The state of doula care

Behind the growing movement to include doulas under Medicaid

(Holly Stapleton for The Lily)
(Holly Stapleton for The Lily)

Updated on March 3 at 9 a.m. Eastern.

This is part of a series from The Lily that examines how the role of doulas intersects with private and public insurance, race, socioeconomic status, policy and the medical community.

LaToya Morris felt “terrified” throughout her pregnancy.

Last year, as she neared 35, Morris constantly worried about experiencing a miscarriage or stillbirth.

“Every day was a struggle for me,” Morris said. “I was scared that I was going to lose my baby.”

Although Morris had a strong support system, she didn’t want to “burden” friends and family with her fears. Almost seven months into her pregnancy, Morris’s co-worker connected her to a birth doula. The doula, Mary Norby, gave Morris someone to confide in, which “calmed” her.

Morris’s doctors considered her pregnancy high-risk, so they planned to induce labor on Sept. 7. That day, Norby drove Morris and her mother to the hospital.

LaToya Morris says the doula who supported her in giving birth to her daughter "made me feel like I was going to be okay." (Jenn Ackerman for The Lily)
LaToya Morris says the doula who supported her in giving birth to her daughter "made me feel like I was going to be okay." (Jenn Ackerman for The Lily)

Hours passed; although Morris’s water broke, her cervix wasn’t dilating. Confined to her room due to coronavirus safety precautions, Morris couldn’t take walks down the hall with her doula, which might have helped in pre-pandemic days. But when her back and feet hurt, Norby offered a massage. In her role as a doula, Norby brought a sense of comfort and relaxation to the room, Morris said.

After three days, doctors presented Morris with two options: Wait to see if the baby would come out vaginally, or undergo a Caesarean section. With input from her mother, Morris decided on the C-section. On Sept. 10, she gave birth to her daughter, Brooklyn, in the operating room with Norby by her side, holding her hand.

‘Essential’ coverage

As the United States continues to grapple with pregnancy-related deaths and infant mortality, which disproportionately affect Black, Native American and Pacific Islander communities, policymakers are taking a closer look at how doulas may be able to help reduce health disparities. Doulas provide support during pregnancy and beyond, which can be especially helpful when someone is dealing with additional stress, such as racism or a pandemic that may be worsening maternal health outcomes.

But hiring a doula can be expensive for expecting parents. Fees vary greatly, but often fall between $600 and $2,000.

As Morris prepared for the arrival of her first child, she couldn’t afford to hire a doula. However, she qualified for Minnesota’s Medicaid program, which considers doula services a covered benefit.

Hiring a doula can be expensive for expecting parents. Fees vary greatly, but often fall between $600 and $2,000.

To Morris, having Norby there made all the difference.

“I was really, really scared,” said Morris, who is a medical assistant based in Brooklyn Park, Minn. “None of the other nurses or anesthesiologists could calm me down, but Mary did. She made me feel like I was going to be okay. And in the outcome, I was okay.”

For about six years starting in 2014, Minnesota and Oregon were the only states that mandated coverage of doula services through Medicaid, a state and federal program that provides health insurance to more than 64 million people in the United States. Research shows that those who have continuous labor support, such as a doula, are less likely to report negative feelings about childbirth, have a C-section or use pain-relieving drugs. Researchers have also found that people who delivered babies with doula support had lower preterm birthrates than those who did not.

Maternal health advocates nationwide have been pushing for more states to cover doulas through Medicaid.

“There’s a lot of grass-roots efforts advocating for this,” said Twylla Dillion, the executive director of HealthConnect One, a national organization known for its community-based doula model.

Does your employer-based health plan cover doula services? We want to hear from you.

The National Health Law Program estimates that about 21 states and the District of Columbia have proposed legislation related to doulas in the past two years. In several instances, advocates have been successful in getting bills passed, including in Indiana and New Jersey.

In Congress, the Black Maternal Health Caucus is championing the Momnibus, a package of 12 bills aimed at reducing maternal mortality and morbidity. The legislation encourages the use of doulas from pregnancy to one year postpartum. Rep. Gwen Moore (D-Wis.), a member of the caucus, introduced her own doula-related bill in 2019. The Mamas First Act would have required states’ Medicaid programs to cover doula and midwifery services. Moore plans to reintroduce the bill in 2021.

Although doulas alone “will not solve the maternal mortality crisis,” their work is an “essential part of the solution,” said Katy Backes Kozhimannil, a professor at the University of Minnesota’s School of Public Health.

For lawmakers, making a financial case for covering doula services through Medicaid is also getting easier.

Medicaid finances a significant portion of U.S. births. Research shows that paying doulas to support birthing individuals could save states money by reducing the number of unnecessary C-sections and preterm births. (C-sections are more expensive than vaginal births, and caring for infants born prematurely is costly.)

“Making sure that everyone has a doula is a really sound financial decision for a state Medicaid program,” said Kozhimannil, who has spearheaded studies on the cost-effectiveness of doula care. “But there are so many reasons why doula support is useful other than saving money.”

Clara Sharp, the executive director of the nonprofit Ahavah BirthWorks in North Minneapolis, emphasized the emotional support doulas provide. This aspect can positively impact an individual’s mental health, she said.

“We should be putting a dollar value on that,” said Sharp, a doula who has predominantly served Black families in her community for 30 years.

Developing a meaningful bond

Like many doulas in the Twin Cities, Ashley Kidd-Tatge balances other work — she is a professional classical singer — while taking clients who pay out of pocket and those who are covered by Medicaid.

While Kidd-Tatge said doulas are “essential” for anyone, there is often a stark contrast between clients who hire her to enhance their birth experience and those “who might be using a doula to make sure they stay alive.”

Doulas interviewed for this series described supporting their clients in a multitude of ways: They might help them secure food, housing, diapers, cribs, car seats, breast pumps or even breast milk donations. They encourage their clients to ask questions and advocate for themselves in medical settings. And when doulas see their clients’ needs or desires being ignored, they speak up. During the crucial postpartum period — about one-third of pregnancy-related deaths in women occur between one week and one year after delivery — doulas check in on parents as they settle into life with a new baby.

Ashley Kidd-Tatge is a doula in Minnesota. (Jenn Ackerman for The Lily)
Ashley Kidd-Tatge is a doula in Minnesota. (Jenn Ackerman for The Lily)

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Through states’ Medicaid programs, there is a limit to how many times a doula can visit their client and be paid. In addition to labor support, Oregon covers a total of four maternity support visits, Minnesota covers six, and New Jersey covers eight. There are some exceptions to the rule, most notably in New Jersey. For now, the state will cover more visits if the parent is 19 or younger and offer community doulas a $100 incentive if they ensure that their client attends postpartum doctors’ appointments.

Indeed, in some cases, the doula-client relationship can result in a meaningful bond that impacts the parent’s postpartum experience for years to come.

When Brittney Poole, now 26, was pregnant with her second child, Bri’el, she leaned on Kidd-Tatge, her doula.

Before they grew close, Poole said she felt connected to Kidd-Tatge because they had things in common: Poole identifies as multiracial, Kidd-Tatge is biracial, and they share similar spiritual beliefs.

Everyday Miracles, the nonprofit in Minneapolis that connected them, tries to match doulas to clients according to the pregnant person’s preferences, which can include racial concordance. This approach can improve patient satisfaction and potentially improve birth outcomes, said Rachel R. Hardeman, a reproductive health equity researcher at the University of Minnesota.

Brittney Poole, pictured with her daughter Bri'el, had doula Ashley Kidd-Tatge with her for two births. (Jenn Ackerman for The Lily)
Brittney Poole, pictured with her daughter Bri'el, had doula Ashley Kidd-Tatge with her for two births. (Jenn Ackerman for The Lily)

“Having someone who shares your lived experience in some way [and] understand[s] where you are coming from is incredibly important to people,” Hardeman said in an email.

On April 10, 2018, Poole delivered Bri’el almost exactly as she’d imagined: vaginally, without an epidural and surrounded by the love and support of a Black midwife, her doula and one of her sisters. After Poole left the hospital, Kidd-Tatge texted her daily to make sure she was okay before visiting her in person.

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Although Kidd-Tatge couldn’t be Poole’s doula during her third pregnancy, the two communicated frequently. When Poole felt depressed before and after the birth, she confided in Kidd-Tatge first, she said.

Did you use a postpartum doula after giving birth? Tell us about your experience.

“Not even my mother was told about it,” said Poole, who’s now a mother of four. “When I tell Ashley [Kidd-Tatge] about the different things I’m experiencing, she doesn’t make me feel judged. It’s nice to know you can talk to somebody and feel human at the end of it.”

‘We give voice to what you’re going through’

When clients can relate to their doulas, it may be easier to build trusting relationships. This can be especially important when clients are skeptical of the medical system or feel like providers aren’t listening, according to advocates. For example, if providers aren’t taking patients’ concerns seriously, “we give voice to what you’re going through” and acknowledge that it’s okay to continue seeking help, said Linda Bryant-Daaka, who manages the Sacred Roots Doula Program at the Black Parent Initiative in Portland, Ore.

Providing culturally congruent care is the main focus of Sacred Roots and the Community Doula Program in Oregon’s Benton, Lincoln and Linn counties, all located south of the Portland metro area.

The Community Doula Program launched in 2018 with support from InterCommunity Health Network (IHN-CCO), a coordinated care organization that serves Medicaid clients. Since its inception, the program has trained more than 100 doulas who reflect the populations they serve, including Analuz Torres Gutierrez, who primarily works with Spanish- or Mam-speaking clients.

Most of the people Torres Gutierrez supports are giving birth in the United States for the first time, she said. U.S. hospitals are often “new and foreign to them,” according to Torres Gutierrez, who is from Oaxaca, Mexico. “I spend a lot of time explaining how the system works, the type of services that are here for them, and the types of choices they’re able to make.”

Doula Analuz Torres Guttierez says most of her clients are giving birth in the United States for the first time. (Wesley Lapointe for The Lily)
Doula Analuz Torres Guttierez says most of her clients are giving birth in the United States for the first time. (Wesley Lapointe for The Lily)

For these clients, the presence of a doula “can make the difference between having a good experience at the hospital or not,” she said. “That stays with you. You will always remember when you had a baby.”

Despite the critical nature of her work, Torres Gutierrez said she probably wouldn’t be able to maintain her life as a doula without a flexible full-time job and a supportive husband. Through Medicaid, she received just $350 for attending four maternity support visits and a birth. (The rate has since increased as part of the Community Doula Program’s contract with IHN-CCO.) Depending on a client’s needs, visits can be time-consuming. The amount of time people spend in labor also varies greatly: Torres Gutierrez recently attended a birth that lasted 32 hours.

“I have friends who are doulas who have two part-time jobs to make ends meet,” Torres Gutierrez said, adding that Oregon’s Medicaid reimbursement rates barely cover the cost of child care.

An uphill battle

The goal of Medicaid coverage of doula care is threefold, according to advocates: support people who are giving birth, provide culturally congruent care and compensate doulas fairly for their work.

Shafia Monroe, an African American midwife, doula trainer and entrepreneur, began advocating for Oregon to adopt this model more than a decade ago. She knew Black doulas who repeatedly found themselves in the same difficult position: They wanted to serve their communities, but too often people in dire need of birth and postpartum support couldn’t afford their services — and the doulas couldn’t keep working for free.

Ultimately, in 2011, Monroe helped pass legislation that led to Medicaid coverage of doula care in Oregon. But since then, it’s been a bumpy road. The state’s current policy falls short of what Monroe imagined, she said.

Making sure that everyone has a doula is a really sound financial decision for a state Medicaid program.

Since 2016, the Oregon Health Authority and CCOs have paid doulas less than $37,000 for supporting Medicaid clients through approximately 200 births, according to OHA data. Roughly 19,000 people a year give birth while enrolled in Oregon Health Plan, the state’s Medicaid program.

“There are a lot of doulas who are doing the work but who are not getting reimbursed through Medicaid,” said Kimberly Porter, executive director of Community Doula Alliance in Portland. For many, it’s been an uphill battle: Oregon doulas are still trying to figure out how to navigate complex systems to get compensated.

Minnesota has fared slightly better.

LaToya Morris holds her daughter Brooklyn. (Jenn Ackerman for The Lily)
LaToya Morris holds her daughter Brooklyn. (Jenn Ackerman for The Lily)

Since 2014, doulas have supported Medicaid clients through upward of 850 births, according to Minnesota Department of Human Services data. (About 26,000 people a year give birth while enrolled in Medical Assistance, the state’s Medicaid program.) DHS and managed care organizations have spent more than $353,000 on these services, which include prenatal and postpartum support.

Kozhimannil, the University of Minnesota professor, celebrated the fact that hundreds of people in Minnesota experienced doula support through Medicaid coverage. But the numbers are too low, she said: “It is wildly insufficient and disappointing.”

Beyond being barred from hospitals for portions of the pandemic, doulas in Oregon and Minnesota are facing a slew of issues that limit the number of Medicaid clients they can serve. In this series, The Lily will examine these challenges as more states consider Medicaid coverage of doula care.

Although the coronavirus forced some legislators to table doula initiatives in 2020, “advocates and lawmakers must continue pushing for Medicaid coverage of doula care during this pandemic,” said Dillion of HealthConnect One.

How has the pandemic affected your pregnancy, birth or first year as a parent? Tell us about your experience.

Adding the pandemic, quarantine, losing loved ones and heightened racial tensions has made things even more difficult for Black, Brown and Indigenous pregnant people, who faced high rates of maternal and infant mortality before the pandemic hit, Dillion said.

“Those things happening at the same time when you’re already on fire is awful,” she continued, noting that prolonged stress during pregnancy can lead to negative birth outcomes. At a time when stress is at an all-time high, doulas and community health workers can “provide additional trusted support.”

During a year marked by a pandemic and protests, more states are recognizing racism as a public health crisis. Dillion hopes to see change — and more actions taken.

“This has been the case forever,” she said. “What are we going to do about it? Supporting doulas is one way to address that.”

Editor’s Note: A previous version of this story did not make clear that New Jersey offers a total of eight perinatal visits for doulas.

Rachel Ryan and Sarah Lipo, who are students at Marquette University, contributed to this report.

This doula series is funded by the O’Brien Fellowship in Public Service Journalism at Marquette University. Marquette University and administrators of the program played no role in the reporting, editing or presentation of this project. To learn more about this reporting project, click here.

About this story

Editing by Neema Roshania Patel and Lena Felton. Copy editing by Anne Kenderdine. Illustration by Holly Stapleton. Art direction by María Alconada-Brooks. Design editing by Rachel Orr. Design and development by Christine Ashack. Photo editing by Haley Hamblin. Photos by Jenn Ackerman and Wesley Lapointe.