The state of doula care

Oregon covers doula work, but progress is moving at a ‘glacial pace’

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

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.

Mattie Khan knew about the high rates of infant mortality. She knew that in health-care settings, African American women like her weren’t always treated with respect. So, before the birth of her first child in 2007, Khan armed herself with information. She took classes, read books and found a doula in Portland, Ore., who was willing to volunteer her time. Khan welcomed her baby into the world on Christmas Eve after spending about five hours in labor.

By the time Khan was pregnant with her second child, other women of color had started to contact her with questions. They asked Khan — someone who might understand their background and have similar life experiences — to share some of her wisdom.

“They didn’t want to take [prenatal education] classes with someone who didn’t look like them,” Khan said, “so I found myself educating and supporting them.”

People encouraged Khan to take a doula training, but she couldn’t afford the $800-plus price tag. Eventually, a group of women whom Khan had helped throughout their pregnancies pooled their money so that she could attend a training led by Shafia Monroe, an African American midwife and entrepreneur.

Mattie Khan began by working as an independent doula and providing her services free. (Wesley Lapointe for The Washington Post)
Mattie Khan began by working as an independent doula and providing her services free. (Wesley Lapointe for The Washington Post)

“I never wanted to waste their sacrifice and their belief in me,” Khan said. “So I tried to take my role as a doula, as far as I could take it.”

Once Khan started taking clients, word spread. Since most of her clients didn’t have a lot of money, Khan offered her services free while running a small dessert business on the side. She didn’t mind the sacrifice, she said: “I knew that this was something that our community needed.”

But in 2014, when Khan heard that Oregon Health Plan — the state’s Medicaid program — would cover birth doula services, she welcomed the idea of compensation. Khan submitted all of her paperwork to get on the state’s traditional health worker registry, but when it came time to get paid, she found herself at a dead end.

“They made the process so difficult, and I was never able to get reimbursed for any of the births that I did during those times,” Khan said. “It was really confusing, so I just kind of hung it up. It was more of a headache than it was worth.”

Back then, the state only reimbursed birth doulas $75 for attending their client’s labor and delivery, which can span days in some cases. Most birth doulas in Oregon considered the rate to be an insult.

“It was like a slap in the face to what we do,” said Annie Willems, a doula based in Salem.

Progress is moving at a ‘glacial pace’

In Oregon, the original intent of covering birth doula services through Medicaid was to better support people who were already experiencing health disparities, such as Black and Native American individuals, the homeless population and those under the age of 21.

But six years into Medicaid coverage of doula services, the Oregon Health Authority — a state agency that oversees health-care programs — and coordinated care organizations have paid doulas less than $37,000 for supporting clients through approximately 200 births, according to OHA claims data. The OHA cannot report the race/ethnicity of doula clients because of a review of its reporting process, so it’s hard to evaluate whether those priority populations are receiving birth support through Medicaid. A majority of people who received doula services through Medicaid were between the ages of 20 and 39 when they gave birth.

The data does not necessarily reflect the number of Medicaid clients who actually received doula care: Some doulas provided services free or were paid through grant programs. Still, the numbers show that Medicaid coverage of doula services “is falling wildly short,” said Melissa Cheyney, project director for the Community Doula Program in Corvallis, Ore.

[An Ohio county had the second-highest infant mortality rate in the nation. Then they started listening to Black moms.]

In comparison, Minnesota — which began covering doula services shortly after Oregon — has spent more than $353,000 on the Medicaid benefit. Minnesota doulas, who face their own set of barriers, have supported Medicaid enrollees through upward of 850 births since 2014, according to the Minnesota Department of Human Services.

Dana Hargunani, the OHA’s chief medical officer, acknowledged that her agency has “continued work to do,” but noted that being the first state to cover doula services through Medicaid comes with its own set of challenges.

When you start something brand new, no one really knows how to do it. You have to start somewhere.

The OHA’s “number one goal is to eliminate health inequities in the next decade,” Hargunani said. Utilizing Oregon’s traditional health workers — which include birth doulas — and “ensuring culturally accessible care is how we’re going to get there.”

Despite incremental change, doulas interviewed for this series said that the OHA’s efforts to integrate them into the state’s Medicaid system has been frustrating and fragmented.

“When you start something brand new, no one really knows how to do it. You have to start somewhere,” said Cheyney. But efforts to improve the system are moving at a “glacial pace. That’s hard because we know that moms and babies are struggling right now.”

A bureaucratic treasure hunt

When Oregon became the first state to cover birth doula services through Medicaid in early 2014, there was no road map.

Jesse Remer, a founding member of the Oregon Doula Association, said it was like “building the ship while you’re on the ship.”

In the two years after doulas became reimbursable through Medicaid, almost no one had been paid. Some grew discouraged by the complexities of the system and continued to support low-income clients as they had before: They partnered with nonprofit organizations, offered their services on a sliding scale, bartered or worked for free.

Rebeckah Orton moved from Seattle to her hometown of Astoria, Ore., and connected with local doulas to form a collective. (Wesley Lapointe for The Washington Post)
Rebeckah Orton moved from Seattle to her hometown of Astoria, Ore., and connected with local doulas to form a collective. (Wesley Lapointe for The Washington Post)

This was exactly what birth doulas like Rebeckah Orton wanted to avoid. In her early years as a birth doula in Seattle, she noticed that her clientele consisted of “largely wealthy White women” who could afford to pay out of pocket. Orton believed everyone deserved birth support, but “the people who needed it the most had the least amount of access to it,” she said. If birth doulas offered their services pro bono, they oftentimes did so at a “great personal cost.”

Orton discovered that Oregon had a potential solution: paying birth doulas for their services through Medicaid. In late 2016, she moved back to her hometown of Astoria, Ore., and connected with local doulas to form a collective. They built relationships with local providers and advertised that they could support Medicaid clients through birth.

“Our very first client here was on Medicaid and I thought, ‘Okay, now I need to figure out how to get paid for this,’” Orton said. “So I called Oregon Health Plan and I said, ‘I have a Medicaid client coming up, How do I get paid?’ Nobody knew what to do.”

From then on, it was like embarking on a bureaucratic treasure hunt.

Birth doulas in other areas of Oregon shared what they knew, and each person held a piece to the puzzle. To bill for birth doula services, she needed a CMS 1500 form, which she bought at Staples. Correctly filling out the form was another hurdle.

After more than two years of trial and error, a $75 check finally arrived in the mail.

Fighting to get paid

As Orton chipped away at the system, others continued their fight. In 2015, the Oregon Doula Association suggested $600 for two prenatal visits, continuous labor support and two postpartum visits. By 2017, the state settled on $350 for the same package. The OHA did agree to one critical request: Birth doulas would be allowed to bill for themselves. This eliminated their reliance on medical providers, who weren’t always open to the idea of billing for someone who wasn’t on staff.

But the option to bill for themselves presented new challenges, as Orton discovered: Billing coordinated care organizations, which oversee Medicaid plans according to region, is difficult without clear guidance.

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

In 2020, the Oregon Health Authority mandated that each CCO hire a liaison to work with traditional health workers. This has, in part, forced CCOs to address some of the issues birth doulas face, such as contracting, billing and earning a living wage. At minimum, CCOs must reimburse doulas $50 for each prenatal and postpartum visit and $150 for birth support. Doulas argue that these rates aren’t sufficient given the amount of time they spend with clients.

Since CCOs often pay health-care providers more than the state’s fee-for-service rates, some doulas have successfully negotiated higher reimbursement rates. Nine CCOs offer doulas between $700 and $900 total for two prenatal visits, continuous labor support and two postpartum visits.

“There’s value to a doula and there’s value to the doula being a part of the care team,” said Maegan Pelatt, the maternal child youth manager for CareOregon, a nonprofit that serves Medicaid clients and owns two CCOs. “The data and the research speaks for itself. As a health plan, we really need to consider what our role is and the sustainability of it.”

‘Changing the dynamic of birth justice and birth work’

Negotiating with health-care plans isn’t exactly what most doulas sign up for when they commit to birth work.

“Doulas tend to be front-line workers who don’t have a lot of experience or expertise in navigating bureaucracy,” said Rachel Basolo, who is based in Eugene, Ore., and a member of Doulas of Lane County. “That is the barrier for folks” who want to serve the Medicaid population.

To consolidate knowledge, Basolo and others have started forming “doula hubs” in their communities. Typically one person deals with administrative tasks, such as establishing contracts with CCOs, referrals and billing for services, while other doulas support Medicaid clients.

This isn’t exactly what Monroe, the midwife and doula trainer, had in mind when she helped pass legislation in 2011 that led to Medicaid coverage of birth doulas. Monroe envisioned a system in which doulas could be autonomous and entrepreneurial. But if doula hubs are working, “you have to stay with the times,” Monroe said. When she noticed there weren’t any hubs for Black doulas, she called a meeting in her living room and co-founded the Oregon Black Doula Association.

Kimberly Porter, the executive director of Community Doula Alliance, is also creating more space for Black, Indigenous and Latinx doulas. Porter and the Birthingway College of Midwifery partnered with Health Share of Oregon, a CCO, to create a business workshop for 20 doulas of color. Through the workshop, Porter helped approximately 15 people get on the state’s traditional health worker registry, a requirement to get reimbursed through Medicaid.

To get on the registry, doulas must complete a range of sessions on topics such as oral health, trauma-informed care and HIPAA compliance. No single training fulfills the wide-ranging requirements, and some rely on free online courses shared within the doula community. The Community Doula Alliance is trying to remedy the situation by creating new, one-stop trainings.

But for doulas who want to be reimbursed for their work through Medicaid, getting on the registry is only step one. They then need to obtain a national provider identifier — which is used throughout the United States for health-care services — and become an enrolled Oregon Health Plan provider.

Although the OHA said it is willing to walk doulas through this process, several people interviewed for this series reported receiving minimal support in the past. Instead, they’ve reached out to peers, searching for answers — and sometimes given up entirely.

Roberta Eaglehorse-Ortiz has been a doula for 14 years. (Wesley Lapointe for The Washington Post)
Roberta Eaglehorse-Ortiz has been a doula for 14 years. (Wesley Lapointe for The Washington Post)

A member of the Oglala Lakota and Yomba Shoshone tribes, Roberta Eaglehorse-Ortiz was one of the only Native doulas on the state’s registry for three years, but she found the entire process surrounding Medicaid reimbursement frustrating.

Due to several barriers related to becoming a Medicaid provider, Eaglehorse-Ortiz, who has been a doula for 14 years, has never gotten reimbursed for her services through Oregon Health Plan. Over the past three years, she has supported about 10 clients in need free or in exchange for goods or resources, such as deer meat, jewelry or a day’s worth of child care. If Medicaid reimbursement had been more accessible, she could have made up to $3,500.

“That’s not a lot of money,” Eaglehorse-Ortiz said, noting that for her, it’s not just about getting paid. When she advocated for Medicaid coverage of doula services several years ago, she did it because she’d encountered families who needed birth support but felt shame around the fact that they couldn’t come up with the money. If health plans covered doula services, Eaglehorse-Ortiz thought, some of those feelings might dissipate and more people might ask for help.

Eaglehorse-Ortiz remains committed to “changing the dynamic of birth justice and birth work,” she said. That’s why, despite the hurdles, she plans to renew her traditional health worker certification with the OHA. (Certifications expire after three years.)

[Less than 1 percent of America’s lactation consultants are Indigenous. For these women, it’s a way to empower their communities.]

Pushing forward

Even skeptical members of the Oregon doula community are hopeful that their state can become a template for others who are pursuing Medicaid coverage of doula services.

“We just have to keep pushing to make sure that every mother can receive a doula from her community,” Monroe said.

While Oregon does not measure the effectiveness of birth doulas at the state level, early data suggest that the long slog could lead to cost savings by reducing the number of Caesarean sections and preterm births.

The Community Doula Program has only seen one preterm birth out of 125 doula-supported deliveries. Sixteen percent of deliveries were C-sections.

We just have to keep pushing to make sure that every mother can receive a doula from her community.

InterCommunity Health Network — the CCO that serves Oregon’s Medicaid patients in Benton, Lincoln and Linn counties — said that when a complete analysis is finished, it expects to see that the Community Doula Program’s work will result in reduced costs for the CCO.

Cheyney, the project director, values cost-effectiveness but emphasized that the Community Doula Program does “not place clinical outcomes over patient experience.” Sure, vaginal births save money, but the program focuses on how patients feel with a doula present.

For example, birthing individuals who are underhoused “face a lot of stigma,” Cheyney said. “They say, ‘It’s night and day to have an advocate in the room for me.’”

Workforce development

With grant funding from IHN-CCO, the Community Doula Program will continue to train doulas in the future. Alicia Bublitz, a program administrator, said this a crucial step.

If the state wants to increase the number of people who have access to doula services, “that means we also have to talk about workforce development and supporting doulas to become Medicaid providers,” Bublitz said.

Although a fair amount of doulas manage to sustain their work, there can be a good deal of turnover.

After years of constantly being on the go, Khan became a staff doula at a Providence women’s clinic in Portland.

Working on a team of doulas “eliminated the stress of being an independent doula,” Khan said. Her schedule allowed her to spend more time with her children. When Providence dissolved its doula program over the summer to explore other models, Khan decided it was time to explore other opportunities.

“You take on a lot when you’re an independent doula,” Khan said.

A doula for 10 years, Mattie Khan is now looking for a different path. (Wesley Lapointe for The Washington Post)
A doula for 10 years, Mattie Khan is now looking for a different path. (Wesley Lapointe for The Washington Post)

“I’ve been pregnant, so I know that at 2 a.m., you can be sitting in the closet, crying behind clothes for nothing,” she continued. “I know that you’re not sleeping well, so therefore I’m going to be available for you. If you’re crying at 4 a.m. and feeling defeated and overwhelmed, go ahead … and call me because I want to be there for you as much as I can.”

After 10 years of doula work, Khan knows it’s time to move on.

“I’ve reached a point in my life where I can’t stretch myself out that far,” Khan said. “If I’m going to be your support system, I’m going to support you 1,000 percent.”

Rachel Ryan, a graduate student 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 Wesley Lapointe.