NEW YORK — During the peak of Covid-19 lockdown restrictions, Kendra Berger delivered her second child in the hospital. The experience was traumatic for Berger, a 35-year-old former nurse who lives in Holland, New York. She pushed when she wasn’t ready and her baby got stuck in the birthing canal. In the recovery room after birth, Berger started hemorrhaging and wound up needing a blood transfusion. And two weeks after birth, during her visit to the pediatrician with her newborn, she learned her baby’s clavicle had been broken during the delivery.
A few years later, Berger wanted to try for a third child — but given her past experience, she was grappling with fear about giving birth again. Thankfully, she was able to find a doula in her area, Ashley Petit, who accepts Medicaid and specializes in techniques to help patients control their breathing and manage pain during the birthing process.
“My birth experiences between my second and third were like night and day. The third birth was peaceful and beautiful and I loved it,” said Berger.
Berger is one of many mothers on Medicaid who have had doula services covered under the New York State Doula Pilot Program, launched in 2018. The initiative aims to reduce maternal mortality rates and racial disparities in health outcomes by covering four visits with the doula before delivery, up to four visits with the doula after delivery, and doula support during labor and delivery. To date, 1,024 people have participated in the pilot program — and as of Jan. 1 of this year, doula services are covered for any New Yorker on Medicaid.
That change could have a big impact. The presence of a doula during pregnancy can improve health outcomes related to labor and delivery, according to the American College of Obstetricians and Gynecologists. But doula care is often unaffordable for low-income women and women of color in the U.S., who face higher risks of birth-related complications and postpartum-related mental health conditions. Women of color are also more likely to report negative interactions with practitioners and mistreatment during maternity care and, subsequently, dissatisfaction with birth experiences compared to white women.
Currently, 11 states and Washington, D.C., reimburse doula services on Medicaid plans, with at least eight currently in the process of implementing Medicaid doula benefits. But experts in maternal health warn that even though more states are pioneering new programs and investing in the future of doula care, relatively low reimbursement rates and coverage for a limited number of visits may hinder the sustainability of the doula workforce and effectiveness of the programs.
The difference that doulas can make
A doula — also known as a birth companion or post-birth supporter — provides physical, information, and emotional support to pregnant and postpartum people. They are non-medical workers and often do not need to be licensed to provide services. Many states require doulas to be at least 18 years old, CPR-certified for adults and infants, and trained on HIPAA compliance.
Research shows that people who are supported by a doula during labor and childbirth are less likely to require a C-section or use pain medication, and more likely to give birth spontaneously, have a shorter labor, and feel satisfied with their birthing experience. A 2022 Anthem study, for example, used Medicaid claims from multiple states to compare maternal health outcomes between moms who did and did not receive doula care. Women who received doula care had 53% lower odds of cesarean delivery and 58% lower odds of postpartum depression/postpartum anxiety.
“Doulas also go beyond things we think of traditionally with health, such as connecting their clients with any food, housing, and transportation needs they may have,” said Cassondra Marshall, an assistant professor at the University of California Berkeley School of Public Health whose research focuses on maternal health equity.
For Berger, it was especially helpful to have her doula accompany her during birth at the hospital and encourage her to advocate for herself, which meant pushing when she felt ready. Afterward, Berger said, Petit “always reached out with a helping hand. She offered to watch my other children so I could spend more one-on-one time with my newborn and even offered to do laundry.”
Most doula programs in the U.S. serving low-income moms on Medicaid operate on community-based models, meaning that the programs are tailored to address the needs of specific communities that historically have had worse birth outcomes.
“Community-based doulas have shared backgrounds and language and culture with the people they serve. They provide culturally and racially concordant care, which is really one of the hallmarks of this model,” said Marshall.
Investing in doula services
To participate in New York State’s doula program, a doula must be enrolled as a provider in the state Medicaid program. During the pilot project, the reimbursement for doulas for eight visits plus labor and delivery was $606.
“The fees that were associated with the pilot reimbursement were determined in 2018 with the state investment that was available at the time to support those services,” said Jennifer Mane, the Bureau Director of Office of Health Insurance Programs at the New York State Department of Health.
Critics worried that such reimbursement rates affect doulas’ willingness to participate in Medicaid. “The reimbursement rates are too low. Our organization relies on funding in addition to the reimbursement to pay our doulas,” said Julissa Vazquez-Coplin, the manager of the Priscilla Project Manager at Jericho Road Community Health Center in Erie County, which provides a free culturally-tailored doula program for low-income moms of color. The Jericho center pays their doulas more than $75 per visit.
After listening to feedback from both doulas and their clients, New York is investing more funds to expand the program starting in 2024. Pending federal approval, the Medicaid reimbursement for doula care will be up to $1,350 per pregnancy in upstate New York and up to $1,500 in New York City, according to the state’s Department of Health. The hope is that higher reimbursement rates will lead to greater participation from doulas, helping to expand the availability of services for moms.
Investing in doula care now could help states save on health care costs in the long run. One 2016 study estimated that doula-supported deliveries among Medicaid beneficiaries would save $58.4 million and avert 3,288 preterm births each year.
Not only is doula care cost-effective and beneficial for maternal health, it can often provide a much-needed source of support for people having a hard time with motherhood in its earliest stages.
Petit started her company, The Light House Birth and Yoga Collaborative, because of her own struggles navigating the health care system while she was pregnant, with little knowledge of the resources for postpartum care. She said that New York’s newly expanded Medicaid coverage for doulas is an important step towards health equity.
“I have had moms crying with tears of happiness when they learned their insurance covers a doula,” she said.