Could doulas improve maternal health outcomes in the U.S.

As policymakers, health care providers, and researchers continue to explore ways to address the maternal health crisis in the United States, doulas are proving to be a valuable resource in the pursuit of safer, more equitable childbirth experiences.

Maternal health outcomes in the United States remain among the worst of any high-income country, with significant racial and socioeconomic disparities. Black women, in particular, are three to four times more likely to die from pregnancy-related complications than their white counterparts, even when controlling for factors like education and income. These disparities highlight the urgent need for innovative approaches to maternal care that address not only clinical needs but also the social determinants of health that contribute to these disparities.

Doulas have traditionally provided continuous, non-clinical support to pregnant women during labor, childbirth and the postpartum period. But their role can vary widely - from offering emotional support to advocating for the birthing person's preferences. And evidence increasingly shows that they can play a crucial role in reducing some of the risks associated with childbirth.

For health journalists covering this topic, it is crucial to emphasize the many different roles doulas can play in maternal care, the growing evidence base supporting their effectiveness, and the policy changes that are expanding access to these services. As the landscape of maternal health care continues to evolve, doulas are likely to play an increasingly important role in ensuring positive outcomes for mothers and babies across diverse populations and the decisions mothers make on the way they give birth.

Doula care and improved maternal outcomes

A recent study published in the American Journal of Public Health suggests doula care may improve maternal health outcomes among Medicaid enrollees. The study collected data after the Centers for Medicare and Medicaid Services (CMS) and announced it would fund state maternal "non-clinical" initiatives such as doula services.

Researchers found that women who received doula care had significantly improved outcomes compared to those who did not. The benefits included reduced rates of cesarean sections, lower rates of preterm births, and fewer complications during childbirth.

These findings are consistent with previous research on doulas' effectiveness. A comprehensive review of studies found that continuous support from a doula during labor reduced the likelihood of a cesarean birth by 39% and the likelihood of a negative birth experience by 35% while increasing the likelihood of a spontaneous vaginal birth by 15%. The presence of a doula also resulted in shorter labor durations and higher satisfaction with the birthing experience, factors that contribute to overall maternal health and well-being.

For Medicaid recipients, these outcomes are particularly significant, as this population often faces barriers to quality maternal care, including limited access to health care providers, lower socioeconomic status, and higher rates of chronic health conditions. By offering both emotional and informational support, doulas help to mitigate some of these challenges and improve the overall quality of care that Medicaid recipients receive.

So, why aren't more women using doulas?

Despite widely available and accessible services, doula care is still not covered by most health insurance. Doulas are trained professionals who provide emotional, physical, and informational support to mothers before, during, and after childbirth. Unlike midwives or obstetricians, doulas do not provide medical care and are not licensed to deliver babies. Instead, they focus on the non-clinical aspects of the birthing experience.

In 2022, CMS approved a waiver that allowed states to use Medicaid funds to cover doula services as part of their maternal health initiatives. Several states, including Oregon, Minnesota, Massachusetts and New York, have already implemented programs that provide Medicaid coverage for doula care, and more are expected to follow.

Policy changes are a critical step in expanding access to doula care for low-income women, who are disproportionately affected by poor maternal health outcomes. However, access to doula care through private insurance remains limited. While some private insurers have begun to explore the possibility of covering doula services, most do not offer this benefit, leaving many women to pay for doula care out of pocket. The cost of hiring a doula can range from $800 to $2,500, depending on the location and the level of services provided, which puts this support out of reach for many women who might benefit from it.

Virtual and cesarean support

Doulas are also increasingly being used in virtual settings and for cesarean deliveries, both scheduled and emergency. Virtual doula care became more common during the COVID-19 pandemic, when in-person support was often restricted due to hospital policies. Despite the shift to a virtual model, many women still reported positive experiences, and some experts believe that virtual doula care will continue to be an option, especially for women in rural or underserved areas who may not have access to in-person doula services.

Doulas are also recognized for the support they can provide during cesarean deliveries, which account for approximately one-third of all births in the U.S. While cesarean births are typically more clinical in nature, the emotional and physical support that doulas provide can be just as valuable for women undergoing surgery as for those delivering vaginally. Doulas can help ease anxiety, advocate for a woman's preferences in the operating room, and provide postpartum support as women recover from the surgery.

As more states implement Medicaid programs that cover doula care, and as more research is conducted on the benefits of doula support in different birthing scenarios, it is possible that private insurers will also begin to recognize the value of this service and offer coverage to a wider population.

The combination of policy changes, new research, and the evolving role of doulas in both in-person and virtual settings presents an opportunity for health journalists to explore how doulas can help to address the maternal health crisis and improve outcomes for women across diverse populations. Doula care may not be a panacea, but it is a solutions-focused tool in the larger effort to achieve maternal health equity.

Resources

• National Academy for State Health Policy: State Medicaid Approaches to Doula Service Benefit
• DONA International
• "What does a birth doula do?" Harvard Medical School
• "I'm an Ob-Gyn. Here's Why I Had a Doula Help With My Delivery," American College of Obstetricians and Gynecologists