Colorado’s Medicaid program now covers doula care for all pregnant and postpartum members, but advocates don’t expect to see an immediate improvement in maternal health.

Doulas aren’t medical providers, but provide support during pregnancy, birth and the weeks that follow. They can offer advice on ways to cope with labour, assist with lactation and discuss their clients’ concerns about pregnancy and parenting.

Twelve other states and the District of Columbia also allow Medicaid to pay for doula services.

The Colorado Maternal Mortality Review Committee’s most recent report recommended that pregnant and postpartum people have access to a broad variety of providers and support people, including doulas, and that insurance should pay for their services.

Anyone who is pregnant and covered by Medicaid can receive prenatal and postpartum care from a doula, as well as support during the birth, said Susanna Snyder, director of the child and family health division at the Colorado Department of Health Care Policy and Financing. Parents-to-be don’t need a medical referral for a doula, she said.

Medicaid covered more than 22,000 births in Colorado in 2023. The department doesn’t have an estimate of how many mothers will seek out a doula or how many doulas will opt to participate, Snyder said.

The full doula package includes up to 180 minutes each of prenatal and postpartum care, as well as birth support, Snyder said. The doula and client can decide how to divide up the appointments. For example, some may want three hour-long visits, while others want shorter and more frequent appointments, she said.

Racial disparities in maternal health

Covering doula care is an important first step to addressing racial disparities in maternal and infant mortality, said Sharon Devine, who has a doctorate in nursing and is a maternal health education manager for Sister-to-Sister, an organization for Black professional women.

The most recent report on maternal mortality, covering 2016 to 2020, found Black women in Colorado had about twice the rate of pregnancy-related death as white women.

Black women and babies tend to have better outcomes when at least some members of their care team come from the same background, and allowing Medicaid to pay for doula services could encourage a more diverse group to do that work, Devine said.

That said, the benefits would be greater if doulas could offer more postpartum support, Devine said. Most new mothers will probably use up their visits in the weeks immediately after birth, leaving them without someone to check on them even as they remain at elevated risk of dying, she said.

Nationwide, about 30% of maternal deaths happen more than six weeks after the birth.

“I do believe that Medicaid covering doula services will help… but it is not a fix-all solution,” she said. “That postpartum period, from day one to day 365, is very important.”

Sister-to-Sister is working with hospitals to integrate doulas into their care teams, so they’re in a better position to advocate for their clients, Devine said. Clinicians sometimes dismiss when patients, especially women of color, say something is wrong, and doulas can act as go-betweens to make sure their clients get the care they need, she said.

Some studies have found women of color who’d given birth were twice as likely as white women to report health workers ignored them or refused to help during the hospital stay.

“That doula is really there to be persistent,” Devine said.

‘Not enough doulas signed up’

The change is unlikely to have a major effect on maternal and infant health this year, because doulas will need time to complete the certification process before they can start seeing patients, said Indra Lusero, director of the maternal health nonprofit Elephant Circle, who is nonbinary.

The department only released the list of approved trainers and the application portal a few weeks ago, so not many have gotten through the process, they said.

“There are not enough doulas signed up to be Medicaid providers yet,” they said.

New doulas need to complete training with an approved organization, while those with experience don’t have to retrain if they show they’ve attended at least 10 births and have letters of recommendation from two clients and two clinical professionals who’ve worked with them, such as nurses or midwives.

So far, only a “couple” of applications are in the process, with more expected in the coming months, Snyder said. The department didn’t want to start approving applications before doulas could actually get paid, she said. The legislature appropriated $100,000 for scholarships for doulas, which the department is deciding how to distribute.

Elephant Circle is working with interested doulas to help them through the paperwork, which includes a background check and proving they have CPR training, Lucero said. Most doulas get paid out-of-pocket or work with nonprofits with relatively simple rules, so the Medicaid process can be intimidating at first, they said.

Administrative costs of complying with Medicaid’s rules do cut into net reimbursement, but even so, the $1,500 rate for prenatal, birth and postpartum care is “pretty solid” compared to other states that cover doula services, Lucero said. Doulas who charge patients directly vary widely in their fees, so the state’s rate will prove more attractive to some than others, they said.

Making doula care more equitable

Medicaid covering doula care will reduce financial barriers for families, said Heather Hagenson, director of operations and development for women’s outpatient health programs at Intermountain Health.

Intermountain’s Saint Joseph Hospital doesn’t employ doulas, but has a partnership with the Aurora group Mama Bird Doula Services to coordinate patients’ care before and after birth. Few insurance plans cover it, so typically the only patients who have doulas are those who can pay out-of-pocket, she said.

Patients who have a doula are less likely to have a cesarean delivery, have fewer interventions and are less likely to use pain medication, Hagenson said. Vaginal births are less likely to cause complications than cesarean ones, so reducing unnecessary C-sections is a public health priority. Using an epidural or similar pain medication is low-risk, but some mothers want to avoid it for personal reasons.

They also tend to come away more satisfied with the birth experience, because the doula can make sure the medical team understands what they want and that they don’t feel pressured into interventions, Hagenson said.

“We want people to have a positive birth experience, whatever that looks like for them,” she said.

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