The United States has one of the highest maternal mortality rates among high-income countries. Generations of structural racism have contributed to maternal mortality rates of US Black mothers being three to four times higher than that of White mothers. US Black mothers are also 2.1 times more likely than White mothers to experience severe maternal morbidity or adverse pregnancy outcomes that result in adverse long-term health consequences. Doula care can help reduce these harms and close these disparities.
Doula care is an important yet underused resource in improving maternal health equity. Doulas are non-clinical health care personnel who provide physical, emotional, and informational support not only during labor and delivery, but also to expectant and postpartum mothers. Doulas provide support in the form of offering breathing techniques during labor, empowering mothers to advocate for their health care preferences, facilitating communication with providers, sharing guidance with mothers’ loved ones, and providing breastfeeding assistance.
Robust evidence demonstrates the benefits of doula care for mothers and infants. For mothers, doula care is associated with increased maternal engagement in and higher satisfaction with care. Additionally, babies whose mothers received doula services are less likely to have low five-minute Apgar scores of their health at birth. Given the data—including a finding that doula care is one of the most effective evidence-based practices for labor and delivery—the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine back the use and expansion of health insurance coverage of doula care. However, doulas do not generally comprise part of the traditional maternity care team, and it is uncommon for private or public medical insurance to cover their services.
In this blog post, we will discuss barriers to and policy recommendations for expanding Medicaid coverage of doula services in the US.
Barriers To Use Of Doula Services
As of 2015 (the latest data available), only 6 percent of birthing mothers received doula care. There are several reasons for such low rates. First, a lack of awareness of doula services among Medicaid beneficiaries precludes many expectant and new mothers from benefitting from it. Second, mothers with relatively few resources—such as those enrolled in Medicaid during pregnancy—are often unable to afford the cost of doula services, with out-of-pocket costs for private doula care often reaching $1,500 per birth and, in some places such as New York City, up to $2,000. As a result, doula care is often available only to affluent White mothers. Additionally, mothers who live in rural parts of the US are often unable to access doula care due to fewer doulas practicing in those areas. Finally, training, certification processes, and availability of a diverse doula workforce vary state by state.
Doula Care Helps Address Inequities In Maternal Health Outcomes
Increasing use of doula services is an important strategy to improve equity in maternal health outcomes. By supporting mothers to advocate for their personal care preferences, doulas can help combat interpersonal and institutional racism that occurs frequently in the maternal health care context. Doulas can also be instrumental in preventing unwarranted and undesired clinical interventions such as episiotomies by providing evidence-based information and supporting mothers to share in clinical decision making.
Community-based doula support holds particular significance for Black, Indigenous, and People of Color (BIPOC), where distrust of the medical establishment may be more common due to experiences of (historical or direct) disrespect or racism from providers. Moreover, doulas of color have reported motivation to support mothers from their own racial, ethnic, and cultural communities. Mother-doula cultural concordance can strengthen patients’ health care satisfaction as well as outcomes. As such, some organizations focus on the provision of culturally congruent doula services—an objective aligned with the goal of achieving reproductive justice in maternity care.
In addition, community-based doulas can help address social determinants of health that underlie differences in maternal health outcomes. In some cases, doulas may help mothers identify and connect to resources for basic needs, such as food and housing, and may detect physical or emotional abuse and the presence of maternal mental health conditions. Because research suggests that racial disparities in severe maternal morbidity are linked to both clinical care practices and social determinants of health, doula care is a promising intervention to address two key drivers of maternal health inequities.
The benefits of doula care coverage under Medicaid extend beyond improved health outcomes and racial equity. Coverage can reduce health care costs by shifting care away from high-cost specialists, reducing Cesarean deliveries, limiting the use of instrument-assisted births, and increasing breastfeeding. Medicaid coverage of doula services would also drastically reduce out-of-pocket cost barriers to use for low-income mothers—many of whom are BIPOC—and for whom Medicaid currently does not cover the costs associated with doula care in the vast majority of states.
The Current Landscape Of Expansion Of Coverage Of Doula Care Under Medicaid
Because low-income pregnant, birthing, and postpartum BIPOC mothers comprise a disproportionate share of Medicaid enrollees, Medicaid is an important policy lever to reduce inequities through the coverage of doula services. Medicaid coverage of doula care can help address the lack of awareness, cost barriers, and geographical restrictions limiting doula care use, especially among BIPOC mothers. Many researchers and maternal health experts have advocated for expanding postpartum Medicaid coverage to improve maternal health for Medicaid beneficiaries and reduce disparities in outcomes between Black and White mothers in particular.
There is also growing momentum at the federal and state levels to include doula care as a Medicaid benefit. Five federal bills introduced in 2019 or 2020 include recommendations or requirements for state Medicaid programs to cover doula care, including the MOMMIES Act, the Healthy MOMMIES Act, the Helping MOMS Act, the Mamas First Act, and the Maternal CARE Act (see exhibit 1). Furthermore, the Black Maternal Health Caucus recently re-introduced the Black Maternal Health Momnibus Act, a package of 12 bills (including three new ones in the bill’s reintroduction that include doula care), which, if passed, would encourage use of doula services prenatally, during pregnancy, and postpartum. The Medicaid and CHIP Access Commission and the Centers for Medicare and Medicaid Services (CMS) have also issued guidance on increasing access to doula care for Medicaid beneficiaries, as outlined in two of the proposed federal-level bills (see exhbit 1).
Exhibit 1: Proposed federal-level legislation outlining Medicaid coverage of doula care
Source: Authors’ analysis.
However, Medicaid coverage of doula care currently varies widely across states. To date, four state Medicaid programs cover doula services—namely, New Jersey, Oregon, Indiana, and Minnesota, with New York having instated a Doula Pilot Program. The Doula Medicaid Project estimates that, in 2019 and 2020, 15 states were considering including doula services as a Medicaid benefit; this figure has since increased to 21 in addition to Washington, DC, (see exhibit 2). In 2020, Massachusetts came close to enacting Medicaid coverage for doulas, but the bill has not moved forward past referral to the House Ways and Means Committee since January of this year. Other states such as Minnesota have covered doula care “as an extended service for pregnant women” since 2013. (In the state, doulas must train through a Minnesota Department of Health (MDH)-approved organization; register, apply, and pay for a listing on the MDH registry; and practice under supervision of a “qualified health care professional”).
Exhibit 2: State-level Medicaid coverage of doula care: 2019–20
Source: Authors’ analysis.
Including doula services as a standard benefit in state Medicaid programs can help improve maternal health outcomes and enhance equity. Medicaid programs could cover prenatal, labor and delivery, and postpartum doula care, extending to the full postpartum year. Potential federal policy strategies to achieve this goal include Congress designating doula care as a mandated Medicaid benefit (as the Mamas First Act does, with its requirements of doula care coverage at the state level), while requiring CMS to develop a standardized doula care reimbursement system. Although ambitious, a national policy would serve as a more comprehensive option than state-level ones.
However, more feasible options may exist at the state level. To address low uptake of doula care, states could pay for doula services using state-level funds. In its pilot program, New York employed this approach, with fee-for-service Medicaid and managed care organizations covering up to four prenatal care visits, support during labor and delivery, and up to four postpartum care visits.
Alternatively, states could apply for a Delivery System Reform Incentive Payment of Medicaid’s Section 1115 waiver program or a state plan amendment (SPA) to expand Medicaid benefits to include doula care. Rhode Island proposed such an option, requesting that the state receive CMS approval to reimburse doulas on a fee-for-service basis for up to three prenatal care visits, support during labor and delivery, and three postpartum visits. Minnesota and Oregon successfully implemented SPAs, which designated doulas as providers under Medicaid. States could also use waiver funds to reimburse “non-licensed” doulas. However, SPAs may require that doulas operate under the supervision of a licensed health care professional, such as in Minnesota’s and Oregon’s original strategies, which can limit doula autonomy. To address this, state Medicaid agencies should enable the CMS Preventive Services Rule, which allows state-level coverage of non-licensed care providers.
Regardless of whether states use state funding, an SPA, or a waiver, states should also require Medicaid managed care plans to cover these services.
Training And Workforce Policies
States could also use any of the aforementioned state-level policy options to support training and workforce development. The National Health Law Program recommends considering a wide variety of training models in core competencies for Medicaid reimbursement, as well as ensuring adequacy of reimbursement for doulas. In addition, the federal Maternal and Child Health Bureau could support awareness campaigns about the benefits of doula care while promoting avenues for doula training and certification across diverse communities. Such an approach is critical since data on the diversity of the doula workforce is lacking. To our knowledge, the census does not collect labor market information on the doula workforce.
Finally, making doula services reimbursable under Medicaid could attract more doulas into the profession, helping to address shortages in rural areas. In Oregon, more doulas joined the traditional health worker registry after the state’s increase in doula reimbursement rates. Involving doula training organizations and doula leadership directly in the process of establishing training competencies would constitute a crucial component of this strategy.
The Goal: Affordability, Awareness, And Meaningful Access To Doula Care
Many states have demonstrated political will to modify policies to enhance maternal health, indicating an important policy window to advance legislation related to the coverage of doula services under Medicaid. To date, 113 national and 151 state and local organizations have signed a letter sent to the Biden administration encouraging CMS to approve extension of the postpartum coverage period for Medicaid beneficiaries from the current coverage period of 60 days postpartum to 365 days. Several states have already indicated interest in the Medicaid extension policy, which recently passed in the American Rescue Plan of 2021.
The evidence indicates that reimbursement for doula services under Medicaid can improve health outcomes for mothers and infants, reduce racial disparities, and advance maternal health equity in the perinatal period while saving state Medicaid dollars. Given the role that doulas play in mitigating the impacts of social determinants of maternal health and the current attention to improving maternal health in the US, we would do well to develop policies—and to engage doulas in creating them—that assure fair reimbursement and support. These efforts would encourage affordability, awareness, and meaningful access, specifically for communities of color.