What If ACOG Decided To Certify Doulas?

Nov 8, 2013 by

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?”

That depends.

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.

 

 

 

 

17 Comments

  1. Amy Gilliland

    Megan asked me to post this for her:

    I am a Central Florida doula that attends births in Gainesville and can vouch for the fact that NFRMC absolutely DOES require doulas to be registered and unregistered doulas will basically be thrown out.

    Also, my reason for not registering up until this point (I will be in the near future for the sole reason of getting clients plopped in my lap! It’s good for business) had nothing to do with wanting to go by my own doula conscience (lol).

    Not only is the process very expensive, and require certain things I don’t agree with (such as vaccines), but the registration means that I now basically work for the hospital.

    But I don’t! I work for the mother/couple/family. It is a conflict of interest in my humble opinion. There are other reasons as well that I can go into detail when I get a chance!

    Megan

  2. Ruth Callahan

    Fascinating and relevant reading on the beginning process of how and why IBCLC are moving towards licensing.
    http://www.ilca.org/files/USLCA/Resources/Publications/Licensure_FAQs_for_IBCLCs.pdf

    • Amy Gilliland

      Ruth, this brochure was fascinating reading. I’ve heard from some people that this may be in our far off future. BUT the first step for IBCLC’s was setting and maintaining a uniform certification standard independent of where a person received their training. The difference is that so much of birth doula work is about process. Unlike factual information, process cannot be tested.

  3. Ruth Callahan

    Love your thought process and how you can analyze and examine this issue. I agree with you. I’m a doula for 22 years and this has become a more serious issue now because doulas are reaching a tipping point, and critical mass in urban and suburban hospitals. We are here to stay.

    You are sounding the clarion for our next step; and it has to be the doulas that are going to address this in some fashion so the choice of how labor doulas work is not taken away from them.

    Changes are happening as doulas are considered de rigueur for a woman considering a natural birth (even the ones having a cesarean). How doulas are being regarded by OB’s and hospital staff does matter. This should be addressed by doulas in their own self interest in maintaining the type of independence that could be creating a national licensing.

    If doulas and the certifying organizations don’t figure something out about standardizing doula training and the entry level knowledge, SOP, and ethical guidelines of practice, I agree it will get imposed on us either from individual hospital or OB will turn to ACOG to do it. ACOG is that powerful. I live in NY State they had Midwifes under their thumb for decades, unable able to practice independently. ACOG always sees it as a patient (consumer) protection issue.

    Licensing of doulas could be considered in the USA. It could mean some very basic trainings, SOP requirements to use the title “doula” and practice. CAPPA and DONA already are organizations with similar entry level requirement, maybe the coming together of these two organizations would be a good thing to work on this.

  4. Amy – I’ve put together some initial thoughts on what a National Doula Registry Board could look like….
    http://www.sarahstogryn.com/2/post/2013/11/1.html

  5. Amy, I do not know the answer, but I do know this: a Florida hospital is attempting to make doulas contract with them (plus a slew of testing requirements and agreement to “follow directions of hospital staff”) in order to serve clients at their hospital. When we posted about it, several people came back to say that similar requirements were already in place at hospitals in their areas. This scares the *(%&#^@ out of me. Absorbing doulas into the medical system is …. ugh, it gives me the shivers!

    • Amy Gilliland

      Yup. While I don’t want to rush into anything, I think if doula professionals wait too long this is what will be the norm. It will have moved too far into place to stop the momentum of individual hospitals setting the standards.

  6. Lesley Everest

    Amy, I want to thank you so much for this beautifully written article, addressing very real concerns for doulas and doctors. Bravo, Sister!

    As you know, I don’t think becoming certified BY ACOG or SOGC, or whichever medical organization of your country of practice is in power is a good idea. I feel there is something dangerous about what this could do to the feminine spirit of doula care. Without going into it further, I hear far more challenging behaviour at births by medical staff, and do not feel, while I am a fan of Medicine in general, that doulas being approved by an organization that perpetrates widely in birth the very same issues we are looking to avoid is wise. I agree we need partnership, but not to be under their authority.

    My thought is to certainly have a universal scope of practice, code of ethics, and board of grievances for consumers of doula care as well as medical practitioners to feel reassured by. MotherWit is a very small, independent certifying organization. We recognize that in the big scheme of things our certification doesn’t amount to much. It works locally, but I do feel many doulas want to feel under the umbrella of a mother organization for protection and accountability.

    The problem is that I do not think any one certifying organization should be “the one” to create this Universal Code of Doulaness. There is too much bias. We must absolutely honour diversity. Every path to doula work is unique, and we must respect the desire of a student. If someone wants to take a more involved course, or a shorter course, or one with a more holistic approach than an other, it becomes unfair for her to strive to become a member of an organization for that Mother Umbrella that doesn’t resonate with her training approach. So one training organization should not become “the voice” of Unification. We will have far more interdoula cooperation if we abolish this idea.

    My suggestion for a solution would be to have representatives from different doula organizations, big and small, who are definitely interested in a form of standardization that would reassure the medical community of our intentions, practices, an ethics. Together, we can give birth to a Code or Constitution of sorts which honours the diversity of each approach to training and student needs, but in agreement with a universal code of conduct. Holarchy is necessary for a society to thrive. Structure is helpful to curb chaos. But we don’t want a hierarchy which involves domination of one school of thought concerning training.

    This would kill a few birds with one stone. One, it provides a structure of support and accountability doulas, consumers, and parents desire. All involved would know there is no partisan organization here, that it is a Gestalt created by and agreed upon many organizations (who are willing to come together). Two, it eliminates catty training approach backbiting. We don’t need that. It doesn’t serve our cause. It’s like religions fighting among each other, and it doesn’t serve anyone. In our hearts we all just want to serve mothers and babies to the best of our ability. It would open the doors to enriching trainings, in fact, by including wonderful teachers with desired skill sets who are not part of one’s own organization, yet who are connected to a unifying Code. It also keeps students from having an attitude that they are from the BEST organization because IT has all the clout of certifying power. Everyone wants to feel included and represented.

    A code would address expected doula conduct, including providing backup, terms of service, etc, while, again, respecting diversity. I certainly don’t want my unique practice changed by someone else’s ideas, but I am totally on board with proper doula etiquette and excellent service. A multi training formed body would also be available to truly tend the need of any doula who came to them with a heart broken by a bad experience without censor because we would NOT be part of a medical body. Yet, Medicine could be reassured by the fact that there are trainings who are in agreement with a universal code, and demand their students ascribe to it for certification. Yes, doulas will still continue to practice without certification, and I think that’s just fine if they’re great. Honestly, I don’t think one MUST be certified to be a great doula. However, I do think it is fair for medical people to file complaint against doula behaviour if it truly impeded their work. If the doula has no “mother organization” to be accountable to and continues to rub up in conflict with Medicine (even if she is absolutely within code), then sadly she wouldn’t have any recourse if she got kicked out. Someone who is part of an umbrella organizaton would. To have a unified body would give everyone a voice.

    My two cents. I have so much more to say, but I don’t want to get boring. I just want to thank you again for this post as stimulation for a solution. We are all in this together.

    • These are good thoughts! Well put. It addresses the concerns I have but that I was not able to put so well in Amy’s most recent post.

  7. I’m fine with there being an independent registry/association which doulas can be part of *if they chose*, which grants them insurance coverage discounts or prestige or accountability or whatever. But ACOG isn’t independent. They have their own interests which are not necessarily in line with the interests of birthing women or doulas so as far as I’m concerned they have no business certifying doulas. It would be like an herbalist having to get certified by Big Pharma. Um duh? Conflict of interest much?

    Here in Ontario, Canada massage therapists have to be registered with the provincial college in order to use the designation RMT. Being an RMT means that they can accept private insurance as payment, and the association provides advocacy & accountability among other things. A trained practitioner can still offer massage without being an RMT, but they can’t claim to be a massage therapist. Likewise, I am (almost) a certified reflexologist (CR), but my school isn’t on the approved list yet to be a registered reflexology practictioner (RRPr). I can practice as a CR, but in order to accept private insurance payments I need to be an RRPr.

    If the federal government creates a doula registry where doulas from all walks (currently certified or not) agree to meet certain standards and adhere to particular guidelines in exchange for use of the title ‘registered doula’ and its associated priviledges, that’s fine with me – as long as you can still chose to be an unregistered doula if you prefer.

  8. The thought of ACOG having control over doulas, taking away their autonomy makes me NAUSEOUS.

    Simply because a doula is independent or chooses not to certify does not make her a “rebel” as you call it.

    They system is flawed and incorporating doulas into a BROKEN system is not the solution, or even part of a larger solution to repair it.

    Women are quite capable and intelligent enough to become informed educated consumers on how to hire a doula. They may not understand all the variances of varying certifying & educating doula organizations but in the big picture, I believe they know how to select the right doula for them. To assume women are ignorant and need ACOG to tell them how to a hire a doula does a great disservice to pregnant women. ACOG has done enough damage to the maternity care system!

    While doula organizations have requirements to become certified, they ought not need to play “big brother” to make sure they are adhering to a behavioral standards and ethics. We are grown adults and most of this can do this on our own, if not then hopefully we can seek out seasoned doulas and mentors. Also being apart of a doula collective/group of some kind initiates accountability to our sister doulas in our community and we can encourage one another in excellence.

    We do not need an organization to establish professional relationships for us, we can cultivate this on our own.

    I disagree with the whole concept and notion of a large governing body, especially like ACOG, governing doulas. Especially when it comes to a behavioral standard and ethics, it’s an oxymoron to suggest something like ACOG could bring this about in the doula community when they don’t even hold their own OB and GYN’s to behavioral standards & ethics. A laughable paradox truly.

    • Amy Gilliland

      I appreciate you elaborating on the concerns about ACOG. I think you are right on target.
      The word “rebel” came up several times in the social media I reviewed for these posts. Doulas actually viewed themselves or their role as rebelling against the established maternity care system. It was not a word that I chose, but that doulas really used along with “acting up” and “disrupting” (synonyms for rebellious).
      My experience is that women don’t always want to take responsibility for their choices, are overwhelmed by their responsibilities, and have been socialized to believe that they are due something if things don’t turn out the way they wanted. I see it in my clients, my workshop participants, and my college students. For various reasons, very few people get all the information they need to make an informed decision about everything – including choosing a doula. Cindy says that we don’t need organizations to make sure doulas “are adhering to behavioral standards and ethics” and that “we can do this on our own”. What I am commenting on is that according to what I have read and heard, that is not true. Our current system has failed to do this on a widespread basis and doulas, consumers/clients, and medical careproviders and really unhappy about it. Until two months ago, I pretty much agreed with you. But once I started listening and reading intensively, I changed my mind. I do agree that participating in this system or organization ought to be optional – very definitely.
      I really mean it when I say we need to create an environment where all doulas are welcome because we want all women to have doulas available!

      • I *LOVE* the idea of a community doula collective/group; where doulas could choose to be apart of for professional development, accountability, sisterhood, peer review, referral, create a standard of excellence…..but completely optional and tailored to the community they serve.

      • I agree there are some doulas that are indeed behaving unprofessional, without a doubt. Of course it happens in every profession. It’s happened in my community and it can be damaging the doula image.

        However, this is where peer accountability comes in. Even if the doula acting unethically or rebelling, isn’t apart of a collective, I believe as sister doulas we have the right to “call her on the carpet” in love and kindness in private. Recognize her strengths and then encourage her in the areas where she is weak, with tools for improvement. I know not everyone is bold to do such things or believes we ought to mind our own business but if we desire to create a strong community of birth professionals we ought to expect to have unpleasant conversations from time-to-time.

        That is my hope for my community in the near future :O)

  9. Great thoughts, and I agree with you completely!

  10. Sheri Deveney

    I’ve been screaming this from the rafters for the last 5 years. I even developed a workshop to facilitate this discussion. It’s difficult and charges doulas with the task of looking at the uncomfortable, examining their ultimate values and sacred cows. When I ask doulas what they *really* want to change the answer is always the same. They want professionalization,inclusion and respect.
    As a profession we are at a crossroads. We can either take our direction into our own hands or have it done for us. We need innovative thinkers who aren’t afraid to ask the tough questions and are willing to move out of a place of hubris to one of change.
    Thank you Amy for this very thought provoking piece.

  11. Great topic, again, Amy! First a correction, from what I remember, we called ourselves “labor support providers” before we became known as and accepted the moniker “doula.” The term labor assistant in my mind refers to “monitrices” or those who provide clinical care and support.
    The call for an independent certifying agency is a developmental step and an important one as you point out, in taking control of and establishing a process independent of the professional organization of how doulas are certified. It’s useful to look at other models. I am most familiar with direct entry midwifery, and NARM http://narm.org/ is their body for registration and credentialling of CPMs. There are models of doula care where the recognized role in medical systems is as a communty health worker. There are benefits and limitations to this. What do others think? I think you’re spot on with this discussion!

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