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Doubling Down on Doulas to Improve Birth Outcomes

By Megan Carolan, Director of Policy Research; Bryan Boroughs, Vice President

Doulas are labor and birth support professionals who provide non-medical services to expectant mothers, for some combination of before, during, and after birth. Doulas are by no means a new creation – their origin is commonly traced back to a Greek word for “helper” or “servant,” and cultures have employed various birth assistants in different roles throughout history.

Having a labor doula is different than having a partner or family member in the delivery room with you as a “coach” – though this emotional support from family can also be extremely valuable! Because doulas generally undergo training related to the physical, emotional, and social aspects of pregnancy, labor, and the newborn days, they have vast experience which can be used to help a delivering woman stay calm and focused, ask the right questions to feel comfortable with medical decisions, and adapt to the new reality of caring for a tiny baby.

The American College of Obstetrics and Gynecology (ACOG) has endorsed increased use of doulas as “one of the most effective tools to improve labor and delivery outcomes.” The March of Dimes highlights a number of research-backed benefits from having a doula, including shorter duration of labor, reduced C-section rates, fewer “ow” Apgar scores, lower rates of preterm birth and low weight births, and impacts on the experience itself, including reduced negative feelings about childbirth.

Expansion Efforts

Most doulas are private-pay, which means that the families pay directly for their services, not through insurance. At the beginning of 2019, only Minnesota and Oregon had expanded Medicaid access to doula services, but significant progress has been made in other states this year. New York’s pilot has received significant attention, providing opportunities to reflect on challenges they have experienced. New Jersey’s bill providing doula visits only passed in recent months; therefore, no evidence from implementation is yet available. Indiana passed a bill to begin Medicaid-funded doula services for women in three counties, though funding for the program was stripped from the budget.

Localities are also beginning to explore options to fund and provide doula services to some residents. San Francisco introduced a doula program which will focus on Black and Pacific Islander communities accessing MediCal, providing 3 prenatal visits, 3 postnatal visits, and support during labor and delivery as well as training 20-30 new doulas.

ICS is working closely with the BirthMatters program in Spartanburg, SC, a community doula program which serves young expectant mothers who are eligible for Medicaid. Moms are paired with a trained, community-based doula who provides in-home, one-on-one visitation from pregnancy (must enroll by 28 weeks gestation) until the child turns six months. The model is based on the well-documented HealthConnect One program in Chicago and has been implemented for several years. The community is also working to expand the service to more families, potentially leveraging outcomes-based financing, through the city’s Hello Family initiative.

Lessons Learned

As states and communities consider expanding access to doulas, they can learn from challenges experienced by early adopters.

  • Reimbursement rates: Minnesota and Oregon have the longest histories of reimbursing for doula services and yet still face challenges in adequate reimbursement rates to incentivize provider participation. Oregon’s current rate is $350 for each pregnancy, though the Oregon Doula Association recommends a $600 one-time fee per client (for two prenatal visits, two postpartum visits, and labor support). A recent article exploring the impact of the New York program identified insufficient reimbursement rates and general red tape which deterred participation among doulas.
  • Workforce pipeline & certification: Developing standards around doula training and certification is complex. The National Health Law Program notes that, from a Medicaid perspective “licensing means that an individual meets educational, training, and professional standards of conduct….There are currently no formal mandatory licensure, certification, or credentialing requirements for doulas in the United States.” There are four prominent doula-certifying organizations – The Association of Labor Assistants and Childbirth Educators (ALACE); DONA International; Childbirth International (CBI); and Childbirth and Postpartum Professional Association (CAPPA) – though over 100 organizations offer some variation. Because doulas have generally not participated in traditional insurance and Medicaid programs, there can be bureaucratic barriers to getting them enrolled. New York addressed a number of these concerns – doulas must submit a provider enrollment form, but are not required to submit additional licensure forms as doulas are not licensed by New York state. There is no fee for enrollment in the program as a provider. The state has released several technical assistance documents to guide providers through this.
  • Diversity and geographic availability of doulas: The doula workforce is generally white and middle-income, tending to serve similar families who are able to pay for services out of pocket. Not all certifying organizations require training on social determinants of health and implicit bias in health care, which may undermine the knowledge of white doulas working in communities of color. Recommendations for the workforce include both improved, required training on these essential issues and a concentrated effort to recruit and train doulas of color to work with populations through community-based programs.
  • Outreach: Communications is also important in helping patients and medical providers know about the opportunity to work with a doula. Medical providers involved at birth must receive information regarding the benefits of doulas for mothers and babies and develop an understanding of how to work with doulas during the prenatal period and delivery. All professionals working with expectant mothers should see themselves as members of the same care tem.

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