Why are states using doulas to improve birth outcomes and maternal health?

To help solve the crisis in maternal mortality among Black, brown, and low-income communities, eight states and Washington, DC are turning to doula care and using Medicaid money to fund it. Two more states will join them in 2023. And a new federal program this year is expanding the use of doulas in areas with high maternal and infant mortality rates.

Black mothers are almost three times as likely as white mothers to have a life-threatening delivery complication. They are eight times more likely to die from a pregnancy-related issue. There are also racial gaps in breastfeeding and Cesarean sections. And more Black babies are born preterm^[1] or at low birth weights, which are major factors in infant mortality.^[2]

A growing body of research points to doula care as a cost-saving and effective intervention for infant and maternal health.

What is a doula?

A doula is a trained nonmedical support for childbearing people and their families. Doulas provide physical, emotional, and informational support for their clients.

Doulas provide prenatal, labor, postpartum, and miscarriage support. They also offer new parents evidence-based education on infant care and lactation, as well as support with navigating community and health resources.

Generally, doulas offer multiple prenatal visits, support during labor and delivery, and postpartum care. Doula care typically occurs between 36 and 42 weeks of pregnancy, to account for the uncertainty of birth timing.

Doulas are not medical professionals, which distinguishes them from midwives, many of whom can prescribe and administer drugs.^[3] Unlike nurses or doctors, doulas are not licensed or credentialed by the government in most states.^[4]

There are some exceptions. For example, in Oregon, doulas must be credentialed as traditional health workers to bill Medicaid and receive reimbursements from the government.

What evidence is there for the benefits of doulas?

Research studies and data from government programs show the positive impact doulas have on health outcomes for mothers and infants.

From 2010 to 2015, the New York City Department of Health and Mental Hygiene’s By My Side Birth Support program offered doula services to pregnant people living in neighborhoods where over 30% of the population lived below the federal poverty line. Preterm birth rates were halved in doula-serviced pregnancies in comparison to the overall rate for these neighborhoods.

Other research found that doula support is associated with labor periods that were shorter by an average of 42 minutes. Doula support was also connected to a lower likelihood of postpartum depression.

One 2016 study found doula usage saved money by reducing preterm births and the use of Caesarean sections.^[5]

These positive health outcomes have generated various efforts to fund doula programs at national, state, and municipal levels.

Despite its numerous health benefits, the cost of doula support often ranges in the thousands, rendering it unaffordable for many. The New York City Health Department found that the average cost of retaining the services of a birth doula was $1,550 per client, which covered anywhere from two to 12 at-home visits.

As a result, most of the low-income people who stand to gain the most from doulas may not have access to them.

Given Medicaid’s vital role in covering births among low-income mothers, some state governments have chosen funding doulas through Medicaid to make the service more accessible.

How many births are funded by Medicaid?

The role that Medicaid plays as a provider of maternity-related care for low-income mothers, mothers of color, and mothers living in rural areas is critical. It covered approximately 1.6 million births in 2018, about 43% of all births in the US for that year.

Medicaid covered about 63% percent of births in Louisiana and Mississippi, the highest rates in the nation.

Births funded by Medicaid were most concentrated among mothers who had less education, American Indian or Alaska Native mothers, Black mothers, and Native Hawaiian and Pacific Islander mothers.

Mothers with a high school education or less had the highest rates of Medicaid-funded births.

Learn more about health in the US.

Medicaid funded births for American Indian or Alaska Native mothers and Black mothers at more than twice the rate of white mothers and more than three times the rate of Asian mothers.

Which states are funding doulas with government money?

While eligibility requirements, billing rates, and levels of success vary widely, 10 states currently reimburse doulas through Medicaid or are set to do so in 2023.

Eight states – Florida, Maryland, Minnesota, New Jersey, Nevada, Oregon, Rhode Island, and Virginia – are currently reimbursing doulas through Medicaid.

Washington, DC started reimbursing doulas in October this year. California and Michigan will start covering doula care through Medicaid in 2023.

Other states are funding the usage of doulas in more limited ways. Iowa, New York, Texas, and Wisconsin have run doula pilot programs where mothers in eligible areas can apply for government-funded doula services. And since 2018, Washington has required jails to allow pregnant people to have access to doulas during labor, childbirth, and the perinatal period more broadly.

In April 2022, the Department of Health and Human Services announced $4.5 million for hiring, training, and paying doulas to practice in communities that are most affected by maternal and infant health issues. The funding will raise the number of Healthy Start doula programs in the United States from 25 to 50.^[6]

For a fuller picture of health in the US, read about how the US maternal mortality rate increased nearly 40% in 2021, and get the data directly in your inbox by signing up for our weekly newsletter.