Insurance Coverage of Doula Services

Doulas can improve maternal health outcomes.

Missouri’s maternal mortality rate is 25% higher than the national average and dispro-portionately affects black mothers (MO DHSS 2022; MOST 2021; CDC 2019). Advanced maternal age, co-existing medical conditions, carrying multiples, and c-sections can increase the risk of negative maternal and infant health outcomes, including maternal death (MO DHSS 2022; Keag 2018; Mascarello 2017).

• Nationally, black women have more c-sections (31%) compared to white women (25%; CDC 2021).
• In MO, fewer women of color start prenatal care in the 1st trimester (80%) compared to white women (89%; MO DHSS 2016).

A doula is a certified non-medical professional who provides personal and emotional support and education during pregnancy, labor, delivery, and after birth. Doulas do not deliver newborns or provide any medication (Bradley 2022).

• Doulas are associated with better birth experiences, shorter labor, and less pain medication use (Bohren 2017).
• In a survey of CA mothers, twice the number of women reported being involved in the decision making, feeling supported, and being communicated with when a doula was present (Mallick 2022).

Globally, continuous care by doulas during labor and delivery has led to fewer c-sections and more vaginal births without tools to assist the delivery (Bohren 2017).

• • In a study of Medicaid patients in MN, those with a doula had a lower c-section rate than those without (22% and 32% respectively; Kozhimannil 2013).
  • There are no studies describing the demographics of doulas or how they impact the health outcomes of women of color.

16 states cover or plan to cover doula services via Medicaid.

The average cost of doula services is between $700 - $1,500 over the course of the pregnancy, which is usually not covered by private or public insurance (Health Affairs 2015).

• From 2011-2012, about 6% of U.S. women had a doula during childbirth.

About a third of women who knew of doula care wanted a doula but could not obtain one.

• These women were more likely to be Black, a first-time mother, have public insurance or be uninsured (Kozhimannil 2014).

States that expand Medicaid coverage can classify doula services as an optional benefit or preventative service.

• Nine states require Medicaid to cover doulas as a preventative service (NASHP 2023).
• RI is the only state that requires private insurers to cover doula services.

There is some evidence that doula services are cost effective for Medicaid programs because of fewer medical interventions during birth (Kozhimannil 2016).

• No studies have measured if adding coverage for doulas changes patient premiums.

As states expand Medicaid coverage to include doulas, cost and administrative barriers to doula participation and patient access to doulas include (Figure 1; Health Law 2023):

• • Doula reimbursement rates
  • Registry enrollment and doula credentialing requirements (e.g., certification, application fees)
  • Physician supervision and referral requirements
  • Optional doula benefit coverage, instead of preventative service coverage
  • Cultural competency (e.g. doulas who speak the patient’s language)

Figure 1. States that require Medicaid to reimburse for doula services (dark yellow), are in the process of implementation (light yellow) or have taken an adjacent course of action such as a pilot program, a registry, commissioned a study, etc. (navy blue). Data from Health Law 2023.

Healthy Blue has a doula pilot program for their patients in MO.

Healthy Blue, a Medicaid plan in MO, launched a doula pilot program in 2022. All Healthy Blue patients in St. Louis, Kansas City, Springfield, Cape Girardeau and Columbia are referred to a doula by their case manager or social service coordinator.

• Healthy Blue pays doulas upfront (based on regional costs) for an agreed number of clients in a year.

The doula meets with the client at least 3 times before the birth to discuss a birth plan, health history, and provide childbirth education. The doula provides continuous support during labor and delivery and makes at least 2 postpartum wellness-visits.

While results are not currently available, the pilot program is measuring if increased access to doulas (e.g., increased awareness, lower costs) improves maternal health outcomes and experience and infant health outcomes (MO Healthy Blue; Buckhall, personal communication).

References

Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017 Jul 6;7(7):CD003766. doi: 10.1002/14651858.CD003766.pub6. PMID: 28681500; PMCID: PMC6483123. 

​Bradley, E., Barker, A., Payne, H., Amadou, O., & Davis, J. (2022, April). Medicaid Reimbursement for Doula Services: Definitions and Policy Considerations. Retrieved from Center for Health Economics and Policy: https://cpb-us-w2.wpmucdn.com/sites.wustl.edu/dist/1/2391/files/2022/04/Medicaid-Reimbursement-for-Doula-Services-April-2022-1.pdf 

​Buckhall, A. (2023 , March 3). doula with Healthy Blue Missouri and owner of Beni Births LLC. (S. Anderson, Interviewer) 

​Chen, A. (2023, February). Doula Medicaid Project. Retrieved from National Health Law Program: https://healthlaw.org/doulamedicaidproject/#:~:text=The%20National%20Health%20Law%20Program%E2%80%99s%20Doula%20Medicaid%20Project,want%20access%20to%20a%20doula%20will%20have%20one. 

​Hasan, A. (2023, January 31). State Medicaid Approaches to Doula Service Benefits. Retrieved from National Academy for State Health Policy: https://nashp.org/state-medicaid-approaches-to-doula-service-benefits/ 

​Healthy Blue Missouri. (n.d.). Doula Pilot Program for Pregnant Women. Retrieved from Healthy Blue Missouri: https://provider.healthybluemo.com/docs/gpp/MO_CAID_DoulaPilotProgram.pdf?v=202110252219 

​Hoyert DL. Maternal mortality rates in the United States, 2019. NCHS Health E-Stats. 2021. DOI: https://doi.org/10.15620/cdc:103855external icon. 

​Kathawa CA, Arora KS, Zielinski R, Low LK. Perspectives of Doulas of Color on their Role in Alleviating Racial Disparities in Birth Outcomes: A Qualitative Study. J Midwifery Womens Health. 2022 Jan;67(1):31-38. doi: 10.1111/jmwh.13305. Epub 2021 Nov 26. PMID: 34825764. 

​Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018 Jan 23;15(1):e1002494. doi: 10.1371/journal.pmed.1002494. PMID: 29360829; PMCID: PMC5779640. 

​Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013 Apr;103(4):e113-21. doi: 10.2105/AJPH.2012.301201. Epub 2013 Feb 14. PMID: 23409910; PMCID: PMC3617571. 

​Kozhimannil KB, Attanasio LB, Jou J, Joarnt LK, Johnson PJ, Gjerdingen DK. Potential benefits of increased access to doula support during childbirth. Am J Manag Care. 2014 Aug 1;20(8):e340-52. PMID: 25295797; PMCID: PMC5538578. 

​Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth. 2016 Mar;43(1):20-7. doi: 10.1111/birt.12218. Epub 2016 Jan 14. PMID: 26762249; PMCID: PMC5544530. 

​Kozhimannil, K., & Hardeman, R. (2015, July 1). How Medicaid Coverage for Doula Care could Improve Birth Outcomes, Reduce Costs, and Improve Equity. Retrieved from Health Affairs Forefront Health Policy Lab: https://www.healthaffairs.org/do/10.1377/forefront.20150701.049026/full/ 

​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. 

​Martin, J. A., Hamilton, B. E., & Osterman, M. J. (2021, September). NCHS Data Brief No 418. Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/nchs/data/databriefs/db418.pdf 

​Mascarello KC, Horta BL, Silveira MF. Maternal complications and cesarean section without indication: systematic review and meta-analysis. Rev Saude Publica. 2017;51:105. doi: 10.11606/S1518-8787.2017051000389. Epub 2017 Nov 17. PMID: 29166440; PMCID: PMC5697917. 

​Missouri Department of Health and Senior Services. (2018, March). Missouri Pregnancy Risk Assessment Monitoring System Surveillance Report. Retrieved from Data, Surveillance Systems & Statistical Reports: https://health.mo.gov/data/prams/pdf/prams_report2015.pdf 

​Missouri Department of Health and Senior Services. (2022). A Multi Year Look at Maternal Mortalilty in Missouri, 2017-2019 Pregnancy- Associated Mortality Review Annual Report. Retrieved from Missouri DHSS: https://health.mo.gov/data/pamr/pdf/2019-annual-report.pdf