Can The Doula Practice Become A Thriving Business?

When I was studying to become a doula in Israel, in 1997, my teachers told us something like this: “You can not make a living form practicing doula. Do not quit your jobs if you need to provide for your families. Think about it a s a skill you have acquired, which will enrich your friend and family, and will change the lives of women in your community.  

So for a while I kept my position as professor assistant and continued teaching some college classes in film theory, but that was simply not enough. My frustration was as big as my passion to support healthy and safe births, and take part in his transformational experience.  It took about a year for me to quite teaching, and to take this leap of faith into my call- becoming a birth doula.

However, I also had to earn money and take part in providing for my growing family. This meant that my call had to also be transformed into a viable business.  What did I know about running a business and becoming self employed? In one word: Nothing!

I made it through ups and downs with great motivation, a lot of passion, many mistakes, trials and errors, and persistence.

These days, when I am mentoring new doulas, I dedicate a full class, 5 hours, to cover the business aspects of developing the doula practice: The economics of doulas fees, technical arrangements; liability insurance, contracts, how to promote yourself – which organizations have “meet the doula “events, how to maintain relationships with leads, how to maintain relationships with past clients for future referrals, websites, blogs, giving lectures, and more.

It is not easy. Every self employed must have a lot of self motivation and discipline. We must understand that our work is not only to support our clients, it is also to find clients and sources of referrals, collect fees and maintain working relationships.

It is doable, it is possible, if we accept it and not reject it, if we agree to practice the  business aspects of our profession.

Supervising My Doula Students

As my students are nearing the end of their program, there is a lot of excitement about finding   clients for their supervised births. Each and every one of my students is going to support two clients for no cost, and will be supervised by me and by the wonderful midwives who practice at El-Camino hospital in Mountain view, CA -  Lin Lee, Bethany Monte and Olga Libova.

 I am so grateful for being able to offer this opportunity of supervision. When I was studying to become a doula, I had to take 100 hours shifts in Labor and delivery in a hospital located in Jerusalem. I did not have the chance to get to know the couples ahead of time, so there was a missing piece in the process. I just showed up for a shift, day or night, and offered my support as a doula in-training. I found then, and I still see now, the value in practicing all the doula tools,   applying the new knowledge, and practicing this new presence of a birth care giver, under the supervision of experienced midwives. When I was designing my own training program, I knew I wanted to give this opportunity of practicing under supervision to my students.  At its fourth year, it is obvious to me that we have a win-win situation in hand- my students are matched up with the midwives’ clients, and get their hands-on experience and supervision, and the couples are enjoying the presence of a knowledgeable and passionate doula for no-cost.

I supervise my students via text messaging and phone calls, day or night, I am there for them.

I ask questions which will help them and me to analyze the progress of the birth, and I encourage my students to be sensitive to all aspects: emotional reactions of both mother and partner, the relationship with staff, whether or not there is a need to deviate from the clients’ preference list, and more. I remind them of options- another position or another trick to help the baby change position or drop to pelvis, I advise when there is a need to call the nurse, and help them phrase the question in an accurate and respectful way, and more. Most of all, as my student say – it is knowing that I am there for them which  gives them confident to practice all that they have learned.

Obstetric Gynecology Is No Science- A Reminder to both doctors and doulas

One of the qualities of science is that it is predictable.  When creating a scientific experiment you are making an assumption regarding the result.  When the findings are in line with the assumption time after time, it becomes a prediction you can rely on. If obstetric gynecology was a science, doctors would have been able to manage birth. However, the body has a mind of its own, and we can never fully predict the result of any medical intervention by 100 percent.  This is a lesson which both doctors and doulas should be reminded.  Why doulas? Since part of the doula role is to advise her clients to avoid a medical intervention suggested by the doctors, if she thinks it is not evidence –based care and has high potential to take her client to a cesarean.

At a recent birth which I have attended, the doctor decided to induce my client 3 days before her due date. The client had hypertension for the last two months of her pregnancy; she was swollen and suffered severe headaches, which in a way increased her chances to be induced. However, my client was told by her doctor that the reason for the induction is a reduction of amniotic fluids, which her associated with the hypertension.  My client was never told how much of a decrease there was, and the truth is there is always decrease of fluids as mother is nearing the birth. 

My client was admitted to the hospital on Tuesday at 1pm with a firm, long and closed cervix, and a baby in station (-4), meaning- baby was not engaged in pelvis. The disengagement of the baby 3 days before the mother’s estimated due date is a concern which should not be ignored, Why is the baby so high? Something must be In the way of this baby to come down to the -3 or

-2 position , which is common around due date. Looking at the client’s belly, and investigating about where she feels the kicking and wiggly sensations coming from the baby, I suggested that the baby is posterior.

Upon admission, at 1pm, my client received 12 hour doze of Cervidil., which took her  to ½ cm dilation. The doctor wanted to proceed to Amniotomy- rupturing membranes. When she consulted with me over the phone, I told her that to the best of my knowledge it’s a no-no. Here is what Henci Goer wrote about it in her book: “The Thinking Women Guide to a better Birth” : “Studies suggest that early amniotomy may not benefit slowly progressing labor….If the baby is posterior…labor often progresses slowly until the baby turns into the anterior position. With membrane rupture, the head may surge downward into the pelvis and get stuck. …releasing an amniotic fluid adds to the baby’s stress by exposing the umbilical cord to compression during contraction. In addition, one potential cause of fetal distress is that the umbilical cord has slipped between the head and the cervix. Rupturing membranes could then cause prolapse”.

Relying on my experience and my knowledge, I advised her to ask for low dose Pitocin. And so she did.  Pit was started at 9 am, and around 1pm I joined her. She had contractions every 3 minutes for a minute long for a while, but she was not progressing still. At 5 pm I decided to talk to the nurse and see what the plan was. They decided to stop the Pitocin and let my client eat and rest. I went back home and talked to my client at 9pm again, when she told me the doctor decided to try Cervidil again.  At that point I asked her for her blood pressure, and when she reassured me it was on the lower side, I raised the question- why not going home? The client can go home, have a good night rest and come back tomorrow morning to the clinic to be monitored. 

The couple decided to stay at the hospital, and proceed with induction.  To make a long story short, after 12 more hours of Pitocin, the doctor did operate and amniotomy, when the baby was still at -4 and the cervix at 1.5 cm.  As her doula, I shared my opinion and knowledge with my client – that was not evidence based care, extremely invasive, and has high potential to end up with prolapse, deceleration of baby’s heart rate and cesarean. 

However, breaking the water got my client to 4 cm in 3 hours. After 2 more hours she was in 6 cm. Pitocin had to be increased again and again, but the baby was just strong.  Around 8:30 pm she was stuck again at 8.5 cm, and the doctor came to diagnose a posterior baby (Told you J) , He was kind to agree to collaborate with all my requests for position change, even thought my client was already on Epidural. We managed to bring the baby to an anterior position after 6 hours, started pushing at 11:30pm, and the baby was born vaginally at 3:38 am on Friday.

Although it was quite a triumph- a long induced birth which ended vaginally, I can’t tell you I felt good. I was haunted by the thought that we could have agreed to amniotomy when the doctor first suggested it , at ½ cm, and maybe save the mother many hours, since after all  things did start to progress with the amniotomy.  But I have no proof that we wouldn’t end up at the operation room as well. The doctor took a huge risk breaking the water with such high baby, but this time it worked just fine. There is really no way to fully predict the result of medical interventions in birth, we can only rely on our best knowledge and our experience, and hope for the best.  I had to remind myself of this concept of unpredictability of OBGYN, and believe in my contribution as a doula  -  the comfort measures I applied, such as relaxation and visualization techniques and breathing techniques, and the positions we changed in order to bring the baby to the anterior position.  Who knows if we wouldn’t end up with a cesarean without these positions? 

What's between Pathologies and Pacing and Leading in the doula practice?

Only two classes into the birth doula training of 2010, and so much growth is taking place in the group.  We share a growing intimacy, and we support each other’s personal growth. Every year I am in awe of how fast these courageous and remarkable women, my students, are willing to commit to the process of growing and becoming a care-give and a leader.  A good birth doula is a care giver and a leader, a sister and a friend.  

The theory content of our first class meeting covered the Physiology and Anatomy of birth.  Then we all watched together a movie made by BBC called “An everyday miracle”, presenting the struggle the egg and sperm goes through on the way to become a human fetus and baby. It took us to a journey inside of the mom’s body from the moment she was trying to conceive, all the way to the successful homebirth and the embrace of the new baby.   Every time I watch this movie, I get this sense again of how privileged I am to take part in so many healthy births.

Then we had the coaching part of our meeting, an exercise in tows.  This time it was a fun activity which was an opening to understanding and practicing of the Pacing and Leading principle.

In this fun exercise I asked my students to partner up in twos. I gave every couple an eye cover, like the one you get in airplanes.  While one was covering her eyes, the other one had to guide her through drawing a picture on a blank paper, using whatever leading tools she needed. Then they switched roles, and the follower became the leader. There was a lot of laughter in the room, and many different styles of leadership that I could observe.  I sent my students home with a list of questions regarding this exercise and what they could learn from it.  Here are some questions the students were asked:

1. In which role did you feel better/more comfortable - the leader or the follower?
2. How was your leading style different than the one of your partner, or other members if you were watching them?
3. What was your leader doing that was beneficial for you?
4. What was missing? (Example: clarity, more confidence, more instructions, more encouragement…)
5. What kind of understandings can you reach from this exercise re the doula role? What can you learn from this exercise about yourself as you are becoming a doula?

Today was our second meeting, which covered pathologies. Needless to say not my favorite subject of all, but something a doula has got to be familiar with. Many of them I categorize as FYI – for your information only, b/c there is nothing for doulas to do other than be a resource to our clients. Some other pathogenic conditions might show up during birth – such as being over due, having prolonged early phase, failure to progress in active labor, OP baby or any other mal position, or  heavy bleeding,  and birth doulas  should be accountable for these, and know their Para-medical tools to deal with these.  After a long and exhausting theoretical part of the class meeting, we took our lunch break, and then there was time for coaching and growing. I tell my students when they inquire about the training that so much of the learning takes place in the informal part of the class- lunch break. Then it is wisdom time. :)

Today during lunch I used pathologies to refer to pacing and leading. How do we react as doulas when a birth client calls us with some new diagnose – breech baby, diabetes, need for induction, narrow pelvis etc. How do we not presuppose her emotional reaction to what she just heard from her OB and confuse it with ours?  How do we look for clues whether or not she is interested in more information regarding her options? How can we not judge her for not wanting more information? How do we become a resource for her, but still do not give her any medical advice?  How do we empower her to rely on her partner and friends, and not feel solely accountable for the decision? How do we empower her to go back to her OB with further inquiry, while being well informed, and present him/her with articles and evidence based information?

This whole process is relying on pacing and leading, or we are risking loosing our client, either because we impose our belief system on her, or we sound judgmental, or she feels like she is disappointing us, or she just realized we are not good support for her.  With good pacing this will not happen, and we will follow clues which signal that she is ready for our lead. 

During this conversation, and later when we shared the answers to the pacing and leading exercise, I was very touched by the growing intimacy and by the sharing. I feel so much respect when already at the second meeting students are observing areas which challenge them, and become clear about their need to practice new habit and behaviors and grow in these areas while becoming the excellent birth doula they want to become.

Namaste.

What a student can teach her mentor...

With my 14 years of experience, I feel pretty confident to joke around the pushing phase saying:

"No baby has ever fallen out of her mom's vagina". Well, no more jokes around it.

My wonderful student from last year, Dorit, called me on her way back from supporting a birth client, still under what may sound like panic reaction to what happened at the birth. I listened, I was shocked and amazed, I grounded myself  and helped her understand what happened ,and calmed her down. My advice was: Sit down now, as soon as you are home, to write this experience for yourself. It will help you not to forget details and time frames, and will assist with processing this experience.

Here is what she wrote to me and to her sister doulas the next day (posted her with her permission):

I got the first phone call at 4am. Alex (age 21, second birth) told me that her water broke and she is going to the hospital with her husband and will call me at the morning. Around 11:30 am I talked to her. She updated me that they just started the induction and she started to feel the contraction. I arrived at the hospital at noon. Alex was sitting on the bed. I encouraged her to take a walk with me (her husband told me that they all tried to convince her all morning) . We took a long walk and after that went to the shower, Alex was great with the contraction, and she planned to take an Epidural close to Transition phase.

From the minute I arrived, the nurses all the time asked her to take the big E (Epidural), they didn't know what was her dilation. Alex asked not be checked virginally until the E (she said that she can’t stand that). She got the E at 2pm, when she had a 6 cm dilation!

At 3:30 pm the nurses changed shifts. Around 3:45 we called them and asked to switch sides, Alex asked if it's OK to be seated for a while, since she was coughing heavily all day. We put her in a sitting position and continued chatting with a very nice student nurse, who attended L&D the first time in her life. About 10 min after, the nurse came back in and asked Alex to turn on her side in order to monitor the baby better. We helped the mom turn, and the nurse was looking for the baby's heart beat...nothing....for me it looks like for ever, she asked us to help the mother fix her position, and in that moment the student nurse picked- up the blanket and said "THE BABY IS OUT"!! We called for help and in seconds had 15 people in the room. Alex was in a big panic (me to). I was with, her holding her hand, trying to calm her down, until we heard the baby first cry and were relieved.

Little Julien delivered himself at 4:04, 6.30 pound.

So, want to be a doula? How amazing is our job? Having doula students is exposing me to so many situations in labor, I am enriching my knowledge and experience through mentoring. I love having amazing strong women like Dorit as my students.







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The Labor Practice - my new passion: integrating childbirth education and coaching concepts

If you know me personally, or professionally, you know I wear different hats: I am a childbirth educator and group facilitator, I am a  birth doula and  a doula mentor, and I practice life coaching and hypnosis. I feel like I always wear all of my hats, and it is just a shift of focus, a slight adjustment which I make in what gets more focus, or maybe you can see it as a shift between foreground and background. For example, when leading 
my student as a childbirth educator, I am always a coach and a group facilitator, but the context of childbirth education gets the focus. Sometimes I work as a coach, and I think  "wow, she would really benefit from hypnosis", and then I might suggest this client to try hypnotherapy in order to bring about the change in the area she is being coached.  I think my doula students are the ones that really gets to experience me wearing all my hats: As a doula mentor I am incorporating years of experience as a birth doula and as childbirth educator,  with my coaching skills. I coach my students around emerging issues and facilitate their growth into the position of the care-giver and birth doula. As part of the training they get to partially experience  hypnotherapy, as I lead them through relaxation and guided imagery, and teach them several visualization techniques to work with.  Since the training is in group sessions,  I do serve them as a group facilitator - creating safe and intimate container, encourage all-inclusive atmosphere, balancing the agenda with the group pace and with emerging issues of individuals who creates the group, taking an anecdote being shared by a group member and making it into a learning experience for all, being accountable to model nonjudgmental feedback, and more. 


As I keep integrating all my skills and areas of practice, my latest passion is the integration of childbirth education and coaching concepts. It has been about 6 months now since I began developing my new concept of childbirth class - The Labor Practice.  I have just finished writing an article which explains how I got to this concept and how it practically works. For many years we taught expectant moms that if they react to labor pains, the pain of contractions, the same way they react to other pains- with alert, concern, fear and rejection,  their habitual reaction is in the way of a good healthy and safe labor.  Labor tools are in support of the progress of birth as well as the ability to cope with the pain of contractions.  Labor tools are relating to the physiology and anatomy of birth, and when mothers do practice them,  they have better chances of having a healthy birth which progresses in a timely manner (Off course it takes some collaboration from your baby too). It is hard for me to accept philosophies of childbirth education which deny the presence of pain in labor. Contractions are strong cramps of our uterus, and when a muscle cramps, pain is present. 
So how are you being with that pain and what are you doing when you are in pain?  That is a question every mother needs to deal with, and is central in the doula practice. 


The Fear-Tansion-Pain syndrome  is used to describe our habitual reaction to any kind of pain. When it comes to birth, the set of physiological symptoms affiliated with fear and tension is inhibiting the progress of birth. In short, the uterus works on two kinds of “fuels” –oxytocin and oxygen, both are in charge of effective contractions. In the presence of high levels of adrenalin, due to tension, the release of oxytocin is inhibited, and our contractions are not becoming stronger and closer together, meaning- failure to progress.  In the lack of adequate amount of oxygen-  the uterus is not contracting effectively and therefore the result is the same- failure to progress.  

Going back to coaching- it takes a lot of practice to break a habit. It is not enough for mothers to just quire the labor tools  in childbirth class, they need opportunities to practice them. We need to learn the steps of the dance, and then practice them in order to perform. If we want mothers to rely on their birth tools, we need to create these opportunities for them. This is the goal of the Labor Practice- a drop in class, just like step or yoga, to allow mothers and their partners to practice their tools for labor an a weekly basis until the birth.
The classes are designed around topics: a class about using different balls, a class about different techniques of visualization, and a class about expansion of the body in birth, a class about the spiraling of our body in birth, and more. I always begin the class asking mothers what they wish to take that day, and I’ll do my best to meet my students’ needs. For example, sometimes I have 3 couples coming to the class around their due date, wishing to be reminded of their tools, and then I’ll practice with the group about 20 minutes of each phases of the birth reminding them of the different phases and different tools they choose for them. My goal is to give mothers and their partners the opportunity to practice the tools of labor on a weekly basis, so that they know the steps of the dance so well, on their birth day they will dance it. All it takes is practice, practice, practice.


If you want to read more about the Labor Practice, please click on the link to read the article on my website. 


  

Wow, I think I'm ready with two local groups

The last month was all about recruiting students to my upcoming birth doula training. One thing I have learned from the process is that you can no longer be a self employed or a small business and just focus on the service you are offering the world. Whether it is a service like mentoring, coaching, therapy or day-care, or you are selling products, the world has changed, and it is all about SEO- Search Engine Optimization. If Google search engine can not find me – I do not exist! Now imagine me - being a Taurus, big mama, gave birth three times vaginally and naturally, a birth doula, birth doula mentor, with preference for intimacy and eye-contact and lots of touch, having to learn all about attracting potential students via cyber space, and spending hours on key words density, tags, link building, site maps, duplicate content, free press releases, social networks and authority websites….OMG. I was so challenged. However, you can find me now much easier (You and Google spiders :)). By reading my blog right now you are taking part of this effort of telling the world about me and my extensive and amazing birth doula training. So thank you! A big Thank you is sent to the universe for bringing to my life my new friend and doula student Esther, who was so committed and patient in teaching me all the above, and coached me for becoming active, do the work and get results. I love you Esther!

The current results are that my website does come in a more visible and practical place when you search for “Birth doula training in San Jose/San Francisco Bay Area”, or “Becoming a doula”. The more exciting results are that there are amazing 8 students signed for my training, and there is still a month ahead of us, so I am hoping for 1 or 2 more. On my website there are already program schedules for two groups, isn’t it great! (If you are considering joining my training, I am recruiting now for group B). I am assuming this is also thanks to the raving testimonials my past students wrote me in different places, which might be the result of my investment and dedication to provide the most through birth doula training anybody could think of.

This year training has evolved so much. I have prepared more hand outs, I have developed information sheet of how to use the supervisions, and there are more coaching exercises included. The most exciting news is that the Birth doula training at Mama Center is now officially the only training in the USA with close supervision in L&D, as this year students will take shifts joining the midwives for their births. I can't wait to begin! How about you?