What is a Scope of Practice?

This is something that’s been on my mind a lot lately. I run an online midwifery study group and we’re constantly talking about a midwife’s Scope of Practice (SoP) (answer: depends on her state, certification (if any), and her personal skills). This past weekend I attended a CAPPA Labor Doula training workshop- I like keeping my skills sharp and there is always something new to learn. The work shop was amazing, the trainer was very wise and the topic of a doula’s SoP came up repeatedly.

I trained with DONA years ago and chose not to certify. The trainer said that if we are both a doula and a massage therapist, we would need to make separate appointments to meet with our clients- that we should go so far as to exit the home, return to the car and gather new/different files/paperwork before continuing on with our client. It seemed just so… artificial to me. How could I, as a human being, segment myself and my knowledge into different professional personae? Later, this was proven to me as I watched a Lactation Consultant convince a mother NOT to breastfeed as I stood there- just a doula with enough knowledge to know the LC hadn’t done her job. I realized that if I said something about what this mama could do to save her breastfeeding relationship, I would be acting outside of my scope. It was then I decided that I couldn’t commit to DONA’s SoP and the same experience leads me to believe I will not be seeking certification from CAPPA either…

I understand why groups create SoPs; they need to be assured that their certificants understand how they fit into the clinical picture of birth. They need to be explicit in *how* their representatives are to interact with both clients and medical staff. These professional groups are being represented by many hundreds if not thousands of people who impact the way the entire organization is viewed. It makes sense- I get it.

The Scopes of Practice from some of the major organizations limit doula activity to non-clinical emotional, educational and physical comfort during labor.  But as someone who trains doulas to care for clients in bereavement situations, I know that a bereavement doula has a different Scope of Practice. There are times we touch the dead- we bathe and dress them. This could be seen as a clinical action. There are also times we advocate for our clients- we do speak to others (hospital staff, family, friends, etc) on their behalf, helping to translate the needs and wishes of the clients for the others. We do have a specific agendas for our clients- the very short amount of time a client has to parent her/his child after a loss will absolutely impact long-term healing. At times, the family is at a loss as to what to do so we provide them with options and suggestions. We know that there are common reactions that happen around the time of birth that may create long-term regret and heartache, so we encourage families to try things they may initially be resistant to.

Acting as a bereavement doula is certainly different from the common birth doula SoP. Grief changes the landscape.

I also wonder about this delineation of roles. When did attending births go from the most experienced woman acting as midwife and everyone else pitching in as seems best to them into this very specifically role-driven situation? I’m imagining a birth in the year 800 where the mother desires a birthing tea and her attendant says, “Sorry- I’m not an herbalist” or the most experienced woman in the village is at another birth, but the second most experienced woman says, “Yikes- I can’t help you! I’m not certified!” or the midwife looks at the new breastfeeding couple and says, “Geez, I can see you have an issue (and secretly I know what it is and how to help), but I can’t answer you because I’m not a Lactation Specialist.”

I understand the value of specialization (we can’t all be experts on EVERYTHING) and I absolutely do believe in specific training. But, I really feel that our birth culture is becoming TOO segmented. We are taking birth kn0wledge and are parsing it up into different sub specialties and are strangling our innate overall wisdom into these artificially defined categories. I think this causes confusion for both the birth worker and for the family who hired the *woman* not the role.