Expanding Access to Doula Care

Health disparities in the United States have historically contributed to inadequate maternal healthcare, particularly for Black and Indigenous women during the perinatal period. These communities experience significantly higher rates of pregnancy-related death, with Indigenous and Black mothers being two to three times more likely to die during and after childbirth than other races. Black women, in particular, experience the highest mortality rate compared to other racial/ethnic groups, with 50.3 deaths per 100,000 live births. A multitude of factors contribute to this disparity in maternal health outcomes, including social and economic barriers to quality care that can persist for Black women regardless of the mother’s educational attainment.

This ongoing crisis in maternal health underscores the urgent need for systemic change to address the root causes of these inequities and ensure equitable healthcare for all women. Studies suggest that doula care during the perinatal period is especially beneficial for high-risk groups and provides multiple health benefits to both the mother and baby. 

The Role of Doulas

A doula is a non-medical emotional support professional for a mother during pregnancy, childbirth, and postpartum. Doulas are primarily responsible for listening to the concerns of the mother, helping the mother cope with anxiety and stress, and offering reassurance when needed. These services further extend to physical support – doulas are trained in pain management strategies, proper positioning, and massaging techniques to alleviate tension. Doulas also bring an educational aspect to the pregnancy period, offering guidance when navigating new territories such as childbirth, breastfeeding, and postpartum care decisions.

Research suggests the services provided by doula care materialize into numerous beneficial outcomes, such as lower c-section rates, fewer preterm births, a decreased reliance on medications or treatments, shorter labor hours, and higher infant APGAR scores (5–10). Additionally, doulas can help reduce the impacts of racism and racial bias in healthcare settings by advocating directly on behalf of the mother. Through continuous one-on-one emotional support and culturally congruent and patient-centered care, doulas can facilitate explicit communication between clients and medical staff to best address the mother’s needs and honor their wishes.

Medicaid Funded Births

Medicaid is a significant funding source of health services for women and children in the U.S., with 41.5% of mothers using Medicaid funding at the time of birth. Medicaid-funded births for American Indian or Alaska Native mothers and Black mothers are also more than twice the rate of white mothers, and more than three times the rate of Asian mothers. Medicaid recipients, who are often of lower income and identify as persons of color, are at higher risk of preterm birth and low birth weight than privately insured women. 

Each year, Medicaid finances between 40-43% of all births in the United States, with annual expenditures surpassing $13 billion. These costs escalate dramatically when complications arise. Approximately 12% of Medicaid-funded births involve preterm deliveries, while cesarean sections—averaging $13,327 per procedure—become essential when vaginal births are deemed unsafe.

Doula Care Under Medicaid

Though research shows mothers with doulas experience markedly better birth outcomes, access to doulas remains largely inaccessible across the nation. According to the White House Blueprint for Addressing the Maternal Health Crisis (2020), only 6% of women who give birth receive doula care, even though Medicaid covers more than 40% of all births in the United States. This can be attributed to the fact that doula services are often an optional Medicaid benefit. 

Since women who receive birth support from a doula tend to experience better health outcomes and lower rates of cesarean sections, covering doula care presents numerous cost-saving opportunities for states. A theoretical cohort analysis of doula care cost-effectiveness in the first year of birth for 1.6 million low-risk, nulliparous, term, singleton births in the U.S. showed that doula care was associated with over 200,000 fewer C-sections, 46 fewer maternal deaths, 99 fewer uterine ruptures, 26 fewer hysterectomies, and 7,617 increased Quality-Adjusted Life Years (QALYs) even when accounting for additional costs of $185 million. Further analysis also revealed that each doula could save the healthcare system $884. These findings underscore the health and cost-saving benefits of adopting national Medicaid-reimbursable doula services for all mothers who need them.  

How Policymakers Can Support Doulas

Reimbursement for doula services is a sought-after goal across states. For the goal to be attained, policy creators must acknowledge the gravity and immediacy of the issue and approach the matter from a holistic perspective. Rather than working independently on legislation, state officials should collaborate with others who are in the same process of achieving reimbursement and use their experience as a guide. This will help streamline decision-making, save time and effort, and help legislators avoid making the same costly mistakes. Some policy recommendations are as follows:

• Incentivize community-based organizations and birthing centers that provide doula services: By empowering these organizations to expand their reach, particularly to medicine beneficiaries and the uninsured, doula services can have a greater impact. For example, HealthConnect One leads birth equity training and community-based doula programs. They support programs in over 20 states for pregnancy, birth, breastfeeding, and early parenting.
• Align Medicaid policies to cover doula services: By ensuring greater monetary contributions are allocated for Medicaid and private insurance, doula services can be successfully covered. This could look like bundling payments for discrete care episodes – fees related to doula care would already be included. Additionally, by ensuring sufficient reimbursement rates, healthcare providers can expand doula access and encourage more people to become doulas.  
• Give doula services the same consideration as traditional medical and physical health services: This could occur through the creation of rules and regulations that ensure doulas are trained and nationally certified to provide professional care in any state. It could also include covering the costs of doula training and necessary certifications, or setting up grants to financially support the education of doulas from marginalized communities.

Mothers face a critical shortage of quality maternal healthcare that demands immediate legislative action. Research shows that when Medicaid covers doula services, mothers experience significant emotional and physical benefits during pregnancy, birth, and postpartum—times of profound vulnerability. To close these healthcare gaps, we need both policy overhauls and innovative approaches. Expanding Medicaid coverage of doula care and strengthening community-based services can help overcome barriers, such as geographic isolation, provider shortages, and the need for culturally appropriate care. This approach not only promotes health equity but does so without increasing overall healthcare expenditures.