By Christina Gebel, MPH, LCCE, Birth Doula
Today on Science & Sensibility, blogger and researcher Christina Gebel submits an Op-Ed piece in response to a recent Slate article written by Elissa Strauss. Strauss wrote a strong piece exploring licensing and/or national certification of doulas. While there are many facets that still need to be studied when considering this potential change in policy, no one can argue that research on doulas has consistently been shown to improve birth satisfaction and reduce cesareans and other interventions, and as a result, healthcare costs. Christina responds to Strauss’ piece by examining in much greater detail some of the issues. – Sharon Muza, Community Manager, Science & Sensibility.
In her article published in Slate, Elissa Strauss suggests she knows what’s best for women. She responds to a recent report by Choices in Childbirth, which advocates for widespread Medicaid and private insurance reimbursement of doula services in order to increase doula services access, reduce healthcare costs, improve maternal and infant health outcomes, and better the quality of care.
Strauss is willing to accept the cost-savings benefits of doulas but goes on to argue that one big problem exists: doulas are not licensed or regulated and such a move would be “only fair to women.” She argues that one of the benefits of licensure or regulation would be requiring doulas to present unbiased information and goes on to paint doulas as an agenda-driven group, who relentlessly support natural (or un-medicated) childbirth, believing any woman who falls short is “maybe just a big, fat failure.”
Regulation of doulas sounds like a good, straightforward idea that Strauss and many women can get behind, but it is a very complex proposal, which Strauss fails to recognize or acknowledge. Here are some of the complexities that must be taken under consideration:
1. Doulas are NOT clinical providers.
Before any opinions about whether doulas should be regulated can be formed, it is important to realize that doulas are not clinical providers. Doulas provide emotional, physical, and informational support, but they cannot perform medical procedures, make a diagnosis, or make decisions regarding the direction of clinical care. Being non-clinical is what makes a doula different from a health care provider, who can do all three of those things. Any doula who performs those activities isvery wrongly stepping outside of their scope of practice. So, if you’re wondering why doulas aren’t already regulated or need licensure, like an OB or a midwife, that is one crucial difference to understand.
2. Birth professionals have a traumatic history of regulation, especially for Black birth professionals and Black women.
Some of the very first midwives in this country originated long before the 1970s. Black midwives (sometimes called “Granny Midwives”) were called to practice during slavery and beyond. In the early 1900s, public health departments, in the name of high infant mortality and morbidity rates in the South, decided to “train” and regulate these midwives (Hayes, 2003) (no one at the time bothered to think about how living in abject poverty might be contributing to infant mortality and morbidity). Some of the training was useful, but by and large, it stripped the Black midwifery community of its longstanding traditions, folk remedies, and even spirituality.
When vital records (birth and death certificates) became a requirement, midwives were required to fill them out in order to receive a “permit to practice.” (Fraser, 1998) Some Black midwives, who could not read or write, were forced out of practice due to this stipulation and either practiced underground or stopped altogether. (Fraser, 1998) Excessive and insensitive regulation left Black midwives fragmented and was a serious insult to Black women, who preferred these midwives over the care of White doctors, with whom they had a long history of abuse. (Schwartz, 2010)Recognizing the history of regulation in the birth community, and how it can go terribly wrong, is something that must be considered when moving forward.
3. We need community-based doula models that look different from one another.
Without careful planning and thoughtful considerations, regulation has the very potential to strip away much-needed differences in the ways doulas are trained and practice. Being a doula is not only about supporting a woman but also a community, and doula trainings should reflect that in ways of cultural humility, racial and social justice. In an age where the US is becoming more and more diverse and a large immigrant population is giving birth in US healthcare institutions, it would be wrong to advocate for a one-size-fits-all model for regulation, which risks losing valuable nuances. One solution being explored is building upon training for community health workers, a model that already assumes cultural humility, but this route must still be navigated carefully with the needs and desires of the community actively involved in training development.
4. One can not just “claim” to be a doula.
Strauss makes a flippant point when she says that anyone can declare themselves a doula. Anyone who calls him/herself a doula without a skill set, training, and solid experience will very likely be weeded out in client interviews. Clients usually question the doula (rightfully so) about his/her experience and philosophy, usually coming to the doula through a positive word-of-mouth. During my interviews, I find clients are more interested in my experience and philosophy than my certification status.
5. Instead of going by insurance standards, insurers should listen to what women want.
Currently, some insurers have agreed to reimburse trained doulas, asking them to align with providers or managed care organizations, for example. From their angle, that makes sense; however, we must be careful to not let insurers be in the driver’s seat towards regulation, and instead make mothers and doula organizations the driving force.
Going through insurers’ standards alone to reimburse doulas will put doulas in reimbursable and non-reimbursable silos, and who gets on the approved list may be driven by the insurer and not the expertise of reputable doula organizations. Moreover, who gets on the list has a direct impact on women. Women view choosing a doula as a highly personal decision. They might interview several doulas before they pick one who they welcome to one of the most important and vulnerable experiences of their lives. For that reason, it is in the best interest of women for insurers to present women with a wide variety of choices so she can adequately use her autonomy to choose the best fit for her. Furthermore, doula work is arduous, professional work and doulas charge rates that they feel reflects what they offer. Going through insurers will likely lead to low reimbursement rates for doulas, who, as the report repeatedly notes, actually save insurers a lot of money.
6. Regulation could discourage valuable diversity in labor support.
Doulas are already achieving great results. As pointed out in the report itself, doulas support was among the most effective of 41 birth practices reviewed in a study in the American Journal of Obstetrics and Gynecology. (Berghella, Baxter, & Chauhan, 2008) Even when a broad definition of labor support is assessed, such as in the Cochrane database, continuous labor support is found to be advantageous and has “no adverse effects.” (Hodnett, Gates, Hofmeyr, & Sakala, 2013) For different communities, we may not know what type of labor support works, so being inclusive in how we define labor support is crucial.
7. Doulas should not have an agenda, and regulation won’t necessarily fix that.
Strauss seems to think that regulation will fix doulas providing biased viewpoints on things like epidural usage. While some doulas are big advocates of “natural” childbirth, they should never take an agenda into a birth. The informational support role of a doula is to give the family full information about their options so they can be an informed decision maker and an active participant in their healthcare choices, which increases satisfaction with care. (Hodnett, 2002),(Cook & Loomis, 2012) If a mother feels her doula has an agenda, it may require self-advocating in the doula-client relationship, similar to a healthcare provider-patient interaction. However, having an agenda, unfortunately, is not something that goes away with regulation or licensure. Licensed health care providers often have agendas, too. All healthcare workers and doulas, alike, should stay abreast of standards of care and evidence-based medicine, and self-advocacy is also crucial in any healthcare system.
8. We can all agree that increasing access is important.
To me, the most compelling argument that we should regulate doulas is so that we can have them reimbursed by insurers and thereby increase access, especially for mothers who can’t afford the often high cost of private doula care. However, increasing access does not have to mean going through insurers by insurers’ rules. Together, we must work to find a way to increase access while putting the power in mother’s hands to choose the doula she feels is best for her birth. The question should not be what do insurers want. The question should be what do women want. That is what is truly fair to women.
All in all, Strauss fails to respond thoughtfully to the report and the challenges of doula care access. She goes on to talk of her own birth circumstances and her choice to not choose a doula. However, without a knowledge of the research, an accurate reading of the report, knowing the history of regulation for birth workers and the complexities of such a proposal, Strauss is not responding to a problem and offering thoughtful solutions. She is simply talking about herself.
Berghella, V., Baxter, J. K., & Chauhan, S. P. (2008). Evidence-based labor and delivery management. American Journal of Obstetrics and Gynecology, 199(5), 445–454.
Cook, K., & Loomis, C. (2012). The Impact of Choice and Control on Women’s Childbirth Experiences. The Journal of Perinatal Education, 21(3), 158–168.
Fraser, G. J. (1998). African American Midwifery in the South: Dialogues of Birth, Race, and Memory(1st edition). Harvard University Press.
Hayes, R. (2003). Bringin’ in Da Spirit [Film.].
Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology, 186(5 Suppl Nature), S160–172.
Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2013). Continuous support for women during childbirth. In Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003766.pub5/abstract
Schwartz, M. J. (2010). Birthing a Slave: Motherhood and Medicine in the Antebellum South (1 edition). Cambridge, Mass.; London: Harvard University Press.
About Christina Gebel
Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter:@ChristinaGebel and Facebook: Dual Love Doula or contact her through her website www.duallovedoula.wordpress.com.