Best of the International Doula: The pitfalls of Under-Supporting Early Labor: A Complicated Story of Ethics and Client Emotional Well-Being


As a childbirth educator, birth doula, birth doula trainer and owner of, I hear a lot of birth stories from parents about how their doula’s support made a world of difference. More infrequently, I hear stories about doulas who missed important opportunities to provide emotional support, leaving families wondering what exactly they paid for.

Here are two stories that illustrate the pitfalls of under supporting the earliest parts of labor and suggestions for how to respond well to our clients’ emotional needs, even before labor begins.

Story #1: “She never really showed up for us.” In this story, the client signs a contract that states the doula will arrive in time to provide support in “active labor.” Once labor starts, the clients call their doula to let her know contractions are 5-10 minutes apart. The doula responds saying that labor is likely still in the latent phase, and they should call her when contractions are closer together and more intense.

After laboring most of the day home alone, the clients decide to leave for the hospital, calling the doula on their way. The doula shows up at the hospital within an hour. The laboring woman is close to pushing. The parents feel the doula provided little support other than to pop by the birth, take a few pictures, admire their baby and leave soon after breastfeeding was established. The doula feels she followed the letter of her contract, and that the parents should have called her earlier if they wanted her physical presence.

Story #2: We didn’t end up needing her.” The client’s water breaks before labor starts. She calls her doula to let her know they are heading to the hospital as per their physician’s instructions. The doula tells her clients to call when they need her.  At the hospital, the clients, along with their providers, decide to induce labor. At each decision point during the induction, the clients let their doula know via text message. The doula always responds with a “when you need me, let me know” reply. After 12 hours, she stops receiving texts from the clients. The doula texts 24 hours after her client’s admission, to find out how they are doing, and discovers they received an epidural and gave birth several hours earlier. The doula is stunned her clients did not call or ask her to come provide support.

So what happened in these stories? The doulas in each story weren’t able to recognize their clients’ emotional needs and missed key opportunities to provide support during the earliest parts of labor. The ways our clients remember their early labor and how we respond to their communication at that time can set the tone, as well as shape their perceptions of and the actual outcome of the rest of the labor support we provide.

Let’s break down the stories into best practices for supporting our clients during the earliest parts of labor.

1. Take out any reference to active labor from your contract and service agreements. From the 2014 American College of Obstetricians and Gynecologists reVITALize obstetric data definitions database[i], latent labor is defined as uterine contractions resulting in cervical change from the onset of labor to the onset of the active phase, which begins at five centimeters for multiparous parents and six centimeters for nulliparous parents. The active phase of labor simply marks the acceleration of cervical dilation. As doulas, it can be a mistake to tell clients our support will begin when labor is “active.” While that may sound reasonable to parents during a prenatal interview, and clients may agree when they sign your contract, the reality is that most parents need emotional support well before the onset of active labor. It’s important for doulas to recognize and respond to their clients’ need for emotional support regardless of what phase of labor the client is in.

2. Respond eagerly and enthusiastically to your clients’ communication. In both of the stories, parents reported their doulas didn’t seem to take their labors seriously. One doula told parents that she had several appointments on the same day, and that she’d rather not miss these commitments if labor wasn’t “serious yet.” The other doula only communicated with her clients via text, which means that she didn’t get to hear the worry and concern in the clients’ voices as they headed into the hospital and a possible induction. When our clients contact us, they pass along information they think we should know. From our perspective, that information is only half the story. We need to understand the other half, as well – our clients’ emotions and feelings. The best way to do that is a phone call. When your client texts or emails letting you know something is up, always strive to hear their voice. Pick up the phone and call, or text them back and tell them you’ll call them shortly. When you do, acknowledge what your clients have told you in the text or email and ask clarifying questions. Find out what your clients are feeling and how they are coping. Ask your clients what their plans are and make suggestions for how you can help. Always end your communications with a next step and time for when you will be in contact next.

3. Intuit your clients’ need for emotional support, even when they don’t ask. Sometimes our clients don’t know when to ask for our help. Perhaps they are worried about “bugging” us too early in the process. Perhaps they are unsure about what a doula does to provide reassurance and physical comfort during early labor. When your client calls you in early labor but seems unsure of what to expect, I suggest showing up in person. Ask your client, “May I come over and sit with you to watch a few of these contractions?” When you arrive, you’ll be able to see and hear how your clients are managing their early labor contractions. Based on this, you’ll be able to provide the reassurance they need, along with suggestions for comfortable positions and strategies for rest, nourishment and distraction. You may not end up staying with your clients more than an hour or so, but your physical presence may be just what they need to bolster confidence in themselves, their body and their ability to cope. Before you leave, make sure your clients know you are ready and willing to return as soon as they need a second pair of hands.

4. You go when your client goes. Whenever your clients goes to their hospital or birth center, for whatever reason, offer to accompany them. Think about the client in the second story, whose water breaks before labor starts. Inevitably, your client in such a situation will be directed by her medical provider to go to the hospital to assess the event and baby’s heart tones. At the hospital, recognize that part of providing support means supporting your clients’ ability to self-advocate by helping them know what questions to ask when important medical decisions come up. While your clients may feel they don’t need emotional support at this time, we know differently, that any time clients arrive at their birth place, there will be a myriad of decisions to make and accompanying emotions to support. Gently offer your physical presence. Perhaps say something like, “I know there will be many decisions to make depending on your and baby’s health status. I’d like to be there to support you. Why don’t I meet you there?” Sometimes, the greatest support we’ll ever provide is during the early decisions that ultimately decide the route and outcome of your clients’ births. Don’t miss this opportunity to help your clients ask questions about their care, acknowledge and process their feelings, and help them make confident, comfortable choices with their medical care providers. Go when your client goes.

5. Inductions are special. We know inductions can be lengthy and tap our clients’ emotional and physical reserves well before the intense contractions begin. Our sensitive emotional support during all parts of an induced labor can be critical to helping our clients create positive memories of the experience. Think about when your physical presence may be particularly important during the earliest parts of an induced labor.

  • During check-in at the hospital, you may want to arrive with your clients, help them settle in, assist with asking questions about expected timelines and outcomes of proposed induction methods, and ensure your clients have plans for staying comfortable and confident at the start of the process.
  • During cervical ripening, recognize that the unexpected can happen. Some cervical ripening methods can bring on intense contractions quickly. Sometimes babies don’t always tolerate contractions well. Consider being physically present to provide support at the beginning of the cervical ripening process to make sure your clients are coping well. You may not stay for the whole process but, before you leave, make sure your clients know you are ready and willing to return quickly.
  • Once the Pitocin starts, consider being physically present, for the same reasons cited above. If your clients are managing well, and if contractions are not present (yet) or are still very mild, it may not be necessary to stay. Again, reassure your clients that you can return quickly when anything changes.

Our goal is to promote our clients’ positive memories of their babies’ arrivals. While we cannot predict or control the route or outcome of our clients’ births, we can control how and when we respond to our clients’ emotional needs. Recognizing and responding to our clients’ emotional well-being, especially in the earliest parts of labor, cements our clients’ faith in our steadfast support and contributes to the most positive birth memories.

[i] 2014 ACOG Revitalize Obstetric Data Definitions (Version 1.0)

James, KimAbout the Author

Kim is the DONA International Washington State Representative, as well as a birth doula, birth doula trainer and childbirth educator in Seattle, Washington. Kim is also the owner and operator of



ACOG: OBs Can Prevent Lacerations During Vaginal Births

ACOG updateThe American College of Obstetricians and Gynecologists has released a new Practice Bulletin “Prevention and Management of Obstetric Lacerations at Vaginal Delivery” providing guidelines and recommendations for care providers. This new Practice Bulletin replaces a previous Practice Bulletin, “Episiotomy” from 2006 and “Limitations of Perineal Lacerations as an Obstetric Quality Measure,” a Committee Opinion released in 2015.

Lacerations during vaginal birth is both a common occurrence, 53-79% of women will sustain a laceration the document notes, and a common concern of our clients. Most lacerations, ACOG notes, are of the first-degree or second-degree. This Practice Bulletin also points out that “laceration rates vary based on patient characteristics, birth settings, and obstetric care provider practices.”  Episiotomy is discussed as well.

Preventing Lacerations During Birth

A number of different perineal management interventions have been used in the antepartum period or at the time of delivery in an effort to reduce perineal trauma, including maternal perineal massage, manual perineal support, warm compresses, different birthing positions, and delayed pushing.

— “Prevention and Management of Obstetric Lacerations at Vaginal Delivery”, Practice Bulletin #165, American College of Obstetricians and Gynecologists

Perineal Massage decreases muscle resistance. In research cited in the Practice Bulletin, massage beginning at 34 weeks was found to reduce trauma that required suturing and reduce the need for episiotomy. Reduction in pain after birth was found in multiparous women who received prenatal perineal massage, but not first time mothers. During labor, perineal massage has been associated with fewer third and fourth degree lacerations.

Perineal support, where a care provider uses their hand(s) to provide manual support of perineum during pushing, is mentioned in this Practice Bulletin which notes that research supporting its effectiveness at reducing severe perineal trauma are mixed. As a result, this intervention is not listed in the summary recommendations.

Warm compresses during the second stage were associated with a reduced rate of third-degree and fourth-degree lacerations, but not first-degree or second-degree.  The Practice Bulletin also states that because they “have been shown to be acceptable to women and are, therefore, reasonable to offer.”

Birth position is also not listed in the summary recommendations of this Practice Bulletin. The authors review of studies regarding birthing position is noted to have mixed results with some demonstrating that upright or lateral positions led to fewer episiotomies, less operative births but higher rates of second-degree lacerations. Studies of patients with epidurals did not demonstrate “a clear benefit of any upright position.” Lateral position combined with delayed pushing when an epidural is present has been found to reduce the risk of all types of lacerations but was not included in the summary recommendations in this Practice Bulletin.

First-degree and Second-degree Lacerations

First and second degree lacerations can either be repaired or not, at the provider’s discretion.  Those which are bleeding or distort anatomy are recommended to be sutured. Should a provider elect to repair a first-degree or second-degree laceration, suturing or adhesive glue can be used.  Absorbable sutures are recommended due to less pain reported in first three days after birth and less need for resuturing later.

Severe Lacerations

Much of this Practice Bulletin focuses on obstetric anal sphincter injuries (OASIS) including factors that contribute to these injuries, best methods for their repair and postpartum care. While much of this information applies to the decisions and care that physicians or midwives will provide, there is information that doulas and expectant families should know:

  • Risk factors:  The strongest risk factors for OASIS include forceps delivery,  vacuum-assisted delivery, midline episiotomy and increased fetal birth weight. Midline episiotomy, the most common type performed in the United States, is noted as a “strong,independent risk factor for third-degree or fourth-degree lacerations.” Rates of episiotomy and operative delivery are likely among the care practices referred to in this Practice Bulletin which impact the likelihood of lacerations during vaginal birth.
  • Time needed for repair:  The more significant and complex the injury, the more time will likely be needed for the repair. This can be distressing to families and frustrate them if the repair impacts skin-to-skin contact or the initiation of breastfeeding. Doulas can help by positioning the baby and enlisting partners to help support the baby to facilitate bonding, skin-to-skin contact and/or breastfeeding.
  • Positing & Lighting for repair: The ACOG Practice Bulletin notes that adequate light and visualization are needed for evaluation, repair and closure of a laceration. This can also lend itself to an environment and immediate postpartum experience that was not in the family’s ideal scenario. Shielding the newborn’s eyes from bright light while positioning the family so they can see and focus on their baby may help reduce the impact of the repair on their bonding and first breastfeeding experience. The Practice Bulletin notes that, on average, severe injuries take up to 23 minutes to repair.
  • Antibiotics: When OASIS is present, a single dose of antibiotics is recommended to prevent complications from infection. Patients who received antibiotics in labor, such as for group B strep, may not need additional antibiotics to prevent infection from a severe laceration. Without antibiotics, around 20% of women with an OASIS will develop an infection.
  • Pain management: Use of ice packs has been associated with significantly less pain in first three days after birth. Pain medication can also help, but should be combined with laxatives or stool softeners.
  • Constipation prevention:  To prevent further injury and reduce pain, stool softeners or oral laxatives are recommended in the immediate postpartum period.
  • Evaluation of wound healing:  Significant to severe perineal injuries should be evaluated frequently, ACOG recommends. Letting clients know to expect more frequent and thorough exams postpartum when significant tears are present can help eliminate surprises and set expectations.
  • Risk of future injury:  Evidence indicates that there is an increased risk for severe perineal trauma at a future birth. ACOG also notes that the absolute risk is low at 3%. Doulas should be aware that this may be a concern for multiparous clients, particularly those who had significant pain, infection or other complications from a laceration previously. Reviewing ACOG’s suggested preventative measures and encouraging a client to discuss these with their care provider can help alleviate concerns and provide a sense of control over future injury with a subsequent vaginal birth.


Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure (13).

“Prevention and Management of Obstetric Lacerations at Vaginal Delivery”, Practice Bulletin #165, American College of Obstetricians and Gynecologists

Episiotomy increases the length of lacerations, and routine use is associated with a greater risk of more severe perineal trauma. Research noted in the Practice Bulletin found that midline episiotomy combined with forceps delivery substantially increases the risk of third-degree laceration and fourth-degree laceration.


Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e1–15.


ACOG,. Ob-Gyns Can Prevent And Manage Obstetric Lacerations During Vaginal Delivery, Says New ACOG Practice Bulletin. 2016. Web. 22 Aug. 2016.

Dekker, Rebecca. “What Is The Evidence For Perineal Massage During Pregnancy To Prevent Tearing?“. Science and Sensability. N.p., 2016. Web. 23 Aug. 2016.

The Role of Doulas in Reducing the Primary Cesarean

The rise in cesarean birth rates and the effects of cesarean birth on mother and baby have become common themes in articles about birth and medical care. It seems everyone from the American Congress of Obstetricians and Gynecologists (ACOG) to Consumer Reports to mommy blogs are talking about the need to reduce the number of cesarean births in the United States. Doula support as a way to help achieve a lower cesarean birth rate was first acknowledged by ACOG in 2014. Doulas have again received a strong endorsement for the role we play in supporting vaginal birth, this time from the California Maternal Quality Care Collaborative (CMQCC).  Their evidence-based Toolkit to Support Vaginal Birth and Reduce Primary Cesareans for maternity care practitioners outlines seven strategies, one of which is to #4 Encourage the Use of Doulas and Work Collaboratively to Provide Labor Support.  Their view of doulas can be summed up in one simple quote from the Toolkit:

“Doulas should be considered an integral part of the birth team.”

— California Maternal Quality Care Collaborative, Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (p. 46)

The Toolkit also addresses the role of doulas and how to promote stronger teamwork with nurses. That some providers may not understand the role of doulas and may have an “antagonistic or adversarial view of them” is not ignored (p. 40). Doulas are described as having a unique skillset, and it is noted that we can be both an advocate for the birthing woman and be an ally to care providers, including nurses, when we are allowed to “function appropriately” in our role. The authors are aware that doulas have not been fully accepted in all hospital settings and “there are still many misconceptions about doula care, and often there is a stigma surrounding the ‘type’ of woman who has a doula.” (p.46)

To address this, the Toolkit provides specific recommendations to better integrate and support doulas.


Key Strategies for Supporting Intended Vaginal Birth


Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, Table 9

In detailing this strategy, the Toolkit offers specific recommendations to promote stronger relationships between doulas and nurses to support vaginal birth including:

  • Open communication between the doula and the nurse and a “mutual understanding of roles.” Unit guidelines may need to be developed to foster delineation of roles and expectations. Posting these guidelines at the bedside may be useful.
  • Collegial rapport and joint understanding that the doula’s professional knowledge of labor support techniques complements the nurse’s extensive technical and medical skillset
  • Two-way teaching. Doulas appreciate thoughtful and respectful guidance and feedback, especially those training for future medical or nursing professions. Likewise, nurses and nursing students can learn extensive labor support skills from doulas if willing to do so.

For hospitals, the Toolkit offers these “Innovative strategies to support the use of doulas”:

  • Working with a local doula organization to provide information, support, and resources to families
  • Connecting with community-based doula programs
  • Considering the implementation of a hospital-based program

Many of the strategies outlined in the Toolkit speak to maternity care practices and hospital policies that support vaginal birth.  The importance of education for birthing families is mentioned in more than one strategy with recommendations that practitioners educate families on what to expect in early labor, the safety of laboring at home in early labor, comfort measures partners or other family members can provide throughout labor, and the use of intermittent monitoring in labor. The importance of childbirth education is emphasized in a list of tools available to providers, hospitals and families in Appendix C of the toolkit as well.

The Toolkit is free to download from their website after registering with CMQCC and completing a short survey. As a follow-up, CMQCC will be releasing both a teaching slide set and an implementation guide.

— Adrianne Gordon, CD(DONA), MBA


Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative.

The 8 Best Steps To Take After Your Doula Workshop

Editor’s Note:  If you are just starting your doula journey, don’t miss Penny’s previous post Nine Tips to Get the Most Out of Your Doula Workshop. — AG

start-1414148_640The 8 Best Steps To Take After Your Doula Workshop
By Penny Bussell Stansfield BA (Hons), AdvCD(DONA), BDT, LCCE, CLC, BCLMT

Your doula workshop (also called doula training) is an important first step in your journey to become a birth or postpartum support professional. Once you’ve attended your training, there are several steps to undertake before completing certification. We asked DONA International approved birth doula trainer Penny Stansfield, who has trained over 1,000 doulas, to give us her top tips on the next best steps after your workshop. Feel free to share with others you know who are planning the next step in their doula journey.

  1. Read, read, read ….. By now, you will have read and studied the DONA International Position Papers (The Postpartum Doula’s Role in Maternity Care and The Birth Doula’s Contribution to Modern Maternity Care), Standards of Practice and Code of Ethics.  Complete reading the books on the required reading list.  If there are other birth and postpartum related books that spark your interest and are not on the required reading list, go ahead and read those too. The more books you read, the broader a perspective you will gain in your areas of interest.
  1. Study your manual. Your training manual is a valuable tool full of pertinent, useful and important information. Make a promise to yourself that within two weeks of attending your workshop, you will go through the manual page by page and consolidate the information through note taking or highlighting. I promise you that you will have several “aha” moments! You will read a paragraph and remember that a certain student mentioned this topic. Or perhaps you will read a paragraph and it will remind you of something your trainer said. Or you will make a connection between something you read in the manual and something else you recently read in a book or online. I suggest you create a one-page list of “Key Points from my Doula Training,” then laminate your list and pop it in your doula bag. Minutes before you join your first client, glance down your key points and refresh your memory.
  1. Start preparing materials for your business. Now is the time to start thinking about business materials and social media presence for your business. What are the key elements you need to bring awareness to your community? What do you need to create functional systems for your practice? Remember that you will need to watch at least one of the business webinars on the DONA website – choose one where you feel your knowledge and experience is lacking – or better still, watch them all!
  1. Network, network, network! Continue connecting with birth and postpartum doulas on social media and in-person. Stay connected to your fellow students.  Make sure that your trainer supplies you with a class roster with every student who has given permission for their information to be shared. Students often connect deeply during the workshop, and some choose to go into business together if they live in close proximity. Find out if there are doula agencies or businesses in your area that might be hiring doulas. Now that you have attended your workshop, you will be able to talk confidently and knowledgeably about doulas. Now is a good time to start connecting with health care providers – obstetricians, midwives and pediatricians in your area. Arrange to attend one of their staff meetings, bring their favorite lunch to the meeting and give a short presentation on how doulas can benefit their practice and on your business in particular. Leave brochures and business cards with them and follow up a week or two later with a second visit. Making face-to-face professional connections will enable you to move forward in your business goals.
  1. Finish your resource list. By now, you should have made a good start on your resource list from your work on it both before and during the training. Students from the same town often get together after the training and hash out their resource list together, sharing information and assigning specific categories for a particular student to investigate. A few weeks later, they meet again and pool all the information, discussing each provider/listing in detail. Your resource list is going to be a valuable tool for you and your future clients.
  1. Be focused. Your next major step towards certification will be to find birth or postpartum clients. This is the beginning of your career as a birth or postpartum doula. Make sure that your family and friends understand your commitment and are prepared to support you.
  1. Be prepared for personal growth. After your doula workshop, you will have a tribe of new friends and colleagues and a trainer who is available to mentor you through completing the certification process. Be prepared to step out of your comfort zone as you move forward on your doula journey. Seek support from your trainer and fellow doulas if you hit a tough patch.
  1. ENJOY! Combining your passion for this profession with your newly acquired knowledge and skills with hard work and you will be a success!

105_0560 copyAbout the Author

Penny has been a DONA International birth doula and approved birth doula trainer since 1997. She has trained over 1,000 doulas in over 100 workshops all over the US. She is also a board certified licensed massage therapist and teaches prenatal massage at the graduate level. She lives in Tucson, AZ.

Conference Sneak Peek: Advanced Peanut Ball Techniques


Photo courtesy of Premier Birth Tools

Cheri Grant is known as The Peanut Ball Lady, and her mission is to teach the world about the effectiveness of peanut balls (peanut-shaped exercise balls) in labor. She trains other professionals to become authorized peanut ball trainers, and two of these trainers – Amy Bookwalter and Amy Emerson – will be presenting the DONA International preconference workshop “Advanced Peanut Ball Techniques: Lowering Cesarean Births with Positions.” We asked Cheri to give us a little bit of background about her interest in peanut balls and their value in labor support.

How did you discover the peanut ball and become interested in it as a tool for doulas? 

I was looking for something new to teach doulas in my doula training, and I came upon a study by a nurse at Banner Health in Phoenix, AZ (the first to use peanut balls in labor). The nurse, Tussy, had received reports that peanut balls helped women avoid cesareans. She was curious, and she tested and reported on this new idea, which is the report that I came across. (Here’s more info about the report: Tussey, Botsios, Gerkin, Kelly, Gamez, Mensik, “Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring with an EpiduralThe Journal of Perinatal Education, 24(1), 16–24,

I was intrigued, and I called a nurse on the night shift at Banner Health who said that the peanut balls were working really well for their patients. She also told me that they originally started using the peanut ball because the pillows they used in between patient’s legs kept falling and sliding. They replaced the pillows with the peanut ball and had great success!

After speaking with the nurse, I tried the peanut ball on a few clients, and I was amazed. I learned as much as I could and then started teaching doulas and nurses how to use it. I was also able to quickly get peanut balls available at 13 area hospitals within six weeks by giving in-services, and it took off from there!

After its quick success, I learned more about positioning, how to use it effectively and which size worked well with which client in different positions. I have now sized hundreds of clients and taught more than 500 in-services to nurses and doulas on the proper use of the peanut ball.

We’re really excited about the evidence based research on peanut balls that has happened over the last two years, and especially in the last few months. This research, as well as clinical trials, will be discussed in the workshop.

What will doulas who use the traditional round birth balls learn about peanut shaped balls that might surprise them? 

I want everyone to know that the following information:

  • One size does not fit all clients
  • Different positions require different sizes of peanut balls
  • Peanut balls can be used for comfort and positioning a client to facilitate the birth

Why is positioning so important to help support a client in having a vaginal birth?  

If a baby is stuck in a certain position, or a client’s labor is stalled, you have to move the woman to move the baby. It’s just like having a ring stuck on your finger. You don’t pull it straight off; you twist and turn to get the ring off the finger. In labor, you have to move the woman to get the baby out.

What are some resources on the importance of positioning to reduce the risk of cesarean birth?  

We have lots of information about peanut balls and positioning on our website: We also have a packet, created just for doulas, with lots of helpful information. We’ll go more in depth at the workshop, but this information is a great for anyone wanting to learn more. For those at the workshop, we’ll go through seven traditional peanut ball positions and more than five new positions, including the BEST position to use.

Is there anything a doula should do in preparation for this session?

This is a fun and interactive workshop, so I’d recommend dressing in comfortable clothes. Be ready to practice, and be prepared to have fun!

I love talking about peanut balls, so please don’t hesitate to reach out to me at! Enjoy the workshop at conference!

Certification Still Matters: Certified Doulas Earn Higher Fees and Attract More Clients

Editor’s note:  Last July, Kim James provided an article with information from on which doulas received the most referrals and charged the highest fees. Her article, Certification Matters: CDs and PCDs Get Higher Fees and More Clients, was based on six months of data (January – June 2015).  In this update, Kim draws from a year of data from with the same conclusions. Our thanks to Kim for sharing this update with expanded data. Evidence-based information is important for your doula business too! — AG

Certification Still Matters:  Certified Doulas Earn Higher Fees and Attract More Clients


From the doula availability database,, we have solid evidence that DONA International certified doulas consistently earn a higher fee and receive more referrals than non-certified doulas and doulas certified through other organizations.

From July 1, 2015 through June 30, 2016, 5,258 active doulas in the database received at least two or more referrals.  See chart below:


DONA International certified doulas commanded a 25% higher fee than non-certified doulas and a 7% higher fee than doulas certified through other organizations.  DONA International certified doulas also received twice as many monthly referrals.

What’s more interesting is to look at how DONA International certified doulas compare to other doulas with the same amount of experience.  See chart below:image004

At all levels of experience, certified doulas, and DONA International certified doulas in particular, earn higher fees and attract more clients.

For new doulas, achieving a meaningful certification means you are more attractive to potential clients, especially when you’re just starting out. When you don’t have a lot of births under your belt, having a recognized certification demonstrates to potential clients that you are an effective doula. You’ve achieved a major professional milestone that gives you an edge over doulas with the same amount of experience who are not certified or are certified through lesser-known organizations.

For established doulas, experience is the great equalizer and decreases the fee and referral gaps.  However, achieving and maintaining certification demonstrates your professional commitments and validates your higher fee, even when your practice is established and thriving.

Families who use a database to reach out to doulas are probably looking for mid-priced doulas with moderate experience. When faced with a lot of choices, whether or not a doula is certified seems to matter. For doulas with moderate experience of two to seven years, 60% of all referrals went to certified doulas. Of those certified doulas, 50% were DONA certified.image006

Whether you’re just starting out or firmly established, achieving and maintaining certification is solid business decision that benefits not just families and our profession, but you as a doula business owner.

James, KimAbout the Author

Kim James has run a successful birth doula business for 16 years in Seattle, Washington. Kim’s roles in the birth community include: DONA-approved birth doula trainer at the Simkin Center for Allied Birth Vocations, childbirth and parent educator at Parent Trust for Washington Children, DONA International Washington State Representative and Lamaze International membership committee member. Kim is also the owner and operator of

Conference Sneak Peak: Saturday Night Performance by Melissa Bangs

Melissa BangsPhoto courtesy of Nichole Peterson/NP Images

Hearing someone’s story is one of the best ways to deepen our understanding of their experience.  Storytelling can play a powerful role in healing for the teller and provide perspective to the audience. One brave woman will be telling her story of returning to wholeness through a postpartum mood and anxiety disorder diagnosis at the 2016 DONA International conference.

Melissa Bangs is a storyteller and performer embarking on a one year tour to tell her story of motherhood from the birth of daughter Adelaide to her nearly month long stay in a psychiatric hospital and, finally, her return to health. In Playing Monopoly with God and Other True Stories, she uses honesty and humor to get to the heart of the matter promoting awareness, healing, and hope. Melissa shared a few thoughts with us about her upcoming performance and the role she sees doulas in promoting awareness, compassion and support for women experiencing postpartum mood and anxiety disorders. Tickets are available for Melissa’s 7pm Saturday night conference performance and DONA International will benefit from the proceeds.

— Adrianne Gordon, CD(DONA, MBA


Why are you excited to perform at the 2016 DONA International conference?

Doulas, as well as midwives are, for me, real life superheroes. Each and every one of you should wear a cape.  Truly.

Women are not meant to bear or raise children alone.  Families are not meant to raise children in an isolated way.  And yet we do.  In our modern culture, so many of us are far from support systems and the close-knit, multi-generational models of the past.

Doulas are a beautiful and profound way to close the gaps that modern living has created. Doulas have the power to powerfully prepare, accompany, support, advocate for, hold and honor mamas and papas in these beautifully potent yet often incredibly vulnerable and even bewildering chapters of their lives.  Often a doula will be a mother’s closest ally among all of the healthcare providers within her birth journey.  The potential to support mamas in difficult postpartum chapters is profound.  Of course you all know this!  You do it every day and have done it for eons!

Why is it important for doulas to hear your story?  

My hope is that you will hear and see and feel yourselves in my story, your clients in my story, moms and motherhood.  This is one mother’s story told without shame, with brutal honesty and a great deal of self love.  It is a story that could have remained, like so many shrouded in shame and stigma, and yet, I felt called to share it from a mountain top so that so many others might feel the room, the call, the permission to name what is, to feel less alone, to get help and to forgive.

What’s one thing we should take away from your performance?

If my story does nothing else, may it unleash yours!

And a second thing- postpartum mood and anxiety disorders are the number one birth complication,  and yet, far too often, we are not talking about them.

Whether you are a birth doula or postpartum doula, my hope and call is that the entire birth field, doulas included, will garner extensive and appropriate training on postpartum mood and anxiety disorders and each play our role in peeling back the layers of shame and silence and proactively tackling an issue/an experience that is vastly shared and yet rarely talked about.

How can doulas apply what we learn and experience from your performance?

If you aren’t doing so already, have these conversations with your clients – during pregnancy, just after birth and in the weeks and many months that follow. Ask the tough questions.  Provide the full spectrum of possibilities. If you haven’t already, fully educate yourself on postpartum mood and anxiety disorders and the referral resources in your community.

You are, as you know better than I, the front line.  Postpartum doulas are often the only professional worker seeing mama.  Or it may look like the doula, perhaps the midwife for a handful of visits, and then the pediatrician.  Each has their role in providing a safety net for moms, a role in education, prevention, screening and accessing services when needed.

Doulas already know, so intimately and deeply, how important this topic is.  Many know it much more so than I do.

How can doulas best support women dealing with postpartum mood disorders?

Have the open and frank conversations about all of it, from the bliss to the abyss.  Make  known before baby is here the array of PMAD (postpartum mood and anxiety disorder) possibilities.  Normalize it, because it is very common.  Make yourself an ally and nonjudgmental resource that moms (and dads!) can reach out to with questions with strange and disturbing thoughts or experiences and with the vulnerable and bewildered parts of themselves that they have never met before.  Be the safe place, the informed place, the place of resources.

In the realm of maternal mental health at this time in the U.S., therapy and pharmaceutical medication are the two most common responses, and each have their own power and efficacy.  Therapy alone has proven to cut the rates of postpartum depression in half.  This is monumental.  Talk to mama! Get to her talking to other mamas!  Let her know about postpartum support groups or form one.

Medication can also prove effective and even life-saving for some mamas.  Find a psychiatrist or psychiatric nurse practitioner with perinatal mood and anxiety disorder training and expertise to refer your clients to.  Beware that many do not have this training and can be a real disservice to mamas.  If you don’t have a lot of local resources, connect moms to Postpartum Support International and Postpartum Progress so they have access to a hotline, closed discussion groups on Facebook, and highly trained professionals for support.

Also, educate yourself about alternatives available to psychotropic drugs as these options do not work for many moms. I, for one, could feel nothing on my medication. Nothing.  I had to find another way, and I did. I found a naturopathic physician who tested and balanced my hormones and neurotransmitters, and brought me back to stasis and off medication incredibly quickly.  She gave me my life back.

What else would you like doulas to know?

Doulas sit in a powerful place with the possibility of educating leagues of mamas and papas about the possibilities for their postpartum experience and the options for help and treatment, if needed.

You are the wonder women; you engage in the miraculous nature of new life every day, and you bear witness! I see you at the forefront of closing the enormous gap in services for mamas and families postpartum in this country.

Thank you for all you do and have done!

What’s next for you?

In September, we kick off a nine city west coast tour with the show.

We have just moved into a 19 foot Shasta Airflyte trailer and will for the next year make our way from Bellingham to Baja.  By we, I mean my 6’4” hubby Eric, our 130 lb Bernese Mountain dog, Etta James, and my nearly four year old daughter,  Adelaide, the only member in the entourage who has graciously agreed to remain small for the journey, and me.

We kick off the tour in Bellingham at Mount Baker Theatre September 13th and 14th.  Our second stop in late October is Seattle’s town hall, a unique and powerful performance space.  Then we wind our way down the coast from there.

Beyond the tour and in tandem- conferences, university performances and leading the preliminary phases of statewide strategic planning on maternal mental health in Montana (my other hat… strategic planner). Oh yes, and a book!

Find out more about Melissa, her story and performances at

Is Homebirth Safe?

The safety of homebirth has been much discussed in the birth community over the last few months following the publication of a study in the New England Journal of Medicine at the end of 2015. At the upcoming DONA International Annual Conference, Dr. Michael Klein, a Family Physician, pediatrician, and neonatologist who has delivered more than 2000 babies during his 30 year career will speak on this very important topic. Dr. Klein has not only expertise and experience to bring to the conversation on the safety of homebirth, but also a unique perspective to share. He has worked alongside midwives for over three decades, is both an American and a Canadian, served as a member of the British Columbia Midwifery Implementation Committee that oversaw the integration of midwifery into regulated practice and is one of the researchers that studied five years of outcomes of all home births in British Columbia. Here he shares some of this thoughts on the NEJM study and the safety of homebirth in general. His session at the 2016 Annual Conference is one not to be missed! – Adrianne Gordon, CD(DONA), MBA, Blog Manager

Our five-year British Columbia study has conclusively demonstrated the safety of home birth, such that the College of Physicians and Surgeons of British Columbia have rescinded their long-time ban on physicians working with midwives in home birth.  Similar studies from Ontario, including the most recent study just published in the Canadian Medical Association Journal, continue to show home birth to be safe. (2,3)  In all Canadian studies and several US studies, women experiencing out-of-hospital birth received dramatically fewer interventions, including caesarean sections, than their counterparts giving birth in hospital — leading to fewer complications in the present and future pregnancies.

Why the controversy?The controversial New England Journal of Medicine study is limited in what it can tell us. It is a high level look at outcomes by planned birth site. Such an analysis cannot and does not claim to allow us to know what was actually going on. We can only say that something was going on between the births in the two main outcome categories. Looking at the case reviews from 2012, and assuming a similar result for 2013, I find that a total of eight cases of perinatal death occurred in the planned out of hospital (OOH) category. It was on the basis of this very small number of cases that the statement was made thatthe number of perinatal deaths occurred in the OOH group compared to hospital (similar to 2012-13).

The review also shows that some of the women planning OOH births clearly rejected conventional screening or had conditions incompatible with appropriate home birth criteria. With such a small number of cases, it is impossible to know if the outcomes of interest are due to care, system issues, certification or licensure of attendants or a combination of these factors. Regardless of licensure or certification, midwives like doctors, will have variable skills and judgement. I do not see how it is possible to make a judgement on the quality of care provided by various types of midwives, based on such small numbers.

What should a woman planning home birth know? Doulas in the U.S., Canada and elsewhere need to know the basic information about the conditions for a potentially safe home birth. In the U.S., I would say that when thinking about a home birth or OOH birth a woman needs to ask the chosen provider:

1. How much training and experience does she have and in what settings and under whose mentorship did she acquire that experience?

2. What are her relationships with her backup system and receiving physicians? (Will her backup supports receive her consultation or transfer easily and without judgement)

3. How often does she require transfer for her clients? (It ought to be 15-20% for various reasons)

4. How quickly can she effect transfer should transfer be needed?

The answers to these questions will help women decide if OOH birth is a reasonable and potentially safe decision. Doulas, while not responsible for the birth, nevertheless need to be up to date with the home birth data and appreciate local conditions that may or may not be appropriate for a safe home birth.

And home birth saves money too. All studies that have looked at the costs of home birth vs hospital conclude that home birth is substantially less expensive for the system. (5)

It is critical that those choosing to deliver outside of the hospital or birth center are attended by qualified providers, who must have minimum educational requirements, performance standards, and professional accountability.

Michael KleinAbout the Author

Michael C. Klein MD, CCFP, FAAP (Neonatal/Perinatal), FCPS, ABFP
Professor Emeritus, Departments of Family Practice and Pediatrics
Senior Scientist Emeritus BC Child and Family Research Institute
Centre Developmental Neurosciences & Child Health
Children’s and Women’s Health Centre of British Columbia


  1. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK, et al. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ Canadian Medical Association Journal 2009;181(6-7):377-83  
  2. Hutton EK; Reitsma AH; Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth. 36(3):180-9, 2009 Sep.
  3. Hutton EK, Capaletti A, Reitsma A, et al Outcomes associated with planned place of birth among women with low-risk pregnancies  CMAJDecember 22, 2015 First published December 22, 2015, doi:10.1503/cmaj.150564
  4. Snowden JM  Ph.D. Tilden E, Snyder J et al. Planned Out-of-Hospital Birth and Birth Outcomes. New England Journal of Medicine. 2015;373:2642-53. DOI: 10.1056/NEJMsa1501738
  5. Janssen PA, Mitton C, Aghajanian J (2015) Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians. PLoS ONE 10(7): e0133524. doi:10.1371/journal.pone.0133524

10 Reasons You Should be at the 2016 Conference!

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In just a few weeks, the DONA International Annual Conference: ENGAGE will take place near Seattle, WA. Here are 10 reasons you should be at #DONA16!

  1. Learn new skills and evidence based information.  Continuing to grow your skillset and stay up-to-date on the latest research in the maternity care field is critical for growth as birth and postpartum professionals. This year’s conference provides 7 general sessions and 24 concurrent sessions with leaders in the field plus 3 pre-conference sessions. It’s an all-star line-up you won’t want to miss!
  2. Build your practice. The 2016 conference includes sessions on how you can better engage in building your doula practice including practice models, systems and tools to streamline the business aspects of your practice and marketing to reach your ideal clients. However you want to approach building your practice, we’ll have sessions that support your goals.
  3. Meet re-certification requirements. Maintaining certification demonstrates commitment and furthers the idea of doula support as a legitimate profession to be respected by families and care providers. While there are a number of ways to earn this continuing education contact hours none are as are engaging and fun as the annual conference!
  4. Expand your network.  Connect with doulas from around the world to learn from and support each other. The work we do is challenging! While each area is unique, many of the challenges of creating a sustainable practice, attracting ideal clients, meeting changing client needs, educating the community about doula support and building relationships with care providers are universal. Learn from those who have been in the field for years as well as those who have newer and have fresh ideas and perspective.
  5. Meet your DONA International founders and Board members in-person.  The annual conference provides a unique opportunity for members across the globe to meet and talk with those who founded not only DONA International, but the profession. Breaks and meals are a great time to get to know your Board of Directors personally.
  6. Learn about the future of DONA International. The annual member meeting at the conference will be very special this year as we celebrate the future of our organization to better meet your needs and uphold the standards DONA International has set for the profession. Find about the member survey results and be the first to hear some exciting announcements. Come find out what’s next for the world’s largest and longest-standing, premier doula organization!
  7. Be inspired! Between the great sessions, networking with speakers, founders, Board members and attendees the conference is a wealth of inspiration. How will you grow as a doula? How will you better meet the needs of your clients and community? What ideas, resources, tools and skills will you take back to your doula work so that you can have more impact and meet your professional goals? The sky is the limit on what you can achieve and who you can touch! Be prepared to leave energized and ready to take expand your work in birth and postpartum support.
  8. Return to our Seattle area roots.  Let’s face it, conference aren’t just all work, there’s lot of play too! Celebrating the future of DONA International where the organization started has a lot of members really excited. The area has a lot to offer from the Bellevue Arts Museum to Pike Place, the Space Needle and beautiful scenery.
  9. Stock your library and toolkit. The annual conference always includes an exhibitor area to discover books, tools and other resources hand selected specifically for doulas. This year we’re also adding a silent auction you won’t want to miss!
  10. Invest in yourself. As doulas we givers, the annual conference is an important opportunity to invest in yourself as a birth and/or postpartum support professional for renewal, skill building, networking and time to focus on your practice. When you purchase your conference ticket, you are investing in your own growth as a professional.  2016 is the first in-person conference created just for DONA International members in four years. You don’t want to miss this chance to devote this time and energy to yourself.

See the full agenda with sessions and speaker bios at Early bird registration ends soon! Get your ticket before the price increases!

Sailing Through Certification: Packet Reviewer Tips Part 2

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This is the second installment in our Sailing through Certification: Tips from a Packet Reviewer series.  Birth doula certification packet reviewer, Julia Schetky, posts tips on DONA International’s Facebook groups each week with tips for those preparing that precious packet. The first post here at The DONA Doula Chronicles, covered some key tips on legibility, completeness and organization that apply to both birth and postpartum packets purchased anytime. Be sure to start there!  This second part of the series covers the all important essays  and the resource list. We’ve also included special tips for the resource and reading lists for packets purchased before October 2015.

Don’t forget to post our social media channels when you get that certification call so we can congratulate  you!

Essay: Value of Birth or Postpartum Support

This element of the certification process helps the doula integrate all she has learned and demonstrate that learning. It also shows understanding of the role of a doula and our scope of practice.

  • Review the description of this essay in your packet. It lists all of the things that should be discussed in your essay. All of these items need to be addressed or you will have to revise your essay and re-submit it to the reviewer.
  • The position paper, Scope of Practice and Code of Ethics are key resources for writing this essay. Reread them when you get ready to write it and keep them handy as a reference.
  • Code of Ethics/Standards of Practice elements need to address whether doulas are clinical or non-clinical care, the role of advocacy and continuity of care.
  • List how doulas make a quantifiable and measurable impact on families. Hints: there are at least five and the research publishes in the Cochrane Library in 2011 is your go-to resource.
  • How do doulas impact partners and families? Be sure to demonstrate your knowledge of how doula support is valuable to them as well as the birthing individual.

Essay: Birth or Postpartum Support

In many professions, those who are in training are observed when they first work begin providing their services as a resident, apprentice or junior associate. The essays, along with the Labor Progression Sheet for birth doulas, fills this role by giving DONA International insight into how you supported this client, what skills you used and how you navigated your role as the experience unfolded. Birth doulas, keep that Labor Progression Sheet handy so you can be sure the two documents work together to tell the whole story and so you know what details you don’t need to cover in your brief essay.

  • Respect the word limit! We know it’s hard to summarize the hours you’ve spent with a client and all that happened during their labor or postpartum experience into such a brief essay. This is CliffNotes version of the experience. Be succinct. Remove any extra words and focus on the specific things that are asked for.
  • Using headings before paragraphs that summarize each piece (for example from the birth doula packet purchased prior to October 2015: Description of the Birth, Role as the Doula, Mother’s Reaction to the Process, What You Learned).
  • Edit, edit and edit some more!

Resource List

Some doulas see the creation of a resource list as busy work, but nothing could be further from the truth!  Doulas are an important bridge for families to other services and resources in the community. Having strong knowledge of where you can refer clients when needs arise is a key function of being a doula. The resource list is really a tool for you to provide the support and information your clients need.

  • Remember the total list is at least 45 items.
  • Resources are needed in 30 categories to ensure you have appropriate referrals and information sources for a range of client needs.
  • Include at least two ways that clients can get in touch with each resource (phone, email, website or physical address).

Additional Tips for Packets Purchased Before October 2015

For those working on completing a certification packet purchased before October 2015, here are some tips that will support a quick review of your certification packet.

References List

  • When you are notified your packet has been received for review, notify your references so they are expecting to hear from someone with DONA International. Find out what the best times are to reach them and let your reviewer know.
  • Birth professionals:  Be sure these references know you well know to answer questions about how you work with others in the birth and postpartum community. Also consider how reachable these references are. It’s notoriously difficult for packet reviewers to reach doctors via their main office phone number or to connect with nurses who work night shift.
  • Clients: Consider how reachable this person is and if they can speak to your strengths as a doula as well as areas where you need to grow.
  • Have a back-up reference or two in case your primary references are hard to reach. This is often a factor in packet reviews that take longer than average.

Reading List

  • For the first section, you must have read all three items listed.
  • In the subsequent sections, you are to read at least one from each category.

We are grateful to Julia Schetky, CD(DONA) for her support of DONA International doulas working toward certification. For additional support, feel free to contact Certification Director Johanna D’Aleo at