There is a complex history between socio-demographic and historical factors surrounding women of color and rural women, and their ability to have a birth experience that is “characterized by personal agency and security, connectedness, respect, and knowledge” (Kozhimannil & Hardeman, 2015). We have populations that would greatly benefit from doula services and don’t have access to them. Only 6% of US birthing women have doula support and many are paying anywhere from $700-1500 for private doula services (Kozhimannil & Hardeman, 2015), which is outside the financial reach of many families. Most doulas are white upper-middle class women providing support to white upper-middle class clients (Kozhimannil & Hardeman, 2015). Doulas serving diverse racial/ethnic and class backgrounds will hopefully help reduce racial disparities in maternal and infant health (Morton & Basile, 2017). This is not feasible unless we have policies in place to advocate for doula access. Low-income women and women of color, while incredibly resilient, are groups at highest risk of poor birth outcomes and are also the most likely groups to report wanting but not having access to doula services (Kozhimannil & Hardeman, 2015).
Morton & Basile (2017) reference a study regarding a Minnesota doula program and go on to say that cost savings would only apply if the doula was reimbursed $300 or less. However, we know that this study had limitations and that many doulas charge upwards of $1000 to clients out-of-pocket. Private doulas are able to charge this amount in affluent communities because they have demonstrated their worth. Looking further into Medicaid reimbursement for doulas, many advocates want to employ community health workers or people from the client’s specific community to be their birth doula, rather than have a doula who works for the hospital whom they don’t meet in advance (Morton & Basile, 2017). We know from our Washington Midwife & Doula Lobby Days about the need for greater reimbursement for doulas. $300 per birth is not sustainable for a doula to make a living, and therefore creates a barrier for doulas who otherwise could represent and advocate for their own communities. In order for birthing people to feel supported, they need to trust their doula. Again, I advocate for doulas that can be privately chosen and reimbursed rather than assigning a doula from a hospital pool.
However, for states to reimburse for doula services, do we inevitably create barriers for doulas? Medicaid programs can only pay licensed providers in order to receive federal matching funds, so if doulas aren’t licensed, they would need to work under the supervision of a licensed clinician and bill under the clinician’s NPI number in order to be reimbursed (Kozhimannil & Hardeman, 2015). Currently, there is no licensing body for doulas. Do we want to create some of the same issues we see in midwifery, such as increasing access to the profession by having licensure, but at the cost of creating barriers to accessing education for that profession? Do the doulas that come from communities at the highest risk for poor birth outcomes who are serving their communities even need formal doula training or is just being present as a supportive person beneficial? If doulas need to have formal training and certification or licensure to be reimbursed, will we then only approve certain programs to train doulas? What makes a certain program approved? What if a second midwife or birth assistant provided continuous labor support? Can they then call themselves a doula and get reimbursement?
I’m very excited for the possibility of doulas getting adequate reimbursement. I want to see doulas able to financially support themselves and serve their communities, yet at the same time I’m very concerned about the risk of creating more barriers for doulas of color or doulas from rural communities.
By Camille Friason, Bastyr University Midwifery Student
Kozhimannil, K.B. & Hardeman, R. (2015). How Medicaid coverage for doula care could improve birth outcomes, reduce costs, and improve equity. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20150701.049026/full/
Midwives’ Association of Washington State (MAWS). (2019). Midwife lobby day legislative agenda. Retrieved from https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/2019_maws_legislative_agenda.pdf
Morton, C.H. & Basile, M. (2017). Medicaid coverage for doula care: Re-examining the arguments through a reproductive justice lens, part one. Retrieved from https://www.scienceandsensibility.org/p/bl/et/blogid=2&blogaid=570
Open Arms Perinatal Services. (2019). Advocacy. Retrieved from https://www.openarmsps.org/get-involved/advocacy/