matter which statistic I cite from the study, what emerged is that only about half the people in those trainings were there with the intention of becoming a birth doula with their own independent practice. And only an additional small percentage intended to become a doula in another setting, such as volunteering or working for a hospital or other program. Remember, this is for trainings where registration is open to anyone[i]. I thought it would be about 70%, but here it was at less than 50%.

The Survey: First I had people choose ALL their reasons for attending from the list of 18 reasons (ALL). Next, they had to choose their top five reasons and rank them in order. Then I could compare what reasons were popular with ones that remained important. “Becoming a birth doula” only ranked for about half the people whether I was looking at all the reasons (tied for third place), the top 5 reason, two 2 or even #1. So why else were people there?

By far the main reason all people were taking a doula training was for social enrichment, not for any professional or personal reasons. “Increase my birth knowledge” was chosen by 74% in ALL, was in the top 5 for 65% and the top 2 for 37% of attendees. This means it was the prime motivating factor.

So what, Amy? Duh. That was my first reaction.

However, when I examined this issue more deeply its significance became clear. It means people are seeking out real knowledge about birth – learned knowledge from those who have been sitting with birthing people during their whole labors, over and over again. People gave up two to three days of their lives to acquire it! This means doulas’ views of birth are spreading. Birth doula workshops are often accessible, welcoming and oxytocin inspiring. Pregnancy and birth are powerful and meaningful to us. We’re attracting people who want this knowledge, and whether or not they actually use it doesn’t matter. Why? Because it changes the conversation about birth in the general public. The doula training has become a medium for transmitting a powerful vision of birth as a laboring person-centered and/or woman-centered one that deserves support.

This interpretation was strengthened by the popularity of two other reasons: “knowledgeably discuss birth issues with all women” (tied for #3 with becoming a birth doula in ALL motivations, and ranking 6th in people’s top 5 reasons), and “want to be around women who believe in women’s bodies and ability to birth” (#2 in ALL motivations, and #4 in the top 5).

This strong desire for inspiration and enrichment was not focused on the individual, but to “help women have better births (not as a doula or birth professional) (#10 in ALL, and #11 in the top 5). In other words, when analyzed as a separate group people who didn’t want to become birth doulas wanted to understand birth more comprehensively and from a perspective they couldn’t get from a book. They wanted hands-on learning but also to comprehend birth by focusing on the needs of the individual persons who are laboring and being born. Doulas put the persons at the center, not the process of birthing, and this is very different from other perspectives in our society. Even midwives need to pay equal attention to both.

Every birth is a symphony of social forces: majority culture values, neighborhood influences, family needs, the home/hospital atmosphere, the effectiveness of the body’s processes, and the individual wholistic needs of the laboring parent and the child. Through open doula trainings, we export the message that caring is a skill, it is not innate or inborn simply because of gender, and it is a skill that can be learned. We also emphasize meeting the needs of the individual over the system the person is birthing in, which is contrary to institutional values.

These messages are revolutionary and have already created social change simply by being enacted by doulas for the last thirty years. As more people grow to see birth the way doulas do, the demands they make on our institutions to humanize and be more rewarding and supportive places for staff to work will change, along with positive results for mothers and babies. The change has to be comprehensive – not just for patients but also for those who care for them. Doula trainings have become another significant medium in our modern society for the message that caring for individuals needs to be placed front and center in our birthing institutions.

 

[i] These results likely apply to other face to face trainings where general knowledge is emphasized. However they probably do not apply to workshops where a substantial part of the curriculum is devoted to a specific interest, especially if that is the reason people sign up. (Ex: shared religious beliefs about birth, a particular method of labor coping, or a desire to build a financially successful doula business).

This is Part One in a three part series about what motivates people to attend birth doula trainings.

 

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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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Why It’s a Calling

Mar 17, 2014 by

Doula work is hard!  It is physically challenging, emotionally draining and requires a personal connection that leaves life long impressions.  Doulas sacrifice to be there for their clients.  They prioritize other people’s birth memories above the needs of their own families.  They get paid less than what they are worth – often wages are barely above the poverty line.  There is a limit to how many clients one can physically and psychically manage.  Yet, this work is something that so many of us cannot imagine not doing.  It fulfills some part of who we are – it expresses our life essence.  To help another woman through childbirth – as she is physically going through the process of giving life to another human being – is what we feel we are called to do.

A calling is often referred to in religious terms because that is our most familiar cultural reference.  But a calling means that there is a purpose within us to connect to others and improve their lives.  We want to ensure that another person’s journey is eased by our presence.  What we give is not only a skill or a service, but the essence of our own humanity.  Doulas in my study said it was a passion, a priority, without doulaing they would feel that a part of them was missing.

Ten of the sixty doulas in my study described or mentioned the word “calling”.  Tracy said, “Being a doula is a part of who you are.  You can’t try to be a doula…you either have it in you or you don’t.“  Nancy shared, “It’s my passion and it tests my compassion.  In my real life, I’m a banker!  But that’s a career and this is a passion.”  Sadie said, “It was in my heart.  For so long before I took my workshop I knew it was in my heart and I’ve never been happier even though it’s been so hard.”

The calling of birth doula work often comes at great cost.  I’m not talking about the missed birthday parties or band recitals, although those certainly matter.  It cost us when we sit holding hands of a woman who is being victimized by her own choices, or who is not respected because she is young, not white, or doesn’t speak English.  When we SEE that infants are whole human beings with a full consciousness and no one else acts in a way that acknowledges it, it costs us.  When we know a physician feels he cannot trust the system and acts in a way that is self-protective rather than letting labor continue without interference, it costs us.  When we trust birth but no one else in the system we are working in does, it costs us.

We don’t do this work because we are martyrs.  We do this work because we are willing to pay the price.  We know it makes a difference to this mother, this baby, this family.  We know that our presence will reassure nurses and doctors to allow this mother to labor another hour because she is cared for.  We know that the price we pay is a drop in the bucket to what is gained by everyone else by our presence.  We do birth doula work because we are called to make a difference in the world.

Our spirit yearning for expression in the world says, “Yes!”

This is your role.

Be of service.

Make a difference.

Hold the spirit alive.

Like a soft spring breeze it whispers, “Doula this world –it needs you.”

 

 

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How Professional Birth Doulas Benefit Doctors

Feb 23, 2014 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

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

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

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

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

 

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

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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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“Being Whoever She Needs You To Be” – Part One: When It’s Easy

Aug 6, 2013 by

On the surface, this seems like a deceptively simple concept.  Many of us understand that different mothers have different needs.  Some women need a sister, some a mother, some a grandmother, some a new birth knowledgeable friend.  As I’ve said before, women hire you based on what they need – which is an intuitive process.  She already senses you have the potential to fulfill her needs.  What comes next is a process of adapting one’s skills and communications to best meet those needs. You can think of “being whoever she needs me to be” as a description of HOW you doula a mother.  Maybe you can relate to these two doulas’ words:

As one doula put it:  “I will match the energy in the room.  I will match their moods.  I will take on the music that they’re listening to.  I will join in the conversations that they’re discussing.  I will ask more about their life because I want to know more about them, I may pray with them.  But I don’t think I actually lose my inner self.  My inner self actually connects with their inner selves.” 

Another doula says:  “It’s taking your cues from them, picking up on the energy and just relating to them in whatever capacity they need. Sometimes I’m an information giver and I don’t do anything hands-on because they want that between them. Sometimes the dad doesn’t want to do anything hands-on, and I’m totally hands-on. And sometimes they don’t want the information because they have all the information that they believe they need in their heads. So it really depends totally on the couple.”

When I was analyzing my first few doula interviews, this concept arose spontaneously. After that, I heard almost every experienced doula describe it.  Later on, I selected passages from over 40 interviews and analyzed them, grouping similar ideas together.  From that I’ve been able to outline this process and come to understand that sometimes ‘being whoever she needs you to be’ is very satisfying, and other times it can hurt you down to your core.  Today’s post is focusing on the process and when it is easy to be the doula she needs.

Emotional support, physical support, informational support and empowerment – these are the four cornerstones of how doulas support mothers.  The doula is sensing what the mother and her partner need and being as effective as possible in providing good care. But it is the mother who is shaping the doula, who is bringing out of the doula what is inside to meet her needs.  Most of the time we enter a labor room curious about how the labor will unfold and not knowing what will be demanded of us.  We just roll with whatever comes our way.  Because we are adapting our skills to meet their needs, parents get to determine what roles we play in their lives.  We have extend ourselves in a position of service for them – and they get to choose how they wish us to serve. 

There are several roles or ways mothers need their doula to be that were fairly common.  Doulas did not struggle at all with these functions.  Here, different doulas describe roles that are common and easy to adapt to. Sometimes mothers want you to be the person who provides:

Informational Support and Empowerment:  “This mom said, “I don’t want any of this hippie-dippy stuff.  I need answers. I need someone who will help me ask the right questions and gather information.”

Forceful Guidance: “I think she needed to have a strong person who wouldn’t back down when she resisted and said, “Oh, but I’m so comfortable here.”  She needed someone who would insist that she move around and do things to make the labor more effective.”

Sometimes I’ll hear the partner in the other room say, “[The doula] said you have to get out of bed and take a shower. Because she said you’re going to feel much better.  So let’s go.”  And then two seconds later they’re in the shower and Mom’s going, “Oh, my God, I can’t believe I didn’t want to, this is so much better.”

Physical Strength:  “Right now I probably couldn’t pick up that television, but at a birth I could hold you up as long as you needed me to.  It’s amazing! I am an amazingly strong person at a birth.  I am that kind of a doula. I will sit up in a bed behind her and push with her.  I will catch her puke. I mean, I know doulas who won’t catch puke. I’ll catch her puke.  I’ll do anything.  I will do anything.”

Comforting Presence:  “As soon as I walked in the door, her husband left, went home, ‘the construction guys were coming’. It was me and the woman, and I sat there and I held her hand. She was sitting in the rocking chair, and I knelt in front of her, and basically what I did was, I staved off the people who were coming by every 20 minutes or so asking if she wanted medication, which she never did even though they gave her the pitch. She never took an epidural or any other medication. Put a sign on the door and said, “Leave us alone.” And then literally all I did was hold that woman’s hand. She would open her eyes and look at me. And she would close her eyes back, and I sat there and held her hand. And she told me afterward she could not have done it without me. Amy, all I did was hold her hand. I did nothing. I didn’t do a comfort measure. I did nothing.”

Acceptance and Humor:  “They were an Orthodox Jewish couple.  So her husband could not be there for the actual birth. But he sat behind a curtain and prayed.  At one point I said, like from the Wizard of Oz, “Pay no attention to that man behind the curtain!” And oh, I’d never say that to anyone else!”

To Let Her Lead:  “I’m thinking we’re in for a long night because she is so high need so early.  She doesn’t sound like she’s having coping related responses to what’s going on at 1-2 centimeters.  But she was not willing to relax, and she’s not going to sleep anyway no matter what I try to do positioning wise or massaging or whatever.  She’s not gonna sleep so we might as well work.  And that’s where she was at.  She did not, she did not want to relax enough to try and fall asleep which I felt would benefit her labor if she would relax and let go.”

Many of these roles or needs could not be predicted.  While we might know that we are expected to help with position changes, what we don’t know is whether she is resistant or not.  We don’t know if simply sitting with her will be all she needs or we’ll be exhausted from walking, stroking, massaging and holding her up.  While we always strive to follow the mother’s lead, there are times when sleep might be better than activity.  But we have to figure out what is more important – her being in charge or the textbook idea to rest.  How we give encouragement also shifts.  When a woman needs mothering or grandmothering, your response is different than if she is a logical and practical person.  People are very different from one another.  A good doula responds to become whoever she needs you to be.

 

Next time:  “No, I Won’t”, Hostess, Scapegoat: When “Being Who She Needs You To Be” is Difficult

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Hard Research: Birth Doulas Save Insurers and Hospitals Money

Jul 17, 2013 by

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

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

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

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

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

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

HOW TO USE THIS RESEARCH:

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

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

 

 

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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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