Could a state like Georgia improve birth outcomes through doula support – and could Medicaid pay for it?
Leaders at one Atlanta-based nonprofit want to find out.
Earlier this year, the Healthy Mothers, Healthy Babies Coalition of Georgia launched a pilot program to provide a doula – a non-medical professional trained to provide support during pregnancy, birth and afterward – to 175 pregnant Medicaid recipients across Georgia.
“We think of doulas as being present for a birth and assume that’s all a doula does,” said Precious Andrews, director of special projects at Healthy Mothers, Healthy Babies Coalition of Georgia. “But they do so much more. They can be the taxi driver to appointments, the babysitter when mom has more than one child. They can be an educator for mom, and a breastfeeding supporter.
“The scope of what they can do is just so wide.”
The goal of the pilot program is to demonstrate how doula care might impact pregnancy outcomes for low-income families and how Medicaid – the government-sponsored health insurance for low-income people – could cover the cost. In Georgia, Medicaid covers nearly half of all births.
The pilot is funded through grants from care management organizations that contract with Georgia Medicaid. And while Medicaid itself is not directly involved with the pilot program, the Centers for Medicaid and Medicaid Services have issued federal policy guidance saying that doula support is associated with improved health outcomes, including decreased likelihood of postpartum depression and near-universal breastfeeding among people who have lower incomes.
“Regardless of how you give birth, I think everyone who wants to have a doula deserves to have a doula,” said Chanel Stryker-Boykin, a doula in metro Atlanta who is participating in the pilot program.
“For people who may not normally have access to a doula, we’re providing that access, barrier-free.”
A sustainable model?
Back in May, the program enrolled pregnant Medicaid recipients and assigned them certified doulas to support them throughout their pregnancy, birth and the postpartum period (the weeks following a birth). Participants also get access to prenatal classes, peer support groups and a care package.
The program pays for two prenatal doula visits, labor and delivery care, and two postpartum doula visits. Doulas receive $50 per visit and $550 for attending labor and delivery.
It’s a dual effort, said Andrews: to make doulas accessible to families who might not otherwise be able to afford their services, and to compensate doulas fairly.
“Most of us do this as a calling,” said Stryker-Boykin. “But everyone deserves to be paid for their work. If we’re saying doulas are such a benefit to maternal health outcomes and can shift birth experiences to be more positive, then we have to recognize they are valuable and deserve to be paid, to keep this model sustainable.”
Andrews said the program is also meant to serve as a model for how Georgia Medicaid could cover doula care – from the doula reimbursement structure to the potential improvement in birth outcomes.
Across the South, as in Georgia, Medicaid covers nearly half of all births. Among Black Georgians, Medicaid covers two-thirds of births.
And Georgia, like its Southern neighbors, has poor birth outcomes compared with national averages. It’s got one of the nation’s highest maternal mortality rates and ranks among the 10 states with the highest rates of babies born early and underweight.
Rates are worse for Black mothers and babies. Black women are three times more likely to die from pregnancy-related complications compared to white women, and Black babies are twice as likely to die in infancy as white babies.
“If you’re giving birth anywhere in this country, especially if you’re a Black-identifying person, you need childbirth education and adequate postpartum support. You deserve it,” said Stryker-Boykin.
Andrews experienced a health emergency after the birth of her daughter. She hired a postpartum doula who helped her breastfeed and reminded her to take her medication, babysat her toddler and helped clean the house.
Andrews calls her a “godsend.”
“We get so caught up in making sure mom and baby deliver safely, but mom and baby still need help after all of that is said and done,” said Andrews. “Once the ‘new car smell’ is gone, people are not checking on you or helping as much, but that doula is there to say, ‘What do you need? This is what I can do for you.’”
There’s still widespread misunderstanding of the role that doulas can play in a pregnant person’s healthcare, she said, and a lack of awareness among potential clients – especially those outside urban areas.
To increase doula access across Georgia, particularly in rural and underserved areas, the coalition also has a scholarship program that recruits and trains doulas, certified breastfeeding specialists, childbirth educators and certified maternal mental health peer support specialists. Some of the doulas who came through their training, like Stryker-Boykin, are now working with pregnant mothers in the Medicaid pilot.
“Our maternal health system in Georgia is challenging to navigate,” said Stryker-Boykin. “But it’s also beautiful to see so many birth givers recognizing the power they hold. With that power comes the need to be informed and to make decisions about their birth experiences. It’s powerful and beautiful to be a part of that.”
‘These are our people’
Andrews said research supports the positive impact doulas can have on birth givers and on states’ bottom lines.
A study published in the journal Birth in 2016 found that women who received doula support had lower preterm and cesarean birth rates compared to all Medicaid recipients. The study also found that coverage of doula support could save state Medicaid programs nearly $1,000 per beneficiary. Another study found that access to doula services for low-income pregnant people could improve birth-related outcomes for people of color in underserved communities.
About a dozen states currently reimburse for doula services through Medicaid or are in the process of doing so. Another five, including Georgia, are considering a Medicaid doula program, according to the Georgetown University Health Policy Institute Center for Children and Families.
Doula pilot programs in other states have resulted in Medicaid coverage. Florida’s Medicaid program began covering doula services in 2018 for some of its recipients. In the wake of doula pilot programs in California, that state’s Medicaid program announced it will add doula services to its coverage beginning January 2023. In its announcement, California’s health department said it based its doula reimbursement rates in part on doula pilot programs that were operated by managed care plans in California – similar to the format that Georgia’s pilot program is following.
Andrews said the data gathered through Georgia’s pilot will be presented to state legislators next year.
“You can’t always think a legislator wants to see something from Florida or California; they need to see there’s a demand in a state where they work,” said Andrews. “These are Georgia residents. These are our people and there’s a demand for doulas to be paid through Medicaid – now what are you going to do about it?”