Expanding Access to Doula Care: State of the Union

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By: Christina Gebel, MPH, LCCE, Co-founder, Accompany Doula Care; Sarah Hodin, MPH, CD(DONA), LCCE, National Senior Manager of Maternal Newborn Health Programs, Steward Health Care

Over the last couple of years, doulas have been featured in several mainstream media articles from the New York Times to People Magazine and the Washington Post among others. Perhaps due to this increased public attention around the benefits of doula care, states have sought to develop strategies for expanding access to this valuable service.

What is a Doula?

According to DONA International, doulas are non-clinical professionals who provide educational, emotional, and physical support to clients during pregnancy, labor and delivery, and postpartum. What exactly does a doula do? There are many types of doulas:

  • Birth doulas support clients during pregnancy, birth, and the early postpartum period.
  • Postpartum doulas typically focus more on the weeks (or months) following birth.
  • Full-spectrum doulas provide additional support surrounding miscarriage and abortion.
  • Community-based doulas often serve clients in under-resourced communities and take on additional responsibilities with a focus on health equity and the social determinants of health.

Currently, there is no federal regulation of the doula profession, and therefore, no universally-accepted competencies. In the United States, there are over 80 organizations and programs that train or certify doulas, and each has its own approach, scope of practice, and educational content.

The Evidence on Doula Care

According to a Cochrane Review published in 2017, continuous support during childbirth is linked to benefits for birthing people including higher patient satisfaction, increased likelihood of spontaneous vaginal delivery, and shorter labors, while posing no risk of harm to parent or baby. Some studies have also found that doula care is associated with decreased risks of preterm birth and postpartum depression, better infant APGAR scores, and higher breastfeeding rates in some populations. More rigorous research is needed to better understand how doula care impacts short- and long-term maternal and newborn health outcomes in different populations.

Reductions in C-sections and preterm births in particular can lead to substantial cost savings for health care systems, pointing to a potential return on investment from doula care. In addition to reducing costs, doulas offer a unique opportunity for health care systems to reduce workloads for nurses and frontline providers with many simultaneous responsibilities, retain patients for future pregnancies and other services, and attract new patients by providing a unique, valuable service.

In 2017, the American College of Obstetricians and Gynecologists (ACOG) reaffirmed their position on continuous labor support, such as that provided by doulas, stating:

“Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Benefits found in randomized trials include shortened labor, decreased need for analgesia, fewer operative deliveries, and fewer reports of dissatisfaction with the experience of labor.”

Importantly, Medicaid and private payers could actually improve outcomes and ultimately reduce total medical expenditure by covering doula care.

Barriers to Doula Access

As doula care is not currently a covered health care service in most states, the vast majority of doulas make a living by serving clients who are able to pay out-of-pocket. This leaves families who would arguably benefit most from doula care without access to this valuable service—including pregnant Medicaid beneficiaries who, by definition, have lower household incomes.

Doula programs that target under-resourced and marginalized communities – as well as communities of color that experience inequities in maternal newborn outcomes – have been established in an effort to fill this gap and expand access to doula care. A 2017 study conducted by HealthConnect One found that of 98 doula programs serving these populations, 70% were funded by private foundation grants. Funding from government grants, patient contributions, and Medicaid managed care were far less common.

However, with the shift towards value-based health care models and demand for doulas growing, change may be on the horizon.

State Doula Legislation

There are currently three states that have passed legislation implementing third-party reimbursement for doula services through Medicaid: Indiana, Oregon and Minnesota. Importantly, though, Indiana’s bill includes no funding for this initiative, calling into doubt whether programming will be implemented.

Additionally, though New York has not yet passed legislation, the state has already launched a pilot doula program for Medicaid beneficiaries in certain areas. However, community-based doulas and advocates have criticized the design of the pilot program, including its low reimbursement rates and lack of attention to racial equity.

Several other states have introduced legislation related to Medicaid coverage of doula services (see below). Among the states that have passed or introduced doula legislation, there is wide variation in the content of each bill. On the whole, most bills aim to define the doula’s role and scope of work; mandate or allow for coverage of doula services under the state Medicaid program and/or through private payers; establish reimbursement rates for doula services; and list competency and/or training requirements for doulas to be eligible for reimbursement.

While doula legislation aims to increase access to families who could not otherwise afford doula services, implementation remains challenging. A document out of New York, entitled Advancing Birth Justice, summarizes well the complexity and opportunity of doula legislation. Aspects like reimbursement amounts can be crucial to building a diverse and sustainable doula workforce; however, if structural and practical barriers are too steep for doulas to actually get reimbursed for their services, that, too, can inhibit effective implementation. That is why some states like Massachusetts have held town halls in order to glean the wisdom, desires, and preferences of the birth worker community to maximize the positive impact of doula legislation.

Arizona HB2605 Doulas; voluntary certification
Connecticut SB 1078 An Act Concerning Doula Certification and Medicaid Reimbursement for Doula Services
Illinois HB 0004 Medicaid-Doula Services
Illinois SB 1909 Health Pregnancy/Postpartum
Indiana SB 416 An Act to amend the Indiana Code concerning Medicaid
Massachusetts H 1182 An Act relative to Medicaid coverage for doula services.
New Jersey SB 3365 Establishes perinatal episode of care pilot program in Medicaid
New Jersey SB 1784 An Act concerning Medicaid coverage for doula care and amending P.L. 1968
New York A 04408 An Act to amend the social services law, in relation to including doulas as medical services providers for Medicaid recipients
New York S 3344 Relates to the professional certification of doulas
New York SB S5656 Includes doulas as medical services providers for Medicaid recipients
Rhode Island SB 678 Medical Assistance: Perinatal Doula Services
Texas HB 4301 Relating to Medicaid coverage of doula services.
Vermont H 219 An act relating to Medicaid coverage for doula services
Washington Engrossed Substitute HB 1109
WA State Health Care Authority Budget
Code Title: Doula Services
Program Title: Maternity Support Services Program
Washington D.C. B23-0632 Maternal Health Care Improvement and Expansion Act of 2019
Wisconsin WI State Budget Item Healthy Women, Healthy Babies State Budget Initiative

Federal Doula Legislation

Five federal bills have been introduced that include language related to Medicaid coverage of doula services as well:

S 1343 MOMMIES Act Sen. Cory Booker
HR 2602 Healthy MOMMIES Act Rep. Ayanna Pressley
HR 2751 Mamas First Act Rep. Gwen Moore
H.R. 3344 Opportunities to Support Mothers and Deliver Children Act Rep. Gwen Moore
S 1600 Maternal CARE Act Sen. Kamala Harris

 What’s Next?

The landscape of doula care in the United States is clearly changing, but in the meantime, low-income families in underserved communities often do not have access to the support they need during pregnancy, birth, and postpartum. Luckily, community-based doulas and some pilot Medicaid managed care programs are working to fill this gap while state and federal legislation is pending. With momentum continuing to build around the value of doula care, the national landscape may indeed look very different in the coming months.

Suggested Reading:

(2019) Ancient Song Doula Services, Every Mother Counts, and Village Birth International. Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf

(2016) Choices in Childbirth. Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health. https://transform.childbirthconnection.org/reports/doula/

(2017) HealthConnect One. Sustainable Funding for Doula Programs: A Study. https://www.healthconnectone.org/hc_one_resources/sustainable-funding-doula-programs-study/

(2018) National Health Law Program. Routes to Success for Medicaid Coverage of Doula Care. https://healthlaw.org/resource/routes-to-success-for-medicaid-coverage-of-doula-care/