Barb Himes, IBCLC, CD

However, many factors interfere with maternal access to health care before, during, and after pregnancy, including racial/ethnic disparities and socioeconomics. Mortality rates due to pregnancy and birth complications are more than three times higher in Black than white women, and Black infants are more than twice as likely to be born prematurely or die within their first year of life than non Latinx white infants. Further complicating this is that women have also reported feeling they experience diminished autonomy or in-difference in the provider-patient relationship, which could affect their outcomes and attitudes toward accessing care. (1)

On the economic side, according to the Centers for Medicare and Medicaid Services (CMS), nearly two out of three adult women enrolled in Medicaid are of childbearing age, and Medicaid covers around 42% of births in the United States. Of those, whites make up 41.8% of women covered by Medicaid or the Children’s Health Insurance Program (CHIP), Hispanic women 28.1%, Black women 21.0%, and the rest Asian or native ethnicities.

In addition, only 21% of women in 2018 had a family income of 250% of the Federal Poverty Level (FPL) compared to 56.7% for women overall, and 20% had a family income of only 50 to 99% of the FPL. (2) The lack of financial resources can get in the way of access to health care to the degree needed throughout the birthing process and add to the risk of compromised health for infants.

But there is something that can address this combination of financial and social strain and help pregnant women get adequate care: make doulas part of the maternal health support network covered by Medicaid. This approach advanced by the National Health Law Program’s Doula Medicaid Project monitors the status of Medicaid efforts regarding doula reimbursement in the United States, state by state. The ongoing-updated chart can be found at https://healthlaw.org/doulamedicaidproject/. The program’s goal is to ensure that all pregnant enrollees in Medicaid who want access to a doula will have one. 

According to the latest standings, there are currently four states (Oregon, New Jersey, Minnesota, Florida) where Medicaid is actively reimbursing for doula services, and eight states are putting Medicaid doula benefits in place. Ten states report action has been proposed but has made no progress, and those remaining have been taking steps related to care, such as setting up doula registries and certification programs. 

This initiative matters because it contributes to maternal health care support, directly affecting maternal outcomes in at-risk populations and providing a method of care that fosters a level of trust that can enhance health care compliance to the benefit of mother and baby.

Doulas are a trained personal support system for expectant mothers and, depending upon the care plan, can be with the mother for prenatal and postpartum visits and the birth. Research studies indicate that doula support has contributed to better birth outcomes, reduced caesarian sections, advanced breastfeeding, and bolstered maternal emotional wellbeing. (3) They also serve mothers and their partners in their homes, literally meeting families where they live.

The Doula Medicaid Project is taking place as Medicaid itself continues its Maternal and Infant Health Initiative, working with states to increase the use and quality of postpartum care visits and decrease rates of caesarian sections in low-risk pregnancies, as well as increase well-child visits.

In 2018, there were 17 maternal deaths for every 100,000 live births in the United States, a rate that is more than double that of most other developed countries, which have a more integrated system of physician and midwife support than the U.S. (4) Unlike midwives, doulas do not deliver babies. However, in this country, they share with midwives a history of providing maternal support decreased by regulations in the 20th century with the advent of physician-centric health systems.

There is room for both, and the expansion of Medicaid to cover doulas is a positive step toward improving maternal and infant health. 

References:

1. Vedam, S., Stoll, K., Taiwo, T.K., et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 16, 77 (2019). https://doi.org/10.1186/s12978-019-0729-2
2. Medicaid and CHIP Beneficiary Profile: Maternal and Infant Health DECEMBER 2020, Centers for Medicare and Medicaid Services. https://www.medicaid.gov/medicaid/quality-of-care/downloads/mih-beneficiary-profile.pdf
3. Gruber, Kenneth J et al. “Impact of doulas on healthy birth outcomes.” The Journal of perinatal education vol. 22,1 (2013): 49-58. doi:10.1891/1058-1243.22.1.49
4. Roose Tikkanen et al., Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries (Commonwealth Fund, Nov. 2020).