In the last few years, the US maternal health crisis is finally being recognized a newsworthy topic. For many of us, it no longer comes as a shock that the US has worse maternal health outcomes than any other developed country and these rates are only getting worse. The disparities that affect communities of color and low-income communities have also been highlighted across various platforms. In the US, black women are 3-4 times more likely to die of a pregnancy and childbirth-related complication compared to white women. In New York City, the difference is even greater – black women are 12 times more likely to die from pregnancy-related causes.
Despite the increasing coverage, we do not hear often enough about the solutions to the crisis, and this information gap can lead to complacency. What can we do to improve health outcomes and move towards health equity? What works? We need to hear more about innovative, valuable solutions, so that we can take action to make them more widely available.
One of the most successful ways to improve maternal health outcomes is by having doula support. Doulas are trained to provide non-clinical emotional, physical and informational support for women before, during, and after labor and birth. Research shows that doula support results in a reduction of cesarean rates and negative birth experiences, shorter labor, higher rates of breastfeeding, and fewer preterm births. Doula care can be particularly beneficial for women of color and women from low-income communities and can help reduce health disparities by ensuring that pregnant women who face the greatest risks have the added support they need.
Despite these benefits, doula support is underutilized, with cost often cited as a key barrier. Community-based doula programs provide culturally appropriate support at no cost to people in communities at risk of poor outcomes. Most often, community doulas are trusted members of the community they serve, and can help address disparities by bridging language and cultural gaps and navigate our complex health system. Community programs are tailored to the specific needs of the community they serve and usually include prenatal and postpartum home visits, childbirth, parenting, and breastfeeding education, and referrals for health or social services. These programs and others generally encompass all of the services that private doulas offer, with additional home visits and a wider array of services and referrals for individuals who need more comprehensive support.
Medicaid coverage of community-based doula services can make doulas accessible to those who need it most, improving health outcomes and respectful care, while also reducing spending. Statewide Medicaid reimbursement for doulas has been put in place in Oregon and Minnesota.
In 2018, to address racial and economic disparities in maternal and infant health outcomes, New York State Governor Andrew Cuomo announced a comprehensive initiative that included the development of a Medicaid Pilot to cover doula services. New York State’s commitment to the Medicaid Doula Pilot is an important step towards addressing long-standing health disparities. Having launched this March, the pilot will be available for Medicaid enrollees in Erie, Kings, or Onondaga County, all selected for their high maternal and infant mortality rates and high number of births covered by Medicaid. Doulas who want to participate must apply for enrollment with the state and are required to provide a doula training certificate or proof of training. Once enrolled, the scope of services allows for up to 4 prenatal visits, intrapartum care, and up to 4 postpartum visits.
New York and other states interested in Medicaid doula coverage should turn to the organizations and communities where community-based doula programs are established and operating. The NY State Medicaid doula pilot may be a new addition, but community-based doula organizations and programs supporting low-income communities and communities of color have existed in New York for many years, including Ancient Song Doula Services, Village Birth International, By My Side Birth Support Program, and Healthy Women Healthy Futures.
The community doula organizations’ experience and expertise is invaluable. They have identified the solutions that work and the approaches that are most successful. They have worked with community doulas, understand the breadth and depth of their capacity, and are familiar with the supervision and mentorship that can best support and assist their effectiveness.
Despite the NY State Pilot having strong potential to reduce racial and economic disparities in maternal health outcomes, since its design phase, the NY State Medicaid Doula Pilot has been criticized for several components that will impact the program meeting its intended outcomes. By making the enrollment requirements of doulas similar to those of traditional doulas, the Pilot lacks components of community-based doula models. The traditional doula service model, and the trainings associated with it, do not address many of the issues that are essential to serving Medicaid enrolled clients with complex social needs because historically, doulas have not catered to this population.
Additionally, the NY Pilot has failed to take lessons learned from programs in other states, where implementation has proven difficult. Reimbursement rates have been a key driver to poor uptake of programs because rates are too low and do not reflect the amount of time doulas spend with clients as well as the expenses incurred for travel, supplies, etc. For the NY State Medicaid pilot to operate and become sustainable models, reimbursement rates must be increased and allow doulas to support themselves and their families at a living wage and to account for the time doulas spend with clients, plus additional costs incurred.
Medicaid coverage of doula support is increasingly recognized as a promising model to improve maternal and infant health outcomes, improve the experience of and satisfaction with care, and improve health equity, while reducing or maintaining current levels of health spending. In order to fully realize the promise of this model of support and care, attention must be paid to the details of the service model, the composition of the service provider workforce, and the circumstances under which the work is being performed. Additionally, the voices of those working in existing programs and organizations must be brought to the table. As experts in this field, they know what works and does not work, and they have the ability to support the development of strong systems tackling inequities.
To read more about existing doula models that work to reduce disparities and how to incorporate lessons learned from other settings, read our recent report, “Advancing Birth Justice: Community-Based Doula Models as a Standard of Care to Ending Racial Disparities.”