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20 Jan 2016

How Doula Regulation Misses the Point

By Annie Kocher

How Doula Regulation Misses the Point

As awareness of the benefits of doula care grows, many birth workers are exploring ways to make doula care more affordable and accessible to all birthing people. These ideas include longstanding models of volunteer doula services as well as new possibilities like Medicaid coverage for doula care. In the growing sea of opinions on this issue, many voices are suggesting that before public insurance coverage is possible, the doula profession must be centrally regulated. However, this perspective reflects a fundamental misunderstanding of the nature of doula care.

As DTI doula and educator Jenny Bennett pointed out in a blog piece last week, although doulas are well-versed in the clinical care model and experts in the physiology of birth, doulas do not provide clinical care. Those doulas with training in other modalities, such as those who are licensed practitioners of massage or certified professional rescuers, practice those skills within the guidelines of their additional licensing. From a legal perspective, a doula has the same status as any other visitor in the birth setting.

Doula and scholar, Camalo Gaskin adds that the presence of the doula at birth is in many ways analogous to the presence of clergy at the time of death. (Here, Gaskin critiques and references the work of Birth, Breath, and Death author Amy Wright Glenn, a hospital chaplain and theology scholar. She also references her extensive conversations with thinker, surgeon, and obstetrician Dr. Michel Odent, who advocates for the doula role’s autonomy from the hospital hierarchy.) Church Persons, like doulas, have important spiritual and sometimes even physical participation in the process. They may stay a long or short time. They will have specified relevant knowledge, but the service and information they offer is dependent on the needs of the individual family. They have been requested because they provide personal, non-medical care.

During such pivotal rites of passage, should we give our religious guides a status as hospital employees before we allow them to visit and pray over our brothers and sisters? Should we make it harder for them to visit those whose life ends in a hospital than to visit those who face death in the comfort of their own home? If not, then why apply those same standards to doulas?

The line of thinking that concludes that doulas should be regulated comes from a worldview that is based on fear and distrust. It is the storm of thought that tells parents in a million images, words, and cultural practices that they are not good enough. That in order to give birth, in order to love or protect their children, in order to love or protect themselves, they must rely on a system of default rules and regulations. This way of thinking disregards the autonomy of the birthing family by assuming a regulating board will know better than them what they need in a doula.

It is no surprise that virtually everyone enters parenthood burdened by insecurities. However, it is also no surprise that most will eventually realize that they are deeply and truly capable. Birth is a profoundly intuitive process that bucks our expectations, our measurements, and our plans—as well as our fears. It will proceed without caution constantly forward, sometimes breathtakingly powerful and fast, sometimes agonizingly slow and heavy as the world itself. But like life, the only sure thing is that it will change—as we will, with it and through it. As doulas, our interaction with these truths is characterized by trust in the face of uncertainty. The nature of doulas’ work challenges any rigid system of power and therefore cannot truly ever be integrated within one.

There is no more one way to doula than one way to birth or one kind of birth giver. Many families look for a doula whose practice style is compatible with their ideal birth experience. Doula support can take a million different forms, because it includes whatever a family needs most. It could be playing the bongos while someone dances her baby out. It could be a Vietnamese “mother roasting” after the birth. It could be telling a joke at just the right time. In birth, one size does not fit all. Judging all doulas based on the same criteria would not work; the profession, by nature, defies regulation.

Doulas of one form or another have been attending to birthing people for thousands of years. There is nothing new about this kind of support. Unfortunately, there is also nothing new about people creating barriers to it. Don’t be fooled by the fancy decorations and justifications people hang on barriers to birthing people’s health and safety.

This is not healthcare we are talking about, it’s whole care. And let’s remind anyone listening that despite the ‘unregulated’ and ‘unscientific’ madness supposedly rampant among doulas, our work has stellar success rates. Doulas improve health outcomes and reduce costs. How? By the immeasurable power of empathetic, creative, personal support.

True, doulas and the field of medical science work beside each other—each informed by the other—but not as one. As we consider the real and imagined friction between these two modalities, it is important to recognize that no culture exists without birth mythology. The overwhelmingly dominant model of care in the U.S.—medicalized hospital birth—is our mythology. Every bit of it represents the U.S. cultural systems of belief, symbols, taboos, and ways of being.

One of the worst problems in this system is an increasing maternal mortality rate that disproportionately affects women of color, non-native English speakers, and those whose lives do not otherwise conform to cultural norms. In the midst of this crisis, doulas work from the outside to encourage positive change within. This unique vantage point is what allows us to carve out pathways for diverse populations, including those currently marginalized or underserved.

Yes, our mythology is diverse. This is our strength and the hope of our field.

And of course, we know who is told to follow rules: those who are not in power. For example, female-presenting people are taught to be ‘good girls’ and obey. Why? Because those in power said so. We’re taught to see the rule makers as wise and knowledgeable in ways beyond our understanding so we don’t discover our own power. Doulas’ work is to increase accessibility in all forms, precisely by holding space for our clients to discover their own capacities.

The DTI community and doula community at large are characterized by a rare commitment to sharing and generosity. Doulas are in the business of cultivating openings. We will not be shut up or down. We respect systems of healthcare and strive to facilitate positive change for individuals operating within them. We strive to open the possibility for more diverse narratives of how to give birth.

As many theorizers including Laban and Jung have said on the project of re-discovering health and enchantment in a dominant culture of regulation, cultural change is possible through the liberation of the individual. Doulas are successful precisely because they work as and with individuals, in a spirit of freedom. We are the change we wish to see in birth.

Doulas provide continuity of care throughout pregnancies, lifetimes, millennia.

In the words of Kathi Valeii, “You can’t regulate this.”

Much Love,

Annie Kocher for DTI

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