Widespread access to doula support would improve outcomes for women and babies, enhance women’s experience of care, and reduce the cost of care. So says a new issue brief written by Childbirth Connection, a program of the National Partnership for Women & Families, and the nonprofit advocacy organization Choices in Childbirth.
The issue brief calls calls doula care a “high-value form of care” that should be covered by Medicaid and private insurance companies, and provides instruction on how this can be achieved.
Doulas are people trained to provide continuous one-on-one support to women during labor and the postpartum period, utilizing emotional, physical and informational support.
The health benefits of having a doula during labor have been well documented. This 2013 Cochrane Review of the existing research shows that receiving continuous, one-on-one support brings significant health benefits. Women who have doula support are less likely to have a cesarean section, less likely to use pain medications, less likely to use pitocin, a drug that induces or speeds up labor, and more likely to have a shorter labor and to breastfeed than women who don’t receive continuous support. In addition, they report greater satisfaction with their birth experiences.
Doulas are a newer phenomenon on the U.S. health care scene, arising out of a desire to improve the experiences of women giving birth primarily in hospitals, where it is often difficult to find support for alternative childbirth methods. Doulas are a growing profession, with 6% of women having the support of a doula in 2011-2012, according to CiC. While that represents significant growth over the decades since the role of the doula was popularized, it’s still just a small fraction of the people who could benefit from doula support.
Currently, the vast majority of people who hire a doula do so by paying out of pocket. The cost for a birth or postpartum doula can range widely, from free to low-cost doulas through volunteer programs to upwards of $3000 for the services of an experienced doula in an expensive city like New York. Because of the cost, most people who hire doulas are from middle and upper class backgrounds, and doula care often doesn’t reach those who could deeply benefit from the support.
Volunteer doula programs, barter systems and sliding scales are all efforts to get doula services to people across the income spectrum, but they are limited in scope and sustainability.
The issue brief proposes instead that doula services should be covered by both private insurance and by Medicaid. The cost savings associated with doula care, mostly from the lower rates of interventions listed above, make a strong financial argument for this move. From the brief:
Because doula support increases the likelihood of vaginal birth, it lowers the cost of maternity care while improving women’s and infants’ health. Other factors that would contribute to cost savings include reduced use of epidural pain relief and instrument assisted births, increased breastfeeding and a reduction in repeat cesarean births, associated complications and chronic conditions.
The issue brief lays out the steps necessary to move in this direction, and makes specific recommendations on how to move forward from a policy standpoint.
Even if this proposal were to move forward, significant obstacles remain. From the brief:
Currently, only two states – Minnesota and Oregon – have passed targeted legislation to obtain Medicaid reimbursement for doula support, including continuous support during labor and birth, as well as several prenatal and postpartum home visits. Implementation has been challenging, and bureaucratic hurdles make obtaining reimbursement difficult. At this time, few doulas, if any, have actually received Medicaid reimbursement in either state. Across the country, a relatively small number of doula agencies have contracted with individual Medicaid managed care organizations and other health plans to cover doula services. The extent of these untracked local arrangements is unknown.
These bureaucratic challenges will take some real work to address. The current model for doula care is agile because the trainings are relatively low-cost and easy to access, and the processes for certification and payment similarly transparent. If we move toward this model, questions of training requirements for doulas, as well as the rate of reimbursement by insurance companies, may present a challenge to the model currently used.
I emailed with staff at CiC to ask about these challenges, and they acknowledged that they are important questions that will need to be addressed in subsequent phases of the process toward insurance reimbursement for doulas. They hope to offer more specific recommendations addressing these questions in future materials.
While questions about implementation remain, Medicaid and insurance coverage of doulas will undoubtedly increase the number of women who have access to beneficial doula care.