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 expectant parents, starting during pregnancy and continuing throughout 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
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.
WHAT PROGRESS HAVE STATES MADE SINCE THE 2020 ROADMAP TO INCREASE ACCESS TO COMMUNITY-BASED DOULAS?
The Number of States Covering Doula Services Under Medicaid Increased Substantially
Community-based doulas have recently gained traction as a strategy for state policymakers to improve perinatal outcomes for infants and parents. Many states are starting to reimburse and cover doula services under Medicaid, a key state policy lever for increasing access to doula services. For families who cannot afford the out-of-pocket expenses for doula care, Medicaid coverage removes a financial barrier to care. Medicaid covers 41% of all live births in the US, therefore including doula services as a covered service expands access to a significant portion of families nationwide.2
In 2020, only three states covered and reimbursed for doula services under Medicaid and now 20 states cover doula services. As of October 2024, an additional seven states are in the process of implementing Medicaid coverage for doula services and several other states have enacted legislation to explore policy options related to Medicaid coverage for doulas.
Additionally, since October 2020, 49 states (including the District of Columbia) have extended postpartum Medicaid coverage to 12 months, which increases the access that new parents have to doula care during the postpartum period.
Medicaid Reimbursement Rates Have Increased Over Time Toward Equitable Pay
As more states have implemented Medicaid reimbursement for doula services, reimbursement rates have increased among both early and new adopters. Equitable reimbursement rates reflect the time devoted to patients and quality of individualized care delivered by doulas. States increase reimbursement rates to better sustain the existing doula workforce and incentivize enrollment of doulas as Medicaid providers.
For example, Minnesota started with a total reimbursement rate of up to $257 in 2014, increased to $770 in 2019, and increased again to $3,200 in 2024. The state has increased reimbursement rates for prenatal and postpartum visits and attendance at labor and delivery and increased the number of covered visits under Medicaid. In total, four states (California, Minnesota, Nevada, and Oregon) have increased reimbursement rates for doula services. As of November 2024, Michigan proposed a policy to increase the Medicaid reimbursement rate for doulas up to $2,700 total. If approved, the policy will be effective retroactively as of October 1, 2024.
States that implemented doula coverage more recently have trended toward using higher reimbursement rates. For example, Washington enacted legislation in 2024 to implement Medicaid coverage of doula services with an expected reimbursement rate of up to $3,500.
As States Struggle with Implementation, Workforce Support Is Critical
States implementing Medicaid reimbursement for doula care have experienced challenges—such as low numbers of doulas pursuing Medicaid reimbursement, financial barriers for doulas to receive updated training, delayed Medicaid reimbursement, and doulas not receiving reimbursement due to administrative barriers. To combat these implementation challenges, support a sustainable community-based doula workforce, and ensure families have access to doula care, states have turned to workforce supports.
Workforce supports can include implementing higher reimbursement rates supporting better doula compensation, providing grants or scholarships to support training and education, and establishing collaborative support systems to assist with billing, administrative work, and provide mentorship. Before fully implementing any of these supports, states may also implement pilot programs as a steppingstone to statewide Medicaid coverage or to identify possible implementation issues early.
Community-Based Doulas Are a Part of a Larger Movement Toward Community-Based Care
Since the 2020 Roadmap, states have recognized the impact of community-based care that provides person-centered, holistic care. Community-based organizations provide culturally relevant care and share lived experiences with their clients. The holistic care approach can also include connections to social services and supports.3
New investments at the federal level also support whole-person maternity care, including support for doula services.4 Additionally, states are recognizing that whole-person maternity care can improve child-parent relationships and, therefore, improve child development outcomes.5
For more information on state progress to increase access for community-based doulas, check out the 2024 Prenatal-to-3 State Policy Roadmap.
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
- (n.d.) State Health Facts: Births Financed by Medicaid, 2022. https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/
- Zephyrin, L.C., Christie, S., Suttiratana, S., and Charlemagne, M. (2023, September 13). How Community-Led Maternal Health Models Can Thrive with Federal Funding. The Commonwealth Fund. https://www.commonwealthfund.org/blog/2024/how-community-led-maternal-health-models-can-thrive-federal-funding
- Centers for Medicare and Medicaid Services. (n.d). Transforming Maternal Health (TMaH) Model. Retrieved October 1, 2024 from https://www.cms.gov/priorities/innovation/innovation-models/transforming-maternal-health-tmah-model
- Center for the Study of Social Policy (2022). Policy Change to Promote Early Relational Health. https://nurtureconnection.org/resource/policy-change-to-promote-early-relational-health/
