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The Doula Business by Cheryl Murfin

If there is one thing that Seattle childbirth education and doula pioneer Penny Simkin knows, it is this: Women never forget giving birth.

And how a woman is treated during this transformative experience — whether she feels cared for, nurtured and empowered during birth or directed, coerced and ignored — matters more than whether a mother labors with drugs or without, or whether her baby comes out vaginally or by Cesarean section.

How does Simkin, who is considered by many of her students and peers to be the “mother” of Northwest doulas, know this?

She asked.

In the early 1980s, Simkin became aware of studies coming out of Guatemala indicating that, as she puts it,“if a kindly woman were in attendance at a birth to cluck over the mother and hold her hand, it made big a difference.”

How much of a difference? According to researchers Drs. Marshall Klaus and John Kennell, the presence of that kindly, supportive woman with a laboring Guatemalan mother significantly reduced the length of her labor, the risk of pharmacological augmentation of labor, use of epidural and Cesarean section.

“When I first heard this, I sort of tucked it away, but it got me thinking,” says Simkin, who at 72 continues to teach childbirth education and labor support to packed classrooms.

In 1987, after nearly two decades of providing childbirth education to expectant parents — and joining many informally during their labors as birth mentor and friend — Simkin launched her own study on the long-term impacts of childbirth on women.

“I had the birth stories that these women who had attended my classes had written right after their babies were born (between 1968 and 1974), and 15 or 20 years later, I asked them to write their experience down again, without referring to the stories they had written,” Simkin recalls. “It was uncanny how similar the versions of these stories were.” The women in the study also participated in lengthy interviews about their birth experience and the long-term impact it had on them.

The bottom line was this: Women who felt a sense of accomplishment during childbirth, who felt in control of both their responses to contractions and of what was done to them by providers, and who felt the birth enhanced their self-esteem, reported being satisfied and empowered by the experience even 20 years later. Most important, the level of satisfaction these women felt was not associated with how the baby was born but with the relationship with their provider.
In other words, how they were emotionally and physically cared for by doctors, nurses, and, in the rare case back then, midwives, had a great impact on the woman’s sense of accomplishment, control and self-esteem.

“What I realized is that we can’t always control how a birth goes, but we can control the care we give,” says Simkin. “And the fact is, even now we don’t have enough care at births.”
With this information and the growing body of research produced by colleagues like Klaus and Kennell in hand, Simkin began looking for a place to offer training for a legion of “kindly women” she envisioned would support other women in labor.

Simkin is quick to tell you that she did not invent the word doula. The literal translation from Greek is akin to “servant woman,” and it was introduced in this country by author Dana Raphael to describe a woman assisting families with a newborn (now what is referred to as a postpartum doula). Drs. Klaus and Kennell took the word and used it as a birth term in their writings.

At first, Simkin was turned down by numerous groups, but eventually she joined Seattle Midwifery School and helped develop the first Labor Support Course, offering the first class to 23 students in 1988. Shortly thereafter, doula pioneers Annie Kennedy, Dana Blue, Sandy Szalay and others worked with Penny to establish the Pacific Association for Labor Support (now PALS Doulas) to assist doulas in their work.

“It wasn’t the only place that this idea of training labor support providers was coming up, but it was one of the very first and one of the most formal courses with actual objectives,” Simkin says. In the years following that first course, thousands of women (and a few men) have completed the course that Simkin still teaches on occasion.

In 2008, Seattle Midwifery School named its allied birth education programs after Simkin. These programs, including the Labor Support Course and many others, are now offered at the Simkin Center for Allied Birth Vocations at Bastyr University, into which Seattle Midwifery School merged this year.

Each month, students arrive at the Labor Support Course to learn the age-old tricks that help a mother climb the mountain that is labor to reach the point where she joyfully holds her baby, beaming with pride. What a doula learns is not highly technical, but scientific research certainly backs up the efficacy of this form of hands-on emotional and physical support.

In just about any class, Simkin teaches doula students and parents about the three elements that help a woman manage her labor well: ritual, rhythm and relaxation. Each is a tool that helps a laboring woman cope with discomfort.

“If you see she is rocking, you want to encourage her,” Simkin tells her students. “Tell her she is helping her baby find his way.”

Doula students in the current Labor Support Course and parents in local childbirth education courses are likely to learn about the gate control theory, the idea that women are great multitaskers and that this skill is very useful in labor. If the woman is sitting on a bed and doing nothing but contemplating her belly — with no other sensory input to distract her brain — she will feel her contractions more intensely. But if a birth partner adds stimulation in the form of a firm one-way massage down the arm, heat on the lower back, movement, music, and something to smell, taste or look at, her mind must now manage five things at once. Contractions feel less intense to a multitasking brain.

Simkin reminds her students and expectant parents that the mother is not in her labor alone. The baby is in a process as well.

What it Takes to Be a Doula

So what does the mother of Northwest doulas believe it takes to be a doula?

“You have to be emotionally clear and able to give any woman you are working with whatever she needs for as long as she needs it,” Simkin says. That may be six hours or six days, depending on the labor. Doulas often spend 24 hours or more with a laboring woman or couple.

“The person called to this work must have stamina, patience, a peaceful spirit, confidence in the process, and a genuine interest in helping the woman have the best possible birth experience as she (the mother, not the doula) defines it,” she says.

A doula is someone who can remain neutral in the political cyclone that is childbirth today, she adds. And a doula must be able to provide factual information while parking her own interests and desires at the door in order to assume the values and desires of her client. A doula should never push her preference — be it about the use of drugs or a position — on her client.

Aside from these traits, Simkin feels strongly that a good doula is one who can and will keep confidences: “What she tells us stays with us. We don’t broadcast a mother’s experience.” And she cautions her students that it is difficult to be a professional doula when you have small children at home given the unpredictable schedule and considerable time commitment the job requires.

“You can’t be a new doula and be a new parent or have other inflexible job commitments. You have to be 100 percent reliable,” she says. “We can’t say to women that we’ll be there and then not be there. And if we can’t be 100 percent reliable, we have to make sure we have a backup doula so we know the mother is covered.”

When Penny Simkin began her doula work, there were perhaps five others in the city also informally attending births to support laboring mothers.

Now, according to doulamatch.net, a new and popular national doula matching Web site developed by local doula Kim James, there are more than 200 active doulas working in Washington State, some full time, some part time. PALS Doulas, the professional organization that certifies birth doulas in the region, has nearly 40 certified birth doulas listed on its Web site and many other members working toward certification.

The Business of Being a Birth Doula

While one does not have to be certified to practice as a birth doula, the leaders of PALS Doulas stress that being certified is an indication to both parents and health care providers, including obstetricians, nurses and midwives, that the doula has experience and follows a specific code of ethics and scope of practice that she understands extends only to emotional support, physical support, information and advocacy.

“One of the reasons we have a professional organization is that we have a grievance process,” says Carrie Kenner, owner of Big Belly Services and president of the PALS board of directors. “It is important from professional to professional to have our grievance process understood and utilized, and to have our certification process understood and utilized by all parties so that we are seen as a trusted part of the birth team.

Professional doulas working in Seattle generally get started as volunteers and then develop a paying practice. Most paid doulas have given thousands of hours to the community in unpaid doula care and many continue to offer some pro bono care as part of their business.

The cost of doula care ranges widely depending on the doula’s experience, from free to upwards of $1,200, a price generally associated with a more experienced doula and one that often includes prenatal and postpartum home visits, breast-feeding assistance and 24-hour phone support to new parents in the first weeks of life.

Within the childbirth industry there is continuing debate about how much, if anything, doulas should be reimbursed for their services.

Alissa Wehrman, owner of SUNbirth Services and head of the PALS certification program, is quick to point out that no one comes to the work for the money. The hours can be long and physical exhaustion is common. People who choose the profession do so because they love to serve women, believe in the power of the birth experience to transform lives and feel that women have the right to make informed choices about their care. Still, she is clear about what compensation covers:

“We get paid because we provide a valuable service. We don’t get paid just for the hours we are at a birth, but for the experience we bring, the continued care, the commitment to continuing education, the hours of being on call, the birthday parties we miss,” Wehrman says.

As one doula recently put it, “according to the living wage calculator, in the Seattle area a single person without children needs to earn a minimum of about $20,000 annually. According to our business calculations for what averages to a 40-hour work week, many doulas are charging well below what it takes to operate a business and make that amount.”

“It’s concerning because it means women are not receiving a living wage for their work,” says Vanna Waldron, who is just launching her practice, Down to Earth Doulas, with partner Rebecca Allen. “It also deters doulas who do not have another source of financial stability from joining the profession.”

Paid or unpaid, doulas are becoming more and more common in Seattle-area hospitals and birth centers, fulfilling the dream that Simkin and her colleagues had when they developed the first doula training program in Seattle and launched both PALS and DONA, an international doula association. That dream was to provide “a doula for every woman who wants one.”

While many of the women first trained in the Labor Support Course developed by Simkin were Caucasian, the doula profession has been greatly diversified recently under the leadership of Open Arms Perinatal Services. Open Arms has dedicated itself to training doulas from specific ethnic communities and linking them to pregnant women in those communities.

In fact, Open Arms was contracted several years ago to create the community doula program now operating under the White Center Early Learning Initiative (WCELI), an effort funded in part by the Bill & Melinda Gates Foundation and others to ensure that all children in Washington communities are ready for kindergarten when their time arrives. The community doula program recognizes that preparing for kindergarten includes ensuring that new parents are well supported before, during and after a child’s birth.

As a partner in WCELI, Open Arms provides birth doulas to women from various cultures having their first babies in the United States. The doulas work closely with the initiative’s home visiting team at King County Public Health.

Open Arms also actively recruits and trains women from White Center’s Somali and Latino communities to become outreach doulas. Outreach doulas, similar to typical birth doulas, provide services to women from pregnancy to birth, but they also continue to meet with and help the family for up to two years after delivery. Because outreach doulas are of and from the communities they serve, they are often better able to navigate the cultural barriers that can make it difficult for women to have satisfying birthing and parenting experiences.

The national Americorps volunteer service program has also recognized the value of doulas. Sea-Mar Community Health Centers, which provide health care and education to Latino families throughout Western Washington, offer services from bilingual doulas to its families through an Americorps position.

A New Generation of Doulas

Vanna Waldron honed her skills as a doula in her AmeriCorps position at Sea-Mar after getting her undergraduate degree in Latin American studies and gender and women’s studies at Oberlin College.

“I was particularly interested in immigration issues and how the United States’ policies affect families and mothers from Latin America,” says Waldron, who, like many doulas, entered the field as a step to becoming a midwife.

“I interned at Maternidad La Luz, a birth center and midwifery school in El Paso, Texas,” she says. “I’ve found that in addition to the hard work of birth that all women face, immigrant mothers from Latin America are often also presented with the challenges of language barriers, racism, immigration status, a lack of employment protections, an unknown medical system and living far away from their support network.”

Waldron and her partner Allen have both taken cultural versatility training through Open Arms to help them provide culturally competent care to their clients. But as Waldron launches her new practice, she says she is learning more and more about the kinds of support that help women in labor transcend culture.

Why Do It?

Alissa Wehrman, who has been an active doula for nearly a decade, is thoughtful when asked how she gets up in the middle of the night, often staying up for days, only to go home and be called to another birth by another client perhaps just hours later. She works hard to take care of herself, her body and her family, including trying to keep two months free of babies.

“Being a doula, it’s like a big wave, it’s an ocean. Two or three weeks ago I was so tired I was a disaster, really. Now I’ve had a little break and I am clear, reasonably rested. It’s hard on everybody,” she says. “But it’s also a sort of meditation. The transition from your own family, from where you are when the call comes, that is hard. But once you go, once you get there, it’s Zen. Everything else goes away. That’s what nobody else gets about why we do this work.
“The truth is, I have to fall in love with each of my clients,” adds Wehrman. “If you don’t, why would you get up at four in the morning and be willing to do whatever it takes for as long as it takes? It is a huge deal to be ready for a birth. We are doing a huge service — we are not just showing up in the middle of the night, we are leaving a life.”

A Simkin Future

If Penny Simkin had her way, there would be a lot more doulas leaving their lives to care not just for women in labor but for people in any kind of need.

“I want a doula for everything,” says Simkin, who is currently focusing her efforts on helping survivors of sexual abuse navigate birth.

“I don’t want them just for birth but for everything; surgery, for children in hospitals…. I played the role surgery doula for a woman recently and it was so important that I be there. I think any time people are facing hardship there is a place for a doula.”

Cheryl Murfin is a freelance writer and owner of Nesting Instincts, a Seattle-based doula care business.

The Difference Between Birth And Postpartum Doulas

Birth doulas are labor support professionals experienced in childbirth who provide continuous physical, emotional and informational support to the laboring woman before, during and just after childbirth. Birth doulas assist women giving birth in hospitals, birth centers and at home. The birth doula accompanies her client in labor, gives emotional and physical support, suggests comfort measures, and offers encouragement and suggestions for both her client and the client’s partner. Whenever possible, the birth doula delivers pre- and postpartum emotional support, including explanations of practices and procedures, throughout her course of service. The doula also advocates for the client’s wishes as expressed in her birth plan, in prenatal conversations and in intrapartum (during birth) discussions. She helps the mother incorporate changes in the plan if and when the need arises, and she enhances communication between her client and the client’s primary caregiver.

The doula does not speak on behalf of her client or make decisions for her, which may cause deterioration in the relationship between the mother and her caregiver. The doula’s advocacy role is to offer support, information and mediation or negotiation.

Birth doulas are not regulated or licensed professionals; however, many hold certification as a part of their professional practice. Source: www.palsdoulas.org

Postpartum doulas care for mothers and their families in their home in the first few weeks following the birth of their baby. The doula provides nonmedical support and companionship, assists with newborn care and sibling adjustment, meal preparation and household organization.

As a nonjudgmental caregiver, the postpartum doula assists the new mother with her recovery from the birth experience, allowing her to focus on the needs of the new baby; helps the new family by demonstrating practical newborn care and supports the mother with the method of feeding she has chosen. A postpartum doula provides individually tailored emotional and practical in-home support.

Services vary from family to family but often include breast-feeding/bottle-feeding support and assistance, suggestions and assistance with the mother’s recovery, advice on infant and parent sleep patterns, guidance on newborn care, recognition of and response to postpartum mood disorders, light housekeeping, laundry and meal preparation and sibling and pet care.

Postpartum doulas are not regulated or licensed professionals; however, many hold certification as a part of their professional practice. Source: www.napsdoulas.com

WEB EXTRA: One Birth by Cheryl Murfin, CD

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