State Policy Approaches to Incorporating Doula Services into Maternal Care

August 09, 2018|3:59 p.m.| ASTHO Staff

Maternal mortality rates in the United States continue to rise, with ethnic and racial minority populations facing even starker statistics. Policymakers are pursuing a variety of approaches to improve perinatal and postnatal care to support healthy and safe pregnancies, including expanding access to doula services. A doula is a trained professional that provides continuous physical, emotional, and informational support during and shortly after childbirth. Through this continuous support system, doulas positively impact both mothers and babies, as well as help families achieve a healthy and positive birthing experience. For women at-risk for adverse birth outcomes because of racial disparities, doula care can provide positive benefits and improve factors that mediate mortality, including decreasing cesarean births, operative vaginal births, use of analgesics, and duration of labor.

Women in the United States are increasingly interested in doula services, with six percent of individuals reporting that they used a doula in a 2012 survey, up from three percent in 2006. Approaches to expand access to doula services include allowing Medicaid to cover the services, ensuring women in correctional facilities can access doula services, and incorporating doulas into clinical care and key advisory bodies.

A growing body of evidence suggests that continuous support from doulas or other non-clinical labor support can improve birth outcomes for both mothers and infants, fewer preterm and low-birth weight infants, and reductions in cesarean sections. These outcomes may save state Medicaid dollars. Medicaid covers a significant number of births, and researchers modeling the cost-effectiveness of Medicaid coverage for doula services found calculated average savings of $986.

Reimbursing Doula Services through Medicaid: Currently, two states, Minnesota (see Subd. 28b) and Oregon (see 410-130-0015), allow reimbursement for doula services through the Medicaid program. Additionally, legislators in New Jersey, New York, and Vermont introduced bills in 2018 to add doula services as a covered benefit for Medicaid, as well as private insurance. In New York, the executive branch is also advancing this strategy. In April 2018, Gov. Andrew Cuomo announced a comprehensive initiative to improve maternal mortality and address disparities in maternal mortality, which included a pilot program to provide for doulas services in Medicaid.

Both Minnesota and Oregon recently modified their laws and regulations to increase access to doula services. In the 2018 budget, Minnesota increased the reimbursement rates for doulas. In Oregon, a law enacted in 2017 (HB 2015) requires the Oregon Health Authority (OHA) to review and revise reimbursement rates, if necessary, every two years and provided an annual report to the legislature on the status of doulas in the state. The new law also requires Oregon’s coordinated care organizations, which deliver Medicaid services, to provide information about how to access doula services online and through any printed explanations of benefits. Finally, the new law tasked OHA with facilitating direct payments to doulas, which was addressed through rulemaking (see OAR 410-130-0015).  

Ensuring doulas have access to women in correctional facilities: Minnesota, Oklahoma, and Washington state currently require correctional facilities to ensure that incarcerated women who are pregnant or who have recently given birth have access to doula services if those services are provided free of charge or are paid for by the women. Lawmakers in Wisconsin introduced similar bills in 2018 (AB 801 and SB 393).

Requiring birthing facilities to have appropriate policies that address doulas: Louisiana currently requires alternative birthing units to “develop, implement, enforce, monitor, and review” policies related to the “care and services of mothers and newborns.” One of the policies specified in the regulation covers “family support and participation,” which covers “criteria for labor and delivery attendance; and doula.” A proposed bill in New Jersey would require birthing centers and hospitals providing maternal car to review and update labor and delivery policies. The bill specifically identifies “better integration of doulas into the maternal care team” as a goal for the revised policies.

Including doulas as members of key advisory committees: Lawmakers in Washington, D.C. and Oregon established maternal mortality review committees. These committees bring together multi-disciplinary experts and stakeholders to review instances of maternal death to examine the factors and processes that may have contributed to the fatal outcome. Through this work, committees can often make recommendations, as well as promote and implement population-level prevention activities in their jurisdictions. Both Washington, D.C. and Oregon included doulas in the membership of the committees. Additionally, Louisiana established the Healthy Moms, Healthy Babies Advisory Council. This council brings together members of the legislature, executive branch, and other stakeholders, including those who provide doula or community-based support services for women giving birth, to study and make recommendations to address maternal mortality and disparities.

Controversy surrounding doulas: Although doula care is an evidence-based practice with proven benefits, there is hesitancy to incorporate doulas into the medical environment. Concern exists around a doula’s ability to advocate for a woman’s needs while simultaneously respecting medical practice. In addition, not all doulas are certified, nor do they need to be to call themselves a doula. Although medical training is not necessary, many doulas do choose to get certified. Several organizations, such as DONA International, provide doula training and certification. Women can also choose to become certified as community-based doulas through HealthConnect One. This community-based doula program model, which has been replicated nationwide to serve unique populations, trains doulas to provide culturally sensitive pregnancy and childbirth education to underserved women in their own community. While all doula services can be beneficial, creating a standard for the training and certification of doulas may improve understanding and acceptance of doula care.

Reducing maternal morbidity and mortality improves both maternal and infant health outcomes and promotes overall health and wellbeing across the lifespan. As policymakers continue to consider, enact, and implement initiatives to ensure that women, families, and infants thrive, ASTHO will highlight emerging and on-going policy trends, such as leveraging the roles of doulas to improve outcomes.

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