The Doula – A ‘Peer’, A ‘Companion’, A ‘Lay Woman’ or A ‘Professional in the Field of Birth Support’?
March, 7, 2015
It seems that in the past year or so doulas are making news headlines. In addition to our presence in the news, we also had quite an impressive presence in social media and in the blogging arena. Doulas in North America were also acknowledged this past year when the first comprehensive study ever written about women supported birth was published in Morton’s and Clift’s ‘Birth Ambassadors”. The book is a genuine presentation of the doula role, types of practice and training system in America, from a sociological point of view. In contrast to the growing interest in doulas, and our growing presence, we can sense a growing frustration in the doula community in regards to the doula’s professional status and acknowledgement. The lack of acknowledgement from the medical system makes it hard for doulas to be hired and paid for their services, resulting in lack of commitment to the doula practice as a career path. And when we do commit, we still feel like we have to get into L&D through the backdoor. Some of the frustration can be heard in the voices who are exploring the call for a National Certification , like Amy Gilliland’s. Not to say that there is any harm in such development, but I wonder if this is indeed the answer to our need to being acknowledged as a professional in the field of birth support.
In order to begin exploring this dilemma, I would like to first share my personal experience. I became a doula in 1998 in Jerusalem, Israel. It was the first doula training ever conducted in my country. My trainer had been practicing as a doula for many years within the orthodox community in Jerusalem, where birthing women are not allowed to be around their husbands. It was a year-long, hospital-based training with an additional 100 hours of internship in Labor and Delivery. Sixteen years ago it cost me $1500 worth in INS*. Doula trainings in Israel are still a year-long commitment, and many are hospital based or affiliated with a naturalistic college. The average cost of the training is about $4000 in INS. My trainer, Mrs. Shoshana Goldbaum, required a high level of intellectual investment and demonstration of knowledge throughout the year from all trainees. Imagine my surprise when towards the end of our training, she began talking about doula care as a community service. She encouraged us to support our friends, neighbors or family members as doulas, but she cautioned us not to quit our jobs and try make a career out of it. As much as I was puzzled by her advice, I tried to follow it at first. I continued with my three teaching jobs, and after six months it became clear: I was never going to be a doula with a business, a professional doula. I felt that my investment in this year-long training; an investment of time, money and intellect would never bear fruit. How could I be a mother of two children, ages 4 and 2, continue to hold my teaching jobs to support my family, and practice as a doula? I couldn’t. One year after taking the training, I decided I had to try. I quit my teaching jobs in June 1999 in order to become a professional doula.
Fast-forward sixteen years to a couple of months ago when I took Gail’s Tully amazing ‘Spinning Babies’ workshop. Oh, what a blast! At this point in my life I am a well-established childbirth educator, birth doula and doula trainer in the Bay Area, California. I have had a very fulfilling career as a birth professional**. However, I felt like all of my professional achievements were about to be cast aside when we came back from our lunch break and Gail paused in her teaching to remind us all that we ‘should come from a peer position’***. Déjà Vu? My trainer is again telling me that a doula is not a professional, but a peer? After sixteen years of practicing and continuous studying, I wondered: did I invest my time, my money and my intellect, only to find out that I am a ‘peer’ or a ‘companion’? If I am not a birth professional yet, when will I ever be?
As much as the opening to this post is personal, I believe that there are thousands of doulas in North America who share my frustration. After the workshop, I touched base with my colleagues who attended the workshop by posting in our local Facebook doula group. I posed a question: ‘Had anyone else felt frustrated when being asked to practice from a peer position?’ It was a fruitful discussion that led to the following conclusion: those doulas who have practiced over a decade shared my frustration. Newer doulas, practicing just a couple of years, did not question or have any difficulty with this guidance. So where does the difference lie?
I think that there is a change which happens over time in how doulas perceive themselves, when it comes to their role and professional status. According to Morton “Those who attend a doula-training workshop are a self-selected group of mostly women who have a fascination with birth and desire to support other women through the birth experience. Those who become certified and /or actively practice as doulas are an even more committed group” and she continues: “Given the relatively low-cost and short time commitment required, attending a doula training workshop is a realistic and manageable way for women to tangibly connect with a long-standing interest in birth”. (Morton, p. 114-116) Presumably this change in professional status takes place when a woman who attended a doula training transitions from ‘I have a long-standing interest in birth’ to ‘I want to have a professionally fulfilling career as a doula’.
For those of us who demonstrate a higher level of commitment to develop a doula practice and become career professionals, it is time to reflect on barriers to the acknowledgment we seek, beginning with the ‘low-cost and short time commitment required training’. In comparison to other doula training models in the world, among them the UK, Brazil and Israel, doula trainings in North America are extremely short. A typical training is a four day workshop in which students learn the definition of the doula role, are presented with the benefits of the doula service and its impact on births, and acquire basic tools to provide emotional, physiological and informational support to the laboring woman before, during and after delivery. (Morton, 2014). There is no internship and no supervision following this workshop. I can see how this type of training might be adequate to meet the minimum requirements of the doula as a ‘lay woman’ or a ‘supportive companion’ who provide a positive care during labor and childbirth, as well as those who provide postpartum support’ (Sosa, Kennell , Robertsoon & Urrutia, , 1980). Further, I can totally see how women who do not wish to pursue a career path, but rather want to ‘connect with a long-standing interest in birth’ and provide a community service in which women traditionally provided support to one another during birth, can benefit from this training model. However, those of us who wish to become professional doulas, do we really feel comfortable establishing our doula practice on the basis of a mere four days’ workshop? Do we really feel skilled and competent in the task of supporting a laboring mother and her partner after attending such a workshop? And how reasonable is it to charge $2000 per birth (“’not far away’ from [OB] insurance fee for a normal birth, excluding prenatal care”) , based on four days’ workshop, when all we claim to provide is ‘supportive companionship’ based on natural talent, passion and intuition? (Morton, 169-171),
This short training model was designed by well-respected doula leaders, like Marshall and Phyllis Klaus, John Kennell and Penny Simkin, the pioneer leaders in the field of doula support, whom we all appreciate and are deeply grateful to for their intellectual and research contributions. However, their work brings us to the second thing doulas need to reflect on- how we perceive ourselves. From the choice of word that describes our role as ‘doula’, which stands for a female servant in ancient Greek, to the perception of the doula as an ‘experienced female’, who is a ‘supportive lay woman’, ‘supportive companion’, or a ‘partner’ providing ‘constant human support’ (Morton, p.175), all the way to the suggestion that we are ‘Mothering the Mother’ – an intuitive nurturing practice that requires no training. Nothing in the doula role definition, as crafted by these pioneers, suggests a professional status. Klaus and Kennell’s book ‘Mothering the mother’ led thousands of doulas to believe that their loving and mother-like supportive presence was all it took to reduce medical interventions like epidurals, forceps and cesarean operations in birth by 50% or more, to shorten the length of labor by 25%, as well as increase breastfeeding rates and facilitate the bonding process. There have been plenty of studies since then challenging these findings, but what is more important is that so many doulas feel ‘”helpless and discouraged when, in spite of all their efforts and long hours, they could not make ‘enough’ difference. Mother after mother was induced, or labors did not unfold naturally; birth after birth was medicalized? For many dedicated doulas, the feeling of loss become so great, they simply quit being doulas”(England, 2000). In such a situation, presence, natural talent, and supportive companionship are not enough.
Experienced doulas like myself, who did not quit but rather continued to develop our doula practice, know that presence, companionship and natural talents for caring, are not enough. We do not see these attributes as defining our overall role as doulas. We have as many years of continuous education as we have years of practicing as doulas. From college classes to hands-on workshops, we continue to acquire leadership skills and plenty of practical tools and techniques to provide so much more than simply continuous supportive presence. Years of practice have taught us that one of the keys to healthy normal birth is birth progress, and this is what we strive for in our work. We are FTP fighters! (Failure-to-Progress, the entering point of medical interventions and birth management). The difference we make is not to be found in the continuous support but rather the leadership, coaching and practical techniques that we apply. We hear so many times that ‘birth is like a marathon’ – it takes an immense level of commitment and conviction on the part of the runner; it takes great investment in the body and one’s health condition; it takes years of practice; the runner has to be able to cope with pain; and last but not least, great coaches lead runners to better results and then cheer for them at the finish line. And that, my friends, is a better job description and perspective of the doula role.
I have dedicated the past two years to the important topic of doula leadership and doulas’ professional status. In 2005, I was one of those doulas who wanted to quit. Not because I did not receive professional acknowledgement, but because I felt that I had failed to fulfill the promise of doula benefits in light of the growing rates of medical interventions in birth. During this time of frustration, I signed up for a year-long transformational coaching training in order to become a life coach. It turned out this training led me to understand that I was already a coach – in the field of birth. Most importantly, I also learned that as a doula, I coached my client during the performance, the birth, and that was entering the “race” too late. In the end, I never went on to practice as a life coach. Instead, I invested two years to create the Birth Coach Method, a doula training program that integrates coaching principles and strategies into doula practice. The Birth Coach Method demonstrates the need for prenatal coaching in contrast to the exhausting commitment of doulas to provide continuous 24-36 hours of support during childbirth, which most of the time does not result in optimal outcomes. I seek to make a change in the field of birth support with a different set of tools and strategies, which I believe will achieve two goals: The first is to lead more women towards healthy and physiological birth, and the second is to provide doulas with the professional acknowledgement they deserve.
The doula movement and the coaching professions both began in the 1980s. Unlike doulas, coaches enjoy acceptance and acknowledgement in so many different areas of human life: relationship, career, executive, lifestyle, ADHD and parenting, to name but a few. Coaching, just like doula care, encountered initial objections from the mental health establishment. However, it is now clear that healthy, competent individuals who suffer no pathology, can perform better and achieve great results when they work with skilled coaches. Coaches, unlike therapists, do not establish a hierarchical relationship with their clients. The coach is no authority to the client, but yet she is not a peer. The coach is a professional using professional tools, skills and strategies to evoke excellence in others. It is in this respect only that I can relate to Tully’s suggestion that we ‘practice from a peer position’. Doulas are not authorities, but rather leaders who empower birthing women to gain clarity, change perspective, explore options, accept what is possible, and perform well in birth – mentally, emotionally and physically.
There is a big difference between getting the professional acknowledgement doulas seek and ‘claiming membership in the maternity care team’ (Morton, p. 304-305). Coaches are acknowledged and hired by organizations and individuals, but they are not members of the psychotherapy and mental health “teams”. The coaches’ power derives from their care for competent and healthy individuals who struggle at times, seek to initiate a change, or for those who wish to improve their skills to perform better. Doulas’ practice and philosophy is radical exactly because we ‘not only contend that giving birth is a normal life event…Doulas also believe that the way society treats birthing women and the processes that babies go through as they are born, embody and create social values that are reflected in dominant understandings and representations of childbirth’ (Morton, 305). It is also in this sense, of caring for healthy and competent individuals, and perceiving ourselves as empowerment forces for the healthy processes of life, that doulas and coaches resemble one another.
There are many wonderful, kind, and nurturing women who declare themselves doulas. Some of them went through training, some did not. Some of them are in business, some are doulaing as a hobby or a service to their social circles and their family. There is nothing wrong with any of these types of doulas. ‘We need all kind of doulas’ says Amy Gilliland, a doula leader and one of the champions for national certification. However, the dilemma of the ‘other doulas’, or ‘hobby doulas‘, did not escape her notice: “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,” she says. As for our struggle to be professionally acknowledged, she says: “The right of way is not something you automatically receive, it is something the other driver gives you’. To that I can only say that we have the right of way. We have the right of way as the ‘lay woman,’ the ‘companion,’ and the ‘peer’, but those of us who grew and developed professionally know these terms do not describe what we are. While Gilliland thinks that national certification is the solution, I think that it might be just a patch on a bigger issue. It may be one more layer in the pile of mistakes that has been made over the years with regard to the perception, role definition, and training model of doulas in North America. Gilliland is right—there are no ‘professional nurses’ and ‘hobby nurses’, so why steer the wheel in the direction of ‘professional doulas’ and ‘hobby doulas’? There is something else that we miss here – nurses and doctors need privileges in order to practice in hospitals. Nurses are hired by hospitals, therefore there are no ‘lay nurses’. We can go by the example of Certified Nurse Midwives vs. Lay Midwives, but the latter cannot practice inside hospitals even though they have been hired by their clients. Another example comes from the field of legal services; we have the lawyer, the mediator, and the arbitrator. Each provides different services around conflict resolution. Each also requires different trainings. While working on this post I have also learned that so many trained doulas do not fulfill the requirements to become certified. They are working in the field with no such certification, rightfully stating that they are trained. This situation raises even a bigger doubt that the National Certification for doulas will solve our problem.
In light of the long history of the doula as a non-professional ‘lay woman’, I suggest we have ‘doulas’ and ‘Birth Coaches.’ Coaching is the practice of professional doulas, who coach healthy and competent birthing women to perform well during labor and give birth in a healthy and physiological manner. We do that by conducting prenatal coaching sessions, by supporting and coaching women during their childbirth, and by conducting postpartum coaching sessions for healthy closure and positive memories of their experience. Professional doulas practice with coaching tools and skills and manifest coaching competencies.
So how can we move forward to transform professional doulas into Birth Coaches? Organizations that provide training programs in the field of birth support can introduce different training levels which will attract women with differing motivations and levels of commitment. I would be honored to collaborate with any organization for that matter. Doulas in business can decide that they want to practice like coaches and be acknowledged as professional coaches. I advise women who seek education in the field of birth support with the goal of having a career path to be mindful about the training they choose. I want to see prenatal coaching integrated in the birth support field, because history has proved that a continuous caring presence is not enough.
To Healthy Births on Earths!
Birth Coach Method Founder
Resources and notes:
- England, P. (2000) What are you bringing to birth? PALS Papers: A Quarterly Publication of the Pacific Association for Labor Support, Summer.
- Gilliland A. (2015) Doulaing the Doula: Back Door or Front Door, http://doulaingthedoula.com/back-door-or-front-door/
- Gilliland A. (2015) Doulaing the Doula: Benefits of National Doula Certification, http://doulaingthedoula.com/benefits-of-national-doula-certification/
- Gilliland A. (2015) Doulaing the Doula : We Need all Kinds of Doulas, http://doulaingthedoula.com/we-need-all-kinds-of-doulas/
- Hartocollis A. (2015) Doulas, a Growing Force in Maternity Culture, Seek Greater Acceptance, the N.Y Times, http://www.nytimes.com/2015/02/11/nyregion/doulas-the-latest-wave-in-maternity-culture-are-organizing-for-more-recognition.html?_r=2
- Life-Choma N, (2014) Birth Coach Method: Imagine Re-Birthing the Doula Profession, What Would You Change? http://www.birthcoachdoulatraining.com/imagine-giving-birth-profession-doula-profession-change/
- Morton, C. H & Clift Y. (2014) Birth Ambassadors; Doulas and the Re-Emergence of Woman-Supported Birth in America.
- Perez M. (2015) RH Reality Check, Reproductive and Sexual Health and Justice, By Comparing Doulas to Amazon Prime, the New York Times Seriously Minimizes Our Impact, http://rhrealitycheck.org/article/2015/02/20/comparing-doulas-amazon-prime-new-york-times-seriously-minimizes-impact/
- Sosa R., Kennell J., H., Robertson S., & Urrutia J. (1980) The effect of a supportive companion on Perinatal problems, length of labor and mother-infant interaction, New England Journal of Medicine, 303, p. 597-600.
* Israeli Currency = Israeli New Shekels (INS).
**I have directed two birth resource centers and established the first hospital-based doula program in Israel. In the past six years I have led local doula training programs, including one for nurses. My DVD ‘Practicing for an Active Birth’ was endorsed by the Palo Alto Medical Foundation and received positive reviews from OBGYNs. I created the Birth Coach Method online doula training and classes which has allowed me to reach to aspiring and certified doulas all over the world.
*** I thank Gail Tully from the bottom of my heart, for provoking me, and then so kindly replying to my email. Thank you for reading this article and providing your feedback. Your leadership and friendship mean a lot to me. I also thank Christine Morton,, PH.D, Julie Dubruoillet, CD and Author, Audrey Kalman, CD and Author, Patricia Madden, CD, HeatherGail Love-Joy, PP Doula and DONA president, and Alit Ronen, RN.