These states are starting to embrace doulas — especially for vulnerable moms

Published on
January 31, 2020

Eighteen months after Sharmin Sultana and her family immigrated to the United States from Bangladesh, she became pregnant with her third child. She was overwhelmed by having a baby in America. “I did not have a vehicle and I was not sure how I would go to the hospital,” she recalls. “I did not know I needed a car seat for taking my baby home from the hospital. I did not know where to shop for my baby.” 

A friend suggested she call the Priscilla Project, a local program that provides doula care and other support for pregnant women and new mothers. A doula, Sondra Dawes, visited Sultana at home, answered her questions, took her shopping, listened to her fears, and helped to calm them. Sultana found the help so valuable that after her daughter was born 3 1/2 years ago, she trained to become a doula. Now she works with the Priscilla Project, in Buffalo, New York.

A combination of coach, guide, consoler and advocate, a doula in the delivery room will wipe the sweaty forehead of a woman, show her positions to ease pain, and perhaps most importantly, listen to her and make sure the medical staff does too. “Mom is very nervous sometimes, even if it’s a second baby,” Sultana said. “If she knows somebody is with her, it makes it easier for her.”

It also can improve birth outcomes both for mother and baby. Studies of thousands of births over decades show that when doulas or other companions attend women through their labor, they deliver their babies faster, use less pain medication and have lower Cesarean rates (40% lower in one study). They have fewer preterm and low birth-weight infants, and their babies have better APGAR scores, a measure of a newborn’s health. The benefits are greatest for low-income women, women of color, and those who face cultural or language barriers — in short, women at highest risk of complications during pregnancy and childbirth. A few states are now leading the way to make sure doula services are available to women who need them most.

Two states, Oregon and Minnesota, cover doulas through Medicaid, and both revised their regulations in the past two years to expand access. Last March, New York state launched a pilot program that provides Medicaid reimbursement for doula services, part of a broader initiative to reduce racial disparities in maternal deaths. The three-year pilot targets two counties that have some of the worst infant and maternal mortality statistics in the state and the largest number of Medicaid births: Erie County, in the Buffalo area, and Kings County, or Brooklyn.

Several other states have adopted laws and policies that implicitly recognize the value of doula support, even if they won’t pay for it. Washington state and Oklahoma, for example, allow incarcerated women to receive doula assistance before, during and right after childbirth, but they must find a free program or pick up the tab on their own. 

The efforts to expand doula access, encouraging as they are, beg the question: Why don’t more states and the federal government cover the care through Medicaid and require private insurers to include it as a standard maternity benefit? The U.S. has the highest rate of infant and maternal deaths among affluent industrialized countries, with shameful racial disparities. Black women die of pregnancy- and birth-related complications at nearly three times the rate of white women, and Native American women die at double the rate. Programs across the country like the Priscilla Project offer free doula services in underserved communities, but there are not nearly enough. Most women who want a doula must pay out of pocket — an average $1,200 in New York City, according to one study.  For too many families, this essential service is an unaffordable luxury.

Doulas, of course, cannot eliminate stark racial disparities in the care, health and survival of women and their babies. But the health establishment is increasingly vocal that the support can narrow the gap.

In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine called for greater use of “one of the most effective tools to improve labor and delivery outcomes, the continuous presence of support personnel, such as a doula.” It's not clear from the research exactly why such support makes a difference, but comforting and empowering women and reducing the routine use of interventions certainly help. 

In 2015, the World Health Organization listed continuous support by a doula or another companion on its Safe Childbirth Checklist. The following year the Health Care Payment Learning & Action Network, convened by the U.S. Department of Health and Human Services to figure out ways of improving the value delivered by the health care system, recommended that insurers include doula services in maternity coverage. And the March of Dimes has called for increased access to doula care — and reimbursement by Medicaid and private insurers — as a way to decrease maternal anxiety and depression and improve communication between health care providers and pregnant women, especially low-income women and women of color.

If all that’s not enough to persuade policymakers to finance doula care, they might consider the math. In a study published last summer, Oregon researchers designed a model to evaluate the cost-effectiveness of doula support for 1.6 million women — roughly the number of women who have low-risk, first-time births annually in the U.S. The researchers calculated that doula support saved $91 million through reductions in medical interventions and serious complications such as uterine rupture. Doula care also increased the quality-adjusted life years, a measure of healthy longevity, not only for the mom and her first child but also for her second one, even if she didn’t have a doula that time.

For the doulas of the Priscilla Project, the research simply confirms what they have seen. Maybe the biggest testament to the service is this: Eight of the 19 certified doulas working with the project were previously clients. The doulas serve women in Spanish, Somali, Nepali, Bengali, Mandarin, Karen, Burmese, Swahili, Hindi, Urdu, Arabic, French, Kibembe, Shan, Kirundi and other languages, in addition to English.

The Priscilla Project has provided doula services since 2003. By participating in the New York state pilot, it will finally get reimbursement for them. But money isn’t the whole point, said Sondra Dawes, the program coordinator. “Our goal is to prove that every woman should have a doula.”