What If ACOG Decided To Certify Doulas?
For thirty years or so, birth assistants (now doulas) have been attending mothers. The good news is that now doulas are everywhere. We’ve reach a critical mass where many people birthing these days have heard of doulas. But our growth has been random and erratic, working in isolated groups, going to births and getting the word out. For almost two decades there were about four doula organizations; last month I easily counted 14 – each with different philosophies and visions for doula supported birth.
Among physicians and nurses, doulas have a mixed reputation. At worst doulas can be seen as interfering with patient care. A more begrudging view is that doulas are annoyances to be tolerated. Sometimes doulas are seen positively but that relationship is usually fragile or reserved for individual doulas. Originally, certification was conceived to be a reassurance to medical careproviders that certain standards of ethical behavior could be expected. However, most doulas today only view certification as a marketing tool: “My clients don’t care whether I’m certified.”
In any case, the current certification process has failed in both reassuring medical staff and clients. (There are exceptions to this on a local level.) The great majority of organizations offering doula training do not have any behavioral standards for the people who complete their courses. Even though they title course completion as “certification”, they really aren’t certifying anything except that someone completed their organization’s checklist. According to the publicly available information on their web sites, there is no vetting of their candidate’s character, no compliance with professional ethics, nor any standards of behavior that must be adhered to. What exactly is being certified??? While these organizations may or may not do a good job training birth doulas, they do not seem to be certifying them to any particular standard.
Let’s consider the point of view of physicians and nurses. I think we can safely assume they would like reassurance and some control over the people calling themselves doulas who they are forced to work with in the labor room. As a profession we have not been able to provide it. So who can blame them if they decide to do it?
What if ACOG (American College of Obstetricians and Gynecologists) decided that the mosquito-like annoyance of birth doulas needed dealing with? Swatting at the occasional bug has not been working. What if they set up their own registry or certification process and promoted it to their patients? They may not be able to get rid of birth doulas but they sure can influence and frame the discourse about doulas with their patients and the general public. What they want us to do and what we want to do in our current standards of practice may be very different. Even if they follow evidence-based guidelines by the Cochrane Collaboration, it doesn’t say anything about birth plans or empowerment or client involvement in medical choices. We don’t have that evidence.
But ACOG does not need a lot of evidence; they have money, power, and access to patients. With only one (somewhat flawed) study they changed medical practice regarding breech birth in one year! The same is true of VBAC. Even with a potent consumer movement, we have been unable to create strong social change influencing the rate of VBAC in our countries. Only now that we have careproviders reexamining their own practices is there any possibility for change.
I do not like to act from a place of fear. I prefer to plan and be proactive rather than react. My concern is that we are far too complacent about our own place in the birth world. Right now it is dependent on being ignored by the people with all the power. Birthing women and medical consumers do not have the power; large groups of doctors and hospital administrators do. If we do not provide an answer to their “doula problem” that is on our terms, they will take action and dictate the terms. We have to solve our own problem regarding certification and we have to solve it soon.
Is it time for an independent certifying organization? As an independent group, it would be divorced from training issues and philosophical issues that exist within a particular organization. It could employ a robust complaint and grievance process. It could actively promote birth doula standards of practice and spend money to explain these standards to health professionals. It could offer different levels of certification that reflected achievement in the profession. It could build on existing certifications set by organizations who have them. The only purpose would be to certify birth doulas, provide ethical guidance, and to set and ensure standards of behavior. This organization could actively work to cultivate the trust of physicians, nurses, and midwives.
On the positive side, this would mean that doulas who trained with an organization that only offers certificates of completion would be able to obtain certification that reflects real ethical standards. If promoted well, this certification could reassure medical people by defining professional behavior. It would let everyone know what to expect. Consumers could discover what appropriate norms are for professionals. As doulas we get to choose what those standards are. If we are a large group who earns a reputation of being trustworthy, we may be able to negotiate for doulas with a certain level of certification to remain while patients receive epidurals or to get into the operating room. We could be viewed as the professionals we are.
On the negative side, it means surrendering a rebel image (if you have one). It would mean distinguishing the difference between professional and non-professional doulas without judging someone for being a hobby doula or a friend doula. (As I’ve stated previously if we want every woman to have a doula who wants one, that means we need to accept all kinds of doulas.) The challenge will be to remain inclusive and nonjudgmental while maintaining there are different standards of behavior. It means realizing that the organizational model of offering training, support and certification in one place is no longer working from an expanded system standpoint. Most people are shopping for doula training based on location, price, or teaching method (workshop, correspondence). They are not considering any of the certification or profession issues discussed on this blog.
A big fear that has been around since we first started attending births professionally is that birth doula care will be co-opted by “The System”. “Doulas need to be outside the hospital system not a part of it.” Well, that depends on what you value about birth doula support. What I value is a supported birth as the mom sees it – no matter what her birth philosophy, caregiver, or place of birth. I think that if we want doulas to be widely available to every woman who wants one, that means that doula support will take many forms. This fear says, “If we have a separate certifying organization that appeals to physicians and nurses then it would be reflecting the values of the hospital system – which we usually view as disempowering to mothers. So wouldn’t we be colluding with this philosophy?”
This will only work if we understand the situation we are in and commit to this process. It must be a consensus process and one that involves asking all stakeholders what they envision for doula certification. Yes, that means asking nurses, doctors, mothers, consumers, administrators, insurance companies, and most importantly ourselves, what we want this to look like. What do we want certification to do? What do other stakeholders want certification to do? A lot of professions go through growing pains. I think that we have reached a point in our growth where we have to assess our current status and actively chart our future. For 35 years it’s been about getting known and people understanding the importance of what we bring to the perinatal period. We’ve done that.
While I would like things to go along as they have been, there are a lot of unhappy people out there when it comes to certification – many of them working doulas. Until two months ago when I started listening to them, I really had no idea just how fractured our current system was. I don’t know exactly what a certification organization might look like at the end of a conscious consensus process. It’s kind of like looking at adolescence; I really don’t really want to have the experience of going through it but I really want the benefits of being on the other side.
Right now we can be in charge of our own destiny. If ACOG or a similar organization decides what our behavior and standards should be, they have the power to restrict doulas from the labor room. When I consider that alternative, I feel more compelled to consider conscious action.