Doulas—trained professionals providing emotional, physical, and informational support for women and birthing people—hold historical significance for Black families and communities. Despite attempts by both the American medical system and policymakers to discredit and ostracize Black birth workers such as doulas and granny midwives, they have continued to preserve many traditional birth practices over centuries, providing a holistic model of care.
Research shows that there are strong evidence-based benefits that doula care provides for pregnant and postpartum women and birthing people. While doulas do not provide clinical care at births, the patient-centered and holistic care that they offer has been associated with lower cesarean rates and fewer obstetric complications. Community-based doulas in particular can offer culturally appropriate support for those most at risk for poor outcomes.
Today, expanding coverage for doula care is critical for achieving improved and equitable maternal health outcomes. New data from the Centers for Disease Control and Prevention (CDC) show that in 2021, the United States had the worst maternal mortality rate since data have been captured. The COVID-19 pandemic has had stark impacts on an already dire maternal health crisis, with a 40 percent increase in maternal deaths between 2020 and 2021 alone. When the CDC data gets broken down by race, this crisis is even more concerning—Black women and birthing people are over 2.5 times more likely than their white counterparts to die from pregnancy-related causes.
Black Maternal Health Week
Black Maternal Health Week (BMHW) is a week-long campaign designed to bring awareness to and amplify the voices, perspectives, and lived experiences of Black Mamas and birthing people. BMHW was conceived by the Black Mamas Matter Alliance (BMMA) and is promoted annually. This year, BMMA continues to highlight and center “culturally-congruent practices with a focus on Black Midwifery care and full-spectrum Black-led Doula care.”
In order for doulas to sustainably provide care to the communities that need their services most, they need to be financially accessible and fairly compensated. This BMHW provides an opportunity to uplift Black-led and community-based doula care and highlight policy solutions to improve and expand its coverage.
Doulas and Medicaid
Roughly 40 percent of all births in the United States are covered by Medicaid, and among Black women and birthing people, that number increases to 65 percent of births. Efforts to expand Medicaid and increase Medicaid coverage of doula care will be greatly beneficial for Black maternal health outcomes.
Currently, more than half of all states are either providing Medicaid coverage for doula care, in the process of implementing coverage, or taking actions related to Medicaid coverage for doula care. Over half of all states have also chosen to provide access to twelve months of Medicaid and Children’s Health Insurance Program (CHIP) postpartum coverage. While these are promising developments, much more progress is still needed in order to make doula care affordable and accessible for anyone who chooses to seek doula services for their pregnancy, childbirth, or postpartum period.
Roughly 40 percent of all births in the United States are covered by Medicaid, and among Black women and birthing people, that number increases to 65 percent of births.
For example, there are a number of barriers that doulas face in accessing Medicaid reimbursement even when they work in a state that includes doula care in its Medicaid coverage. States often require certifications from a narrow list of nationally known (and predominantly white-led) doula organizations in order for providers to qualify for Medicaid reimbursement. This can limit and exclude community-based doulas who may have received training and certification from organizations not listed by state Medicaid agencies, may no longer have proof of their certification, or may have learned through apprenticeships and shadowing as opposed to a formal training—particularly affecting doulas who are low-income or people of color. Many of these training/certification requirements are rooted in white supremacy, echoing the troubling history of how Black birth workers were originally excluded from medicine and childbirth care to begin with. What’s more, these requirements are not even necessarily responsive to or capable of addressing the needs of communities of color.
When doulas are able to successfully receive reimbursement from Medicaid for the care they provide, the reimbursement rates are too often inequitable and unsustainable, and the cumbersome billing process can deter utilization. Community doula organizations, academics, and advocacy groups have all recommended that policymakers increase doula reimbursement rates, use grants or other funding sources to subsidize doula training and diversify the doula workforce, and collaborate in partnership with various stakeholders to increase doula participation in Medicaid.
Currently, doula reimbursement rates for state Medicaid programs are operating under a per-birth and per-visit compensation model, and the rates do not adequately cover the full and complex range of services provided by community-based doulas. What is considered a livable wage for doulas will vary by state, and that is why including local community doula organizations in decisions about state Medicaid reimbursement plans is critical in order for policymakers to understand and fund the full scope of doula care.
Doulas and Private Insurance
While improving Medicaid coverage of doula care is important for filling a gap when it comes to maternal health equity, private insurance coverage of doulas is also a space where much progress still needs to be made. As we know, the Black maternal health crisis impacts Black women and birthing people across socioeconomic levels, and private insurance plans not covering doula care puts it financially out of reach for many. Out-of-pocket costs for hiring a doula can be upward of $1,500 per birth. For women and birthing people who have private insurance but still cannot afford the out-of-pocket costs, they are left without their full range of birthing options.
Only one state (Rhode Island) currently requires private health insurance plans to cover doula care.
Several other states are considering it, but have yet to mandate it. In addition to being part of the solution when it comes to reducing poor maternal health outcomes and maternal health inequities, covering doula care is also a cost-effective decision for insurance companies: women and birthing people who choose to have a doula are less likely to require costly medical interventions before, during, and after childbirth.
With maternal health outcomes worsening and Black women and birthing people being disproportionately harmed, it is critical that doula care be made financially accessible for Black families and communities. To ensure the sustainability of and diversity within the doula workforce, doulas should be compensated fairly for the essential care they provide and the unique, underutilized skills they contribute to solving the maternal health crisis in the United States.
To improve maternal health outcomes for Black women and birthing people by expanding coverage for doula care, policymakers should consider the following:
- Congress should make birth doula services a mandatory Medicaid benefit. As it stands, nurse midwife services and freestanding birth center services are already mandatory Medicaid benefits. By explicitly including doula services, the Medicaid program will enable millions more low-income pregnant and postpartum women and birthing people to access a birthing experience that works best for them. Expanding access to doula care for Medicaid enrollees was even highlighted as a key strategy for addressing racial disparities in maternal health outcomes by the Biden administration in the White House Blueprint for Addressing the Maternal Health Crisis.
- States that have yet to add doula coverage to their state Medicaid programs should do so through a state plan amendment (SPA). In the absence of federal-level action by Congress to make doula services a mandatory Medicaid benefit, states can lead the way by taking action and following in the footsteps of their peers who already included Medicaid coverage of doula care through a SPA.
- State legislatures should mandate private insurance coverage of doula services. While socioeconomic status is an important determinant of health, we know that requiring public insurance is not the only factor preventing Black women and birthing people from having positive maternal health outcomes. The Black maternal health crisis is pervasive across income levels, and everyone deserves to have access to doula care should they want it.
- All of the above solutions must keep equity in mind by:
- including administrative support to assist doulas with the often arduous process of navigating insurance credentialing, enrollment, and contracting; and
- having rate setting and reimbursement plans that will allow doulas to have a living wage
Black birth workers have a painful history in America. For Black families and communities, the health care system not only has never centered their lived experiences, but also has actively worked for centuries to harm and exclude them. It is important to be cognizant of these facts as efforts are made to enmesh traditional and community-based care practices such as doula care within the existing insurance and health care systems.
Allowing for improved and expanded methods of coverage for doula services will enable more low-income families and people of color—especially Black women and birthing people of all economic backgrounds—to access high-quality, compassionate, and respectful maternity care. This Black Maternal Health Week, we move toward envisioning a future where equitable maternal health outcomes are the norm and preventable maternal deaths are non-existent. Accountability in policy implementation processes and the inclusion of Black-led, community-based doulas at every level of maternal health policymaking are of the utmost importance to achieving this future.