Tuesday, 17 May 2011

Against the professionalisation of doulas - why?

Having recently stuck my head above the parapet for challenging some of the principles raised during the process of Doula UK's imminent Board changeover - and got it nipped (!) - I feel an urge to further elaborate on why I disagree with the professionalisation of doulas.

Admittedly much of the literature written on doulas does apply words such as 'qualified',   'professionally trained' and 'certified' to the lay childbirth companion, but this is because the vast majority of these texts are American. And the way American English is used to describe the US doula does, in many ways, make her a different entity to the UK doula. 

The reason for this difference however, is because midwifery practice in the US is also very different to that in the UK. And it is the midwife-doula relationship that lies at the heart of my argument against the professionalisation of doulas.

There has always been discussion among the doula community - as the newcomers to the UK childbirth arena - about how to creatively build bridges with midwives, in the belief that this can only help towards sensitively and effectively supporting women and birthing families. While the doula's first allegiance is to the mother and father she is working with, she is also mindful that her positive relationship with the attending midwife can play a key part in ensuring the protection of an undisturbed birth environment.  

Equally, there is concern among the midwifery community regarding the increasing number of birthing mothers and couples who are enlisting doula support and how, hand in hand with Government cuts, the presence of doulas may be aiding the erosion of the role of the midwife. Why, if the UK midwife autonomously provides physical, emotional as well as spiritual care to the birthing family, should there be a need for any additional support? What can a doula provide that women and couples are not already offered by their midwife?

I make no excuse in refraining from attempting to respond to these questions here, for to remotely adequately comment on this sensitive issue deserves an evidence based paper written for another time and place. My point is not about what the doula or the midwife does or does not do in any case. Rather to suggest how insulting it might feel for the midwife, who is a professionally trained, qualified and registered practitioner, to contend not only with another figure in the childbirth arena who potentially threatens her very existence, but also with one who - further to having undertaken a course comprising of just a few days as opposed to years - deigns to describe herself as a 'professionally trained' or 'qualified' practitioner. 

This is my point against the professionalisation of doulas.

I have to admit that I just do not understand why some doulas and doula organisations choose to use this terminology at all. Does it stem from the need to big-up the doula role, to make it more acceptable, more accountable, more credible? Does it come from a place of lack of confidence in the right to 'be' there as a non-professional support person? Or is it down to people simply not thinking through what they are saying, not considering the implications behind the words they are using? Perhaps not fully understanding the role of the midwife too?

As part of the doula community's commitment to building bridges with midwives and maintaining harmony in the way that birthing families are supported in the longterm, I would so welcome an 'outing' of this issue. And I would so like to hear Doula UK, as the leading voice for UK doulas, take a much stronger position against the use of professionalised language in reference to doulas for all the reasons I outline in this post. 

To end on a positive note however, much to encourage and support the coming together of doulas and midwives, to share learning, skills and knowledge of our not dis-similar yet in many ways very different roles, is already unfolding. Meetings, MSLCs, workshops and study days are providing forums for discussion and exchange, to build on understanding and to air concerns regarding each other's roles. And I applaud those who are instigating these opportunities. Let's keep working on it!

6 comments:

  1. Great post as usual, Adela. I absolutely agree on most points. I am not a fan of the necessity of certification and professionalization of doula work either. I so support you on this. I personally never want to see a day where it is the norm for doulas to be staffed in hospitals. I cling protectively to our grass roots nature, women helping women give birth without having to succumb to a very patriarchal mode of training and organization.

    There once was a time when midwifery was in this league as well. The practice of lay midwifery is far older than certified midwifery. When obstetrics came into play, midwives probably wanted their essential role of supportive emotional and spiritual care of the woman and family, as well as their unique tricks of the trade honoured in light of this new fangled profession usurping their territory. They tired of the witch hunts and disparaging attitudes. They took the "professionalized" route. The results of that are both good and bad, as you know, and obstetrics in my neck of the woods still look at midwives and think they're all posers claiming to be qualified to deal with birth. I think doulas are trying to do the same thing now, trying to establish a recognized niche to honour their tireless, humble role of support. And I don't think it's that necessary. It's not a role that needs to be "biggened", though it is one that needs to be respected and honoured, as the work is effective and desired by those we serve. In our culture, slapping terms like "qualified" and "professional" onto something is what makes it viable and recognized. Sad, but true.

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  2. I personally don't worry about how a midwife would feel upset by the use of "professional" or "qualified" for the reasons you mentioned. My concern with those words go beyond that. I am North American, so perhaps these words hold different weight here. I say "professional training" for my doula preparation courses because if I didn't, no North American would come :) However, I strongly explain to potential students who ask about professional organizations and papers etc. that the doula role is not like that, that if they "certify" with me, all it means "professionally" is that I said they did well, not that this gives them any sort of special status in the echelons of doula-hood, that the fact they jumped through those hoops is in no way indicative of the goodness or not of their real work. It just means they have been prepared in ways I think are suitable to begin going out into the world and supporting women in the tough OB led hospital environment we have here. My emphasis is on embacing the humbleness of this role, not trying to make it all spiffy. If this quibble about words is enough to shatter a potentially beautiful relationship between primary caregivers and doulas, the problem goes deeper than that. I think the issue is more that primary caregivers don't understand our role that well.

    I don't think it's a doula's job to protect the egos of the "real" professionals in order to maintain good relationships by being super low key. At this point in my doula career, I actually have been plying my trade and studying for more years and have more birth witnessing experience than many starting out midwives and medical residents...different roles, knowledge, and modes of study, yes, but you get my drift. Put it this way: I don't get into a snit if a brand new midwife with her new professional qualifications explains words and medical theories to tell the lowly doula (me) where it's all at with this birth thing she (the midwife) is qualified to be deemed an expert in simply because she passed certain tests. All I care about is that she takes good care of my client. Being qualified and registered in no way makes one professional. To be a "professional" here more means you behave professionally, ie. respectfully and conscietiously. I can behave professionally being a lay person.

    I'm just a doula. Period. I have no papers. My qualifications are my experience, the fact my clients want me there, and the fact I love birth and just want them to have a happy experience with whatever caregiver or place of birth they choose. When midwives learn exactly what my role is, which is usually about me outlining what I'm NOT qualified to do and that I'm happy to take their lead most of the time, they always relax and we work great together. In fact, it often makes their lives much easier. I don't WANT to be doing the clinical stuff they do or have the level of clinical responsibility they take on. When they realize that I make absolutely no claim to be clinically qualified, there should be no quibble.

    Midwives, at least, understand the nature of our role, and are more sympathetic to it. Try opening up our thoughts and the nature of our role to hard core obstetricians. This is what I'm trying to do on this side of the pond without sacrificing the integrity of my work. It is HARD, let me tell you. But if I show up to a meeting with OBs to discuss my role and how to build bridges and improve maternity care, I leave the patchouli and peasant skirt at home and don't use words like "grass roots". I answer questions about my "qualifications" and exude "professionalism". Sometimes a bit of a game must be played...even if I'm giggling on the inside.

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  3. Adela, I feel a great deal of respect for the pioneering doulas who founded Doula UK. I imagine it must be particularly difficult to see an organisation that you created with so much love and determination now in conflict.

    At the same time, I feel the conflict that has recently come to light is not a new one, but rather has been inherent to Doula UK for at least as long as I've been a part of it (so July 2007). On the one hand, there is the idealistic language and vision of woman-to-woman, non-professional support. On the other, the language of 'professionalism' - new doulas are referred to as 'trainees', they must receive 'certification' from a recognised course prior to joining, encouraing members to sign contracts with clients, to keep written records of births, etc. etc. I think pretty much all of us would be in agreement that a period of working closely with a more experienced doula is of great benefit - but calling a doula who is at this stage of her journey a 'new doula' or 'a doula who is working through the DUK recognition process' would be more in keeping with the Doula UK's self-proclaimed ideal of doulas as 'lay supporters.' It would also, to me, make more sense, if we were adhering strictly to this vision not to call doula courses 'trainings' or even 'courses' but rather do as Michel Odent and Liliana Lammers do and call them 'information sessions'.

    continued below

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  4. durhamdoula's comment cont'd ...

    I myself, as you know, began my active journey as a doula with Michel and Liliana's 'information session'. One point I took away from it and keep clear in my heart and mind is that women do not need another layer of 'professionalism' added to their care. Doulas are not health care professionals. I do not want to be a health care professional. In that sense, I agree with you fully.

    I work very hard to keep to this model. At the same time, I've found that for myself, I feel more comfortable having a contract with clients. I also adhere to my own brand of 'professionalism' if you like. But this is something altogether different than the professionalism of midwives or other healthcare providers.

    Midwives working in the NHS are, in my experience working in the Northeast, health care professionals - they don't have the time (or many of them even the inclination) to do more than offer standard medical care. I love midwives, don't get me wrong. If midwives were able, under the current system, to do their jobs in a way that allowed them to offer physical, emotional and spiritual support to women as well as medical care, I would not be a doula. I am fortunate enough to know a number of independent midwives who still uphold a model of authentic midwifery care and I always, always recommend this model to expectant parents who might be interested in it.

    I see an ideal of professionalism for doulas to be something altogether different than the professionalism of a midwife working today in the NHS. My brand of professionalism is that I keep my promises, behave with integrity toward my clients, and respect the limits of my role whatever my personal beliefs about a client's decision. My professionalism lies in keeping up to date in areas of importance to me and my clients. It lies in putting my clients first 100% of the time - even if that pushes the boundaries of my comfort zone. I speak only for myself in this. I believe each doula must find her own way of practicing. I'm on the fringes of Doula UK - my vision of doulaing, is, I hope, if anything, most loyal to the model provided by Liliana and Michel, although some of my practice varies from what I learned with them.

    But I wonder, Adela, if perhaps Doula UK isn't ripe for another pioneering leap forward. Could this conflict be a catalyst for ironing out some of the previously unspoken contradictions in practice? Could it not be a point for redefining what 'professionalism' for UK doulas means? Not as a pale imitation of the professional midwife, but as something altogether different, that harkens back to authentic heart of being 'with woman'.'

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  5. Thank you Lesley and Rebecca for your measured and heartfelt responses here, your thoughts and suggestions are very much appreciated and your insights to the discussion greatly valued!

    I have been reflecting on how to go forward from here. Apart from continuing to write, to spread the word and encourage healthy debate that is ..

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  6. I want to have the role of the Doula, as a midwife. I want to protect that part of my role as a midwife. In some ways I envy the role of a Doula, a privileged role of supporting women without responsibility for the outcome of the birth. Unfortunately the only birth I enjoy as a midwife is the one I look back on with retrospect. The one where the outcome in known to be wonderful, how the woman wanted and where both mum and babe are safe and well. Birth does not follow a pre ordained pathway unfortunately. It has its own individual pathway. It cannot be planned, one has to surrender to its chosen path.

    It is not the role of the midwife to deal with the abnormal birth, her role is to know it is no longer normal. Her role is to be with woman. The definition of midwife is to be with woman, not for woman to be with Doula.

    Midwife defined-
    a midwife was literally a "with woman" or "a woman who assists other women in childbirth."

    For me as a midwife who is reluctant to give up my role of being with woman, a Doula has the best of both worlds, they are with woman but not with responsibility for woman or outcome!

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