Should We Have ONE Certification Organization for Doulas?

There’s been some talk lately (nothing new really) about having one national organization for certifying doulas. While it seems like it could be a nice idea, I have some concerns.

First, the good…

In terms of recognition, one doula organization could do some great things. Marketing and awareness for the consumer could be broadened. Recognition in media outlets may increase. We may gain respect as an industry – think of the recognition achieved by being an IBCLC as opposed to a lactation educator, etc.

Recognition for the consumer would be wonderful. With more women aware of doula care, it’s certainly possible many more women would be interested in exploring this in their own birth. If I fully embrace my idealist side, I’d even go so far as to say birthing practices would change en masse and we may see a turnaround in our cultural birth practices.

However, I think have one organization would certainly have some negatives. These negatives have the potential of out-weighing the positives.

Personally, I’m hoping to begin doula certification within the year. I’ve gone back and forth about doula organizations to certify with throughout my pursuit of this career. There is the possibility of doing a DONA training in our area in the fall; otherwise, I’m generally looking at doing distance learning or traveling three hours or more.

However, I’ve never been totally comfortable with certifying through DONA. I’ve had it recommended to me many times before (I’ve even blogged about deciding to certify with them). But it seems to be such an impersonal organization. I don’t want to join an organization simply because it is “premier,” (which is very true of DONA, and I certainly respect that), but there needs to be something more. Maybe I’m missing something, and more consideration will certainly follow before I make any decisions.

That little tangent discussion of DONA will be relevant later; I’ll come back.

I think for some, the biggest issue with having one certifying organization would be in the possible restrictions placed on its members. Most commonly, the restriction doulas complain about is involving “free birth” or unassisted birth. For me personally, I’m not sure I agree with having a doula (a trained support professional) at an unassisted birth, and I’m not sure I would take a client planning unassisted birth. However, there are doulas who would like to serve women and families in such capacity (I can think of one I know personally who is skilled in this area). And I think they should be allowed to do so (and encouraged! If you have such expertise and feel called to serve in such a way: do it!!)

I’m a little concerned that having one doula certifying organization would in some way “medicalize” the profession. Doulas are non-medical professionals, and I feel they should remain so. Doulas who are student midwives/midwives’ assistants walk a fine balance, and I don’t know how they juggle the two. But for the majority of doulas who are not in that situation, medicalization would harm the profession. I’d be afraid of “protocols” and “standard practice” and other such generalized guidelines that might interfere with the personalized care doulas are “famous” for. Doulas are uniquely available to hands-on at all times, without having to stop and chart or do a particular procedure. While many doulas do chart their notes, they typically wait until the birth is finished and the family is settled before hurriedly scribbling.

I’m not saying that I am afraid a certifying organization would begin to require doulas to do medical tasks. However, I do think that unfortunately some families already feel that doulas are part of the medical team, particularly in assisting the midwife. This assumption may cause them to not look further into the possibility of doula care. So many believe that doulas are only for homebirth, possibly stemming from that assumption of assisting the midwife.

So what should be done?

I honestly don’t know.

Back to my concern about DONA, one of the great benefits of the current situation in having multiple organizations is that there are many different philosophies. A common piece of advice for new doulas trying to pick a certifying organization is to “see which philosophy fits you best.” Losing this could be detrimental to the profession.

It also allows some to study and become experts in doula care and choose not to certify. There are a number who go this route, and they should be allowed to continue to do so. I think that families are able to interview doulas and decide for themselves who best to serve them, whether or not they are certified. I would be concerned that simply one organization would attempt to push out “rouge” and “uncertified” doulas.

Me, I’m choosing to certify. I do think that for me, especially among nursing professionals, having certification will be one step in showing my skills. But for all the other doulas out there, I don’t know that any one person/organization should be making that same call.

How do you feel?

Common Sense Labor Practices - the Walsh argument

It looks like I’ll be finished reading Denis Walsh’s Evidence-based Care in Normal Labour and Birthing soon. I’ve really enjoyed it.

One thing I really like about this book is the underlying theme of using common sense to return to normal labor and birth. The author seems to come back to this idea at least once in each chapter, but I think it is best displayed in the argument surrounding the following topic: Movement in Labor and Birth.

Why is it that we seem to need randomized clinical trials to show us that moving and using gravity in upright positions would be good for birthing?

I was really struck when I was reading about this concept. Well, duh. Of course, even those promoting natural birth do forget about this. We try and try to prove that this works, but why is that we must prove something so common sense? Are we that far away from good birthing practices?

Quite simply: Yes. [insert a number of choice words]

As a culture, we have truly become a nation that absolutely relies on medical intervention. It’s pervasive. We go to the doctor with flu symptoms and find ourselves getting chest x-rays, bloodwork, and antibiotics (Let’s not forget that the flu is a virus. Antibiotics are for bacterial infections, not viruses). Our child gets a bad bump on the soccer field, and he’s in the ER for a CT scan (see this article).

Recently, we took my son to the doctor (not our pediatrician), for a suspected ear infection. Fortunately, he didn’t have one, but the doctor offered us a prescription for something just in case. When I declined, he replied that was fine, and that he offered because some people feel unsatisfied if they come to the doctor and don’t get something, even if nothing is wrong.

Novel idea, I know, but if you’re not sick, you don’t need something.

And this is much of what Walsh is arguing. If not sick, which pregnancy and labor should never be considered pathologies, then why are we doing randomized clinical trials to prove that natural labor needs natural things? (The same argument can then made against IVs, routine AROM, monitoring…)

I’m not making a new argument of course. I’m simply reiterating what many are already saying.

Pregnancy, labor and birth are normal the vast majority of the time. They require normal, common sense things. If they cease being so, then we’ll call for something else. Don’t do anything just to say that you’ve done something.

Preventing ALL Death and Injury?

I’m currently reading Denis Walsh’s Evidence-based Care for Normal Labour and Birth. In my reading this week, I was struck by the chapter called “Fetal Heart Monitoring in Labour.” I understand that fetal heart monitoring is not proven beneficial, though it continues to be in widespread practice. I was familiar with much of the information presented, but the following reference caught me off guard.

Walsh discusses a number of studies and reviews throughout the book, and in this particular case, the review being discussed brings up one (of many) possibly disadvantages for continuous electronic fetal monitoring. Walsh quotes directly, as will I, the following: “[it] shifts staff focus and resources away from the mother and may encourage a belief that all perinatal mortality and neurological injury can be prevented.” (Reference below).

Can I just stop and say “WOW”?

Of course, it makes perfect sense. This attitude is pervasive in western culture. All death should be prevented until natural causes in old age. All other death is negligent and/or preventable by future technologies.

Again, WOW.

I come from this culture of course, and I struggle constantly with the idea. Late last year, my dad was diagnosed with prostate cancer. His prognosis was very good: he was (and is) in excellent health, and it was caught very early. He had surgery and has thus far done well without any other treatment.

My mother, of course, panicked with this diagnosis. Current research suggested to her that even with surgery and complete removal of the tumor, it only extended my dad’s life expectancy ten years. She was distraught.

Let’s put the above in perspective. This year, my dad will be 66. Ten years is 76. My dad (due to good health) probably had a previous life expectancy of 80.

Was surgery helpful? Certainly. Would my dad have died sooner without it? Yes, probably. He has a genetic risk for prostate cancer, so his cancer was likely vigorous. Does he have cancer now? Nope, not as far as we can tell.

Should my mom still be concerned about his life expectancy? Nope, not in my opinion. He will die eventually anyway.

That’s heartless sounding of course, but it’s true. Some of us will die from cancer. If we cure cancer, it’s likely some will die of other causes, beyond the “natural.”

My point is, as a culture, we are terrified of death. We string ourselves out at the end of life, struggling for each breath in some sterile hospital, without being allowed to die in dignity and grace surrounded by family and friends at home.

Unfortunately, birth is no different. Birth is a symbolic act of life beginning in another (though I would argue the life began long before, it just needed constant care in a different environment before birth). It is logical that once life begins, it will certainly eventually end. And as much as we would like to, many times we cannot prevent it, not should we.

I do not believe there will ever be a time when NO women and NO babies die in childbirth. That would be like saying there will never be any more SIDS or miscarriages. As tragic as these things are, they happen. They are a part of the life cycle.

Therefore, we need (as much as possible considering the culture we’ve been raised in) to attempt to lose this idea of preventing all perinatal mortality and injury. It will likely never happen. Our focus should be on healthy normal childbirth so we can recognize when it goes astray. When it goes astray from normal, we should focus on doing what we can, WITHOUT CAUSING FURTHER INJURY OR HARM to either the baby or the mother. After that, we should focus on supporting and counseling the family through a difficult life event.

Reference: Alfirevic, Z., Devane, D. and Gyte, G. (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, Issue 3.

Baby fever and putting it off...

I have baby fever. It’s unfortunate that right now we can’t have another, so I’m going to lament and have myself a pity party.

As some may know, in January I decided to apply to nursing school with a local two-year R.N. program. Nursing had been in the back of my mind as an eventual pathway to midwifery, but I hadn’t truly considered it for awhile. The decision to apply was very much spur-of-the-moment, and to be honest I can’t remember all the reasons my husband and I considered when we made the decision I should apply. A primary concern of course was financial stability: we’ve struggled our entire married life, and I was not going to reenter full-time public school teaching unless I had to. (We did consider it, and I’m thankful my husband said he’d rather we struggle a way longer than put me through that). My husband is also going for nursing, though he’s not starting the program this fall with me. We felt that since I have a bachelor’s degree, I would get through the nursing program faster than he would. Then I’d be able to do a three day a week/full-time thing while he finished up the program himself. Three days a week would give me enough time home that I would still feel like a full-time mommy, at least as much as I am now working part-time and going to school part-time.

Of course, going to school full-time and then trying to find a job is really difficult pregnant and/or with a new baby. Not impossible, but…

I’ve considered the fact that I could probably take time off from the nursing program. Legally, I’m allowed a semester off (R.N. programs have some special requirements due to accreditation), though I’ve been told by the program director that I’m not allowed any time off. I could fight him on it, but I wonder if it’s worth it. I don’t want any difficulties going through, and I want to be finished and move on with my life. I also get his perspective; they’ve had a lot of concerns about the program’s accreditation with people not passing/dropping out. Rumor has it that of the latest class in the hospital partnership, only about half are making it to next semester. That’s got to be nerve-wracking as a program director to be staring accreditation worries in the face.

Also, I think about what I’m going to be looking at with my next birth. We want a large family, and I’ve already had one cesarean. I don’t want to have another and I’m really considering my options to ensure a VBAC this time. Out-of-hospital birth certainly seems to be the best option, but is it an option for me with my medical history? If I’m risked out of midwifery services, do I “free-birth?” (probably not, but it’s been on the table). How do I manage a hospital VBAC fight while struggling with clinicals? (and a family?)

Apart from the next birth, what about the next postpartum: I want to do everything I can to have a healthy postpartum transition this time around. Fewer stressors would equal reduced risk for me developing postpartum depression again. I was switching from working full-time to mothering full-time at the last birth, so being settled and having less life change is ideal.

Having a great start breastfeeding is also key in my mind: not being able to get out to find the help we needed was a huge factor in our failure to continue breastfeeding. Little man needed specialized care, and that simply did not get met. I would like to not battle with returning to school and pumping; arguing to pump at work seems to be a much easier battle.

So yeah, we’ve decided to avoid for the time being. Neither of us is very happy about it. We both have baby fever to the extreme, and the little man is not very little anymore. He’s talking now, and it’s really obvious that he’s a BOY rather than a little baby. It’s hard also when I consider that by the time I’m done with school, he’ll be almost FOUR. We had hoped to get them close together, so it’s a bit of a blow for us. Of course, we know that conception is not controlled by us, so I guess we’ll see if anything else comes up.

Until then, I’m burying myself in my birth studies, focusing on being the best nursing student, mothering my little man, and being a wife to my fabulous husband. These next two years (or so) better fly by.