10.23.2014

Scapegoats and Birth Teams

Dear Nurse -

"I don't like doulas. Just in case my actions didn't make it obvious enough, let me spell it out for you - 'your presence isn't welcome. You complicate my job and my relationship with the doctor."

I'm sorry that you have been bullied by the hospital contractors enough that you feel the need to treat doulas like that. I get it, I do. A doula's presence can sometimes make your job harder, no matter how hard we try to make it easier.

A doula's presence should allow you more freedom to focus on the details of your job - like charting, other rooms where women don't have additional support, and supporting mom in the medical aspect of her care. A doula should be able to focus her attention on physically and emotionally supporting mom during her labor, changing out linens, helping mom to the bathroom, helping her into different positions, cleaning up her messes, and getting her fluids and nourishment.

Sometimes, though, our presence can complicate your position. Sometimes, when we see a medical provider attempting to coerce mom into interventions or medications for the sake of the providers comfort, schedule, or personal bias, we might have to put on our advocacy and educator hats. This can place you between that proverbial rock and hard place.

Please remember though, we aren't the bad guys. Bad policies, medical advice for the doctor's best interests, and convenience sake are the culprits for the position that you are in. A doctor who bullies mom most likely also bullies nurse when nurse doesn't follow through with their orders - even if it is mom's refusal of those orders that made it so that you cannot fulfill those orders.

But let's call a spade a spade, shall we?
The provider wants you to do xyz to mom. Mom asks educated questions about xyz, and you repeat what you have been told to repeat; that it's 'necessary and non-negotiable'. I remind mom of her rights as a consumer and patient and offer, while attempting to include you in the conversation, other possible options.  
You update doc that mom has opted for abc and will be forgoing xyz. Doctor doesn't like this answer and puts the pressure on you to 'finish the job' that he wanted you to do in the first place. You are put in a hard place. It would've been so much easier if I wasn't there so that you could do xyz. 
Whose fault is this awkwardness really? Mom's for being a proactive partner in her own healthcare? Your's for not assaulting mom to complete what mom has refused? Mine for educating her so that she can have the best chance at achieving a birthing experience that is both safe and fulfilling? Or the provider's for attempting to manipulate both you and the mother?

Your anger and frustration is misplaced. I get it, it's hard to properly place blame when the blame rests on someone who can make or break your career. But to remain silent when you're being mistreated by your superiors is simply enabling them to continue mistreating you. And displacing that blame onto my shoulders only perpetuates the cycle of mistreatment. In essence, doulas become the scapegoat for your dissatisfaction for the way you are treated by your boss.

Did you know that a doula would be happy to back you up if you were to report a provider for mistreatment? Did you know that a mom would have your back in an instant if you had hers? And did you know that, if we began to demand more ethical treatment on all levels of healthcare, and worked together instead of offering up scapegoats for sacrifice, we could really make a difference?

So make your statement earlier or a little more honest and a little less enabling... "Cole, your presence complicates things. I was taking it out on you earlier because it's difficult to stand up to this doctor. Having an educated patient with a solid support team that advocates for her options ticks this doctor off... and he takes it out on me."

Additional reading:
https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-work-environment/resources/MSNJ_Murray_18_05.pdf

10.16.2014

Who's Gonna Pay If I Leave AMA


So a girl walks into a hospital...

Sounds like the start of a joke, yes?

Let's continue...

So, a girl walks into a hospital 'in labor'. She goes through triage, where they separate her from her birth team for 'a quick few minutes'. The check her cervix, she's 3cm. Her water breaks on the table while they're checking her. An hour later, she's 3cm and her contractions have fizzled. Her birth team still hasn't been reunited with her regardless of  her requests for them.

She notifies her nurse of the fact that she's planning on going home, getting freshened up, meet up with her husband, and they'll probably be back sometime later that evening.

The nurse says they can't leave. She says she's going to leave, even if she has to leave AMA.

The doctor says, that, if she leaves the hospital AMA, her insurance won't pay for her care.

I'm here to tell you that that is a lie.

We have a few possible reasons why they would say this:

  1. they don't know any better and really believe this is true. After all, this has been perpetuated as an urban medical myth for quite some time. 
  2. they know better but use this as a coercive tactic to keep mom at the hospital. 
  3. they know better and have every intention of writing in the file to not bill insurance later so mom is footed with the cost in order to 'pay her back' for not following the doctor's orders. 
The truth of the matter is, I have seen all three as reasons in action. Once, I provided proof that insurance would indeed pay for a clients care even if she left at 24 hours postpartum 'AMA'. He was genuinely surprised and happy!

Many other times, I have seen them back pedal defensively when I bring up the same information with clients who want to leave AMA... getting angrier and more coercive.


And yes, I have actually seen it notated on one nurses file electronically after a mom asked the doctor for the paperwork to leave AMA. The doctor went to the nurse, said something in low tones to her, and left the room. The nurse typed in the notes section, "do not bill insurance as patient is leaving AMA". I called her out on it and the nurse blushed the deepest red. The doctor came back in and blamed it on the nurse, who erased the notes. Later, when mom had birthed and received her bill from the hospital, none of the stay had been sent to her insurance claims department; she called her insurance and confirmed. She called the hospital and they attempted to give her the run around about AMA and insurance declination. She had to have her insurance call the hospital to get it covered.

So, bottom line, yes, insurance will still cover you if you check yourself out AMA. For more information see below:

  • http://www.ncbi.nlm.nih.gov/pubmed/22331399
  • http://thehappyhospitalist.blogspot.com/2011/05/will-my-insurance-pay-if-i-leave.html
  • http://www.amednews.com/article/20120705/business/307059997/8/
  • http://www.epmonthly.com/whitecoat/2010/05/will-insurance-deny-payment-if-you-leave-ama/
  • http://www.uchospitals.edu/news/2012/20120203-billing.html
  • http://patients.about.com/od/atthehospital/fl/Choosing-to-Leave-the-Hospital-Against-Medical-Advice.htm

10.08.2014

It's Just Going To Hurt - And I'm Sorry

eventful.com
My husband and I went to a local comedy joint, as we often do, and had the privilege of watching the act of inspirational comedian, Darryl Lenox. Darryl is a man who's personal struggles, both physical and emotional, have provided him with the substance needed to bring his audience to chuckles and tears, motivation and amusement.

At one point, while talking about his eye surgery, he begins to explain how his cataracts were extensive enough that his pain medication wasn't touching the discomfort he was feeling. 

His doctor offered to stop the surgery, or to put him out with general anesthesia. Darryl replied that he didn't want to be put under general anesthesia because, in the event the surgery went awry and he lost his sight completely, he wanted to 'watch the lights go out'.

So his doctor made a very profound statement:

"This is just gonna hurt, and I'm sorry." - Darryl Lenox, 'Blind Ambition'

How many times in our lives would that statement have been helpful? Darryl expounds upon this by giving us a bit of humor.. It would be helpful to have this advice in high school, during our wedding vows, and so many other times... 

And what about birth? There are times when I hold a woman's hands while she is piercing me with the 'look beyond the birthing room' stare. She breathes heavily on my face and gasps, "but it hurts!"... and I do, I hold her gaze and earnestly say, "this is just going to hurt, and I'm sorry." 

Sometimes labor's just uncomfortable, but sometimes it hurts. I'm always honest with my mamas, but sometimes my best tool is to give her this type of honesty.  Breath awareness, counterpressure, massage, mantras... sometimes they all fall to the wayside and we are left with the root of it. 

This is just going to hurt, and I'm sorry.



How much freer could some mamas be, could we all be, if we were given that raw honesty so that we could accept, and surrender to, it? 

10.01.2014

Small-Minded Birth Workers


Some of you might know, or it may come as no surprise to you that don't know, that there are a number doula support groups on Facebook.

The intent of these pages are many-fold. Some are intended to help you grow your business, others are on ethics and peer review, while others are for mentoring and local/community support. Most of these are a combination of some sort.

Now, recently a doula friend of mine, who is a member of one such board, sent me a screen shot of a current conversation.

The focus of this group is outlined as such:
" We are strong business women. This group was formed because _____ saw a need in the doula industry.  ____ trainers wanted a place where doulas could discuss the business side of doula work.
This is a forum where we will be sharing marketing ideas, business strategies, answering questions and facilitating discussions. The purpose and intention of this group is to spread the  _______ message.  _______ is dedicated to helping women turn their passion into a paycheck.  _______ believes that Doulas should be paid for the services they provide and believe it is counter-productive to the industry when other Doulas provide these services for free or low cost."
Ok, duly noted that they don't promote or believe that doulas should offer their services for free or low-cost.

And duly noted that they say in their description that they are a group about the BUSINESS of doula work, But... 

But what I don't understand is how these 'professionals' can pretend that they are professional when they make disparaging remarks and ridicule others in the same profession for having differing business practices.

If we lose site of the heart of what a birth worker is, even/regardless to how it pertains to being a 'business', we cease being community changers. 

Now a side note, many of my fellow doulas and friends, both IRL and online, are a part of this group. Just because they are a part of this group does not mean that they partook in the very unprofessional behavior that you will read herein, or that they support this type of ethic. 

Another aside, I received these screen shots from someone not a part of this conversation - so none of the doulas involved sought me out - I sought them out for their side of the story.

Along the left hand column of this post, you will see a conversation that has since been deleted from the group (per an individual involved in this conversation). Also, since this conversation began, at least two of the women ganged up on have been forcefully booted from the group.

Yes, it's a closed group. Yes, it's a moderated group. And yes, they are allowed to keep whomever they want in the group. That is not the point. The point of this post is the unprofessional, unethical behavior and bullying that occurred in this thread. 

The conversation started with an innocent enough question: "do you see doing a discounted or free birth here and there as your business 'giving back to your community'? I don't."

From one individual who was a part of the conversation, there was some conversation immediately after that initial post that talked about how free and discounted services discounts the work we do as a doula. To which a doula came on and said, "It's making a difference.. it's impacting the community."

The next doula who came on replied a little more directly: "['discounting the work of a doula' poster's name], just because someone has the desire to give freely of THEIR services, THEIR skills and knowledge, THEIR time - does *not* mean that they do not value doula work as a 'profession'. 

That is just small-minded to say, I'm sorry but it is. I see is as less likely for someone who *only* does doula work to be able to do low-fee/free births than someone who offers various services/has another source of income. But those birth workers who *choose* to do that work, shouldn't be put down for it."

Snarky, derisive, rude, and condescending comments begin at that point and blossom into a conversation that is almost too painful to read. These remarks are made by both members and admins of the group, alike. Always lobbed at those who support the right of a doula to choose to give free or discounted services, regardless of their reasons for offering.


I have posted before on my feelings about people asking for low cost or free doula services, but I don't care what side of the fence you are on regarding free and low-cost doula services, the behavior of these moderators and members is completely unethical. 

Ethics: moral principles that govern a person's or group's behavior.
synonyms: moral code, morals, morality, values, rights and wrongs, principles,ideals, standards (of behavior), value system, virtues, dictates of conscience"


It is never professionally ethical to treat someone so disparagingly. Never.

One person asked what principles and basis a dissenter to the 'popular opinion' might be referring to when she said "I cannot disregard the principles and basis of what a Doula was meant for."

Let me expound on that dissenters response... As I pointed out in prior posts, and specifically in the history of birth partnersdoulas and midwives were not only meant for those women who could afford them. A doula was never a luxury item, although the term we use for our profession is one of luxury.

Doulas and midwives, godsibs and sage femme, historically went to every woman - not only those who could afford one. We trudged through hell and high water to ensure she had a good, supportive birth because we believed in a woman's right to have it - not because of what she could provide us.

The moderators and contributing members have completely missed the point of this calling. From their own words, it is easy to see that, to them, it is only a business. To them, the 'principles and basis' for what we do for women and why we do it has been lost.



get wanting to be valued in the community. I get wanting to be seen as a professional in the community. I get it because I wrote about it and continue to write about it. But the militant, aggressive, close-minded, and callous version that they believe? No way, I don't get that.

Hell, midwives in this area take state insurance and, as a default, offer reduced-fee services. Doctors do as well. Chiropractors and massage therapists in this area give reduced fee services and do community services and classes for those who cannot afford it.

Restaurants give free food to the homeless and grocers give food to the food pantries. A local man I know offers car services for the price of parts only on certain Saturdays for single mamas and spouses of deployed partners.

It takes a special kind of business owner to not see the merit of giving back to their community through their services in some capacity. And one I wouldn't want to do business with.

Shame on you, moderators and others involved in this disparaging and bullying thread. Shame on you for doing the very thing that you claim to be avoiding: making the doula profession unprofessional in every regard.

I will think of you next time I spend my time sending packets of information and resources and free samples to the 18 year old who is working her ass off trying to graduate with her class at the end of the year regardless of the fact that her mom and dad have all but disowned her and her baby's daddy is nowhere to be seen.

I'll think of you when I send her the name and number of an amazing midwife in the area that does offer her time and services free of charge just so that she can get out of the care of the only provider that her state insurance will cover that is within walking distance of her home because no one will drive her to a better doctor further away.

I'll think of you when I send her to a stellar up-and-coming doula who has a heart for these situations and plans on, someday, getting her midwifery license and traveling to third-world countries to help train birth professionals in every village.


And I'll think of you when she births her baby, on her own, into her own hands, surrounded by women who cannot disregard the principles and basis of what a Doula was meant for.

- actual situation in my professional past

*edited to black out their pictures ;) after receiving numerous 'requests' (well, threats) from a number of the women involved,. Only one woman contacted me and actually asked. Most of them cited Exploitative Law. But this doesn't fall into that category as seen here. As I told them, my intent was to draw attention to unprofessional behavior in our profession, not to individuals... As is apparent through my blacking out of the offenders names (insert roll eyes).. so I obliged. 

Some said it was yellow journalism. Some said I was muckraking. Some said was unprofessional for calling them out. But here's the thing: I didn't sensationalize or exaggerate it in the least. Hence the screen shots. It's only muckraking if I a) SOUGHT it out (which I didn't seek out this information b) it's considered 'scandalous'... to which I asked if they thought their behavior was scandalous? and c) they'd have to be famous. :/ 

And would you consider me a bully if I stood up against bullying? That's what's happening here. So there you have it. 


So...

Rather than end on that note, tell me birth workers, how are you giving back to your community. Mamas, what are you doing to give back to those in your sphere of influence. 
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