Dhara Patel is an intern for the National Health Law Program, working on issues related to reproductive health.
As I scrolled through the stories of women who had pregnancy-related deaths on ProPublica’s Lost Mothers page, a surge of emotions overwhelmed me. The numbers and statistics we typically use when discussing maternal mortality now had individual human experiences attached to them, and the pain and sorrow of the friends and family of these “lost mothers” permeated the online pages, making it difficult for me to read all the stories in one sitting. I could relate to these women, who had similar joys and experiences to my own. Some were immigrants, while others were students. Most were living happy, healthy lives until the individual tragedies that stole them from the world and from their loved ones. Many of these women were like my own mother, who drew her energy and happiness from her children. But unlike my mother, these women did not survive their last pregnancy. They could not watch their children grow up.
Seven hundred women die each year in the United States from childbirth or pregnancy-related complications, and over percent of these cases are preventable. Our maternal health outcomes, when compared to other similarly situated countries, is dismal. This is particularly the case for black women, Latinx women, and indigenous women, who are more likely to lack access to reproductive health care, increasing their risk for a pregnancy-related death. Many also experience structural and interpersonal racism which leads to chronic stress and poor quality care. Both of these factors can increase the risk for maternal mortality.
One strategy that has emerged to help improve maternal health is expanded coverage of doula care, which can help reduce the impacts of racism on pregnant women of color by providing individually tailored, culturally appropriate, and patient centered care. Doulas are birth companions who provide non-medical support to women before, during, and after childbirth. They can also provide support for miscarriage and abortion care. Much of the support that a doula provides during the prenatal period involves childbirth education and information on how women can maintain a healthy pregnancy. Doulas are also present for women throughout labor and delivery where they serve as patient advocates and support women emotionally, mentally, and physically.
Research has demonstrated a multitude of health benefits of doula services, some of the most notable being reduced cesarean sections, increased breastfeeding initiation rates, and fewer low birthweight babies. However, not everyone is able to afford a doula. Doula services can cost anywhere from a few hundred to upwards of a few thousand dollars. Legislative proposals at both the state and federal levels aim to expand access to doulas for low-income individuals and their families, in particular through Medicaid coverage.
At the federal level, the primary focus is on gathering data rather than funding doula services. Most doula bills would increase research on the potential uses of doulas, their needs, and the gaps in the services they provide. Few solely focus on implementing Medicaid coverage for doula services. All of the federal bills are still in the committee stage.
States have been more progressive in legislation around doula care. Minnesota and Oregon successfully enacted legislation to provide Medicaid reimbursement for doula services in 2014. Connecticut, Indiana, Illinois, Massachusetts, New York, New Jersey, Rhode Island, Texas, and Vermont have also recently introduced legislation for Medicaid coverage of doula care.
It is important to note that even if more states expand access to doula care for their Medicaid enrollees, practical challenges exist to successful implementation. Low reimbursement rates in both Minnesota and Oregon have prevented some doulas from serving Medicaid enrollees. Oregon successfully increased the doula reimbursement rates from only $75 for labor/delivery to $350 for each pregnancy, but Minnesota has limited reimbursement up to $25.71 for each prenatal and postpartum visit and up to $257.10 for labor and delivery. To increase access to doulas, Medicaid reimbursements must be sustainable and adhere to a living wage to ensure doula participation in Medicaid programs is high and shortages are rare.
The diversity of the doula workforce also remains a challenge. Many doulas are white and middle-income, and they primarily serve white and middle-income individuals who can afford to pay out of pocket for doula services. Moreover, few doula certifying organizations provide training on the social determinants of health, racism, implicit bias, and similar topics. A successful statewide program for Medicaid coverage of doula care would ideally address this need to diversify the doula workforce.
State bills pertaining to doula care are also increasing access to doulas in another underserved population: incarcerated women. These bills allow incarcerated women to have the support of a doula before, during, and after childbirth. Previously, incarcerated women in many states had limited access to support services and were not allowed the support of families and friends during labor. With the enactment of legislation like Washington’s HB 2016 in 2018, these restrictions on support services during pregnancy and labor are changing. The one caveat is that these bills typically require incarcerated women to pay for such services on their own. While the lack of state funding for these services has limited their impact, the bills are nonetheless a positive step towards expanding access and centering doula care and birth support on communities that are often hidden from the mainstream.
For more information, please see the following National Health Law Program resources:
- State and Federal Legislative Proposals Relating to Doula Care
- Good Birth For All Podcast on Medicaid Coverage for Doula Care
- Routes to Success for Medicaid Coverage of Doula Care