State Call to Action: Reduce Maternal Health Disparities through Coverage of Community-Based Doula Care
A Center for Community Resilience ‘Emerging Voices in Public Health’ guest blog by Raashmi Krishnasamy, MPH ’21, George Washington University Milken Institute School of Public Health
U.S. rates of maternal morbidity and mortality remain among some of the highest in the world, with people of color at increased risk for poor maternal health outcomes. For example, pre-term birth is the second leading cause of infant mortality in the United States and the leading cause of mortality among Black infants. Although pre-term births have declined over the past century, Black women consistently experience pre-term birth at 1.5 to 1.6 times higher than their White counterparts. A recent report by the March of Dimes Interdisciplinary Scientific Working Group suggests that racism is a highly plausible, major upstream contributor to the Black-White disparity in pre-term birth through multiple pathways and biological mechanisms. In addition, the Kaiser Family Foundation reports, “Black and American Indian /Alaskan Native (AI/AN) women have pregnancy-related mortality rates that are over three and two times higher, respectively, compared to the rate for White women (40.8 and 29.7 vs. 12.7 per 100,000 live births).” Disparities even persist across education levels: among women with a college education or higher, Black women have more than five times the pregnancy-related mortality of their White counterparts.
Black maternal mortality has long been associated with the long-term effects of structural racism — COVID-19 only exacerbated the deadly impact. Studies show that the pandemic led to significant increases in stillbirths, maternal death, and surgically managed ectopic pregnancies. The potential impact across generations is both inequitable and devastating. But a promising solution rests in prioritizing community-based doula programs that value and advocate for the needs, lived experiences, and medical wishes of women of color. To achieve broad access to such programs, states must modify financing models to allow for Medicaid coverage of these practices. Community-based doula care has been found to improve birth outcomes by supporting mothers throughout pregnancy, labor and delivery, and postpartum; it has also been found to be cost-effective.
What is Killing Black Mothers?
COVID-19 deepened disparities in maternal health care, yet they existed long before the pandemic ravaged the United States. Historically, Black women have been mistreated and misused for the advancement of capitalist economies and medicine. Enslaved Black women were forced to provide a brutally taxing source of labor, including producing children to continually ‘stock’ a system of chattel slavery. The modern field of obstetrics and gynecology was born out of unethical medical experiments performed on enslaved women who were not in a position to provide consent. As Owens and Fett write in the American Journal of Public Health, “The early history of physicians, slavery, and racial theory belies the notion that medicine is a value-neutral profession devoid of the toxicity of racism.”
Today, practices of systemic racism against pregnant women of color can be measured by instances of unequal and dehumanizing treatment, and invalidation of patients’ concerns in clinical settings. Women of color report significantly higher rates of shouting and scolding, ignoring, and refusal of requests for help during the course of their pregnancy. According to research in the journal Reproductive Health, 27.2% of women of color of low socioeconomic status reported any mistreatment, compared to 18.7% of white women of low socioeconomic status. These experiences persist even when controlling for insurance status, income, age, and severity of conditions. Such treatment in the medical system contributes to the impact of “weathering” — which proposes that Black women experience earlier deterioration of health because of the cumulative impact of psychosocial, economic, and environmental stressors. The National Partnership for Women and Families cites weathering as a contributor to maternal health disparities.
A Systemic Approach to Addressing Maternal Health Disparities
There is evidence that expansion of access to community-based doulas may improve maternal and infant outcomes and reduce health disparities in communities of color. As described in the 2019 report, Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities, community-based doulas “are birth workers serving families within varying communities that center African descended people, Indigenous families, and people of color. [They] offer an expanded model of traditional doula care that provides culturally appropriate support to people in communities at risk of poor outcomes… are usually trusted members of the community they serve who are particularly well-suited to address issues related to discrimination and disparities by bridging language and cultural gaps and serving as a health navigator or liaison between the client and service providers.”
Community-based doulas combat the issue of mothers feeling invalidated by providers in the clinical setting by serving as an advocate for their patients and elevating the health needs and concerns of pregnant patients. The use of community-based doulas is associated with improved health literacy — which could benefit maternal health disparities such as increased prenatal visits and improved birth outcomes. Fewer studies have explored the role of community-based doulas in postpartum care, but research suggests their presence could improve access to mental health resources among new mothers. In addition, doulas recognize the institutional biases that exist within the health care system and try to mediate their impact on mothers, which could aid in combating maternal health disparities and mothers’ experience of racism in seeking health care and supportive services.
Mothers who participated in New York’s By My Side program, which offers free doula services in low-income Black and Latino neighborhoods, reported feeling valued and supported. One mother said of her doula, “When [the hospital staff] would say I needed certain things, she let me know that it was my decision if I wanted it or not, and that I didn’t have to do anything I didn’t want to. She let me know that I had a voice and a choice.”
The Case for Expanding Community-Based Doula Care
Depending on the geographic location, the cost of childbirth can vary between $8,000 and $20,000. Medicaid and private coverage of doula care has the potential to generate cost savings by lowering preterm birth rates, cesarean rates, reducing repeat cesareans, reducing the use of epidural analgesia, and increasing rates of breastfeeding, which helps reduce preventable and chronic health conditions, including diabetes and obesity, in both mother and baby. Labor support provided by doulas has been found to limit stress responses with the body’s natural labor process, foster safe and effective labor, birth, maternal-newborn attachment, and breastfeeding, and provides mothers with the autonomy to have a less medicalized, surgery-free birth, if they wish.
The national push for value-based care to improve maternal and infant health outcomes using Medicaid has been beneficial in expanding coverage of community-based doula care, but many states have yet to expand coverage to include these services. A study conducted to explore the potential cost-savings of doula care in Medicaid beneficiaries found that the cesarean rate was 22.3% among doula-supported births (a sample taken from Minneapolis, MN), significantly lower than the 31.5% found among all Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. The same study notes that state Medicaid pays for close to half of all U.S. births (45% in 2009), with the highest costs coming from cesarean deliveries and births with clinical complications. A different study also found lower cesarian and preterm rates with a community-based doula program in mothers who were Medicaid beneficiaries. That study’s cost-effectiveness analysis indicated potential savings associated with doula support reimbursed at an average of $986 (ranging from $929 to $1,047 across states).
State Strategies for Expansion of Community-Based Doula Care
States can modify Medicaid coverage of community-based doula care through a range of actions, as the Doula Medicaid Project. Legislative and implementation efforts have been made in more than 20 states and the District of Columbia to include doula services as a Medicaid benefit. Key approaches to expanding coverage include the following:
(1) Submit a Delivery System Reform Incentive Payment (DSRIP) Waiver — DSRIP waivers are a section of State 1115 waivers that are often utilized to test innovative care delivery models. These waivers can be utilized to “transform Medicaid payment and delivery systems by linking funding with improvements meeting specific metrics.” Since community-based doula programs have been shown to improve maternity care while reducing unnecessary spending, these programs fit the criteria for inclusion in DSRIP initiatives.
(2) Modify existing state Medicaid programs — To date, Minnesota, Oregon, New Jersey, and New York, have passed legislation leading to authorization of Medicaid coverage of doula services, with New York having launched a pilot expansion of the state Medicaid program to cover doula services. All of these states have taken steps to create certification bodies, registration procedures, core competencies, scope of services, and reimbursement procedures. Other states can follow these state modifications as examples and expand their Medicaid programs as necessary.
(3) Replicate state model of newly launched federal TRICARE program — In January 2022, Congress directed the Secretary of Defense to launch a five-year pilot program to evaluate the cost, quality of care, and impact on maternal and infant health outcomes using doulas under the TRICARE program, the primary insurer for the United States Military. It is unclear whether the new federal TRICARE program will specifically cover community-based doulas; however, given the significant potential impact community-based doula care could have on reducing maternal health disparities, it would be crucial for these programs to be covered and included. States could adopt a similar pilot program that specifically covers community-based doulas, collects race and ethnicity data, as well as survey beneficiaries about quality of care received.
The Time is Now for Meaningful Action
The new TRICARE pilot provides an incredible opportunity to expand doula care access to a large number of pregnant people. Yet, to capitalize on its full potential and to ensure equity, reimbursement for community-based doulas and full data analysis to address maternal health disparities must be included. Given the devastating impact of the pandemic on women of color and the nation’s continued rising rates of maternal and infant mortality in communities of color, state governments must take immediate action to modify current financing models to accommodate the coverage of community-based maternal health initiatives. Similarly, we must support the legislators, advocates and stakeholders who have begun efforts to expand community-based doula access in their states to keep on fighting. Women and infants of color cannot wait any longer.