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



  1. I am a certified doula and am also a student midwife. I am getting ready to set for my exam through NARM to become a CPM. I have loved being a doula and have encouraged several other women in the area to pursue certification. Doulas are so needed and part of the team. As a midwife, we encourage many of our women to hire doulas, even for their home births. I still attend hospital births in my role as a doula and have a wonderful relationship with the hospital and several of othe OBGYNs. One of my goals to have a mentorship program to help skill women in our area. Besides the things learned during doula certification, there are so many more things to know that, would help doulas be more professional in the hospital setting and in establishing relationships with the OBs and midwives, as well as raising the awareness and need for doulas in the community. Nationalized certification, is just that, certification. It is not licensure. Certification should include some kind of one on one training and shadowing with another certified doula, in order to get the real life experience. Without a national certification, we as certified doulas should be investing in the upcoming doulas as well as our own community by building a strong birthing community. Doulas are not midwives so that should not be part of the equation. Doulas should not being doing the “medical” sides of things such as vitals on the mom, heart tones on baby or, vaginal checks, but their role to the midwife is of utmost importance. To build a community of women working together is one of my greatest desires. We need each other.

    As I have built relationships with doulas, I know the good ones and I also know those that I would never send anyone to because of their unprofessionalism or stepping over the boundaries of a doula and asserting that they have been medically traiined. There are some doulas who should not be allowed in the hospitals because they are rude and disrespectful to the staff. We want to build collaberation with OBs, hospitals, nurses, midwives, and other doulas. This is my goal-to build a stronger birthing community and it is a big task. Would love to keep up with you and all of your work. Thank you.

    Cynthia Barger
    Wichita Birth Assistance

  2. Doulas are the saviour of women. They are the new midwives. Midwives have to jump through so many hoops these days that being ‘with woman’ is made so much harder, so doulas are a very welcome site. There will be regulation as you become more popular and I just hope it will not put the really good ones off. Keep up the good work, you make our working lives so much easier.

  3. I think that doulas around our nation experience vastly different reception from other birth professionals in the hospitals in our areas. Our nation has super cities with huge and many hospitals, and tiny country hospitals in rural communities, and everything in between. Places where home birth, natural birth and midwifery is the norm and places where surgical birth & epidurals are epidemic (the norm) and there are NO midwives, and doulas would be seen as the interloper. In that huge variety I don’t think one doula’s experience can compare with another’s. So, I don’t think these topics are pertinent to the discussion. Or rather, does it point out the need for national certification to create a standard by which all may be compared?

    Because of the differing experiences some may think nat. cert. is not necessary, where others may feel it’s a pipe dream just to have doula care being the norm so why bother- which puts them closer in their thinking than it might first appear.

    But for those in the middle area or for anyone pondering the reasonableness of Nat. Certification: what will Nat. Cert. do FOR us (as individuals, as a professional body)? Or TO us? (to the companies and organizations that train doulas, to the profession/work itself)? What farther reaching effects might it have? WOuld it be mandatory? Who would create it? What kind of testing would it entail? Many many national and state certifications DO require the passing of a written exam- usually extensive and difficult as well as fairly costly. Would the testing itself leave very good doulas in the dust because the heart of doula work IS heart, not brains, not the ability to pass a test, and NOT the financial means to get to the location of the test as well as the fee involved? The doula is highly skilled in comforting and caring, reading people and connecting to moms- how do you test that? We can’t even teach it. Do we risk creating knowledgeable but cold or exacting professionals by making sure they can pass the test based on knowledge? Do we require a certain number of years in practice or a certain number and variety of births before eligibility to sit for the exam? Would a National Board impose standards on all organizations that train doulas?

    I would ask that Amy pose questions to us. Particular/specific questions that pertain to what she means by “What would national certification look like?” Such as Do you think the nat cert test should include only multiple choice questions? a practical exam? Do schools need to be accredited in order for their pupils to be eligible to sit for the exam? Do trainers have to sit for a national trainer cert exam? Does anyone check up on these trainers even now? If you don’t check up on the trainer how will you know if they actually meet the expectation? Keep going, Amy, with more questions!

    I have 2 different but somewhat related skill based training in my back ground: Medical Lab technology, and Massage Therapy. The medical tech portion DOES have a national test and by passing that exam it does say you are very knowledgeable about that subject, the tests, how they work, what they look for etc, Passing the exam says you have met an exacting standard, not everyone passes. It was long and hard. Some states have a stare licensing exam as well. They are paraprofessionals working along side others who have direct care of patients.

    The other profession, Massage therapy is a closer example to doulahood. It is a paraprofession, working along side chiropractors, physical therapists, athletic coaches and doctors,etc, and is seen for all the merits if offers from stress reduction and relaxation to truly physically therapeutic work… and in my training we had to learn some basic counseling-like skills, such as active listening. ( It IS called therapy for a reason). Today, at least in NYS, every small town has a massage therapist, sometimes 2 or more. Getting massage has become very mainstream. No one thinks you are doing something shady if you announce you got a massage today- rather there are probably people who look up in envy. ( there is even a massage studio near here CALLED Massage Envy!) And everyone knows what a massage is all about.

    But when I started in it, that was not true. Massage therapists were professionals but they also were breaking ground if they were doing it. There were not a lot of places to get trained. They had to really want to do massage, to touch and care for people. They had a calling, a lot of them. They faced a lot of people who would say: you do WHAT?, ew!, you mean you own a massage PARLOR? Do the men want sexual favors? DO you do it? Etc. SO those who did do it were very dedicated. And the pay was not nearly so good then- I started at $30/ 1 hour massage! Today those fees can run over a hundred. A massage therapist cannot work a 40 hour week, doing 40 massages its too hard, too tiring, and even being careful you get wear and tear on your body. So the income was limited to what you could do and how many clients you could attract. Essentially part time or long long days.

    There IS a national certification which is acquired by sitting for an exam. NYS, FL, and other states Do have a licensing exam and now some require proof of continuing education. I’m not so sure I think the continuing ed is really necessary in that profession. But the exam does weed out those who were not properly trained and don’t have the background knowledge necessary to avoid harming their clientele. However it also weeds out those who can give a darn good massage but maybe aren’t the brainiest people… too bad for everyone!

    I have always been careful about who I let massage me but that was based on my own emotional reasons. Today, I interview the person before I ever make an appointment. I want to know where they trained, what their philosophy is, what their focus is, why they got into it. There are lot of people who are NOT doing this because they were called or because they really care about people. They are doing it because it is good money. They have no finesse, they don’t really care, you are just another warm body laying on the table and they do what they do the same for everyone regardless of your particular need.- ( cold, exacting, impersonal in a field that was once full of those who were not like that). There are a lot of schools to teach people- not all having the same approach or philosophy, not teaching the finesse, the softer side, and many focused on only the physical, the muscular therapy. And there are TONS of massage therapists around but they are not all good at it or for the profession. Used to be there was no insurance coverage, then a little bit such as workers comp or under auto insurance due to an accident. Now medical insurance plans (some of them) cover massage under the preventative medicine care. I have no idea how much work that is for the massage therapist though. My guess is that it is a lot of work or a long delay in being paid, so probably many massage therapists DON’T accept insurance.

    It would be nice if national certification were part of getting Doula care covered by insurance but will the fact of coverage mean so much paperwork that doulas can’t really afford to bill? It might mean that we can charge a lot more for our services which might compensate for the paperwork time and mean a really fair wage for our hard working time. But that might mean we get doulas who are less called to the work and more into the money which WILL change our profession.

    I know this is long winded but sometimes examples are helpful and I did ask what questions I could think of. Who else has thoughts?

    • Having just gone back to your post from last year ” what if ACOG certified doulas?” I see there are some well thought out answers there in the comments section. One person in particular has some well thought out ideas which I find realistic.

    • Amy Gilliland

      Ellen, I wanted you to know that I printed out your comments so that I could digest them over time. Thank you so much for your effort and contributions to this conversation. We do need to hear from each other! What you said influenced all of my later posts. They are a response to your comments, rather than what I put here.
      I will continue to posit questions. I think living the questions, holding them in front of us as we ponder what we know, is a very important part of the process. It isn’t answers that lead you somewhere – it is knowing the right questions to ask in the first place.

  4. I think there is total, 100 percent validity here. The problem is that doula organizations are expensive to certify with. Once you certify with one, spend the hundreds of dollars on the training seminar, the books, the free hours just to be certified by one. Even if that one organization doesn’t think highly of another very well known organization. That drives me a little crazy. I worked as a hospital doula, I was certified and practiced independantly both in bith and postpartum before then but when I worked at the hospital I got my HIPAA certification, my OSHA certification. I did rounds on the mother/baby unit and worked as a lactation consultant and would be on the labor and delivery floor for 16 hours with mostly midwives, other doula’s one anesthesiologist and one OB/GYN that was on call, and slept in the on call room for emergency C-sections. WE did VBAC’s while in the squatting position. Water births etc.
    There is a place where we all must come together for the better good. Where is that place, and what role does money play in who plays in the sandbox and who doesnt.


  1. Benefits of National Doula Certification | Doulaing The Doula - […] 1.  Social movements - The Next Step In The Doula Revolution […]

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