Doula Regulation, Yes Or No?

Regulation of doulas has been a topic of conversation in the birth world for many years. Should doulas be regulated? If so, who by? But perhaps we should start at the beginning; what exactly do we mean by regulation?

The Gov.uk website defines a regulated profession as one that:

‘…is defined in the Professional Qualifications Bill. It means a profession which is regulated by law in the UK or a part of the UK. ‘Profession’ includes an occupation or trade, or any subdivision and specialism within a profession. The Bill sets out that a profession is regulated by law where there is a legal requirement to have certain qualifications or experience (or meet an alternative condition or requirement) in order to undertake certain professional activities or use a protected title.’

So by the definition outlined in the Bill, doulas are not currently a regulated profession. The point of this article is to ask, ‘should we be?’ And to explore why this subject is currently at the top of our in tray.

Recently the Healthcare Safety Investigation Branch (HSIB) released an article about doulas. They cite a very small number of cases, with adverse outcomes, which involved doulas. Whilst they do emphasize the many cases they investigated that involved positive input from doulas, the thrust of the article is negative towards doulas and crucially gives no hint that they listened to the doulas’ perspective on the stories. Yet these extremely rare and ineffectually investigated cases results in the suggestion of regulation, or at least some guidance for doulas, health professionals and parents.

‘HSIB will be meeting with the Regional Chief Midwives with a view to national learning which supports the introduction of national guidance for health professionals, doulas and mothers combined.’

So would regulation or national guidance be a good or bad thing for doulas? Well, I don’t think we have enough information, and to be frank, I don’t think the HSIB have enough information either. For starters, there is no indication that the HSIB actually talked to any of the doulas involved in the cases they investigated. A robust investigation should not mean taking a statement from the Health Professional involved, who blames the doula, and then taking that at face value.

Secondly, the article implies that doulas are not fully aware of their boundaries and are not making their clients aware of the remit of our role. If they were to ask, we would be able to supply them with the written agreements we give to all our clients that clearly state the limitations of our care and our inability to give clinical care or advice.

Thirdly, it implies that mothers need “guidance” (for that, read help/direction) in their decision to take on a doula. Note it just says “mothers” – a implication being that men are not stupid enough to be taken in by charlatans? What “guidance” might all kinds of parents need when taking on a doula? Well, perhaps the guidance already written and published by Doula UK?

Most of us are members of a doula community that also has clear guidance for members. Developing Doulas has guiding principles, called The 7Cs which everyone in our community strives to follow. Many of us are also members of Doula UK – the organisation which all doulas, trained by one of the Doula UK Approved courses, can join. Every Doula UK member should work within the letter and spirit of the Code of Conduct, which includes ensuring that our clients are fully conversant with the scope of our role.

All doula organisations work hard to ensure that doulas are working within their boundaries and have opportunities for growth and reflection. There are now a number of mentoring systems as well as systems that support both doula and client if a relationship has broken down. We invite feedback from all our clients in order to learn and improve the care we provide. But we would be stupid to suggest that our systems are perfect or that no doulas have ever worked outside their boundaries, or made a mistake when tired or emotional. We do, undeniably, need robust, supportive communities for all doulas in the UK.

And it makes sense for the NHS to get on board with doulas. After all, the Cochrane review recommends that all women be able to choose doula support if they want it. Doula support helps even out social inequalities and disparities in care, as this PhD study concluded. And all the academic research on lay birth support agrees that part of the power of our role is our independence – we work for no one apart from our clients and have no role other than to unconditionally support our clients’ wishes.

One aspect of this problem is the knowledge gap between doulas and health professionals. By that I mean that doulas go to great trouble to learn about the remit and role of midwives and doctors, but we see very little of the same from NHS staff. There used to be guidance for midwives working alongside doulas published by NHS Scotland, but this has been removed from their website without warning or explanation. NHS Wales does have a sensible explanation of what a doula is, but doesn’t really provide staff with any information about why parents may choose to work with a doula or how to build bridges with local doula communities so that we can build collaborative team work in the birth room. The RCM also has a position statement on doulas that again does nothing to help midwives think about how they might deepen the positive, collaborative relationships with their local doulas that we know are possible and precious.

If I were a parent engaging a doula, I’d want to know that my midwife feels comfortable with the idea, that she understands the role, that there will be no negative vibes in the birthroom, and that my doula and midwife each understand the other’s role and boundaries. I’d want to see that my midwives have a knowledge of my doula’s guiding documents, just as my doula has a knowledge of the rules that guide a midwife. In short, I’d want to feel happy that these people are on the same team.

So we certainly need support for maternity staff to meet and talk with local doulas regularly. Building mutually respectful relationships, collaborating on care and being able to trust that we all have the same aims, makes for safer, more satisfying care for parents.

Now, as we know, mistakes are sometimes made. A doula may not provide her clients with all the information or adequately explain the boundaries of her role. A doula may inadvertently give advice or even provide care that could be seen as stepping over into the medical domain. And sometimes, despite our best efforts, our clients thank us for our advice, even though we have gone to great lengths to explain we don’t give advice! But would regulation help with this?

I’m not sure. It doesn’t seem to be working very well for other regulated professions – we are regularly treated to stories of good midwives being made to suffer through years-long NMC investigations, only to be told they have no case to answer. We also hear and witness extremely poor care that is never addressed. Regulation in itself does not keep people safe. To be effective, regulatory systems have to work with compassion, empathy and with skill to ensure that all parties are supported with love to learn, grow and improve.

I am not anti – regulation, per se. It may give a credibility to doulaing that we currently do not possess and in extremely rare cases it may give us the power to require someone to step away from the doula role, temporarily or even permanently. But right now, I’m not sure I believe it would be done with the loving care it deserves. It certainly couldn’t be done without the enthusiastic consent and proactive input from the doula community itself.

As the HSIB say themselves:

‘Staff working within maternity units need to understand the role of a doula and the expectation of their role in supporting mothers.’

But I’m not sure HSIB has my trust, considering their role investigating maternity cases has been stripped from them, they are being investigated by The Kings Fund and allegations of the leadership covering up whistleblowing are currently circulating. Minh Alexander, on their whistleblowing blog says about the HSIB:

“The whole safety of the HSIB maternity investigation programme has since come into serious question and has had to be remodelled nationally.”

There is also the question of money – the costs to doulas of maintaining their registration. As a doula on instagram said today:

“The cost will have to be passed on to clients. Making doulas only available to the most wealthy people. This is not what any doula wants. We believe doulas should be available to all.” Caz Sayles, doula

It makes sense to me that if the powers that be do decide they require us to be regulated, that Doula UK takes on that role as it is the closest thing we have in the UK to a membership that is open to all appropriately trained doulas. But as an organisation run by volunteers, that would require adequately funding salaries and organisational infrastructure.

So, for me, the jury is out. Guidance that requires mutual knowledge and respect and a robust support system for doulas gets my vote. Regulation as a tick box exercise gets a hard no from me.

Rather than impose layers of bureaucracy, lets just talk, share, learn, build relationships and work together. But given that most staff don’t even have the time to go to the toilet right now, I’m not sure how this can be achieved.