Much has happened since we wrote the first blog in this series, Expanding Access to Doula Care: State of the Union in January 2020—not only regarding policy, but also the maternal newborn health landscape more generally.
After the COVID-19 pandemic hit the U.S. in March 2020, we started seeing and hearing about hospitals across the country banning doulas from supporting clients during birth. In some cases, patients were forced to give birth alone without any support whatsoever. There were also reports of parents being forcibly separated from their newborns, against recommendations from the World Health Organization. Similar to other aspects of maternal newborn health, BIPOC birthing people have been disproportionately impacted by changes in policy and practice due to the pandemic.
Meanwhile, several states introduced (or re-introduced) doula-related legislation, with varying language and levels of success. Now more than ever, given the threatened state of birth support during the pandemic and for the foreseeable future, passing effective, equitable doula legislation is imperative.
Working towards doula reimbursement and integration offers both challenges and opportunities. Local activists and stakeholders can and should learn from efforts across the country in navigating both. Below is an attempt to summarize some best practices and lessons learned so far as states have navigated the complexities of doula-related legislation.
- Invite doulas to participate in and lead the legislation process, ensuring equitable access to these discussions.
Including doulas in the early stages of bill development is essential to success. We have seen some of the consequences of excluding doulas from the legislative process. Advocates in Massachusetts set a positive example by holding a series of town halls in various parts of the state to listen to doulas’ questions, concerns, and desires, which informed the language of the bill.
Doulas are the experts on what issues should be addressed locally (e.g., fears about being told how to practice, overly burdensome reimbursement systems, increased state surveillance of doula work, etc.) and should be welcomed as key advisers to legislators and stakeholders.
- Center the voices of doulas who have already been working with Medicaid populations and/or marginalized communities.
Community-based doulas who have been working with low-income, under-resourced, and/or marginalized communities hold invaluable expertise and should be centered in discussions around doula coverage and integration. The “Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities” report explains:
“Racism and implicit bias continue to drive health inequity in the United States. Community-based doula care reflects an organized, collective framework where African American, African immigrant/refugee, Latinx, Indigenous or historically underserved individuals formalize and implement programs with the specific aim of serving their own communities…These programs are culturally infused, generationally informed, and responsive to years of ongoing oppression resulting in trauma informed actions that pull families together in crisis.”
- Consider settings standards around competencies or basic requirements for doulas.
There are more than 80 organizations in the U.S. alone that claim to train and/or certify doulas, but there is no federal oversight of these programs. Simply stated, there is not a governing body that decides who is allowed to call themselves a doula. Since doulas are not a licensed or regulated profession, concerns about ensuring proper training, knowledge, and/or experience are valid.
The doula workforce is extremely diverse in terms of scope of practice, populations served, and training received, among other factors. Furthermore, doulas who choose to work with Medicaid populations need specific skills, knowledge, and support networks to meet the unique needs of those populations.
The “Advancing Birth Justice” report offers a list of core competencies that can be used as a starting point for doula legislation, highlighting social determinants of health, systemic racism and discrimination, environmental stressors, resource navigation, among other key areas of focus.
- Make any participation in Medicaid reimbursement programs optional.
Some states have proposed mandatory state-based certification and/or registration in order for doulas to refer to themselves as a “certified doula,” even if those doulas do not seek reimbursement from Medicaid or other insurance providers. Participation in state reimbursement programs should be optional, allowing for doulas who choose to continue practicing privately to continue to do so.
Understanding the historical context is key. Doulas, like midwives, have been practicing privately for centuries (not necessarily under those titles) particularly in Black and Indigenous communities. While states may institute requirements for doulas who choose to participate in state Medicaid programs, they should not stigmatize doulas who choose not to seek reimbursement.
- Pay doulas a living wage.
If doulas are not compensated fairly for the valuable services they provide, they will not participate in state Medicaid reimbursement programs.
One of the most common arguments presented that aims to stifle doula compensation rates centers around comparing payments to those of obstetricians and other hospital-based maternity care providers. However, unlike most of these health care providers, doulas are often on-call 24/7 for weeks or months at a time for a limited number of clients. Additionally, reimbursement rates for midwives and other health care workers are often too low, and should not be used as a reference point for fair compensation.
Finally, existing evidence has demonstrated a return on investment associated with doula care. When states discuss the additional costs associated with covering doulas through Medicaid, they should also consider the expected cost savings.
- Start planning for implementation before enacting legislation.
If states want doulas to participate in Medicaid reimbursement programs, states should work collaboratively with doulas to identify and minimize structural barriers. The U.S. health care system is so complex that providers and hospitals struggle with billing correctly—imagine this process for a doula who has never billed for services and lacks administrative support.
Additionally, states should develop projections for doula utilization and assess whether the current doula workforce is sufficient to meet the needs of that state’s Medicaid population, considering geographic distribution, language offerings, etc. Most states will need to develop strategies for doula workforce development to meet the needs of the populations served, including ongoing training, mentorship, and support.
- Learn from other states that have presented or enacted doula-related legislation, and let those lessons learned inform current legislative efforts.
States should avoid working in silos when developing and implementing doula-related legislation. Collaborating with other states who seek or have achieved doula reimbursement to leverage lessons learned can maximize impact, reduce duplicative efforts, and prevent states from repeating mistakes.
Where Do We Go From Here?
Despite the inevitable challenges and valid concerns associated with doula-related legislation, creating opportunities for doulas to be integrated into the health care system could result in benefits for doulas, families, and health care providers.
We can’t help but ask…how might birthing families’ experiences have been different during the COVID-19 pandemic if doulas had been integrated into the health care system and allowed to be present at hospital births? We have seen the harm and trauma that can result from lack of support. We now have an opportunity to ensure that doulas are treated as part of the care team, and that families who can benefit most from doula care have access to this valuable service.