As a doula for Austin-based Black Mamas ATX, Ebony Williams helps expectant mothers learn how to advocate for themselves during the birthing process. And she saw the effect of her work just recently when working with a patient from Malawi.  

The patient was not very familiar with the culture, and English was not her first language. But the mother wanted a natural birth, like she had in her home country. At the hospital, however, she was frequently encouraged to seek other options and made to feel as if she doesn’t understand the process of a natural birth, Williams said.

“They kind of put doubt in her as though she wasn’t going to be able to do [a natural birth],” Williams stated. “She birthed her baby in 30 minutes. The baby came out, the baby was healthy, the baby was happy. The mom was healthy, the mom was happy. And she really kind of defied the odds of what they thought. … She was very, very thankful [to me] because she didn’t have any family here. I was only the person who was there to support her through her birth, and even postpartum.”

While doulas don’t provide medical care, they are trained professionals who offer physical, emotional and informational support to mothers during the prenatal, birth and postpartum periods. They can also provide support whether the mother is looking to have a natural birth or not. And they’re creating positive outcomes: Women who are supported by a doula are less likely to have a cesarean birth or have a low birth weight baby, according to the University of Washington. Between 2011 and 2012 (the most recent national data available), 6% of American mothers used a doula, up from 3% in 2005, according to a 2013 survey by the National Partnership for Women and Families. The same organization found that in 2016, 10% of mothers in California used a doula.

Doulas are often cited as a way to reduce maternal health disparities. Pregnancy-related mortality rates are three times higher for Black women and two times higher for American Indian and Alaska Native women than they are for White women. 

But despite the benefits of doula care, there is little insurance coverage for the services. Without coverage, doula services can cost up to $1,500 per birth. A shift is happening, though, particularly in Medicaid, said Usha Ranji, associate director of women’s health policy at KFF.

“I’m hearing a lot more interest, and it’s not just among patients,” Ranji said. “It is also among payers, states in particular under Medicaid. … I think a lot of parties are really looking to strengthen the quality of maternity care.”

Emotional, physical and informational support

Williams typically starts meeting with her patients when they’re about 28 weeks into their pregnancy. Black Mamas ATX — where Williams works — is a nonprofit organization focused on reducing and eliminating maternal mortality and morbidity rates for Black women. She usually has monthly meetings (in-person or virtual) with her clients, in which she discusses nutrition, helps them understand what’s happening during doctor’s appointments, preps questions to ask their doctor and more.

“Meeting with them at 28 weeks or prior gives us really that time throughout their whole pregnancy to meet and coach. … Even mothers who are birthing for the second time at a hospital — or even mothers who birthed three or four times — we go through the hospital education and they still are like, ‘I don’t know what that is, I heard them say they gave this to me, but I don’t know what it is or what it did to me or why I got it.’ [That] is a problem,” Williams said.

Towards the end of the pregnancy, Williams has more in-person meetings to go over techniques and exercises to move the baby. Then during the postpartum period, Williams continues to provide support like breastfeeding assistance. Sometimes, she’s even just a person to vent to, she added.

For Qef Johnson, a doula based in New York City, her responsibilities are similar. Johnson offers in-person doula care to clients through her private practice, as well as virtual care through Maven Clinic, a virtual women’s and family health clinic that serves employers and health plans. With her patients, she is reviewing birth plans, offering pain management techniques, going over breathing, massaging during labor, helping with childcare during the postpartum period and more. But ultimately, she’s helping mothers understand the process and know how to speak up for themselves.

“As a doula, … I’m supplying you with all the information,” Johnson said. “Sometimes I’m even helping you figure out how to communicate best with your provider so that you can go and say, ‘This is what we want.’ Sometimes it might be communicating your birth plan effectively so everybody really understands it. I’m really there to help people advocate for themselves and also help them feel that they can engage with their providers.” 

This kind of support and education is vital in the current maternal care environment, said Maya Hardigan, founder and CEO of Mae, a startup that provides digital and in-person maternal health support (including with doulas). Black women often don’t feel that they’re being listened to during pregnancy.

“I think this notion of interacting with Black women and not fully listening to their preferences, not fully receiving their consent, is a very pervasive and problematic way of treating patients,” especially during a pregnancy when they are so “incredibly vulnerable,” Hardigan said.

Insurance coverage of doula care

Despite the benefits of doula services, health insurance coverage is “sparse,” Ranji of KFF said. But it is increasing, especially in Medicaid, she added.

“More than 40% of births in this country are covered by the Medicaid program, so Medicaid plays a really big part,” Ranji said. “Medicaid in particular covers people who are low-income and covers the majority of births among many communities of color. When it comes to addressing racial disparities, racial inequities in birth and birth outcomes, Medicaid is a huge player.”

Currently, 10 states and the District of Columbia are actively reimbursing doula services under Medicaid, according to the National Health Law Program’s Doula Medicaid Project. Another six states are in the process of implementing Medicaid doula benefits. Other states have introduced legislation but haven’t made progress, or have taken “adjacent” actions like creating pilot programs. In nine states, National Health Law was unable to find any Medicaid efforts for doula reimbursement.

However, even in the states that are reimbursing doula care, the execution is “choppy,” declared Hardigan of Mae.

“We’re seeing a lot of variability around reimbursement rates,” Hardigan said. “We’re seeing, for example, Maryland reimburse about half of the amount that Rhode Island or the state of Michigan is reimbursing. If the quality of the work isn’t valued with the dollars, then the supply of doulas isn’t there to support the mothers.”

In Texas, where Black Mamas ATX is located, there is no Medicaid coverage for doula care. Instead, the nonprofit organization receives donations and grants in order to offer its services for no cost. However, there is a pilot program taking place in Austin called Giving Austin Labor Support.

“There are shifts and moves towards this potentially happening, but everything is in the pilot stage, no one has committed,” said Kelenne Blake-Fallon, executive director of Black Mamas ATX.

While there is some coverage of doulas in Medicaid, there is much less traction in the world of private insurance. Rhode Island is the only state that has passed legislation requiring doula coverage from private health plans, according to the National Health Law Program. California, Indiana, Massachusetts, Missouri, New York and Virginia are all considering expanding private coverage of doula care.

When it comes to employer-sponsored coverage of doulas, it’s “really hit or miss,” said Mike Stancil, CEO of Pittsburgh Business Group on Health. Coverage of players like midwives and lactation consultants has moved a little faster. But he’s starting to notice more of an interest among employers in covering doula care.

“We’re finally shifting over to understand that there is this outcomes benefit when you have this culturally-appropriate care and you’re providing people with the support that they need — even if it’s not directly clinical support, if its emotional support, if it’s making sure that there are cultural traditions that are respected,” Stancil said.

Some digital health companies, like Mae and Maven Clinic, are stepping in to streamline the coverage of doula care. Mae works with health plans, primarily Medicaid, and just recently launched a pilot program with Aetna Better Health of Maryland. Mae’s platform offers access to community-based doulas and helps them get reimbursed, something that Maven Clinic also does.

“These particular individuals that we work with have been doing this work in their communities for decades in some cases,” Hardigan said. “They have a very deep commitment towards serving this population in particular, and sometimes that means they’re doing it for full out-of-pocket pay. Sometimes that means they’re doing it on a sliding scale for mothers who are in need. Sometimes that means they’re doing it for free. What we’re helping to bring to these community-based doula partners … is really just that pathway for helping them be reimbursed through our insurance partnerships.”

Is there a future where doula coverage becomes more mainstream? Blake-Fallon of Black Mamas ATX is an “optimist” that doula care will someday be widely accepted and covered by insurance.

“We’re here already, and we’ve already made changes … We’re already in the system. We just need to grow and become a stronger, larger, more impactful and more accepted and supported aspect of that system,” Blake-Fallon said.

Photo: Prostock-Studio, Getty Images