The United States is currently experiencing a maternal health crisis, but it’s pregnant people of color who experience its worst effects: Black women, American Indian, and Alaska Native women are up to three times more likely to die from pregnancy-related causes than White women and are also more likely to experience severe complications from pregnancy and birth.1 While a staggering one in six women report that they experienced mistreatment by health care providers during childbirth, women of color reported such mistreatment even more frequently.
While no one policy change can solve this complex crisis, policymakers are increasingly looking to expand access to care provided by doulas, which evidence suggests is an essential step toward advancing maternal health equity. Doulas are non-medical professionals who provide emotional, physical, and informational support during prenatal, birth, and postpartum periods and help advocate for the needs and wishes of the mother before, during, and after pregnancy. Research shows that doulas can be particularly beneficial for women of color, women with low incomes, and women living in underserved communities. Expanding access to doula care can help reduce health disparities by ensuring that pregnant people who face the greatest risks have the added support they need to have a positive birthing experience.
While doula care has been part of maternal health care for centuries, it has become out of reach for most low-income pregnant people due to cost barriers. But with evidence showing that doula care reduces birth complications, increases engagement with care, and can reduce costs for Medicaid programs overall, a growing number of states are working to expand access in Medicaid. Medicaid pays for at least 43 percent of births each year and has the unique ability to reach new parents and children throughout pregnancy, birth, postpartum, and the early childhood years.
Our prenatal-to-three health policy team has been looking at how states are working to operationalize doula care through Medicaid and how it might be scaled. The project has been a central focus area for me (Tomás E. Guarnizo) during my time at Georgetown CCF as part of the National Urban Fellows program. I first witnessed the need for doula care while working as a medical interpreter in Orlando and Chicago, where I interpreted several live births, prenatal and postpartum care visits. In each case, I sensed a palpable feeling of anxiety and isolation coming from the mom. Even though everyone on the care team did their best to make sure the mother and family felt comfortable and supported, none of us had spent the necessary time accompanying, advising, and building a relationship with the mother to ensure a sense of safety and comfort, before, during, and after the birth.
Having an informed, supportive advocate by your side during such a monumental and potentially high-risk life change can make a world of difference. More and more policymakers agree. Increasing access to doula care has been endorsed at the highest levels of government, with Vice President Kamala Harris recently referring to doulas as “a literal lifeline” for pregnant people. CMS highlighted the strong base of evidence supporting doula care and referenced it as a “person-centered care model” of perinatal support that states could consider adopting as they work towards extending postpartum coverage for one year after the end of pregnancy.
What Can State Experience Tell Us?
NHeLP’s Doula Medicaid Project has closely tracked state progress moving to Medicaid-funded doulas. So far, four states have begun to reimburse doulas through Medicaid, eight states plan to implement a Medicaid doula program in 2022— including Illinois, which has a current request open for public comments on implementation — and five more have shown significant interest in passing legislation in their upcoming legislative sessions. How can new states design Medicaid doula care with the best chance to drive improvements in health equity and maternal health? Here’s what we are learning from early adopter states:
1. Engage with communities throughout the development and implementation process
Every community has specific needs, and mothers and doulas navigate unique specific challenges influenced by geography, culture, customs, and history. A doula program that works for one state might not work for another. State agencies, practicing doulas, mothers, and community members should convene to identify their state’s specific needs and design appropriate solutions to meet those needs and overcome the challenges together. This table of leaders should work together to design and implement sustainable community engagement strategies to ensure all voices involved are heard during the program implementation. Together, state leaders should:
- Engage with and learn from practicing doulas, mothers, medical practitioners, and communities to understand what type of services doulas are already providing in the region.
- Create a set of shared common terms, administrative processes, and service delivery parameters (e.g., defining service components and streamlining Medicaid billing requirements for various services such as miscarriage and abortion support)
- Develop community outreach campaigns to inform communities and birthing people about the availability of doula care and services through Medicaid and engage practicing and future doulas to increase Medicaid doula capacity and build interest for workforce development.
- Educate medical professionals on the role of and benefits of doula care, and ways doulas can be included in care teams.
2. Lower administrative barriers to facilitate equitable access to doula care
Doulas often serve as advocates and cultural brokers for Black and Brown mothers and birthing people. Within the larger doula practice, community-based doulas are trusted members of the community they serve and specialize in providing culturally sensitive care, addressing discrimination, and meeting language gaps.
Since community-based doulas come from the communities they serve, many of them may have experienced similar systemic barriers that they are well-positioned to navigate with their clients. By approaching doula care in Medicaid as a health equity strategy, states should look for ways to reduce financial and administrative burdens for doulas who want to support people in Medicaid.
State Medicaid agencies should have some level of provider credentialing or verification in place to ensure quality and program integrity. But states should also consider ways to streamline such credentialing requirements, giving credit for the years of work doulas have already experienced or helping to offset enrollment fees or training costs for doula certification through grant programs and need-based financial aid.
Among the strategies states have used so far: Oregon will waive otherwise costly and time-intensive training requirements for some “traditional health workers” (e.g. community health workers including peer wellness specialists, personal health navigators, or peer support specialists) if the providers can show they’ve provided 3,000 hours of care since 2008. States could also consider a similar waiver or grant program to minimize costs for experienced doulas. In New Jersey, where the state has just begun to implement doula care in Medicaid, the state has helped individuals interested in becoming doula care providers by designating Medicaid agency staff members as “doula guides” who are specifically charged to help doulas with the credentialing process. The agency also created a series of trainings for doulas to provide technical support on various topics, from enrollment and claims submission to MCO contracting.
Medicaid billing procedures have also proved to be a significant barrier and burden for doulas and can discourage reach to new providers. In Oregon, doulas can directly bill for their services but many have found it very difficult. One Oregon doula told The Washington Post that it took her two years of navigating the bureaucratic maze of Medicaid billing only to receive a $75 dollar check for her services. In response to these challenges, some Oregon doulas have organized and created “doula hubs” or groups of doulas that divide the administrative tasks related to successfully receiving payment through Medicaid. Ohio is using its centralized provider credentialing hub to create one streamlined application for doulas and home visitors seeking to enroll as Medicaid providers. This will be implemented alongside the state’s new centralized fiscal intermediary to streamline billing, prior authorization, and other processes across Medicaid managed care companies.
3. Set reimbursement rates high enough to create sustainable provider capacity
Doula work is often a labor of love. Doulas describe their career choice as their passion. Setting reimbursement rates in Medicaid is a perennial problem across all provider areas, but for states wanting to include doula care in Medicaid, special attention should be paid to the unique factors that make doula care different from current medical-based care.
State Medicaid rates impact whether doulas will enroll as Medicaid providers—lower rates discourage participation. Experienced doulas in the early adopter states report that rates do not reflect the full, comprehensive time and care provided or the administrative time to bill, which together may not amount to a living wage. Doula care usually consists of several prenatal visits, continuous support during labor and delivery, and postpartum visits. This could easily add up to more than 100 hours of care provided to each client during their pregnancy.
Minnesota increased doula care reimbursement rates in 2019 to $770 for up to six visits and labor support after a lower rate did not attract doula provider uptake. In California, the state’s initial proposed bundled rate for prenatal, birth, and postpartum care was $450. However, a report in The Sacramento Bee found that at this rate per birth, doulas would be unable to afford a standard one-bedroom apartment in any major city in the state, according to fair market rates set by the U.S. Department of Housing and Urban Development.
When setting reimbursement rates, states should take care to hear directly from doulas about what they need to deliver sustainable, high-quality care to Medicaid beneficiaries. Rates should reflect such input and the urgent need for new provider capacity to meet the needs of people giving birth who will benefit most from doula care. Even as they help to ensure better health outcomes for moms and babies, research shows that doulas can contribute to the potential for reduced costs associated with pregnancy and birth complications.
If health equity is the goal, it may be time to think differently
The evidence is clear: incorporating doula care into Medicaid has important potential to improve outcomes for mothers and babies, particularly those of color who need change most urgently. Successful implementation of community-based services in Medicaid, like doulas, may require state agencies to re-envision how care should be provided and appropriately reimbursed, led by the trusted and lived experiences of community providers and mothers. It may take more time upfront to engage and find consensus among new voices, but building trust and sustained community-driven support through an inclusive and reflective process can pave the way for long-term success.
- Editor’s Note: To maintain accuracy, CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. This includes self-reported data collected by the U.S. Census Bureau. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women. Available data included in this report does not capture information about pregnant people and people who give birth who do not identify as women.