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The real joy in being a labor and delivery nurse and a birth doula is being able to combine the holistic and medical aspects of my professional practices to help mothers and babies.
Karla Salinero, RN & Doula
Melinda Gates, American philanthropist and women’s healthcare advocate ended her TED presentation in 2010 with this statement: “My vision of happiness is a mother holding a healthy baby in her arms. To me, that is deep happiness.” Putting words into action, the Bill & Melinda Gates Foundation has invested $1.5 billion to improve maternal and child health programs—a goal in alignment with the United Nations Millennium Development Goals 4 & 5 to reduce maternal and child mortality by 2015 (Gates Foundation).
While the philanthropic contributions from the Gates Foundation were aimed at improving maternal and infant health in developing nations, recent birth statistics show that there is cause for concern for the health of mothers and babies in the United States as well.
The Society for Maternal & Fetal Medicine (SMFM), an organization committed to supporting the clinical practice of maternal-fetal medicine for high-risk pregnant women, states that the U.S. has the highest rate of maternal mortality among developed nations (SMFM 2019). In response to these concerning statistics, obstetrics and gynecology organizations are calling for increased maternal support before, during, and after childbirth. One allied health profession that serves the emotional and physical needs of expectant mothers during their birth experiences are doulas. They are professional health coaches dedicated to supporting women and their families through labor, delivery, and postpartum care.
Read on to learn more about the services doulas provide and one woman’s professional journey to becoming a birth doula.
Doulas: A Growing Profession
A growing body of evidence supports what communities of women have known for centuries: when a woman is well-supported during a birth experience, labor, and delivery outcomes are more positive.
In a co-authored study by the American College of Obstetricians and Gynecologists (AGOG) and the Society for Maternal-Fetal Medicine (SMFM), it was concluded that one of the most beneficial resources an expectant mother can have during labor and delivery is continuous one-on-one support from a doula (AGOG 2019). This study concluded that patient satisfaction was higher and cesarean deliveries were significantly reduced when a doula or similar maternal support care was present at the birth (ACOG 2019). The study concludes with the assertion, “Given that there are no associated measurable harms, [doulas are] probably underutilized.” (AGOG, 2019).
Furthermore, research published by the Journal of Perinatal Education (JPE) demonstrated that the outcomes for mothers and infants are more positive when sustained one-on-one support from a doula is provided. This research called on hospitals to include more systems of doula support to help mothers and infants directly, as well as relieve nurses who cannot fully attend to the needs of laboring mothers due to their other professional obligations (JPE).
While there are currently no occupational statistics for doulas, the U.S. Bureau of Labor Statistics (BLS) publishes data on the somewhat-related labor and delivery occupation of nurse midwives. The educational and professional requirements for nurse midwives are far more advanced compared to those required of doulas, but the roles share the common goal of helping mothers during labor and delivery. The number of nurse midwives is growing at a rate of 26 percent (2018-2028), which is much faster than the national average (BLS 2019).
Nurses with advanced degrees are referred to as advanced practice registered nurses (APRNs) or doctors of nursing practice (DNPs) and can specialize in maternal support care for labor and delivery during their clinical training. While these two occupations are vastly different in terms of education and professional preparation, both involve the care of laboring mothers.
How to Become a DONA International Certified Doula
Training courses to become a doula are offered through several accrediting bodies, and one of the most respected organizations in the medical community is DONA International. For the past 25 years, DONA International has certified 13,000 doulas in 56 countries. The organization offers professional training, certification, and continuing education resources which are designed with best practices to empower doulas to support maternal birth needs and work in tandem with medical birth professionals.
Training courses for doulas typically last 16 hours or more and to become certified, there are several tasks and professional mentoring opportunities required. Once completed, the title of “DONA International certified birth doula” is earned. Below is a list of tasks to complete in order to become a certified doula through DONA International:
- Become a member of DONA International
- Purchase a DONA International certification birth packet
- Complete a DONA International-approved training workshop
- Agree to and sign the DONA International code of ethics and standards of practice documents
- Read required texts
- Take a course in breastfeeding basics
- Audit a childbirth education series for expectant parents
- Attend one doula business webinar
- Write an essay on labor support
- Provide documentation of attendance at three separate birth experiences lasting 15 hours or more
- Provide evaluation forms from medical personnel and signed consent forms from clients
Doula Certifications & Specializations
DONA International offers two types of doula certifications: birth doulas and postpartum doulas. While birth doulas work with mothers during labor and delivery, postpartum doulas work with mothers and their families in the first few weeks after delivery.
Ideally, both types of doulas meet with mothers in their third trimester of pregnancy in order to communicate their birth plans and get to know each other as they go through the transition of bringing a child into the world. Birth and postpartum doula certification routes have similar pathways but differ slightly in their didactic course content and the documentation required for certification.
Doulas vs. Midwives
Doulas and midwives both provide birth support during the third and fourth trimesters, but they differ in their training, licensure, and areas of client focus.
A midwife assists with labor and delivery and is primarily focused on the medical needs of the mother and infant. Midwives have a wide range of training and expertise ranging from high school graduates with on-the-job training to APRNs with specialization in labor and delivery. Some states have laws requiring midwives to be licensed, and the Midwives Alliance of North America (MANA) keeps an updated list of individual state licensing requirements for midwives.
A doula is primarily focused on the emotional and physical comfort of expectant, laboring, and postpartum mothers. Doulas can learn by being mentored by more experienced doulas, participating in weekend training courses, or earning doula certification from DONA International or another accrediting organization. There are currently no state licensing requirements for doulas. DONA International has a database of 13,000 certified doulas in more than 50 countries.
In short, midwives are focused on the medical needs of mothers and infants while doulas are focused on providing physical and emotional support through pain management techniques and birth coaching.
Meet the Mentor: Karla Salinero, Labor & Delivery RN and Birth Doula
In this interview, Karla Salinero shares her journey to becoming a doula. As a passionate women’s healthcare advocate, registered labor and delivery nurse, lactation consultant, and DONA International-certified birth doula, she enthusiastically encourages anyone who’s interested in community-oriented birth work to pursue a career as a certified doula.
What inspired you to become a doula?
“My long-term goal is to become a nurse midwife and earn my doctorate of nursing practice, and while I’m working my way up the ranks, I decided one of the best things I could do is get doula certification,” says Ms. Salinero.
“Nurse midwives typically work at hospitals and birthing centers and have education and training as nurse practitioners. I’ve been in women’s health for six years, involved with labor and delivery nursing for two years, and I’m all about serving new mamas and their families through my work. I work with all types of patients from the ‘crunchy granola unmedicated mamas who want midwife deliveries in the birthing center’ to complicated high-risk deliveries in the operating room, and everything in between.”
You’re a labor and delivery nurse, lactation educator, and a doula. How do these different healthcare tracks complement each other?
“The real joy is when I get to combine the holistic and the medical parts of my practice together,” Ms. Salinero reports. “As a labor and delivery nurse, I use all three specializations every day and I’m lucky to work at a hospital where these three skill sets are supported.”
In speaking of her lactation and doula credentials, Ms. Salinero says these extra specializations bolster her abilities as a nurse: “Nurses who have backgrounds in lactation and doula work are a little more sensitive to the needs of laboring mothers. They are able to better meet the needs of their patients because of their specialized training. Being a doula is about being an advocate for the mother, but more importantly guiding her in advocating for herself so that together we can achieve a birth experience that she sought.”
What does a typical birth experience look like?
“There’s no such thing as a typical birth experience!” Ms. Salinero remarks. “Sometimes you can see general trends in labor and delivery which can help you predict or give a little foresight as to how things are progressing. But no matter how much labor and delivery experience you have and no matter how many births you’ve attended, you never really know what’s going to happen. In childbirth, there’s the rule and there’s the exception to the rule. A good doula, labor nurse, or midwife is prepared for the rule and the exception and will work to guide the mother through it.”
“In a perfect world, a birth doula has a chance to meet with the mother first before delivery, so the doula can best support her through her birth experience,” Ms. Salinero says. “The doula will typically ask about the birth plan, whether the mother prefers a medicated or unmedicated birth, and whether or not she would like the doula to advocate for her during her birth experience. Primarily, a doula provides emotional support and pain management techniques for the mother,” Ms. Salinero says. “The birth doula may join the mother at her home while she is still in the early stages of labor, prior to going to the hospital. Early labor may take a few hours or a few days.”
Supporting the needs of the expectant mother also requires that a doula be aware of who the mother wants with her in the birthing environment. “Being aware of how the mother wants to integrate her family members and other support people is essential. Who they do and don’t want in the room during labor is ideally discussed in the first client meeting in the third trimester. Working together as a community is the best part of this work and making sure that the mother’s wishes are met is an important aspect of the spirit of community-oriented birth work.”
Although some doulas are self-employed, others meet clients for the first time as hospital employees. “Some hospitals have doulas that are paid on staff,” Ms. Salinero says. “Other hospitals have volunteer doula programs for doulas who are gaining experience through mentoring”.
Do you have any unique specializations you like to integrate into your work as a doula?
“A good doula comes with a whole bag of tricks to support mothers during birth. These include pain management and breathing techniques. A doula needs to have multiple strategies because what may have worked well for the previous 15 minutes might stop working. Some doulas implement the use of TENS (Transcutaneous Electronic Nerve Stimulation) units or essential oils to manage labor pains. I love to use breathwork. Practicing yoga has given me an appreciation for mindfulness skills I can incorporate during birth work,” says Ms. Salinero.
What are the most rewarding aspects or best parts of being a doula?
“It’s a privilege! Being able to work as a team with other labor and delivery professionals to help a mom and her family is great. Childbirth is one of those major life events that people don’t forget. I’ve heard stories about families who look back and remember specifics about their lives and memories of bringing children into the world are experiences that people can vividly recall,” Ms. Salinero said.
What are the most challenging aspects of being a doula?
“The hardest thing is balancing a labor and delivery career with the needs of my own family,” Ms. Salinero says. “Labor and delivery schedules are unpredictable and in some ways, it’s easier to be a doula when children are older. A big part of career success as a doula is having a supportive life and professional partner. Most doulas have reciprocal agreements with other doulas to be an alternate for one another. They closely coordinate client due dates and if one doula cannot show up for a client’s birth, the alternate doula will take her place. When I meet with clients, I let them know about the alternate doula plan in case I cannot attend their births, and most clients are fine with this arrangement”.
When considering doula training programs, what were the important factors you looked for?
“I did some research and DONA-accreditation was important to me. There’s no licensure for doulas, but having accreditation is helpful in that it helps to legitimize the profession and protect families. A lot of hospitals require DONA certification for doula employment. And hospitals will also allow non-certified doulas as well as mentoring doulas into the labor and delivery rooms as part of a family’s chosen birth team,” says Ms. Salinero.
What advice do you have for aspiring doulas?
“Doulas all love working with mamas in the labor process, and to support our personal and professional needs, creating our own professional and personal support team is essential,” says Ms. Salinero. “Start looking around for doula partners right away to build your professional network. And always remember: a supportive community is best for the mamas, babies, and the doula profession”.
What are some simple things that people can do to have a positive birthing experience?
“For expectant parents: have an open mind. Having a plan is fantastic, but at the same time, things don’t usually go to plan,” Ms. Salinero recommends. “Keeping an open mind and being flexible is the best thing you can do. Otherwise you may be setting yourself up for disappointment. At the end of the day, the goal is to have a healthy mom and baby. Ask questions before and during the birthing process. It’s empowering to know what’s happening and if you don’t know, ask someone.”
“For doulas: remember that birth work is a team sport: nurses, the families, doulas, doctors, and midwives—we’re all in this for a common goal to keep mamas and babies healthy. When we keep that shared goal in mind, great things can happen”.
Is there anything else you’d like people to know about doulas?
“I highly recommend them. From my own personal experience when I had my son, I thought I could apply my own doula skills to my birth experience, but in hindsight, I should have used a doula,” Ms. Salinero says.
“For people who think that doulas are only for hippies, research from ACOG and other leading women’s healthcare resources supports the efficacy of improved birth outcomes when a doula is present during childbirth. From both holistic and medical perspectives, research supports that having a doula present makes birthing go more smoothly,” Ms. Salinero says.
Rachel Drummond is a freelance writer, educator, and yogini from Oregon. She’s taught English to international university students in the United States and Japan for more than a decade and has a master’s degree in education from the University of Oregon. A dedicated Ashtanga yoga practitioner, Rachel is interested in exploring the nuanced philosophical aspects of contemplative physical practices and how they apply in daily life. She writes about this topic among others on her blog (Instagram: @oregon_yogini).