Musings on Doula Certification Pt 2

Jan 23, 2018 | The Doula Profession

or “What did we think would happen…?”

When we first think about certifying, we tend to think about what is generally expected in the field, and how it might or might not affect our own practice and business model. That’s not necessarily wrong, but it is incomplete. Let’s consider today what we might expect from a certifying organization/company, and why.

When we sacrifice our hard earned money to pay into an organization, what do you think should happen with those funds? It’s not a question I asked myself clearly in my early years as a doula, but as I began to volunteer more behind-the-scenes, the question began to form in my mind. I’m going to encourage you to ask it early and clearly. Let’s chat.

Am I the only one who expected certifying bodies would work to achieve consistent, professional standards that would give the doula profession credibility?

In my early days as a doula, there were literally FOUR organizations that certified doulas in North America. Each had a slightly or more-than-slightly different vision about how things should be, and different focuses about where doulas should work and how. At that time, it seemed there was some focus on the future of the profession, some thoughts about how to elevate us beyond hobby/novelty status.

What a contrast to today, when we have between 65 and 80 organizations claiming to certify doulas. How far have we moved from having clear professional standards? What doulas ARE and what doulas DO gets more convoluted every passing year. Just log in and watch conversations in online groups; it’s so disheartening.

What did we hope for? Accreditation for doulas?

One thought that has been kicked around is that of accreditation for training organizations. Educational or training programs which are accredited enable students to use educational grants and other financial aid to train. Over 20 years after the doula professional formally began, the occasional student is able to use a grant to pay for training, but this is usually when a doula course is taken through an already accredited vocational school or college. Independent organizations are still not accredited for the general use of financial aid.

Being unable to use financial aid to access doula training limits new doulas from accessing the career in the first place, particularly those who are not middle or upper-middle class. This is a HUGE equity issue that few seem to want to address. Instead, the focus is on creating programs where the doulas work solely as volunteers, perpetuating the cycle of financial hardship and inequity while both the doula organizations and the healthcare system continues on profiting off the doulas.

What did we hope for? Medicaid and insurance coverage for doula services?

Have you given thought to what it would mean to our profession if we had consistent insurance coverage and/or Medicaid reimbursement for services? I doubt very much that I am alone in feeling this could open the door to eventually increase access to doula services to the most underserved populations while providing financial stability for the professionals. Yes, a couple of states currently offer a tiny payment through Medicaid. The truth is that Medicaid currently pays midwives such a pitiful amount that the average midwife cannot make a living serving only Medicaid clients. So, no, it’s not likely that doulas would be paid well under such a system. But progress along this path would have put us in a position of readiness for the day when our medical system again places value on prevention. As it is, little has been done.

What about insurance coverage, then? A few random clients here and there are able to extract some reimbursement from their reluctant insurance companies, or more commonly, pay for doula services through their HSA, FSA, or Flex accounts. But consistent insurance coverage has remained a pipe dream. The codes we have used in the past are clinical codes which are technically not lawful for doulas to use in the first place. Anybody up for being charged with insurance fraud? No? Me either! But in twenty years, there has been little if any progress in securing codes which are appropriate to doula work.

What did we hope for? Regulation for doulas? Licensure for doulas?

What about licensure, or a legal definition of what a doula is/does? As have discussed before, if four organizations couldn’t get it together to address the future of the profession, it’s unrealistic to expect 65-80 groups to do so. Would there be issues if licensure of doulas came to be? Of course. Regulation is never without its problems, and sometimes very concerning problems. But it seems to me that this conversation should have been happening in the last 20+ years. I’m sure most of us expected that our organizations would be working toward progress and legitimization for the profession. But for all our hope and expectation, for all our often sacrificial financial investment, none of this has actually materialized.

The fact is that moving toward licensure is not in the financial best interest of doula training/certifying bodies. Once the definition of a doula, the educational process by which a person becomes a doula, and the licensure process of being a licensed doula comes to pass, any community college or vocational school can offer doula programs tailored to that state’s licensing process. Guess what happens to all the doula training bodies? They have to compete with schools which can accept financial aid, and certification becomes unimportant when licensure is what is recognized. Ask me sometime how I came to realize this. It’s an interesting story for another time.

More repercussions…

Certifying organizations have missed a critical opportunity for the profession by not pursuing national standards for doulas in a timely manner. During the Obama administration, access to funds was increased dramatically for preventative healthcare including grants for hospitals to address the need for evidence-based training such as the Baby Friendly Initiative. The Affordable Care Act provided a range of preventative healthcare for women at no deductible and no co-pay. If there were ever a time when coverage for doula services might have been a possibility to achieve, or when any effort would have meant steps in the right direction, it was then.

Whatever your political leanings, I think we can all agree that the change in direction with this administration is going to funnel tremendous amounts of money away from preventative healthcare. It could easily be another decade before we recover a direction that again places preventative care as a high priority for coverage. If four organizations could not work together 20+ years ago to move forward productively, do you think 65-80 organizations can get it together to be ready for the next opportune moment? Yeah, neither do I.

Maybe you don’t want insurance coverage, Medicaid coverage, or licensure. Maybe you’re thinking that preparing for a “someday” when our medical system is more human-centered and less greed-centered is a waste of time. Okay, I hear you.

But what about how our profession looks within the context of the birth team RIGHT NOW? What about the credibility of doulas?

We have to ask ourselves, ultimately, how certifying bodies have contributed to how the doula profession is seen within the larger context of healthcare. What happens when there is little, if any, uniformity in doula practice standards?

The experience of the other professionals on the birth team and in the larger community is inconsistent at best, and frustrating at worst. Medical, midwifery, and nursing care providers shake their heads at us, wondering why we can’t get organized and have consistent standards for members of our profession.

I’ll never forget the utter disdain in the voice of the AWHONN representative I talked to at the last ACOG AIM meeting I attended in Washington DC. She told me “you doulas need to get your act together”. She was right! But our certification organizations have not improved this situation at all. In fact, all the splintering and factions have actually contributed to making our profession look unprofessional!

The whole situation which certification bodies have created is, well, disappointing.

This is ultimately why, when presented with the opportunity to make a change, I chose independence. Because YOU as a doula, or a person considering becoming a doula, deserve the most relevant education and training that you can access. I just can’t get behind this whole “certification” thing anymore. It’s a broken system that doesn’t serve the profession, but we just keep recreating the same box over and over again.

Why do we keep doing this? That’s a post for another day.

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