Sunday, January 18, 2009

Peer review again

So I'm going to do it, I've put the word out to local folks who are interested in peer review. I've polled the greater community and I feel like I understand better now after talking with a few close mentor-friends about why this idea isn't sweeping the community. That's fine. I feel like I want to go to the next level with my services, and really take ownership of the consequences of my decisions in a different way from what I previously did.

It's been hard to stay involved in lists and boards where people are throwing medical advice around - it's one thing to refer someone to information so that they can choose for themselves or take that information to their provider (or whatever they want to do with it), and it's another entirely to be telling women online what lies to tell their provider, or what herbs to use to start labor when the doula has no training, etc. It goes on and on. It's not black and white, the medical system is fucked, it lies to women more than anyone else- I think I've seen good informed consent once or twice, once at an abortion I attended where the risks associated with Cytotec took two pages which she had to SIGN (rather than "it's just a little pill" women hear in the hospital when they're being induced), and the other with my own OB/GYN. I do think I'm starting to understand informed consent a little more though and have some understanding of where docs come from when they don't feel they have to educate their patients - a lot of patients either don't want to know, don't care, or can't understand it. That doesn't excuse the provider from helping the client to understand before decisions are made though- but our system isn't set up to allow the provider in a busy clinic more than 3 minutes or whatever per patient. I mean, this system is fucked. It needs a serious overhaul.

Back to my original point (I think I had one)... I am having to really look at my connections and see if a) they're feeding me and b) if I am giving something back. I'm feeling right now that I'm more of a bur in the sides of those who like things just like they are, and that's not so bad, but it's pointless unless it drives discussion and it doesn't seem to be. So I'll just sit on my hands in public and come here (you know, my "private" blog.. hardy har har) and say what I need to say.

My friend said, "Tell the truth." I'm really intent on doing that - the truth as I know it is that the doula community has become so expansive and the definitions of doula work so broad that standards of practice (unless you're in a certifying body who tells you the SOP) are almost impossible to nail down. I frankly believe and have said many times that this HURTS our profession more than it helps us. Doulas are non-clinical care providers, but then we have midwifery students who are also doulas blending the lines... or doulas who want to be midwives going outside their scope... or doulas who think they are shields for clients and need to protect them from a birth the *doula* doesn't want her to have.

Doulas are not heroes. We aren't the protectors of women from the 'big bad provider'. It *disempowers* women to be their voice for them, we are no better than the providers from whom they think they need protection! For me, this means teaching my clients how to discern whether this provider/birth space/decision is right for HER, not for me, not for her outcome, but for this moment, right now, with the information and intuition and resources we have in THIS moment. If my client says she wants a 'natural' birth, what does that mean? "Natural" birth is just a word with a really nebulous definition. Does it mean no pain meds? Does it mean narcotics are okay but not epidural? Does it mean no Pit? Does it mean no vaginal exams? Does it mean homebirth? I might think my version of natural birth is what she's trying to achieve but if I don't listen and really hear my client, we might be moving in two different directions.

Doulas are not quasi-providers. One thing that drives me up the freaking wall is the 'doula as herbalist/homeopath/nurse/midwife'. Wear one hat, girlfriend, you only have one head. I don't know how to word this without sounding bitchy and I'm only half worried about that, so I'll just say it. *Doulas have no place giving medications, herbal or otherwise, to their clients unless they are herbalists!* Oh, and this one... *Doulas have no reason whatsoever to have their hands in a client's vagina!* Even in an emergency situation (unless the doula is the only one present), a father/partner can catch their own baby, there's no reason for the doula to get involved except to continue to provide support and encouragement. Of course there are exceptions, maybe dad fainted or something, whatever, but it's safer for everyone if the doula errs on the side of letting the mother's body do what it needs to do and helping dad to stay calm and present. Is a doula trained to manage a dystocia if it happens? Sure, we've all read/heard about the Gaskin maneuver but do we all know how it works, or what signs to look for that it's working or not? And what happens if we think we know what to do, try something and screw it up worse? Whose responsibility is that?

I don't think that we need to practice in fear at all. I think if doulas stick to what we're there to do, love and support the couple, share resources so that they can make decisions, we really don't have much to fear with regard to the law, or overly controlling doula policies in hospitals.

So what do I say when I see doulas bantying medical advice between them trying to clarify what to tell a client about the risks of something? Right now, I say nothing. I'm too fired up about it, so I'm just holding my breath until I can be settled in myself and calm. It feels good to write, though.


Anonymous said...

When I first trained as a doula, I wasn't really impressed with having a SOP. I knew a little bit about a lot of things and my friends and family regularly sought me out for 'complementary/alternative' options for everything from their cold to their hemorrhoids. I had a hard time NOT giving out that info to doula clients too, and was always looking for the 'grey areas'.

I understood that I wasn't a medical care-provider, but surely a little lavendar water wasn't that big a deal?

Over time though, I've come to realize all the things you've said above.

Now, I use my knowledge of lots of little things to help point my clients towards information IF they're looking for it (this herbal info book is well-respected; this website doesn't have good source material to back it up; this chiropractor has a good reputation etc.). Sometimes they don't want information, they're just happy with the status quo. Their birth. Not mine. That's ok.

It was a hard transition, but I think it is better for the client, and for me, in the end.

I do look up the medical side of things for my own interest - I read about how procedures are done, what their purpose is, what the risks are etc - it helps me be calmer in tricky birth situations expecially, if I at least have an inkling of what's going on. Because of this knowledge, I often find myself in the role of 'translator' between staff & patient when it comes to procedures. For example, the nurse comes in pp and says off-handedly to Mom "Just gonna do a quick fundal check". Mom looks confused and a bit scared because she doesn't understand. I say "The nurse (name whenever possible) is going to press on your belly where your uterus is, to make sure that it is shrinking down to its post-birth size. It could be uncomfortable. Just breath deeply like you did through your contractions. You'll be ok." Mom feels better because she understands what's going on, and strangley enough, the nurses feel better because they know that I understand what's happening and am not second guessing them because of a lack of knowledge on my part. I know not every doula works that way, but so far it's worked really well for me. If the procedure is one the Mom has had questions or concerns about, then I also ask her if she has any questions or concerns she would like to ask the dr/nurse about before they proceed. Sometimes they do, and sometimes, even when it was something they were adamantly against prenatally, they say 'go for it' when in the situation.

I think in some ways, I'm like a comma in a sentence. I don't stop or start the sentence. I don't change it's purpose or its theme or its function. I just create a pause here and there, so that it's easier for the sentence to unfold the way Mom wants it to.

Keep thinking and writing.... it makes me think & write too. :)