Increasing Access to Doulas will Ease the Maternal Health Crisis

May 03, 2024 | Alexandra Kearly, Ramya Dronamraju

Maternal mortality and morbidity rates have not improved in recent years, with one estimate finding that over 80% of pregnancy-related deaths were preventable. Considerable racial and ethnic disparities also persist as maternal mortality rates among minority groups including Native Hawaiian/Pacific Island persons (63 deaths per 100,000 births), Black persons (40 deaths) and American Indiana/Alaska Native persons (32 deaths), are higher when compared to white persons (14 deaths).

Doula care is among the most promising approaches to addressing maternal health disparities. Doulas offer unbiased, non-judgmental support, serve as a liaison between the patient and provider, and improve health outcomes through their patient advocacy and emotional support provided during the prenatal, birth, and postpartum periods. Doula-assisted births are two times less likely to result in birth complications, four times less likely to result in low birthweight babies and are more likely to initiate breastfeeding. Doulas are an important resource for addressing health equity and combating racial biases against pregnant women of color as they improve health outcomes through their patient advocacy and culturally appropriate care. Federal and state agencies are considering and adopting policies and initiatives to improve maternal health by increasing access to doulas.

Federal Strategies to Improve Maternal Health Outcomes

Federal agencies, such as the Health Resources and Services Administration (HRSA) and the Centers for Medicare & Medicaid Services (CMS), are undertaking numerous policy, training, and capacity building strategies aimed at improving access to doulas.

In January 2024, HRSA launched the Enhancing Maternal Health Initiative, which seeks to maximize the impact of grants and programs and foster collaborative partnerships and alignment between grantees to address maternal mortality and maternal health disparities. HRSA identified 11 states of focus (Arizona, Alabama, Georgia, Illinois, Kentucky, Maryland, Michigan, Missouri, Montana, North Carolina, Oregon) and Washington, D.C., where HRSA has significant investment and there is high need. The initiative aims to:

• Convene HRSA grantees from across participating states to foster cross-program and cross-state relationships to drive progress in addressing maternal health.
• Achieve measurable progress in maximizing the impact of HRSA investments.
• Foster new collaborations among HRSA grantees in high-need, high-opportunity states.
• Strengthen HRSA’s internal capacity to maximize impact.

Through new and strengthened collaboration among HRSA grantees, this initiative has the potential to increase access to doula care.

HRSA also partners with states and island jurisdictions to improve public health systems for mothers, children, and their families through Title V Block Grant funding. At least thirty-five state Title V programs promote access to doula care in their Title V Block Grant Application or Annual Report. Examples of activities include referring women in home visiting programs to doula services, supporting doula training or certification, supporting doula care and services, and advancing policies to eliminate barriers to doula care. Additionally, these funds have supported doula access for populations at increased risk for poor birth outcomes. For example, in 2022 Alabama’s home visiting program began supporting referrals to doulas for pregnant teens, Alaska and Arizona have supported training for doulas serving Indigenous populations, and California partnered with Medicaid to introduce a doula benefit to improve culturally competent birth care

In December 2023, CMS launched the Transforming Maternal Health (TMaH) Model. The model seeks to support Medicaid agencies in developing a whole-person approach to pregnancy, childbirth and postpartum care through three pillars:

• Access to care, infrastructure, and workforce (including support to increase access to doulas, perinatal community health workers, and midwives).
• Quality improvement and safety (including support to implement patient safety protocols and promote “birthing friendly" designations).
• Whole-person care delivery (including support to use social risk assessment tools to drive risk-appropriate care and increase screening of health-related social needs, among other priority areas).

State Medicaid agencies will serve as awardees, however, state-level partners, such as State Perinatal Quality Collaboratives (some of which are led by State Health Agencies, or SHAs), Title V programs, Federally Qualified Health Centers, and other community-based organizations are encouraged to participate as important collaborators. Increasing access to doulas will be a key component of the Model.

State Policies Supporting Maternal Health and Doula Access

SHAs are prioritizing maternal, child, and family health, identified as a top priority in ASTHO’s 2023 Environmental Scan of Current and Emerging Public Health Priorities (appearing in 60% of state health improvement plans and/or strategic plans). Further, 84% of state health officials surveyed by ASTHO named maternal, child and family health as a top-three public health program and service priority. While doulas can be an effective resource to improve maternal health outcomes, cost barriers remain. States are supporting doula access by covering doula services through Medicaid and private health plans, implementing doula training and certification programs, and expanding doula services for populations at risk for poor birth outcomes.

Medicaid Coverage for Doula Services

Twelve states and Washington D.C. currently reimburse doula services in Medicaid, including prenatal services (e.g., developing a birth plan), labor and delivery services (e.g., physical comfort measures), and postpartum services (e.g., newborn care education). There are several pathways for states to pursue Medicaid coverage for doula services, including through state legislation. In general, however, states must seek CMS approval, often through a State Plan Amendment (SPA), to implement the change and begin reimbursement.

Since 2023, at least four states extended Medicaid coverage for doula services (Massachusetts, Michigan, New York, and Oklahoma) and at least three states increased reimbursement rates for doula services (California, Nevada and New Jersey). In addition, four states (Michigan, California, Minnesota and Massachusetts) took an additional step to promote access to doula services and issued a standing recommendation for doula services for people covered by Medicaid. A licensed practitioner’s recommendation helps comply with federal regulations for coverage of preventive services. In fact, this is how many states have structured their Medicaid coverage of doula services.

Doula Coverage in Private Health Insurance

States have also passed legislation to require private health plans to cover doula services. In 2023, Louisiana enacted HB 272, requiring private health plans reimburse doula services for up to $1,500. Currently, Illinois is considering HB 5142 which would require private health plans cover doula services.

Doula Training and Certification

To further expand the doula workforce, states have developed doula training and certification programs. Some states require doulas to receive training or certification from state-approved programs to seek reimbursement from Medicaid or private health plans. In 2023, Connecticut enacted SB 986, directing the Commissioner of Public Health to establish doula certification process based on recommendations from the Doula Advisory Committee. Additionally, Arizona launched its voluntary licensing program, as established by Arizona SB 1181 in 2021, to provide applicants who meet the requirements a three-year license to provide state-certified doula services.

In 2024, Tennessee is considering SB 1739, which would direct the health department to create a doula training and certification program.

ASTHO will continue monitoring state policies which expand doula access to improve maternal care.