A Problem with Death Doula Training

A Brief History of Birth and Death in the West – Midwifery and Death Doulas

By Delta Waters RN (Guest Blogger)

Delta Waters RN spent her entire 20-year career focusing on geriatric and hospice specialties. Providing care and comfort for Elders continues to be her joyous vocation. She did elect to take a course in End of Life doula preparation after retiring from nursing and found it to be an exercise in “un-learning” the role of being the nurse and remembering the heart of what brought her to the bedside in the first place: quiet, compassionate witnessing of the human experience. She currently offers advance directive creation courses found at DeltaWatersLifeCare.com . Delta lives in the beautiful Four Corners region of New Mexico with her partner and wire-haired Border Terrier, JoJo.

Communities have always organically produced members, especially women, who actively support others in times of transition like birth and death, often one in the same person.

For example, in the early history of the United States, black midwives who brought with them the intimate, hands-on knowledge of pregnancy and birthing from their lands of origin were valuable in supporting both the white and enslaved women in their surrounding areas to bring in new life within the comfort of home. So essential, in fact, that they were often granted not only amazing latitude to travel freely about but might also receive pay for their efforts.¹These “Granny Midwives” continued to provide their communities with birthing services long after emancipation, even into the 20th century.

Soon, however, birthing became a medical specialty and was relegated to less-than-superior hospital settings. Male doctors effectively pathologized what was by and large a process that nature created perfectly. And the same can be noted for the dying process. As birth became a disorder, death was anointed a condition to be treated as the enemy to be fought with allopathic approaches, sustaining life at all costs.

Human cultural movements are often co-created at the same time related to larger social changes. By the 1960s, there was a backlash in response to the medicalization of birthing and dying. Home birth, with the attending “lay” midwives and specialized support persons (soon to be known as birth doulas), saw a surge in numbers, albeit mostly among middle-class, white families. ² These natural birth champions were fostered by hands-on experience, not formal education. 

While birthing was being reclaimed by the so-called hippie culture, the heart of hospice was born. Dame Cicely Saunders brought the formalized model of hospice care to the U.S. in 1963.³  Soon after, high-profile End of Life and spiritual leaders also began trailblazing in death education awareness such as Elizabeth Kubler-Ross, Stephen Levine and Ram Das. Again, in its totality, these happenings sought to reclaim that which many saw as a natural right to wrest their birthing and deathing away from the dominant patriarchal/medical paradigm and make these natural events their own. 

There is an obvious overlap in the birth/death orbit. When birth doula Phyllis Farley attended an End-of-Life seminar at a Jewish center in NYC in 1998, it led to a doula services program in 2001 at a NYC hospital and, soon after, a doula training program.⁴ By 2010, with the networking abilities of the internet, the death doula role exploded…something old became new again. As it stands today, medically trained hospice nurses serve as the source of medications and specialized treatments for comfort and the End-of-Life doula can carry on reinforcing hospice education and support when the hospice team is limited by regulations in their time allotment at the bedside. The doula’s offering can be the gift of time and experience.

Here’s the Rub…

While home birth and home death have a long human history of being attended by “direct-entry” providers (those with knowledge passed on via time-cultivated, direct experience and trusted elders), the non-medical role of the death doula is quickly moving from sacrosanct to profane. And that’s because of the End-of-Life doula training currently offered.

In my web review, daily active time spent in death awareness groups on social media and many years as a hospice/geriatric RN, I observe that most private course creators are highly educated with decades of hands-on experience…hospice nurses, medical social workers, geriatric/oncology experts, seasoned hospice/hospital chaplains. Most doula teachers are accomplished End of Life practitioners in their own right who see the need for more death doulas. I get that. There’s so much need out there for helping the dying get the support they need.

However, I feel like the latest trend in internet marketing is the “create a course and sell it” model that cheapens the vocation. A role that was once fostered within an organic community is now being sold to those who can afford the “training.” They mostly all seem to say, “Take my course, then hang your shingle!”  Even higher education/continuing education providers are offering web-only or hybrid, self-paced training systems. 

The courses are invariably overviews in my opinion. Aspiring death doulas, by paying sometimes thousands of dollars, are promised they can be Jacks and Janes of all trades by completing their syllabus—well-patient advocates, advance directive creators, homemaking/respite providers, 11th-hour vigil sitters, home funeral facilitators, commemoration/eulogy planners, grief/loss supporters. But in my experience, while the doula programs are great for increasing the layperson’s death literacy, the lessons are not sufficient to educate in skilled death attending. That’s why historically birth midwifery was performed by the old women…they had been around the block and seen it all! Where is the time in the trenches, so to speak, for these newly minted death doulas?

In my estimation, many of the death doula wanna-be’s are folx who had a loved one die recently, had a relevant experience and think they are ready to assist others.  Again, understandable. There is an amazing interaction that happens during the dying Journey that can touch the deep humanity within some might call holy or divine. Yet, I cannot say this, along with a few weeks reading and Zoom-ing and taking quizzes, is sufficient to prepare for skillful time at Death’s bedside. 

Some training courses require around 15 hours of bedside service, usually obtained through hospice volunteering. But even fifteen hours is woefully short of what one might see during a death. While death is a shared human experience, they all have their unique trajectories. There’s so much to learn as I find, looking back on my career, assisting around one thousand End of Life journeys: the gross agitation at 2 a.m. when the hospice nurse is unavailable, aggressively dysfunctional family dynamics, the uncontrollable manifestations of unattended grief. These were not mentioned in my training. I learned how to approach these situations with time and experience. And I had experienced team members with me whose members guided me when I was at a loss.

Nevertheless, the courses insinuate that upon graduating, one can print business cards and provide “a good death” for clients. Death doulas need experience (MANY experiences) over time, side-by-side with a seasoned Death worker. Appallingly, one trade college offers doula certificate courses that “allow you to complete it without any teaching assistance.” ⁵

For just $198 and no direct experience…

What BIPOC  communities have continued to do under the radar, the middle-class is, once again, doing what it does…co-opt it and sell it, showing no regard for unique community needs or honoring extended, direct training.

The time-tested answer

In order to move from the patriarchal notion of elitist secondary education or purchasing a certificate course as the only path to legitimization, I’m calling for the return of the age-old model of learning: the apprenticeship.

In my twenties, I trained to be a direct-entry home birth midwife where I was strongly steeped in the apprenticeship culture. I spent about three years being the third person on the birthing team: two midwives and me. I watched and learned. My hands were eventually, quite literally, guided by the lay midwife’s hands in order to catch the baby safely. All midwives and doulas back then, pre-internet, found success through positive word-of-mouth and lengthy apprenticeships. That’s how a healthy community works.

Experienced death attendants are also midwives, birthing souls back to the other side. And it takes time to skillfully attend to the spiritual, emotional, psychological and physical needs of the Death Journey. Birth and Death are both liminal transition times requiring direct, repeated experience to understand the complexities in order to bring about a desired outcome. 

There are so many highly experienced Death workers right now doing amazing work. I suggest we in the death awareness community tap that knowledge and provide the organically reliable classical training provided by apprenticeship. Then, wherever an aspiring death doula lives, the unique needs of their community will inform their education. I know this is an investment of time but so is dismantling the system of the deeply-rooted patriarchy. But that’s another story for another time…

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1  https://nmaahc.si.edu/explore/stories/historical-significance-doulas-and-midwives

2 https://www.ourbodiesourselves.org/health-info/history-of-midwifery/

3 https://www.nhpco.org/hospice-care-overview/history-of-hospice/

4 https://www.utne.com/community/phyllisfarley/

 5  https://www.iapcollege.com/program/end-of-life-doula-certificate-course-online/?gclid=CjwKCAjwkaSaBhA4EiwALBgQaKoKHLjROSclt6NY7mIIoxtZwwjvX2dNLuECcFeF7lYIs8OS-1f1fBoC7ZQQAvD_BwE