The state of doula care

Doula work is ‘taxing’ with little pay. Can Minnesota make it more sustainable?

(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.

When Yaa Nti thinks about giving birth, she always returns to the arrival of her first son.

She describes it as her most “traumatizing” birth experience, but Nti will never forget the presence of a close family friend who supported her as she labored for four days.

Although her husband was there too, it felt comforting to have another person around in the labor and delivery room. The experience “impressed upon me how important it was to have someone who could empathize” during the birthing process, Nti said.

Nti eventually became a doula in 2014 — the same year Minnesota began covering doula services through its Medicaid program, Medical Assistance.

Most of Nti’s clients in the Twin Cities are from marginalized communities. They “are more likely to have their wishes pushed aside,” she said.

Yaa Nti, a doula, works in the Twin Cities in Minnesota, one of four states that offer doula care through Medicaid. (Jenn Ackerman for The Lily)
Yaa Nti, a doula, works in the Twin Cities in Minnesota, one of four states that offer doula care through Medicaid. (Jenn Ackerman for The Lily)

“In the grand scheme of things, they would need a doula more than others,” Nti said, adding that most of her clients would not be able to afford a doula if it weren’t for Medicaid coverage.

Nti takes clients through Everyday Miracles, a nonprofit that has been a fixture in Minneapolis since 2003. The organization, which aims to improve birth outcomes and reduce health disparities, began connecting pregnant individuals to doulas long before Minnesota’s Medical Assistance program covered doula services.

But Medicaid coverage of doula care has expanded Everyday Miracles’ ability to serve families while compensating doulas for their work. Although the organization still relies on grants and private donations to stay afloat, Medicaid reimbursement for doulas offers a more sustainable pathway to payment.

“Grant funding is fabulous, but it’s not a for-sure thing from year to year,” said Debby Prudhomme, the executive director of Everyday Miracles. “Medicaid, hopefully, is a for-sure source of income [for doulas].”

‘There were so many different obstacles’

When legislation passed to expand access to doula support in 2013, advocates celebrated. But once the policy went into effect in July 2014, they discovered a slew of barriers.

To get on the state’s doula registry — a requirement to be reimbursed through Medicaid — doulas had to prove they were certified through an approved organization and pay a $200 fee. The fee was too much, some argued, especially for doulas who were struggling financially.

Then, to bill for their services, doulas had to find a physician, nurse practitioner or certified nurse midwife who could “supervise” their work. Citing liability issues, most providers refused. As a result, only a few organizations have been able to bill for doula services.

Ahavah BirthWorks, an organization in North Minneapolis that primarily supports African American families, went through the process of setting up a billing system but ended up losing money, Executive Director Clara Sharp said.

It’s super challenging for a small nonprofit to navigate all this. It’s just so much work for an individual doula to do.

“There were so many different obstacles,” Sharp said. After getting a check for $15, she decided to press pause on billing Medicaid and went back to paying doulas through grants instead.

Six years into Medicaid coverage of doula services, few organizations have been able to overcome the obstacles Sharp faced. Today, Everyday Miracles and a birth center in Mille Lacs County, a rural area north of Minneapolis, are two of the only organizations in Minnesota that bill for doula services to Medicaid clients. Doulas who want to bill for themselves face even more limitations.

“It’s super challenging for a small nonprofit to navigate all this,” Prudhomme said. “It’s just so much work for an individual doula to do.”

Kateri Kormann says the time she spent billing managed care organizations for her doula services "was not worth it" considering the amount she received. (Jenn Ackerman for The Lily)
Kateri Kormann says the time she spent billing managed care organizations for her doula services "was not worth it" considering the amount she received. (Jenn Ackerman for The Lily)

Kateri Kormann discovered this in 2015, when people with public and private health insurance started asking her the same question about doula care: “Does my insurance cover this?”

Kormann, a birth doula in rural Minnesota, did some research. She discovered that Medicaid — but not private insurance — would cover her services. After completing all the necessary paperwork to become a provider, Kormann took on about eight Medicaid clients.

Although she was supposed to receive $411 for attending the birth and six prenatal and postpartum visits, Kormann got checks for far less. She continued supporting clients but stopped billing the managed care organization that oversaw their Medicaid coverage.

“I ended up doing pro bono births,” said Kormann. “The time I was putting into billing and the amount of money I was getting back … was not worth it.”

Minnesota doula services for Medicaid clients are concentrated in the Twin Cities metro area. Out of 92 doulas on the state’s registry, only two serve Meeker County, where Kormann lives.

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Kathy Gaalswyk, a birth doula, has had even less success with Medicaid reimbursement in rural north central Minnesota. Asking a provider to “supervise” her work so that she can take Medicaid clients felt like a huge leap, she said. Sometimes, providers don’t even know what a doula is.

“We’re often educating providers and begging our way in the door, even when there’s not a pandemic,” Gaalswyk said. She sees the state’s supervision requirement as a “dealbreaker, especially for rural areas.”

“We have a lot of low-income people out here that really need [doula] services,” she said. When people ask if Gaalswyk and her business partner accept Medicaid clients, they have to say no. “It’s really frustrating.”

‘You end up losing money’

After Medicaid coverage of doula services began, Minnesota doulas were surprised by the payment package: about $26 for each prenatal and postpartum visit and $257 for continuous labor support. The total possible amount, $411, was far below what doulas charged private clients who could afford to pay them.

After accounting for administrative fees and other expenses, doulas saw that they were compensated even less than they expected.

“I’ve been at labors for 72 hours,” said Rochelle Vincent, a Minneapolis doula who also has a full-time job. After buying food and paying for hospital parking and gas, “you end up losing money.”

The low pay limited the number of clients doulas could take through Medicaid: They had bills to pay, too.

I’ve been at labors for 72 hours. ... [After buying food and parking] you end up losing money.

Some felt like the system at large didn’t respect their work or the people they were trying to support, said Akhmiri Sekhr-Ra, a perinatal educator who advocated for the 2013 bill that led to Medicaid coverage of doula services.

“It was really disappointing and disheartening,” Sekhr-Ra said. “[We had] to go back to the table to figure out how [to] get an increase.”

In 2019, Minnesota legislators agreed to raise the rates to $47 per prenatal or postpartum visit and $488 per birth. But it took some wrangling for the state’s managed care organizations to pay the higher rate, which adds up to $770 for the complete package. Prudhomme, who does the billing for Everyday Miracles, said that only one managed care organization, UCare, started paying the increased rate in January as planned. Nine months later, after numerous phone calls and emails, other managed care organizations started getting on board.

Potential cost savings

From 2014 to March 2020, doulas supported Medicaid clients through about 850 births, according to Minnesota Department of Human Services data. Minnesota’s DHS and MCOs spent more than $353,000 on those doula services. About 26,000 people a year give birth while enrolled in Medical Assistance.

Nathan Chomilo, the medical director for MinnesotaCare and Medical Assistance, noted that DHS is also finding other ways to provide access to doula services, citing its community-led integrated care for high-risk pregnancies initiative.

While Katy Backes Kozhimannil, a professor at the University of Minnesota’s School of Public Health, acknowledged that her state is making progress, she said the amount spent on doula care is “small potatoes in the Medicaid world.”

“I would love to see a lot more money spent on doula care,” she said.

Through a study published in 2016, Kozhimannil and her colleagues found that doula care could save states’ Medicaid programs money by reducing the number of Caesarean sections and preterm births. In the states they studied, reimbursing doulas between $929 and $1,047 would be cost saving or cost-effective.

More research is needed to determine whether Medicaid coverage of doula services in Minnesota thus far reflects Kozhimannil’s earlier findings. Of the doula-supported Medicaid births since 2014, about 70 percent were vaginal deliveries and 18 percent were C-sections. The state’s overall C-section rate is 27 percent.

Birth doula Kateri Kormann had told clients that Medicaid — but not private insurance — would cover her services. (Jenn Ackerman for The Lily)
Birth doula Kateri Kormann had told clients that Medicaid — but not private insurance — would cover her services. (Jenn Ackerman for The Lily)

While potential cost savings has helped policymakers make a case for Medicaid coverage of doula care, Kozhimannil emphasized that health plans cover plenty of necessary services that don’t offset costs.

It’s not: “‘Is this going to save money?’” Kozhimannil said. “It’s: ‘Is this going to make a difference and is it of high enough value?’ I think we can see that doula care is.”

An imperfect policy

Susan Lane began organizing with other Minnesota doulas and advocates in the early 2000s. A longtime doula herself, Lane spent a lot of time speaking to lawmakers on both sides of the aisle. These conversations and the collective action of birth workers and parents led to the inclusion of doulas in Minnesota’s health care bill of rights and subsequently Medicaid coverage of doula services.

While Lane is proud of their accomplishments — Minnesota remains one of just four states that offer doula care through Medicaid — she said there is still a lot to improve upon.

“Our objective was to just get some doulas out there helping some people as fast as we could,” Lane said. “We never intended that what we have now is the ideal.”

Now 75, Lane plans to take a step back from lobbying state lawmakers in the near future. Until then, she will support the Birth Equity Community Council, a group based in Ramsey County, as they work with legislators and state agencies to make Medicaid reimbursement for doulas more accessible. BECC wants to eliminate the state’s supervision requirement so that more doulas can bill for their services, regardless of their proximity to the Twin Cities. Since doulas are not medical providers, BECC sees supervision from a clinician as unnecessary.

It’s important that people have someone in the room who understands what systemic racism feels like and are experts in recognizing it.

Chomilo said this was originally a federal requirement. (Oregon and New Jersey, which offer Medicaid coverage of doulas, do not require a licensed provider’s supervision.)

Other doulas interviewed for this series would like to see the Minnesota Department of Health waive the $200 fee to get on the doula registry for low-income applicants. (A DOH spokesperson said this would require legislative action.) Then, there are the reimbursement rates: Doulas say the amount should be higher.

Vincent, the doula based in Minneapolis, said that while she would like to see many of these changes go into effect, she wants more for people who are giving birth, too.

“I’d love to see clients have access to acupuncture, body work, competent care providers who are aware of their biases … [and] more Black and Brown midwives to catch these babies,” said Vincent, who, like many others, was unimpressed by the 2019 reimbursement rate increase.

Diversifying Minnesota’s doula workforce

Facing racism and bias in the health care system is one reason people from marginalized communities might seek doula care. For example, Black women consistently report that in medical settings, their voices go unheard and pregnant men who are transgender face discrimination when they seek care.

“Systemic racism and implicit bias is rampant, and it kills people,” said Nadine Ashby, a doula and community health worker in Minneapolis. “It’s important that people have someone in the room who understands what systemic racism feels like and are experts in recognizing it.”

But to accomplish what Ashby describes, doulas need to reflect the population they serve. That’s partly why Ashby founded Birth Revolution, an anti-racist doula training that will focus on the experiences of BIPOC and LGBTQ birthing people.

[Many doulas work with pregnant women. This group focuses on non-binary, queer and gender non-conforming families.]

Medicaid coverage of doula services has underscored the need to diversify Minnesota’s doula workforce. After legislation passed, University of Minnesota researchers worked with Everyday Miracles and a Minneapolis hospital to train and certify 12 doulas from underrepresented communities.

Others have tried to fill the gaps, too.

Yaa Nti takes doula clients through a nonprofit that uses grants and private donations in addition to Medicaid reimbursement. (Jenn Ackerman for The Lily)
Yaa Nti takes doula clients through a nonprofit that uses grants and private donations in addition to Medicaid reimbursement. (Jenn Ackerman for The Lily)

After community members expressed a need for resources to support fathers, BECC trained 10 men to become perinatal educators as part of the council’s Doulas for Dads program. In 2019, the Division of Indian Work expanded its Ninde Doulas program, which increased the number of Indigenous, Black and Latinx birth workers.

But doula work is not for everyone — and it can take a toll on a person’s health and well-being.

“It’s a taxing job,” said Nti. “You did not push that baby out, but you come back really spent.”

Vincent said prospective doulas need to think through what will be required of them before rushing into the profession.

“It’s not all cute, and I feel like that’s the light that is shined on being a doula,” Vincent said. “It’s being on-call. It’s waking up. It’s having unfettered access to you. It’s research.”

We’re traumatizing ourselves to walk away with $200, and now we have to pay for therapy.

As a Black birth professional, Vincent also has to protect her client from racist systems while simultaneously dealing with racism directed toward her: “I’ve had doors slammed in my face and been told I couldn’t possibly be the doula. I’ve been told, ‘Well, you have to be the sister, right?’ because my client was Black.”

“We’re traumatizing ourselves to walk away with $200, and now we have to pay for therapy,” Vincent said.

Vincent’s experiences highlight a broader issue: Doulas are supporting their clients in a system that needs to improve to truly reduce maternal mortality and improve health outcomes. In Minnesota, the maternal mortality rate among American Indian women is about four times as high as among White mothers, according to the Minnesota Department of Health. The rate among non-Hispanic African American women is 2.3 times as high when compared to White mothers.

[These moms have a lot in common but faced a big difference: One got paid maternity leave and one didn’t]

“Doulas are important,” said Rachel R. Hardeman, a reproductive health equity researcher at the University of Minnesota who worked with Kozhimannil on several doula studies. “Our research and others [have] shown that they make a difference. But we must rethink and redesign the system that is causing so much harm to Black birthing people in order to see the true change we need.”

Sarah Lipo, a 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 Jenn Ackerman.