Community-Based Doulas in Medicaid: The Next Step in Equitable Perinatal Services

Nicole Truhe, Andrea Bennett, Katrina Miller Parrish, Karen George, & Megha Kunju

Community-based models of care that support optimal pregnancy health, from prenatal through the postpartum periods, improve patient satisfaction, outcomes, and create a culturally congruent experience. However, disparities in maternal, fetal, and infant outcomes, which differ by race and socioeconomic status, persist.  Insurance churn and unmet social needs, and eligibility and coverage gaps are highlighted in IMI’s report, Improving Maternal Health Access, Coverage, and Outcomes in Medicaid.

When it comes to the value of community-based services, the outcomes are clear. Birthing persons who receive doula support have lower rates of preterm and cesarean births than a matched group of Medicaid enrollees not receiving services. The cost-effectiveness of using doula services yields an average savings of $986 with further analysis estimating $1360 per doula. A Cochrane review of 26 studies  indicated that birthing persons who received doula services and consistent support were less likely to use pain medications during labor and less likely to have a shorter length of time during active labor, low 5-minute Apgar scores, and postpartum depression.

Though there are numerous health benefits to a community-based models of care, historically, there have been challenges related to access and coverage of doulas as a reimbursable Medicaid-covered service. Minnesota and Oregon were the first states to implement doula services covered by Medicaid, but both experienced various barriers and financial limitations. For example, in Minnesota, doulas must first be registered and approved before they can be reimbursed, often coming with an initial registration fee and limited reimbursement rates. Similarly, Oregon has a registration and training program, costing about $800 to complete, and the state has had prior issues with contract negotiations and reimbursement rates as some Doula organizations have claimed Coordinated Care Organizations are not providing adequate coverage for their services.    

Increasing access to community-based service providers like doulas and community health workers (CHWs) for the Medicaid population by utilizing 1115 waivers, state plan amendments (SPA), and alternative payment models to expand coverage is one such opportunity. Governor Phil Murphy of New Jersey signed a series of legislative initiatives including a bill that will provide Medicaid coverage for doula care in the form of an state plan amendment or waiver. This initiative may improve maternal health outcomes and positively impact disparities by alleviating language and cultural barriers through the incorporation of CHWs. In California, where 51% of the babies born are covered by Medicaid, state officials are also submitting an SPA to add doula services to the list of preventive services covered by Medicaid starting July of 2022. Doula benefits are being added for better population health management and equity with the understanding that doulas can improve the perinatal experience and address health disparities that may occur in the health systems by helping people navigate through their medical care.   

Another avenue to increase the doula and perinatally focused CHWs is to standardize credentialing for maternal support service providers. Currently, a lack of standardization is a barrier for CHWs, particularly in low-income and minority communities. Findings from a 2013 study, indicate a majority of doulas identify as White women, have a high socioeconomic background, and “lack of insurance coverage for these services restricts financial access for people with low-income and limited racial/ethnic diversity.” By providing living wage reimbursement to doulas and CHWs of diverse backgrounds, pregnant individuals will have the benefit of cultural and communal connections necessary to improve health outcomes. Similarly, increasing support for these services by adding certification fee waivers or subsidizing education for CHWs will further alleviate existing financial barriers to training.

Findings from the Institute for Medicaid Innovation’s (IMI) national environmental scan of initiatives found that Medicaid reimbursement is critical for the sustainability of programs, and that the reimbursement amount should reflect the time, effort, and expertise of community-based maternal care professionals. Incorporating the voice of the community-based workforce in the development of programming and policy and engaging provider groups and the targeted community, including doulas and CHWs, are key to ensuring healthcare equity.

To learn more about access and coverage for doulas and CHWs in Medicaid, read IMI’s report Community Based Maternal Support Services: The Role of Doulas and Community Health Workers in Medicaid.