COMMUNITY-BASED DOULAS
WHAT ARE COMMUNITY-BASED DOULAS AND WHY ARE THEY IMPORTANT?
Community-based doulas are trained social service professionals who provide non-clinical emotional, physical, and informational support to birthing people, starting during pregnancy and continuing during the postpartum period. Community-based doulas specialize in culturally competent care that reflects the values and lived experiences of their clients, working in tandem with doctors, nurses, and midwives to provide care throughout the perinatal period.1 Doulas support their clients by providing childbirth education, helping them navigate the health care system, advocating for them throughout the perinatal period, and connecting them with community resources.
Support During the Perinatal Period Improves Wellbeing
Community-based doulas act as a buffer to decrease the influence of stressors during pregnancy, birth, and early parenthood by providing information to clients, helping to navigate complex health care systems, and acting as advocates for the wellbeing and wishes of clients.
Information provided to birthing people includes risk factors and warning signs for developments and issues that affect maternal and infant health outcomes. Community-based doulas teach birthing people about monitoring a fetus’s movements in utero, sleeping patterns, and positions. They also provide information after delivery by modeling developmentally appropriate behaviors such as responding to an infant’s cues and emotional needs.2 Parenting and child development education provided by doulas can additionally help foster nurturing parent-child relationships and increase safe feeding practices for infants.
Community-Based Doulas Provide Unique Care
Community-based doulas go beyond the scope of care given by physicians to help their clients navigate complex health care systems and social service providers. Traditional healthcare providers spend an average of 5.75 hours with patients.3 In comparison, community-based doulas are on call 24/7 for their clients and spend an average of 76 hours with each client throughout their perinatal journey.4 This aid can start as early as initial contact in the prenatal period and expand into the postpartum period to help parents provide thriving environments for their children.5 Connections to community resources can mitigate social determinants of health such as a lack of health literacy or social support issues that are the root cause of health disparities and negative outcomes.6
Community-Based Doulas Can Improve the Birthing Experience as Client Advocates
Community-based doulas act as advocates for their clients and affirm the client’s experience. For example, a community-based doula can recognize and affirm the pain or concern clients feel as they go through the perinatal period and ensure those concerns are taken seriously by medical staff.7 This is vital for Black birthing people who are marginalized by the traditional healthcare system and have an increased chance of complications due to racial bias.8 Birthing people provided with advocacy by doulas during labor and delivery experience less stress, and are less likely to experience medical interventions during labor and delivery, such as cesarean deliveries and labor induction, and are therefore at a decreased risk of adverse birth outcomes from medical interventions.9,10
Culturally Competent Care Is Critical to Address Disparities
Community-based doula care grew from a response to systemic racism and discrimination experienced by people of color in healthcare systems, and substantial disparities in birth outcomes by race and ethnicity.11 Community-based doulas incorporate reproductive justice and birth justice frameworks and use strategies to address structural racism, intergenerational trauma, and implicit bias. The culturally competent care provided by community-based doulas can be one element of a larger comprehensive system of care that reduces maternal and infant health disparities.12
Community-Based Doula Care Can Be Cost-Effective
Limited research suggests community-based doulas may help states save money in the long run. One study of community-based doulas covered by a Medicaid managed care organization in Minnesota discovered that potential cost savings of doula care averaged $986 per patient, and total predicted savings were estimated at $58.4 million each year.13 Additionally, a simulated cost analysis that compared data from Medicaid births without doula support nationwide and Medicaid births with doula support in Minnesota found that states could save at least $2 million a year.14
Search the Prenatal-to-3 Policy Clearinghouse for an ongoing inventory of rigorous evidence reviews, including more information on community-based doulas.
WHAT IMPACT DO COMMUNITY-BASED DOULAS HAVE?
Strong causal evidence of community-based doula programs has demonstrated that doula support increases attendance at medical appointments and education classes, encourages responsive parenting behaviors, and enhances child health and developmental outcomes such as breastfeeding initiation rates and safe sleep practices. Additionally, there is evidence that participation in community-based doula programs improves important birth outcomes including preterm birth, low birthweight, and neonatal intensive care unit visits.
More Research Is Needed to Determine the Potential of Community-Based Doulas to Reduce Racial and Ethnic Disparities
To date, no strong causal studies directly assess the effectiveness of community-based doulas to reduce racial disparities in outcomes for families in the prenatal-to-3 period. The participants in the studies included in our evidence review are mostly birthing people of color, who are more likely to benefit from the support of doulas. Because existing research does not test for differences by racial and ethnic groups, we can conclude birthing people of color benefit from community-based doula programs, but we do not know whether they benefit at the same or different levels as White birthing people.
Because of the nature and populations served by community-based doulas, programs likely decrease racial and ethnic disparities in birth outcomes for infants and birthing people.15 Studies on other types of birth and lay doulas do not use representative samples, consisting of mostly White women. Although there are some rigorous studies showing mixed results, evidence from these studies is not conclusive regarding the benefits of lay and other birth doulas for diverse populations. Rigorous research on community-based doulas does demonstrate beneficial impacts on diverse groups of birthing people.
Future research must focus on examining the differential impacts of community-based doulas by race and ethnicity, and socioeconomic status.
For more information on what we know and what we still need to learn about community-based doulas, see the evidence review on community-based doulas.
WHAT ARE THE KEY POLICY LEVERS TO SUPPORT COMMUNITY-BASED DOULAS ACROSS STATES?
In contrast to the evidence for the four state-level policies that are included in this Roadmap, the current evidence base does not identify a specific policy lever that states should implement to effectively provide community-based doula services to all of the birthing people who want this type of care.
We identified two key policy levers that states can implement to more effectively support community-based doula services in their state. The two key policy levers include:
- Cover and reimburse community-based doula services under Medicaid, and
- Fund grants or scholarships to support doula training and credentialing.
Each policy lever and the variation in state implementation is discussed in greater detail below.
Key Policy Lever: Medicaid Coverage and Reimbursement Rates
To foster access to community-based doulas among families with low incomes, states can cover and reimburse doula services during the perinatal period for families enrolled in Medicaid. Without Medicaid coverage, out-of-pocket costs for doula services may be unaffordable for many families who wish to have doula support in the perinatal period.
In total, 12 states (including the District of Columbia) cover doula services under Medicaid, including community-based doulas. States can use direct reimbursement or provide reimbursement through Managed Care Organizations (MCOs).
As of August 2023, reimbursement rates for the total cost of doula care including prenatal visits, labor and delivery, and postpartum care range from $450 for one patient in Nevada to $1,950.71 in the District of Columbia. States vary in the number of visits covered by Medicaid (e.g., up to 8 total visits) and any requirements on when those visits occur (e.g., Oregon requires a minimum of two prenatal visits and requires 2 postpartum visits). Rates per visit also vary. Additionally, Rhode Island requires doula care coverage for private insurance, and Louisiana is implementing a requirement for doula care to be covered by private insurance effective January 1, 2024.16
Setting fair Medicaid reimbursement rates requires states to recognize the long hours community-based doulas spend with their clients and the true cost of the care they provide. Key factors include market rates for doulas, cost of living, scope of services, supplies, and time spent on clients during and outside of visits, including emotional support, connections to social services and community supports, and 24/7 on-call availability. To help ensure that rates are sufficient as a sustainable source of income, states can set up a formula or minimum threshold to determine rates. Timely reimbursement is critical for community-based doulas, whose wages often rely on payment from individual clients or health insurance providers.
States also make policy choices around who can become a Medicaid provider and take steps to make policies affecting who is considered a doula more inclusive. To recognize the experience and skills of doulas in the state and encourage participation in Medicaid, states can collaborate with doulas to set requirements on who qualifies as a doula (e.g., certification and core competency requirements). State certification requirements do not always accurately reflect the diverse backgrounds and expertise of community-based doulas. Rather than requiring certification from a specific organization, states can provide pathways for doulas to meet criteria to become Medicaid providers through demonstrated expertise or experience based on a list of core competencies.
Failure to codesign these requirements can lead to restrictive requirements that are not reflective of the doula community and low doula participation as Medicaid providers.
Additionally, states can make becoming a Medicaid provider easier or more difficult (e.g., supports to navigate enrollment and billing processes with Medicaid). Doulas traditionally practice outside of the state policy and public insurance arenas and may require onboarding to help navigate unfamiliar systems and terminology.
Key Policy Lever: Grants or Scholarships to Support Doula Training and Credentialing
States can also pass legislation and implement policies that support the community-based doula workforce. States can support doulas by developing clear certification processes, including doulas in workforce advisory committees, and providing funding for education and training opportunities.
Grants and scholarships can support both current and future doulas in obtaining necessary trainings and easing financial stress among workers who are often underfunded. As of August 2023, 9 states provided grants or scholarships for training and credentialing.
State Policy and Administrative Choices Affect Access to Community-Based Doulas
States vary considerably in their level and type of support for community-based doula services. These policy choices can lead to variation in the number of birthing people who have access to this effective strategy. However, no single source of national data exists to understand and compare access to community-based doulas among birthing people. Data are needed to understand birthing people’s access to doula care and to better understand the availability of doulas and workforce challenges they face.
For more information on the state policy levers to maximize the reach and effectiveness of community-based doulas see our State Policy Lever Checklists.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO MORE EFFECTIVELY IMPLEMENT COMMUNITY-BASED DOULAS?
During the 2023 legislative session, more than half of states introduced legislation related to support for community-based doulas. Among the 28 states that introduced legislation related to doulas, 14 states successfully enacted legislation.
5 States Enacted Legislation to Provide Medicaid Coverage for Doula Services
In the last year, five states (Colorado, Delaware, New Hampshire, New York, Ohio) successfully enacted legislation to provide Medicaid coverage for doula services. The states have varying requirements for coverage and effective dates. Several states will not implement coverage until 2024.
In addition, Massachusetts is in the process of implementing Medicaid reimbursement. As of October 1, 2023, MassHealth had released proposed coverage and rate guidance slated to be effective October 30, 2023; however, the regulations were still in the review process and the department was holding public hearings.
Tennessee enacted legislation that takes steps toward Medicaid reimbursement by creating a doula services advisory committee to develop core competencies and standards for doulas within the state, recommend Medicaid reimbursement rates, and propose incentives to encourage doula participation in rural communities.
Although unsuccessful, at least 11 additional states introduced legislation to cover doula services under the state Medicaid program.
States Took Action to Expand Doula Access to Specific Populations
Additionally, several states took steps to increase access to doula services among specific populations. Oregon enacted legislation to establish a doula program for pregnant and postpartum adults in custody at a correctional facility, extending benefits to a population that may otherwise be excluded from doula services. Legislation enacted in Utah requires the Public Employees’ Benefit and Insurance Program to cover doula services under pregnancy and childbirth services. Louisiana enacted legislation to require private insurance plans to cover doula services effective January 1, 2024, becoming only the second state to do so.
2 States Enacted Legislation to Increase Medicaid Reimbursement Rates
Among states with Medicaid coverage in place, two states (Minnesota and Nevada) enacted legislation to increase reimbursement rates. Minnesota plans to increase payments for services provided by a certified doula from $47 per prenatal and postpartum visit and $488 for services at birth ($770 total) to $100 per prenatal or postpartum visit and $1,400 for attending and providing doula services at birth (a total of $2,000). Minnesota released a draft state plan amendment with proposed changes slated to be effective July 1, 2024.
Nevada enacted legislation to increase the state Medicaid reimbursement rate, allowing doulas in urban areas of the state serving Medicaid enrollees to receive up to a total of $1,500 ($100 per visit for up to six prenatal and postpartum visits, and $900 for attending labor and delivery), and an additional 10% incentive added to rural doulas’ total reimbursement, for a total of $1,650. The legislation required the state to submit to CMS a state plan amendment for this change by October 1, 2023.
3 States Enacted Legislation to Provide Financial Supports to the Doula Workforce
In Colorado, Missouri, and Nevada, legislators enacted new laws to provide financial supports to strengthen the doula workforce, including scholarships, training grant programs, and repayment of student loans, respectively. Michigan introduced legislation to provide similar support, but the legislation was not successful. In the last year, Connecticut enacted legislation to establish a voluntary doula certification program and expand the role of the Doula Advisory Committee.
Notes and Sources
- Mallick, L. M., Thoma, M. E., & Shenassa, E. D. (2022). The role of doulas in respectful care for communities of color and Medicaid recipients. Birth, 49(4), 823–832. https://doi.org/10.1111/birt.12655
- Hans, S. L., Thullen, M., Henson, L. G., Lee, H., Edwards, R. C., & Bernstein, V. J. (2013). Promoting Positive Mother-Infant Relationships: A Randomized Trial of Community-based doula Support For Young Mothers: Community-based doula Randomized Trial. Infant Mental Health Journal, 34(5), 446–457. https://doi.org/10.1002/imhj.21400
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Chen, A., & Robles-Fradet, A. (2022, March 2). Challenges Reported by California Doula Pilot Programs. National Health Law Program. https://healthlaw.org/resource/challenges-reported-by-california-doula-pilot-programs/
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Kozhimannil, K. B., Vogelsang, C. A., Hardeman, R. R., & Prasad, S. (2016). Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. The Journal of the American Board of Family Medicine, 29(3), 308–317. https://doi.org/10.3122/jabfm.2016.03.150300
- Salinas, J.L., Salinas, M. & Kahn, M. (2022). Doulas, Racism, and Whiteness: How Birth Support Workers Process Advocacy towards Women of Color. Societies, 12(19). https://doi.org/10.3390/soc12010019
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Masten, Y., Song, H., Esperat, C.R., & McMurry, L.J. (2022). A maternity care home model of enhanced prenatal care to reduce preterm birth rate and NICU use. Birth, 49, 107-115. DOI: 10.1111/birt.12579
- Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7. https://doi.org/10.1002/14651858.CD003766.pub6
- Salinas, J.L., Salinas, M. & Kahn, M. (2022). Doulas, Racism, and Whiteness: How Birth Support Workers Process Advocacy towards Women of Color. Societies, 12(19). https://doi.org/10.3390/soc12010019
- Bakst, C., Moore, J.E., George, K.E. & Shea, K. (2020). Community-Based Maternal Support Services: The Role of Doulas and Community Health Workers in Medicaid. Institute for Medicaid Innovation. https://www.medicaidinnovation.org/_images/content/2020-IMI-Community_Based_Maternal_Support_Services-Report.pdf
- Kozhimannil, K. B., Hardeman, R. R., Alarid‐Escudero, F., Vogelsang, C. A., Blauer‐Peterson, C., & Howell, E. A. (2016). Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth, 43(1), 20–27. https://doi.org/10.1111/birt.12218
- Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., & O’Brien, M. (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health, 103(4), e113–e121. https://doi.org/10.2105/AJPH.2012.301201
- Bey, A., Brill, A., Porchia-Albert, C., Gradilla, M. & Strauss, N. (2019). ADVANCING BIRTH JUSTICE: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf
- Chen, A. (2022, November 14). Current State of Doula Medicaid Implementation Efforts in November 2022. National Health Law Program. https://healthlaw.org/current-state-of-doula-medicaid-implementation-efforts-in-november-2022/
