It’s Your Turn to Make Doula History

Apr 3, 2017 by

AmyConf1993

Amy Gilliland, Madison Area Birth Assistants booth, Oct 1993, Madison Women’s Expo

Lately I’ve thought a lot about what’s left after someone is gone – and who tells their story. It has made me really think about who is going to write the story of our movement. Traditionally history is written by people after events have happened, after the world has already changed. It’s written by people who have the power to write and disseminate information – which is why so many of our perceptions of history are distorted.

What about us? What about our history? Who will write the story of birth and postpartum doulas across North America and the rest of the world? Who will point out the indigenous women who never abandoned each other under the pressures of western medicine? Who will write about the women in the seventies and eighties who said, “I will go with you and I won’t leave you”? Who will write about how we took care of each other when our own families would not support us in breastfeeding or avoiding another cesarean?

The battleground of the doula revolution was not on a national stage. It was quiet, in every labor room across the planet, where one woman held another’s hand and said, “You can do this, I believe in you.” We made a stand for another person’s mental and emotional wellbeing in a system that had little room for it. We protected the space. We stood by her side when she said, “No.” We agitated the system with a smile on our faces. We kept doing it, over and over again, for years, until eventually those in power could no longer ignore us or their own research.

That’s the big story. But what about the little stories? What about the doulas in Pueblo, and Springfield, and West Bend? How did birth change there because of the presence of those early doulas? All of our communities have little stories. Each weaves a thread into the tapestry of our great big story of doulas changing birth in the world. Where are those stories?

Who came before you, person reading my blog? And what was birth like in your town? The time has come for you to seek out retired doulas and nurses and midwives and find out.

You see, if we don’t write our own stories, someone else will tell a tale that serves their own purposes. Or they will be forgotten, seen as not being important. Much of women’s daily lives has been unimportant to historians. But doula history is significant. If any one movement will be singled out as creating change in our system of birth, it is going to be birth doulas. Mostly we’ve been like dripping water, slowly eroding rock, getting the system to change. Lots of drips lead to pitting a foundation, causing it to change in response or else collapse. So while we may not be at most births, we don’t have to be. Our impact continues to grow. We aren’t done yet.

What is your community’s story of change?

Starting in the 1990’s I was the Archivist for Doulas of North America (DONA). Doulas sent me articles from their hometown newspapers. Back then it was a rare occurrence. While we might have wanted to change birth, what we really wanted to do was make sure women didn’t lose their power while having their babies. We couldn’t do that for everyone, so we just focused on the family in front of us. We hoped that over time the value of what we did would show.

Our strategy (if you can call it that) worked. Nowadays there are tens of thousands of trained doulas, and many cities have well established doula communities. ACOG recognizes the value of birth doulas. That means to me that it’s an excellent time to look backwards.

That sounds good to me, you say. But what are you suggesting I DO?

  1. Have fun! Talking about this history of birth in your town can be really fun. Most people like to reminisce and are excited that their memories are important.
  2. Investigate! If you don’t know who came before you, start asking. More experienced doulas may be able to remember a name or two. But don’t stop there. Ask the nursing unit director, the lactation consultant in her sixties, and your local midwives. Childbirth educators often last for decades and may be very knowledgeable about past trends. If everyone is young, ask who they’ve heard about being important in years past. Sometimes the only people who are remembered are the ones people didn’t like, but they don’t want to admit it! That’s fine. One name will lead to another. Look for old newspaper articles in the online archive. Most articles will reference older ones, sometimes going back ten years or more.
  3. If you can’t find a specific person, ask retired perinatal professionals about birth trends. Hospitals were remodeled, attitudes towards induction, breech birth, VBAC, episiotomy, cesarean birth, and having family members present have all changed dramatically in the course of my career.
  4. Interview alone or have a party! Sometimes a celebration is in order. In fact I think we need more parties in our lives that celebrate our accomplishments, especially when it comes to birth. Instead of interviewing one person, you could lead a group of people to reminisce. That might be more enjoyable for everyone.
  5. Ask questions that encourage explanations and depth about events. Here are some OralHistoryTips (pdf doc) I compiled to help you.
  6. Create a timeline of the order of events and include anything that might be relevant. This will likely lead to more interesting questions and observations. If you like mystery novels, this is your project! It’s a discovery of how your community moved from where things were in 1980 to where they are today.
  7. Record your interview and make sure your participant has a microphone near their face to avoid recording background noise. Many smartphones can do this well.  There are apps that can transcribe your interview into written form as long as there is no background noise. You may end up with a really interesting podcast, or a local historical society or oral history project may want your recordings for their files.

Then what?  If you complete your local project, I will publish it on a web site devoted to doula history that is available for everyone to read, including students of history to use in their papers.

This project is about more than you. It’s about those who came before but also for those who will come after. You may not know what they will look like or how they will interpret doulaing for their generation, but our history is important for them to know. And if you don’t record it, probably no one will.

 

Resources:

Christine Morton covers much of the big history of doulas in her book, Birth Ambassadors: Doulas and The Re-Emergence of Women Supported Birth in America. It’s our most extensive resource. Since I lived that history, what struck me the most was what wasn’t in there – including all of our small struggles in our own communities. It’s our responsibility to build on Dr. Morton’s achievement and share our stories to build a more comprehensive history.

Along with Mothering magazine, in the 1980’s and 1990’s many of us eagerly read The Compleat Mother, a quarterly newsprint periodical that espoused a radical wholistic philosophy of empowering women through childbirth.  It was more raw and less polished than Mothering. It did not shy away from exposing the patriarchal philosophy entrenched in the medical system and the feminist power available to us when we took charge of our bodies.  Famous Midwife Gloria LeMay wrote “Remembering Catherine Young”, founder of The Compleat MotherRemembering Catherine Young, 21 July 1952 – 11 September 2001

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“To Heal and Protect”: Attending Birth Doula Trainings for Personal Reasons

Jan 26, 2017 by

-To Heal And Protect-A small but influential group of people attend birth doula trainings not to become doulas, nurses or midwives, nor to positively influence births in other jobs, but to help heal from their own birth experiences (Gilliland, 2016). In any 10 to 12 person training, one or two people are there primarily to make sense of their own births or to make sure their future births are better. Although small in number, their motivations influence the type of discussions that occur in a workshop which makes their presence a significant one.

In this study, this group was defined in two ways. When forced to choose their top five reasons for attending a doula training, participants chose “understand my own labor(s) and birth(s) more deeply” or “make my future labor and births better” as one of their top two answers (n = 38; 8.2%). They also ranked professional reasons lower in their top five answers or omitted them. In the general question (“choose all reasons that apply”), members of this group also selected significantly fewer professional reasons for attending or none at all. There was a very clear demarcation between the “professional” attendees and the “personal” ones. However, this was the only difference. When these two groups were compared to one another on the other variables (age, births attended, parity, etc.) there were no significant differences.

In addition to this well delineated group, about 20% of all attendees chose “understand my births” as reason to attend. So while it’s a primary motivating factor for 1 out of 10, another two people in that training group also have lingering questions. This is a when my knowledge as a trainer with twenty years experience takes over in interpreting the research results from the study.

People who are in a birth doula training to gain healing from their own experience are not primarily invested in learning doula skills in order to use them with another person. They are there to figure out and make sense of their birth. By gaining information about what people need in labor and the components of support, they think they will better understand their own experiences. My hope as a trainer is that these people also develop more compassion for themselves.

In exploring this theme with small groups outside of the published JPE research study, there were five repeated themes in our conversations. They viewed a birth doula training as an avenue for healing because they felt:

  • People in the doula training will understand my story.
  • I will be treated with compassion and not dismissed.
  • I will be able to figure out what happened to me and why it happened.
  • I’ll be able to figure out why I feel the way I do.
  • I can keep what happened to me from happening again (to me or to others).

People seeking healing from a past birth experience have been a part of birth doula trainings since they started happening. In the 1980’s, I took “introduction to midwifery” workshops as well as ones designed to help you become aware of how your own births and growing up in our culture shaped our attitudes. In my decades as a trainer, I’ve learned how to make sure that people with these needs have opportunities to reflect and make sense of their experience – but not at the expense of hijacking the learning needs of the larger group. My primary purpose is to teach the skills that lead to doula success, not to lead a counseling group.

When you think about it, people who want this kind of healing have few opportunities to get these needs met. Where else can you go in our culture where you can get this level of understanding and compassion? Where can you get the information to assess what you actually needed at a significant time? It isn’t just emotional support but information and context that is often lacking when people are making sense of their births. An effective birth doula training can offer all of these things.

What we need to understand is that doula trainings are about training doulas – and part of that is teaching them to all the skills that come with compassionate listening, boundary setting, and putting clients at the center of their own decision making processes.  We have to be aware of and responsible for our own emotions at someone else’s birth or postpartum. The participants who need to heal offer trainers the opportunity to model compassion for ourselves. Further, they offer a living example that to be of service to another birthing family, we need to leave our own attachments outside the door.

Lastly, with these participants we are able to confront the thought that we can protect our clients or keep bad things from happening. We are not omnipotent nor are we the decision makers. Human beings, which includes our clients, are also notorious for learning best from making poor choices and living with the consequences. So doulas may find themselves second guessing a client’s choices or being judgmental. Participants who are processing their births may voice negativity about their choices or themselves during that past birth. When this situation arises in a workshop, it gives trainers a ripe opportunity to model kindness and tenderness towards oneself and others, and the personal empowerment that comes from owning one’s past choices.

As birth doula trainers, our job is significantly more complex than it looks on the surface. While we think we are there primarily to teach strategies to prevent labor dystocia, we are really there to help a whole society heal from damaging birth experiences and learn a greater sense of compassion for one another as we stumble through life.

Gilliland, Amy L. (2016) “What Motivates People To Take Doula Trainings?”Journal of Perinatal Education Summer 2016, Vol 25, No. 3, p. 174-183.

This is the third in a series of posts interpreting this journal article.  The first reflects on people who don’t want to be doulas but want birth knowledge, “Take A Doula Training, Change The World.”  The second focuses on “Career Minded Participants In Birth Doula Trainings“.

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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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What U.S. Birth Professionals Need to Understand About ICWA

Oct 13, 2016 by

icwa-alex-garland-photo-copyThe Indian Child Welfare Act – why is that relevant to my practice? The laws concerning children’s rights changed earlier this year. Although standards vary among the 544 tribal nations recognized by the United States government, some tribes consider a person with one drop of Native American blood as a member.  While only slightly over five million people have full or partial Native American heritage, the growth rate within the population is more than double that of other racial groups. At 26.7%, birth rates between 2000 and 2010 were almost triple that of the nation as a whole at 9.7% (U.S. Census, 2012). The average age of a Native American is 29 years old, compared to 37 years for all Americans (U.S. Census, 2012). This means most of the indigenous U.S. population is in their childbearing years – when they are most likely to be utilizing our health care services.

Why should we care? Recognition of tribal status is important to the individual, the family, and for the continuation of the tribe. The child may qualify for different social programs because of their heritage, but the most significant impact occurs if they enter a Child Protective Services (CPS) system.

Tribal status begins with correct information on the birth certificate. Even misspelling a name can interfere with identification. (The infamous Veronica case went all the way to the Supreme Court in 2013, which was caused in part by an error in spelling the absent father’s name on the birth registration form. Even though he was registered with his tribe, his misspelled name did not show up in a search. So the child was legally adopted by a White family until the father contested.) Since hospital staff are filling out the forms, it is important that parents and their support team ensure that correct names and demographic information appear on the birth certificate. In a recent briefing session, Oklahoma CPS social workers explained, “Even though we have a higher than average population of Native Americans in our state (Oklahoma), nurses still look at the baby to discern race and ethnicity. If the baby looks white or black, they check that off without ever asking the parents.”

Parents may also not realize why it is important to categorize their child’s heritage correctly from the very beginning. It is difficult, but not impossible, to get that changed at a later date – but it must be done with a court order by a judge.

Doulas can explain to families how ICWA affects their child’s rights, their ability to receive assistance or scholarships, and placement in the welfare system if those services are ever needed.

How does a person become recognized as a tribal member? Heritage is not established by clicking a box; the person must be recognized by the tribe. Each tribe has their own standards and they are not the same. After applying, the first step will be genealogical research on the child’s relative, who may or may not be a recognized tribal member. Most tribes keep complex family trees. Some records are online and easily searched, while others have paper records kept in file folders. If the relative is already recognized, establishing heritage may be fairly easy.

Why does this status change how a child is treated in protective services?  Native Americans are dual citizens, and each tribe has the right to be self-governing as a sovereign nation over its own lands and properties. That means that most large nations have their own child welfare services. They work cooperatively with the state or county CPS agency. Anytime a child needs to be removed from the home and a biological relative cannot be found, the child needs an emergency placement. This could happen if there was an auto accident that hospitalized the parents and it took time to notify relatives, or when abuse or neglect is suspected.

It is considered ideal for a Native American (NA) child to be placed with a NA family rather than a non-NA family, preferably within the tribe. The majority of families who take in emergency placements or foster children in the U.S are White. ICWA is designed so that children will be preferentially placed in a qualifying NA home when a biological relative is unavailable – even if that placement is farther away, even hundreds of miles away, from the child’s school or home community. This is the controversy of ICWA: it states that the child’s status as a tribal member is more important to nurture than the child’s emotional or developmental ties with an existing family or community.

Here is how it gets problematic: Let’s say five year old Melinda needs a temporary foster family. She is not listed as having tribal blood on her birth certificate. As her relatives are contacted, one of her paternal aunts mentions that she is a tribal member so her niece is too. Rather than getting the best possible placement from the start, Melinda would be put in a temporary home while her records are investigated. Since placements with a tribal family are harder to come by, she would likely be placed initially with White or Black foster parents. It may take several weeks or months – if all records are in order – before Melinda’s initial placement is confirmed or she is moved to a new tribal foster family. If she is confirmed as a tribal member, she will be moved, with no exceptions. So, what most of us are wondering is, “Why aren’t they thinking about Melinda and putting her needs first?”

In their own way, they are.

So, the individual child’s welfare is considered secondary to the cultural preservation of the tribe? Yes, that is one way to look at it. But the goal is for both to be important. If records are properly kept from the very beginning, many of the heartaches shown in the popular news can be avoided. The world is seen differently by many tribal peoples and this influences their definitions of health, harmony, and balance. The more we can step back and understand the world from that point of view, the more ICWA’s policies make sense from that perspective. In this informative essay, Clark explains that most western European or American thought is linear, and Native peoples tend to think in relational terms. “In the linear view, the person owns or is the problem. In the relational view, the problem is circumstantial and resides in the relationship between factors. The person is not said to have a problem but to be out of harmony. Once harmony is restored, the problem is gone. In the linear model, we are taught to treat the person, and in the relational model, we are taught to treat the balance.” So ICWA helps to bring their world back into balance.

How is this affected by past racist policies to assimilate Native people into White culture? Between 1790 and 1920, it was considered good domestic policy by the U.S. government to bring as many Native peoples as possible into White culture. By 1890, that meant separating children into residential schools where they would not learn their tribal language or beliefs or participate in events and ceremonies. Children would be effectively cut them off from their past and their people. Adoption became a negative thing because it was used as a method to separate NA children from their culture and families of origin. The goal was not to place the child back in their home, but to find whatever possible reason to keep them from returning. This went on for over fifty years, leading to multiple generations of tribal peoples feeling angry, lost and without a sense of belonging. Many of the social problems that Native peoples face today have their roots in U.S. government policies of assimilation. So part of what is happening with ICWA in 2016 is a response to the damage done by assimilation policies of the past – and to bring indigenous peoples back together and into harmony.

 

For more information about the Indian Child Welfare Act:

http://www.adoptuskids.org/adoption-and-foster-care/overview/who-can-adopt-foster/families-for-native-children

http://www.nicwa.org/what_we_do/documents/NICWA%20FAQ.pdf

https://www.childwelfare.gov/topics/systemwide/diverse-populations/americanindian/icwa/

Photo ©Alex Garland This photo has been altered to highlight the mother and child. https://www.flickr.com/photos/backbone_campaign/27186540216

 

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Hospital Agreements: An Opportunity For Engagement [Part II]

Jul 24, 2016 by

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

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

So what can doulas do?

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

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

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

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

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

 

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

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

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

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

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

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

 

 

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Hospital Agreements: The Wrong Solution for the Right Problem

Jun 27, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (3)Birth doulas are concerned about hospitals requiring signed agreements in order for them to practice their livelihood on the facility’s grounds. Some agreements outline scope of practice behaviors and even have vaccination requirements. My concern is that these agreements are seen by hospital leaders as an easy solution, without realizing that agreements without prior negotiation lead to greater conflict and tension, thus worsening the situation for their staff rather than alleviating it. They seek to save institutional energy and time, sidestepping the processes of defining the problem well or evaluating other possible solutions.

It’s also possible hospital leaders do not understand the doula’s role. A few months ago a very experienced labor and delivery nurse asked me about a doula who “just sat on the couch” most of the birth, only “getting up to help them change positions or go to the bathroom”. Her perspective was that the doula’s role was to tell the mother what to do to make her labor more efficient. This also represents a clash in values. In the hospital system, members have been socialized to believe that their primary value is in doing something. Our emphasis is on presence, a state of being that helps to create a safe space where oxytocin can flourish, the laboring person’s body can open up and use it’s own wisdom to get the baby born.

As someone who does frequent workshops and trainings for labor and delivery nurses, I can say that nurses gain their knowledge about birth from different sources; and often they do not know what doulas know. Nurses reading this blog very likely do, but they may not be the people in charge of solving the ‘doula problem’. Doulas read different research literature and have different conclusions. It is risky for doulas to assume that others understand our role or why we place value on physiologic birth[1]. When people don’t understand the doula’s approach to enhancing labor, they misunderstand our actions and motives as well.

To me, the agreements and many doula communities’ reaction to them, are representative of a clash in values, misunderstandings about each person’s role, and short sightedness about the long term relationships that need to exist between birth doulas and hospital staff and administrators. Part of my reasoning comes from the hospitals and doula communities who have effectively worked through their conflicts and found solutions that work. Each group took the time to appreciate the other’s contributions, and develop a long term perspective that included a multifaceted communication network. In my next post, I’ll outline their achievements and share strategies to help get to that point in your own community.

If an agreement is being proffered by your hospital, this means that you have a sparkling opportunity to engage with administrators to resolve conflicts and outline your working relationship. This is a critical time to define your relationship with one another as it has the potential to influence all future interactions. In a way congratulations are in order – the doulas in your area are being seen as a big enough force that they can no longer be ignored. You’ve got their attention and can use it to create positive change in the system that benefits you, your clients, as well as the hospital. The hospital staff just doesn’t know it yet!

Let’s focus on some key questions that we need to ask:

First, has the problem been defined well? Agreements are seen as a solution to a problem that people belonging to the hospital are having. Usually it seems the doulas in the area are often in the dark about what the problem actually is. From what I’ve learned about people and medical systems, a solution can be latched on to without ever really defining the problem well. “I read on the internet that Hospital X was having a doula problem so they developed an agreement. We could do that too.” Having latched on to a solution, the group then moves forward without fully defining the problem first.

Problems that agreements may be seen as solving:

  • Doulas who are using clinical skills while in the hospital.
  • Doulas misinforming the person in labor about their progress.
  • Doulas who are not being collaborative in their labor support strategies with nurses.
  • Doulas who ignore nurse’s experience or expertise in support skills.
  • Doulas who criticize a medical careprovider’s approaches.
  • Doulas who give medical information that the hospital feels should come from their representative.
  • Doulas who are blamed for their client’s strategies to delay or avoid interventions.
  • New doulas who need mentoring, and the nurse doesn’t feel that is their role (the agreement serves a gatekeeping function, keeping newbies away).

Besides the first one, the rest of these problems are relational. In other words, they aren’t easy to define and will depend on the personalities and communication skills of the people involved. That is what makes the agreements so problematic – they really can’t define appropriate behaviors in an accurate way. For example, if an agreement states, “The doula will not openly criticize the medical care being offered to a patient”, what does that mean? What is considered “criticism” and “open”? Is asking about BRAND[2] seen as criticism? Is bringing up alternatives critical? Is reminding a mother about her pre-labor priorities critical? How do doulas know? How do nurses know?

Second, are the perspectives of multiple stakeholders (nurses, physicians (all kinds including anesthesiologists), midwives, administrators, mothers, fathers, babies, laboring patients, family members, lactation professionals, doulas, social workers, etc) being taken into account? Having defined the presenting problem, who else is affected by it? What are their considerations that need to be taken into account? Have they been asked or consulted?

Third, what are all of the possible solutions to the problem? Are there other issues that have come up during this exploration period? What are the short and long term gains of each solution? What if instead of forcing all doulas to sign an agreement, we had twice yearly orientations for new doulas? What if the hospital sponsored events that covered the allowed safe discussion of most annoying behaviors of doulas in nurse’s eyes, and vice versa? What if nurses were free to ask questions about why doulas do things a particular way, without negative repercussions? What if doulas could seek to understand the nurse’s perspective without animosity?

In this way, hospital-doula agreements can be shortsighted. We don’t know what the goals of the hospital or the doula community are or whether they overlap.

Agreements that are created without communication between the negotiating parties will create tension and conflict. An agreement works best when it has been negotiated after a effective communication and conflict resolution process has been established. The agreement is the outcome of a negotiation. When it is handed down with authority as a “power over” move, it is doomed to create tension, defensiveness, and an anxious and tense work environment.

 

 

[1]  Supporting Healthy And Normal Physiologic Childbirth: A Concensus Statement by ACNM, MANA, and NACPM (pdf file) 

[2] Acronym for Benefits, Risks, Alternatives, do Nothing, Decision (after establishing that this is not an emergency)

For a doula’s insights on being handed an agreement, read: https://birthanarchy.com/hospital-doula-agreement/

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Want To Change Birth Tomorrow?

Mar 16, 2015 by

TeenPhotoTalk to the teens in your life today.  From what I can see, the decision about where to give birth and how to cope with labor is made long before conception.  Unlike previous generations, teens today are exposed to media misrepresentations of labor and birth on multiple television shows (Elson, 2009).  Based on a recent literature search (Toohill, 2014), it seems that more young women and men today are afraid of birth than at any previous time.  While the issue is multifaceted (Laursen, 2008; Saisto, 2001) the simultaneous rise in birth “reality” shows and studies of birth fear doesn’t feel coincidental.

Developmentally, girls aged 12-14 begin to ponder their adult future and consider what it means to get pregnant and give birth.  So naturally they turn to TV and to Youtube.  While many home videos are intended to show the raw power and coping potential of women, to an unknowing teen they can be downright scary.  Even videos posted to humor (Two Men Watch  Childbirth For The First Time] – can validate the fears that young people of all genders may have.

As birth professionals, we know the truth.  Given the right circumstances, labor can be coped with.  For the most part, labor is boring, with not much happening for hours at a time.  So TV producers create drama with music, narration, and selective editing.  Women’s bodies know how to create and grow a human being and get them out.  The more we interfere with that process, and that includes TV cameras and lights, the harder it can be on the mom.  Like any major undertaking, including moving house or completing a science project, labor and birth requires planning and support to do in a satisfying way.

Teens need our messages about the real nature of birth and manufactured depictions they see on TV and some uploaded videos.  They need to be engaged with, not talked at.  Even twelve year olds have critical thinking skills and despise being treated as if they are only passive consumers.

So how do you have a conversation with a teen about birth?  Make sure you are having a discussion, not a lecture.  Listen to their answers, and build upon what they share with you.  If possible, let them lead the discussion.  If teens are shy or used to being talked at, your conversation starters may be met with silence.  Use your doula skills to observe their “nonverbal leakage”; people don’t always need words to communicate!

You can start a conversation by responding to a family walking by with a baby, seeing a pregnant woman in a magazine, or even without any reason to at all.  Let your passion give you courage, and proceed from there.  “Hey, you know I’m a doula, right?  Do you know what I do?  Do you know why I do it?”

Another approach is to build on teachable moments.  “Remember that birth scene in ——-?  Did that seem realistic to you?” Build on what was valid in their comment or the scene, but don’t bash if their answer is “yes”.  Say, “I’m concerned when people see that, they’ll think that’s what labor is really like.  Because it scares people/makes birth seem dangerous/makes it seem like its painful for hours without ending.  That’s not the way that I experience it.”  Be REAL – so many people tell teens what they ought to think or do, rather than realizing they are thinking human beings making important life altering decisions almost every day.

Make sure to emphasize that both men and women need support in birth.  This is absolutely critical.  We place a disproportionate burden on men to do labor support and deny their own feelings and the developmental processes of fatherhood.  This is in the process of changing, but only if we continue to hammer home the message that men matter too.

Offer to speak to Girl Scouts (Cadettes, Seniors, and Ambassadors may have health badges), Boys and Girls Clubs, and church teen meetings.  Using the first fifteen minutes of Vicki Elson’s video, Laboring Under An Illusion, can be a great conversation starter.  It’s engaging, to the point, and it will make them laugh.  People remember more when they laugh and that helps to break the ice with groups of adolescents.

Keep your message basic, simple, and repetitive.  Labor and birth aren’t scary.  Ninety-five percent of births are normal and nothing bad happens.  Some people see birth as so safe and normal, they give birth at home and in birth centers.  Pregnancy and birth are wellness conditions, not illnesses.  Given enough support, women’s bodies function well and coping with labor is possible without resorting to medications and interventions.

Young adults will often do what feels right to them and that depends on what perspectives they’ve been exposed to previously.  If we want more informed consumers, we need to start at the most impressionable time: in adolescence when they first see themselves as potential mothers and fathers.

Like what you read?  Please subscribe!  The box is below on your right. Thanks!

Elson, Vicki (2009) Laboring Under An Illusion. DVD, BirthMedia.com 

Laursen, M., Hedegaard, M., Johansen, C. (2008) Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort, BJOG, 115 (3), 354-360

Saisto TSalmela-Aro KNurmi JEHalmesmaki E. (2001) Psychosocial characteristics of women and their partners fearing vaginal childbirthBJOG 108:4928.

Toohill, J., Fenwick, J., Creedy, D., (2014) Prevalence of childbirth fear in an Australian sample of pregnant women. BMC Pregnancy Childbirth. 2014 Aug 14:14:275

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Back Door or Front Door?

Feb 20, 2015 by

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

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

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

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

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

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

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

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

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

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

 

Posts In This Series:

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

2.   Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Doula Certification

5.  Fears, Downsides, and Challenges of National Certification

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

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The Fears, Downsides, and Challenges of National Certification

Jan 7, 2015 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Posts In This Series:

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

2.   Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Doula Certification

5.  This post:  Fears, Downsides, and Challenges of National Certification

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

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Benefits of National Doula Certification

Dec 3, 2014 by

CleanPlusFadeNational certification is a tool to enable professional doulas to move in a particular direction.  What benefits could a program with strong behavior centered standards of practice offer?

1.  Respect from and engagement with physicians, midwives and nurses at every hospital because they have a clear understanding of the accepted standards of practice of nationally certified doulas.  They could ask one question and know what to expect:  Are you nationally certified?

National standards means a group of doulas in a community could negotiate with a hospital to gain privileges and respect for their knowledge.  Possibilities include getting into the OR reliably, being consulted about their client’s progress, sharing knowledge at educational meetings, and discussing conflicts in an arena of professionalism.  Both birth and postpartum doulas could be considered part of the team rather than adjunct or isolated from their client’s care.  Some doulas already have this situation.  But out of the tens of thousands of hospitals and hundreds of thousands of medical staff, I can count those places on my fingers.  Wouldn’t it be great if we all had that negotiating power?

2.  We get to define the standards for appropriate doula behavior, not each individual hospital.

3.  Respect and easy establishment of credentials when moving from one area to another.

4.  Consumers (parents) would have clear understanding of national, evidence based standards of practice and materials that explain “What to expect from a nationally certified doula”.  They would have an established outline of what to do when those expectations are not met, someone objective to listen to their concerns, and an organized grievance procedure.

5.  National behavior centered competencies would outline uniformity in services offered so a unique, standard billing code can be used with Medicaid and other insurers.  There is no guarantee of this, but scientific evidence plus strong standards equal a greater likelihood of this occurring.  I cannot see it happening without it.

6.  The opportunity to participate in public health initiatives based on doula credentials, not on academic or nursing credentials or having someone vouch for you.  Doula support is a key part of the solution for many maternity issues.  But we are not included (or taken seriously) because there are no strong national standards.  Initiatives cannot plan to include doulas because they have no easy way to say who will be eligible to fill the doula’s role unless they do all the training and certifying themselves – which is an initiative all on its own and beyond the scope of the funding they are applying for.  So doulas are left out.  These are missed opportunities for jobs, influence on the maternity care system, and better care for mothers and families.

7.  Doulas are seen as a luxury rather than a necessity for birth and postpartum families.  But for maximum health and well being, there is no substitute for the one on one care a doula provides.  Done well, national standards allow our profession to grow so that not just wealthier families or women lucky enough to live in areas with community-based programs get this service.

8.  Right now, there is no system that recognizes achievement as a doula.  One of the possible reasons we have so many training programs is because the role of “trainer” is the only one achievable after “doula” or “certified doula” in a particular group.  Recognizing levels of achievement and leadership within the profession would meet this very human need to strive for something and be recognized for it.

9.  Separation of training and certification.  A national certification organization would set competencies to be met.  The applicant’s responsibility would be to meet those competencies – likely from a variety of sources and beyond the initial two or three day training workshop or correspondence course.  The term “competencies” is used in many professions especially those that involve education and caring at their core.  Competencies state an area of expertise and specific behaviors that demonstrate that ability.  In your comments to me many of you have mentioned that you deal with competencies in order to be certified as massage therapists, realtors, respiratory therapists, and certified nursing assistants.  For an example of how a competency based system works, go to this home visitor organization web site, and click on the “gold” list.

The next question is, “Who sets the competencies?” and “Who provides the training for these competencies?”  The answer is we do.  This system allows for a natural progression of training that focuses on obtaining the skills that ensure doula success but cannot be taught in an initial 16 to 24 hour basic course.  Interpersonal skills such as listening, relationship closure, debriefing, minimizing trauma, and conflict management come immediately to mind.

10.  National certification with competencies and behavioral standards would allow for expansion of the doula role into other fields.  Community health education workers and home visitors could easily include doula work into their own job descriptions, or permanently include doulas into their programs.  While this is occurring in a few places (Illinois’ the Ounce), it is most often haphazard and dependent on a single person or limited time grant.  Even though the evidence is available and there is a program to replicate, other stakeholders outside the program also need to be convinced.  Funders may also not be able to give money for initiatives where workers do not have established competencies.  Evidence based national certification standards set by doulas makes it more difficult to minimize our effectiveness or brush our contributions aside.

11. National certification available to all shows that we take ourselves seriously, have professional competencies that define our role, and makes that statement to the world.  We are not just hippies, hipsters, yuppies, hobbyists, bored at home parents, soccer moms/dads, frustrated midwives, or trying to exert power over someone’s else life experience.  The market demand for our services shows that we have a part on the team to play, we are here to stay, and we believe that what we have to offer makes a positive difference in the quality of health care and the emotional lives and memories of the families we serve.

12.  Being a part of other health related professions would expand doula employability, wages, and the number of mothers who could receive doula services.  It would also enable more people to become doulas and hopefully at a wage that would support their families.  Many trained and effective doulas are not cut out to be independent business owners.  But this is the only choice for many.  Respect for and expansion of the doula’s role would allow for different models of employment, such as working for social programs, agencies, HMO’s, physician and midwife groups, and collectives.  We don’t have this now because there are no strong standards for employing doulas on staff or for third party reimbursement for their services (see #5).

In sum, national certification offers us legitimacy and opportunities to move our profession forward.  Some of those directions are dependent on interaction with others, however once we start taking our work seriously it will positively influence how we are perceived.  Most likely it will open doors that cannot be imagined today.

 

Note:  What’s the difference between accreditation or certification?  Certification verifies that a person has attained a level of competence and met requirements to practice in a certain discipline.  Accreditation evaluates institutions and programs and ensures they have met standards.  Click here for more.

 

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

Posts In This Series:

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

2.   Balancing Dynamic Tension – Respecting All Doulas 

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

4.  This post: Benefits of National Certification for Doulas

5.   Fears, Downsides, and Challenges of National Certification

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

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Do We Want A Place At The Table?

Nov 11, 2014 by

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

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

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

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

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

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

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

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

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

 

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

Posts In This Series:

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

2.  Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Certification

5.   Fears, Downsides, and Challenges of National Certification

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

 

 

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Doulas: Balancing Dynamic Tension

Oct 26, 2014 by

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

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

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

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

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

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

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

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

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

Posts In This Series:

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

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

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

4.  Benefits of National Doula Certification

5.  Fears, Downsides, and Challenges of National Certification

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

read more

The Next Step In The Doula Revolution

Oct 16, 2014 by

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

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

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

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

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

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

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

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

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

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

 

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Posts In This Series:

1.  This Post: Social movements

2.  Balancing Dynamic Tension – Respecting All Doulas 

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

4.  Benefits of National Doula Certification

5.  Fears, Downsides, and Challenges of National Certification

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

 

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A World Where We Didn’t Need Doulas

Aug 3, 2014 by

A World Where We Didn’t Need Doulas

Maybe it comes from being weaned on Star Trek reruns but I’ve often contemplated alternate universes.  The kind where if a different decision had been made the whole future course of humanity would be altered.  Recently I’ve contemplated what if we had a birth culture today where professional doulas weren’t necessary?  Going back in time, the critical point seems to be a little over one hundred years ago with women deciding to give birth in hospitals.

Like most cultural changes the reasons were multifaceted.  Pain relief was possible in a hospital setting.  At that time relief from labor pain was considered a feminist issue.  Rich women also wanted to set themselves apart from women in the lower classes so paying to go to a hospital accomplished that.  There is also the drive for modernism, to do what is new and improved which was hospital birth.  Once the wealthy had established a new norm and the physician profession benefited financially, a social movement for “safe and healthy” births in the hospital was quickly established.  Within a generation, our birth norms had altered the trajectory of our society. **

But what if something else happened instead?  What if wealthy women demanded that physicians come to their homes?  What if they asked to be attended by a midwife as well as a physician?  What if women surrounded each other with their closest friends and family members instead of strangers?  What if women retained their power by being in their own homes instead of transferring it to someone else in an unfamiliar location?  If physicians could bring their pain relieving medicines into the home or trained midwives to use them, we would have enough caregivers to provide for many laboring mothers.  Women and men would grow up with labor and birth, understanding its meaning and its risks.

As in all things there are probably some women and men who would be more drawn to helping during birth.  But they would have the opportunity to be part of a helping team from a young age and many more people would see birth as normal.  They would understand the caring skills that are necessary to see others through difficult times.  Instead of the unique skills set that doulas have now, these skills would be learned at an early age.  We would all learn to doula one another.

The paradigm of needing assistance during difficult transitions would be widespread.  Simply by growing up in a family or village group, we would learn how to care for one another.  Labor and birth would be our teachers.  Midwives, rather than being derided by physicians and seen as competitors for birth business, would be a necessary part of the paradigm.  Hospital birth would be the exception, not the norm.  With plenty of assistance from loved ones and reassurance from being in their own homes, fewer women might have needed pain relief to cope.  We would have an uninterrupted cycle of support, caring, and knowledge that spanned generations.  There would be no need for doulas because we would all be doulas.  In addition to whatever else we did in the world, doulaing would be second nature.

All the other events in the world – multiple wars, the Depression, the Atomic Age, all would have unfolded differently because we were together and cared about one another.  Touching someone’s brow when they are in pain and connecting with them on a heart level changes a person.  We see the inner power of connection and caring.  I do not think those lessons would be confined to the birth room but would be spread across the world.  Our whole social history would be different if we all learned the value and skills of caring.

So I guess I’m saying that doulaing has the power to change the world.  It shouldn’t have been confined to a select few but something all people should have experienced themselves and learned to do.  However we live in a world that has compartmentalized caring and who does and does not do it.  It has demanded that we professionalize caring in order to exist as a group in the current medical systems.  Sigh.  I think I’ll go watch another Star Trek rerun.

 

*This paragraph is a painfully brief summary.  Two good books written by historians are “Reclaiming Birth: History and Heroines of American Childbirth Reform” by Margot Edwards and Mary Waldorf (1984) and “Brought To Bed: A History of Childbearing in America” (1999) by Judith Walzer Leavitt.  There is also “Birth: The Surprising History of How We Are Born” by Tina Cassidy, a reporter.

** We know today that births in the hospital were not safer nor healthier for mother and baby.  However that was not the public perception of the time.  The propaganda circulating derided midwifery and home birth as “dirty”.   The American Medical Association was originally founded to push midwives from the market of delivering babies.

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Christine Morton On Certification and Professionalism

Dec 2, 2013 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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The Brouhaha Over Certification

Oct 19, 2013 by

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

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

System level questions:

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

Organization level questions:

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

Personal level questions:

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

Pondering those questions led me to these questions

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

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

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

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

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

 

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We Need ALL Kinds of Doulas

Oct 1, 2013 by

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

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

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

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

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

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

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

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Why You Should Keep Your Hands To Yourself

Sep 23, 2013 by

Answer:  “Vaginal exams.”  Jeopardy question:  “What is one thing a doula does not do?”  Most of us hear these reasons in our doula trainings :  doulas are not experienced at it; it introduces germs; it is a medical diagnosis (liability); or that it “muddies the waters” between the doula’s role and that of other medical professionals.  There are doulas and other birth professionals who feel that doing vaginal exams at home in early labor is an advantage.  When I first started as a labor assistant in the mid-1980’s it was assumed that I would someday provide vaginal exams and other clinical skills.  We thought being able to offer more medical information to the mother would be empowering.  After years of personal experience and research, I now theorize that it is more empowering for the mothers and more powerful for the doulas to avoid doing vaginal exams.  Here’s why:

1.  Everyone else wants to put their fingers in her vagina.  Triage nurses, doctors, residents, midwives, midwifery residents, nursing students, you name it.  Even though I would likely be using these skills at her home to gauge when to go to the hospital, I don’t have to add my name to the list.  Doing vaginal exams doesn’t help me be a better doula. I just become another person who is entering the private spaces of her body.

2. It changes the balance of power in the client doula relationship away from an act of service. As a doula my role is to empower and support this mother one hundred percent.  If she wants something I help her to get it; if she doesn’t want something I help her to say “no”.  My role is to help her believe in herself.  As a professional doula, I have no agenda other than to support her and her loved ones. As women we are equals and I am there to serve her as she labors and births her child.

Once I put my hand inside of her we are no longer equals – she doesn’t put her hand in my vagina.  The social roles between us have shifted.  In her mind who I am symbolically has changed.  I used to be there to serve her and now I have touched her intimately and evaluated her!  This shifts the power balance between us so that I have more power than she does – I have personal private knowledge of her she does not have of me (and very likely will never have of me). Our support relationship is no longer the same.

3.  With that one act, the doula role shifts from support to evaluation.  I am judging her body.  I am giving her information about herself that we don’t believe she has any other way.  I am subtly communicating that I don’t trust her to know where she is in labor.  Her intuitive knowledge of her own body and labor isn’t good enough – we need to check the cervix just to be sure.

4.  The doula misses the opportunity to empower the mother.  When you aren’t doing the evaluating, you need to rely on the mother’s internal messages.  She lives in her own body, for goodness’ sake, which is something most people tend to forget.  You can call it intuition or receptivity to subtle nerve pathways perceived by the brain. The mother has access to what is going on in her body and as a doula I can assist her to listen to these messages. If we can help her to identify what she is experiencing and feeling, she can discern for herself what she wants to do.  When we model early on: “It’s your body, what do you feel?  What do you want to do?”, it starts a pattern that can carry on throughout her labor.

5.  Not relying on vaginal exams means that the doula hones other observational skills.  Patterns of breathing, skin color changes, cartilage and bone changes, even the usual bloody show and contraction patterns can all tell us where the mother is in labor.  Combined with her own internal messages we can present her with information so she can decide.  We can also observe signs of progressing labor, dehydration, or other concerns which might lead us to think that going to the hospital or birth center is a good idea.

As doulas, our very presence is an effort to put the mother at the center of her own birth experience.  Our role of unconditional support is special and no one else can offer what the doula does.  Rather than being a limitation, avoiding vaginal exams empowers both the mother and the doula.  Why endanger that when the price can be so high?

 

**Having said that, there are some mothers that really want at home labor support that includes vaginal exams.  That is why we have monitrices who possess both clinical skills and labor support skills and are covered by midwifery or nursing standards of care – even as students.  There are also midwives who will teach the mother’s intimate life partner to get to know her cervix during pregnancy so they can feel for labor changes.  But the expectations that are brought to the midwifery relationship and nursing relationship are different than with professional doula support. 

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We Need To Create Social Change That Values Caregiving

Aug 28, 2013 by

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

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

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

Why?

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

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

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

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

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

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

 

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

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

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

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