Maternal Health Woes Prompting States to Turn to Doula Care

State Medicaid programs are increasingly turning to doula services to help tackle the maternal health crisis, but low reimbursement rates may risk undercutting tangible progress.

Medicaid programs in at least 15 states plus the District of Columbia have implemented doula services or are in the process of doing so. Doulas “are trained professionals who provide continuous physical, emotional, and informational support to clients before, during, and shortly after childbirth,” according to DONA International, America’s largest doula-certifying organization.

The US boasts some of the worst maternal health outcomes in the developed world. According to the CDC, “non-Hispanic Black women averaged 55.3 deaths per 100,000 live births.” Iceland has nearly the same GDP per capita as the US yet only has 4 deaths per 100,000 live births.

Despite these grave figures, promising data compiled by the HHS is showing that Doula services drastically improve maternal health outcomes.

The HHS report, published Dec. 13, found that “doula-assisted mothers were four times less likely to give birth to a baby with low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding.”

One state embracing doulas is Michigan, where a collaboration between policy experts and external stakeholders led the state’s Medicaid program to introduce reimbursement for doula services starting in 2023.

The state’s Medicaid program will start to cover doula support for birth and delivery as well as prenatal, postpartum, and community-based doula services, Farah Hanley, the state’s chief deputy director of health and human services, said.

“We in Michigan have been very focused on addressing existing health and racial disparities, and doula services have been shown to positively impact social determinants of health and supporting birth equity,” Hanley said.

Lifeline for Disadvantaged Women

For women from disadvantaged communities, doula services are a lifeline that can help them navigate a health-care ecosystem where they often face discrimination and hostility due to race and socioeconomic class.

A research survey conducted by the National Partnership for Women and Families found providers treated patients who were white and privately insured better than their nonwhite counterparts.

According to an analysis of the survey in the Journal of Law, Medicine and Ethics, people of color on public health insurance also “reported ‘rough handling’ by hospital personnel and being ignored after expressing fears and/or concerns.”

Nikia Lawson, president of DONA International, saw this maltreatment firsthand while she was working as a doula for a family on Medicaid.

“We were in the birthing space and the doctor was preparing to make a surgical incision to widen her birth canal unnecessarily,” Lawson said “However, on this particular day, I was in the room watching what was unfolding and was able to make contact with the husband and inform him to speak to the doctor directly on behalf of his wife about not receiving this unnecessary surgical incision to her vaginal area.”

Anecdotes like this are not hard to come by, yet despite the benefits that doula services provide for women from disadvantaged communities, many doulas believe that state health programs have a long way to go before the full impact of doula services on maternal health outcomes is seen.

Limited by Reimbursement Rates

For doulas like Lawson, low reimbursement rates are limiting how many Medicaid patients they can effectively cover.

Medicaid reimbursement rates for doulas are often significantly lower than the usual market rate, often upwards of $2,000 per birth.

And in a low-paying state like Nevada, which reimburses doulas $150 per delivery, those rates don’t cover transportation expenses and the costs associated with turning down clients who are willing to pay out of pocket.

“The majority of doulas who desire to serve the marginalized population are themselves marginalized individuals. They’re the ones who want to give back the most. But they’re the ones who have the least in terms of resources to do so,” said Lawson.

Unlike services like midwifery where the lifespan of the service may last a couple of hours, the nature of doula services requires providers to offer continuous care to patients, which often involves providers staying on call for weeks at a time.

Lawson believes states and Medicaid-managed care organizations need to do more to reimburse providers at a rate that creates incentives for them to care for Medicaid patients.

Two States Move to Improve Pay

The calls for better pay haven’t fallen on deaf ears. Earlier this year, Rhode Island and Oregon sought state plan amendments that would increase doula compensation to up to $1,500 per pregnancy. Both state plan amendments were approved by the Centers for Medicare & Medicaid Services.

For Oregon’s Medicaid program, this increase was especially significant. The state went from having one of the lowest reimbursement rates in the country ($150 per pregnancy) to one of the highest ($1,500).

That breakthrough was due in no small part to efforts by community leaders, who made sure the state was doing all it could to reach its affirmed maternal health objectives, Dawn Mautner, Oregon’s Medicaid medical director, said.

“We familiarized ourselves with the growing body of evidence describing doulas’ positive impacts on birth outcomes,” and “it became clear that doulas could and should play a key role in helping us achieve health equity in Oregon,” Mautner said.

Rhode Island went a step further, passing the nation’s first bill ratifying fair compensation for doulas.

The Doula Reimbursement Act, (H. 5929), which took effect in July, ensures that “trained, qualified doula[s] would be eligible for coverage through private insurance and Medicaid, including the state medical assistance program, for up to $1,500 per pregnancy.”

Efforts by doulas, as well as careful analysis of Bureau of Labor Statistics data, helped persuade state lawmakers to take action, said Kelly Coccio, chief public affairs officer for Rhode Island’s Executive Office of Health and Human Services.