Doula Support in Black Maternal Health

The U.S. currently faces a crisis in Black maternal health. Black women die from pregnancy complications at a rate 2 to 4 times higher than White women, and they are more likely to have life-threatening complications of delivery, also called severe maternal morbidity. The Black maternal health crisis reflects many factors, including structural racism and discrimination in health care and society.

Doula Care as Part of the Solution

One way to improve care for pregnant Black women is to increase access to doulas. Doulas are trained to provide physical, emotional, and informational support before, during, and after people give birth. They are not nurses or doctors but work with health care providers toward a safe and positive birth experience. For example, doulas help pregnant women understand their options in making birth plans, give encouragement during labor, and ensure their wishes and concerns are heard by the medical team.

In some cases, doulas work in the same communities in which they live. These community-based doulas are particularly important because they often have similar backgrounds as the people they help. Studies demonstrate that the personalized support provided by doulas improves birth experiences and outcomes for both mother and baby, with even greater benefits observed among families using community-based doula services.

Increasing Access to Doula Care in Medicaid

Medicaid plays a critical role in maternal health, covering 65% of all births to Black women in the U.S. Increasing doula access for people enrolled in Medicaid is a primary focus of the Centers for Medicare & Medicaid Services (CMS) upcoming Transforming Maternal Health Model (TMaH). States have several implementation options to provide Medicaid coverage for doulas:

• States can submit an amendment to their Medicaid State Plan to CMS for approval.
• Medicaid managed care organizations (MCOs) can choose to reimburse doula services for all their patients or for patients who meet certain criteria.
• States can use the Title V Maternal and Child Health Services Block Grant to support community-based organizations that provide doula services to pregnant women covered by Medicaid.

State Medicaid agencies must address 2 key issues to increase access to community-based doulas for Medicaid patients:

• Training. State-required training and licensing fees for doulas to be reimbursed by Medicaid can be expensive. When states limit credentialing to select organizations, they exclude local and community-based organizations that might align closest to Black Medicaid populations. Solutions include:
  • Provide financial help in the form of waivers, grants, or sliding scale adjustments to make doula training more affordable.
  • Move away from requiring certification from specific organizations for doula qualification standards and permit local, low-cost programs to train doulas to care for the specific communities they serve. 
  • Create a “legacy pathway” or “experience pathway” for certifying doulas who have extensive experience but do not have recent formal training. This means that instead of needing a certificate from a training group, these experienced doulas can use evidence of the number of births they have supported to qualify for certification.
• Reimbursement. Although it is important for doula Medicaid programs to be financially sustainable, reimbursement rates that are too low will limit the number of doulas who participate. Solutions include:
  • Determine a rate or fee that pays a fair wage to doulas, taking into account the cost of living where doulas live, the scope of services they provide, and the number of clients they can serve each month.
  • Reimburse travel time for doulas serving in rural areas, where access to maternity care is often limited.

Partnering with the Community

Westat’s experience of supporting federally funded maternal health programs, including the CMS Maternal Opioid Misuse (MOM) Model and the National Institutes of Health (NIH) Maternal Health Community Implementation Program (MH-CIP), highlights the importance of adopting a community-centered approach to addressing maternal health inequities faced by Black women. By integrating community perspectives and resources into care delivery models, initiatives can be more effective, sustainable, and responsive to the diverse needs of women and families.

To integrate doula care into Medicaid, we recommend that states partner with community-based doula organizations or form working groups that include doulas and community members. By including community input from the start, states will have the best chance at increasing access to doulas and supporting equitable, respectful care for Black women.

Doulas are not the sole solution to the Black maternal health crisis. We need to continue finding ways to support Black women and their families more widely. This involves advocating for environments that promote good health during pregnancy, such as ensuring access to affordable healthy food, transportation, and safe, stable housing. These efforts must be undertaken in collaboration with the Black community.

Note from the authors: In this Issue Brief, the terms “women” and “maternal” are used to refer to individuals who are pregnant or give birth. However, we acknowledge and affirm that not all people who experience pregnancy or childbirth identify as women or mothers. We recognize and respect the diversity of gender identities and expressions and strive to be inclusive and respectful of all individuals, regardless of their gender identity or expression.

Contributed by Westat experts Rachel Neenan, a Research Associate, Behavioral Health and Health Policy; Dominick Esposito, PhD, a Vice President, Behavioral Health and Health Policy; and Nicole Harlaar, PhD, a Principal Research Associate, Public Health.