The Evidence Is There: Doulas Improve Maternal Health Outcomes
One of the most promising strategies to support maternal and baby health is an approach that has been around for generations: doula care.
From the ancient Greek term referring to a "woman who serves," doulas are trained, non-clinical professionals who help families before, during, and after pregnancy — not only during labor and delivery. They provide education, physical coaching, and emotional support. A certified doula can help mothers communicate with their doctors or midwives; they can ease the stress and physical demands of pregnancy, labor and delivery; and they help new parents ease into what is a significant life transition providing lactation support and referrals to other support services. Doulas can also provide much-needed support in the event of pregnancy loss.
The Data: How Doula Services Improve Maternal Health Outcomes
Research from Elevance Health shows certified doulas have been effective at improving health outcomes for people who are pregnant and their babies. Data from several states that provide Medicaid coverage of doula care shows that Medicaid beneficiaries who used certified doulas during their pregnancies and deliveries had better outcomes compared to those who didn’t.
Why do these mothers have better health outcomes? While there isn’t one singular reason, we do know that certified doulas offer the support, guidance, resources, and community connections that are associated with better health outcomes during and after pregnancy. An academic review of trials involving more than 15,000 women found that those who had continuous support during labor — the kind of support offered by a doula — had lower rates of Cesarean birth, shorter labors, healthier babies, and greater rates of satisfaction. A larger proportion of people who received certified doula care also attended their postnatal visit, according to Elevance Health research.
Doulas Can Help Those Who Need it Most
When it comes to maternal health outcomes, we need all the successful strategies we can muster, since the maternal mortality rate is tragically high and continues to climb. The overall maternal death rate in the United States reached 23.8 deaths per 100,000 in 2020; just two years earlier, that statistic was 17.4 deaths per 100,000 live births. Those deaths impact people of color disproportionately: the pregnancy-related death rate for Black women is triple that of White women, and there was a 54% increase in the maternal mortality rate for Hispanic/Latino women between 2018-2020.
We’ve been tremendously encouraged by the results demonstrated by our own programs that involve certified doulas, particularly community-based doulas who serve as advocates for their clients and work to mitigate biases. In Fresno County, California, for example, we work with Black Infant Health, a community-based doula service, as well as other community organizations. Within that tightly woven care matrix, nearly all of the women who have taken part in the program delivered babies at full term.
There are some important questions that must be addressed to expand doula care: Does Medicaid cover doulas? Even with the promising data, most states don’t include doula care in Medicaid coverage.
As of January 2023, 10 states, plus the District of Columbia, had included Medicaid coverage of doula care and another five were working to implement doula coverage. Other states cover doula care on a more limited basis.
Are doulas certified? Yes. There are various independent organizations that certify doulas, such as the International Childbirth Education Association, the Doulas of North America (DONA), the Association of Labor Assistants and Childbirth Educators, and more. Some states that do offer Medicaid coverage of doulas, such as the state of Minnesota, keep a registry of doulas who have been certified and meet certain requirements.
Researchers from Elevance Health published a study with the full results of the analysis, and the Elevance Health Public Policy Institute released a brief highlighting data supporting doula care and options for states to expand their Medicaid coverage to certified doula care. The considerations included amending their Medicaid plans to reimburse for doula services — at an equitable reimbursement rate — if someone is referred by a licensed care provider.
What We’re Doing to Support Doula Care
Maternal health is one indicator of community health, and Elevance Health is working toward better maternal and infant health outcomes. The Elevance Health Foundation has committed $30 million over three years toward programs that support maternal and infant health, including $14.5 million in current grants that will impact an estimated 100,000 women.
One organization receiving support is Birth in Color RVA, a doula program receiving a $150,000 grant over two years to fund the training and development of 18 doulas of color in three underrepresented communities in Virginia. It’s just one of the community-based doula programs that is making a real difference in the lives of mothers and babies who need it most. Elevance Health will work to build on this momentum as we advocate to expand doula care services to all pregnancies covered by Medicaid.
How Can States Expand Their Medicaid Programs to Cover Doula Services?
State Plan Amendment (SPA)
States can amend their Medicaid plans to create new benefits, such as reimbursable doula services, if certain conditions are met.
Medicaid Quality Initiatives
Efforts to address health inequities, including maternal health outcomes, could include doula care under a state’s federally required managed care quality strategy.
Managed Care Organization Contracts
States can use these contracts to pilot doula initiatives in specific regions served.
1115 Demonstration Waivers
These waivers can be used to try different benefit designs or new models for delivering care, including paying for doula services.
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