In a Nutshell:

• Maternal and infant health outcomes in the United States and Michigan are worse than in the rest of the developed world, and the racial disparities are particularly striking.
• Research shows that doulas are associated with better delivery outcomes, including reduced cesarean sections, premature deliveries, and length of labor, among other things.
• Michigan could expand access to doula services by codifying Medicaid doula coverage into statute and establishing higher Medicaid reimbursements, requiring coverage for those with private insurance, and funding doula training.

Improving maternal and infant health outcomes is a key public health goal across all levels of government. The challenge is complex and bringing outcomes in the United States and Michigan in line with comparable nations will require a variety of different approaches, but expanding access to doula services is one option.

Doulas play a non-clinical role in the pregnancy and birth process that research has shown leads to better outcomes and, in some cases, lower costs. States, including Michigan, have taken a number of steps to improve patients’ ability to receive doula services, but more can be done to offer expectant and new mothers tools to improve their families’ experiences.

Maternal and Infant Health

Maternal and infant health outcomes in the United States and Michigan – particularly mortality rates –  are worse than in the rest of the developed world, and the racial disparities are particularly striking. For instance, in Michigan, Black women are 2.8 times more likely to die from pregnancy-related causes than White women. While this is a public health problem that has received considerable attention, the most recent data shows things are moving in the wrong direction.

The comparatively poor overall maternal and infant health in the United States and the racial disparities that exist are widely recognized as serious public health problems. Policymakers, the health care industry, academics, and advocacy groups have studied the issue and are pursuing a wide range of interventions to improve the situation. For instance, last summer, the Citizens Research Council called attention to Michigan’s recent decision to fund a pilot program – RxKids – which provides direct cash payments to new and expectant mothers in Flint in the hopes of improving health and social outcomes. 

Efforts to improve maternal and infant health are much broader and include a wide range of policies. The Biden Administration’s maternal and infant health agenda cites the need for improving health care access, particularly through Medicaid; improving clinical practices to ensure all pregnant women are listened to by providers; collecting better data; expanding and diversifying the perinatal workforce; and strengthening economic and social supports. The National Governors Association playbook for tackling maternal and infant health echoes the same approaches.

The Value of Doulas

Both the Biden Administration’s maternal and infant health agenda and the National Governors Association playbook recognize that a part of the solution to the country’s maternal and infant health problems is expanded access to the services of doulas. Doulas are trained professionals who provide physical, emotional, and informational support to patients and their partners during, and shortly after, childbirth to help achieve the healthiest, most satisfying experience possible. Doulas help guide their clients through the pregnancy and birth process, and help them to advocate for their needs. This includes things like birth position expertise, emotional support, and education about options and best practices so that patients and their families are knowledgeable about the process. While doctors and nurses play an important role in the birth process, it is easy to imagine how a professional focused on guiding women and their families through the experience could be helpful.

The evidence clearly supports the value of doulas. Research on doulas – sometimes identified broadly as “continuous support” – shows they are associated with better delivery outcomes, including reduced cesarean sections, premature deliveries, and length of labor. Multiple studies also showed a positive impact on Apgar scores – a standard measure of newborn health immediately after birth. One study found doula-supported mothers were four times less likely to have a low-birth-weight baby and two times less likely to experience a birth complication involving themselves or their babies. Patients working with doulas reported reduced anxiety and stress and higher satisfaction about their childbirth experiences. Working with a doula improved breastfeeding success and duration, especially for lower-income women.

Doula Policy and Options

Given the evidence that doulas make a positive impact on maternal and infant health, policies aimed at increasing access to doula services make sense as part of the response to the country’s maternal and infant health challenges. States have several options to make doula services more available, including expanding or improving coverage for doulas under Medicaid, encouraging or requiring private insurers to offer doula coverage, and supporting doula programs and funding doula training.

Medicaid

In 2022, Medicaid paid for 41 percent of all births nationwide – including 38 percent of births in Michigan, meaning that access to doulas could improve outcomes for two of out every five births. Given that maternal and infant health risks are greater for lower-income populations, improvements for women receiving Medicaid coverage are likely the most important avenue to better outcomes statewide. In addition to the general research supporting the benefits of doulas, evidence from Medicaid found doulas improved outcomes and that doulas led to lower costs.

Thirteen states provide coverage for doulas as part of Medicaid, including Michigan, with other states considering coverage or funding some type of adjacent program short of Medicaid coverage. Michigan’s program, which went into effect in January 2023, was met with criticism due to the approved reimbursement rates – $700 for labor and delivery attendance plus $75 per visit for up to 6 pre- or post-natal visits (up to $1,150 total per pregnancy). The Michigan Department of Health and Human Services (MDHHS) originally proposed much lower rates of reimbursement for doulas for labor and delivery, $350 and then $500, but ultimately increased the figure before final approval.

Michigan’s reimbursement is lower than most of the states that have implemented Medicaid coverage for doulas, and doulas and their national advocates consider Michigan’s rates to be too low to adequately compensate them for their work. States vary in exactly how they structure reimbursement, but something close to $1,500 over the course of a pregnancy is more typical. There is no current data on how many Medicaid patients who give birth opt for a doula, but the maximum annual cost difference between the current rate and $1,500 is about $15 million per year if a doula was included in all of the approximately 39,000 births covered by Medicaid in the state.

While Michigan’s efforts to cover doula services under Medicaid means recipients can receive the services, access to doulas depends on the number of people willing to work as doulas in the state. Increasing reimbursements would support the development of the profession in Michigan. Similarly, coverage for doulas in Michigan was initiated by MDHHS after failed legislative action, and codifying the coverage in statute would likely aid these efforts because there would be more certainty about the future of coverage under Medicaid.

Private Insurance

While Medicaid plays a large role in financing pregnancy-related care, many individuals receive coverage through private insurance and do not have guaranteed doula coverage. Insurers are required to cover maternity care under federal and state law, but these provisions do not currently extend to doula services. In fact, only two states – Louisiana and Rhode Island – require private insurers to cover doula services. Legislation has been introduced in a handful of other states to establish similar requirements.

Requiring private insurance to cover doula services could lead to higher costs for insurers – and indirectly for patients through slightly higher premiums – but given the value of doulas, requiring private insurers to cover doula services is worth consideration, especially if the evidence from the Medicaid context that doulas lead to lower cost births overall translates to the private insurance context. Having assurances that insurers will cover doula care would further support the recruitment and retention of doulas in the state and provide access to individuals who have private insurance but are not wealthy enough to afford the out-of-pocket cost of hiring a doula.

Supporting Doula Workforce Development

In concert with ensuring coverage for doula services and sufficient reimbursements to doulas, states can also play a role in building the doula workforce directly. Nine states have grants or programs to help fund doula training and certification. While there are private efforts to provide scholarships, Michigan does not have a scholarship or grant program to support doula training. Legislation has been introduced to create a scholarship program in Michigan.

Michigan and other states have doula registries, but there is no official census on the number of doulas practicing in the state or around the country or the number of people who might consider becoming doulas if given the appropriate financial support. Given that policies to support doula training are generally scholarship-based, the state can manage the cost of any such program by appropriating a specific amount of money into the dedicated fund and then evaluating the value of the program without an ongoing commitment.

Conclusion

Maternal and infant health outcomes in the United States are lacking compared to other developed countries and Michigan’s outcomes are below the national average. States are rightly interested in policies that could improve outcomes, and while this is a complex issue that requires a variety of solutions, one area of improvement could be expanded access to doula services. Patients who have the support of doulas often have better, healthier experiences, and there is some evidence that doulas can drive down overall costs.

Michigan already provides coverage for doula services through Medicaid, but the approved reimbursement rate is lower than many states and may not attract people to the doula workforce. In addition to increasing Medicaid reimbursements, Michigan could explore requiring doula coverage under private insurance plans and make direct investments in doula training programs.