In recent years, doulas have had a resurgence, shown to improve maternal health outcomes, physically, mentally, and emotionally, particularly among underserved populations. Some Community Health Centers are incorporating doula services.
The United States is experiencing a maternal health crisis, with mortality rates spiking in recent years, highest among Black women. Community Health Centers (including federally qualified health centers or FQHCs) help to narrow overall disparities in health outcomes by providing affordable, high-quality care to everyone, regardless of their ability to pay. Through programs tailored to meet the needs of their pregnant patients, health centers are also helping to reduce maternal health disparities. One promising approach of these programs is the incorporation of doulas.
One step to creating more community-based solutions to the maternal health crisis is mobilizing doulas in their own communities to provide prenatal and postpartum support. Birthing people impacted by social drivers of health have an increased risk of adverse prenatal and postpartum mental health outcomes. The continuous support doulas provide is linked to improved rates of depression, anxiety, and suicide among this population, making the profession a mechanism to promote equity and strengthen the safety-net maternal health workforce.
Doulas Can Support During All Stages of Pregnancy
In recent years, doulas have had a resurgence, improving maternal health outcomes physically, mentally, and emotionally, particularly among underserved populations. Doulas can be trained to support people during any/all stages of pregnancy: perinatal, birth, postpartum, miscarriage, or stillbirth, to name a few. Doulas that are present during labor and delivery are successful in reducing stress, anxiety, and pain as clients prepare to give birth.
After birth, doulas who specialize in postpartum care can promote the importance of postpartum doctor visits and are trained to recognize common mental health issues. Studies show that doula care for birthing people led to fewer C-sections, a decrease in the utilization of pain medication, and a reduction in the maternal mortality rate in communities of color.
Health centers are incorporating doula services. For example, the Community Health Center of Richmond in New York provides free doula breastfeeding support services to their birthing patients through the New York Department of Health’s Citywide Doula Initiative. In Washington, D.C., Community of Hope also connects birthing patients to free doula services through partnerships with doula collaboratives based in the D.C. area.
Doulas Fill Gap in Maternity Care
Doulas also address the maternal health workforce needs while improving the birthing experience overall. Community-based doulas in underserved settings typically come from the communities they serve, providing continuous prenatal and postpartum support in places that may otherwise considered “maternity care deserts.” They can guide clients when navigating the health care system, which can be complex and overwhelming. Because they represent the communities they work with, they are often viewed as highly trusted individuals. Since birthing people of color and birthing people who are low-income face barriers when it comes to receiving equitable perinatal and postpartum health care, doulas with lived experience and/or similar backgrounds can understand the challenges or concerns their clients experience and provide relevant support and even advocacy in the clinical setting.
National and State Efforts to Expand Doulas
Nationally, investments are being made in the maternal health workforce. Last year, the Biden-Harris Administration launched their Blueprint for Addressing the Maternal Health Crisis. It is an expansive plan to promote the overall wellbeing of birthing people. The plan will increase access to and coverage of maternal health services, including behavioral and mental health, and expand the perinatal workforce, including doulas.
The Administration also established the National Maternal Mental Health Hotline: 1-833-TLC-MAMA, operated by professional counselors equipped to provide support, resources, and referrals to pregnant and postpartum people with mental health concerns. Additionally, the Health Resources and Services Administration (HRSA) awarded nearly $6 million in funding to support the expansion and creation of doula training and certification programs to 19 organizations (a few of which are health centers!) in 15 states.
At the state level, the Centers for Medicare and Medicaid Services (CMS) has approved 10 State Plan Amendments for states to begin reimbursing doulas through their Medicaid programs. This is important as half of health center patients are insured through their state’s Medicaid program. These plan amendments are encouraging to see; reimbursement is a necessity in building this profession that has proven its ability to significantly reduce rates of postpartum depression and anxiety among Medicaid beneficiaries. Additionally, 35 states have extended their Medicaid postpartum coverage from 60 days to 12 months, allowing new parents to have their postpartum needs met for a full year after giving birth.
The expansion and support of doulas in community settings is important for health centers, patients, and the maternal health workforce, but gaps remain that limit effectiveness and accessibility to the doula profession and their services. States should be expanding their Medicaid plans to cover doula care. With 40 percent of births in the U.S. covered by Medicaid, some level of doula coverage should be required by CMS. Community-based doulas need to be reimbursed for their services at a competitive rate; while there are states reimbursing doulas, rates differ by state, and some are quite low. Broad coverage and sustainable reimbursement strategies for doulas will open the door for health centers and other safety-net providers to further reach the needs, both mental and physical, of birthing people in their communities.