Interest in doula care grows amid maternal health crisis

The country's worsening maternal health crisis is driving interest in supporting doula care as other parts of the health system caring for pregnant patients face greater strain.

Why it matters: New community-based programs, investments by big national companies and new legislation indicate a broader recognition that doulas and the support services they provide could play a greater role in making pregnancy less dangerous, particularly for women of color.

Yes, but: Many insurers don't cover doulas, meaning patients may have to pay thousands of dollars out of pocket — often putting their services out of reach for those who'd likely benefit most. Lack of awareness about doula care and questions about how to certify and train the nonclinical workforce are also roadblocks.

• The doula workforce is also relatively small. Estimates show there are at least 9,000 doulas in a country with 3.6 million live births each year.

Driving the news: This week, Rep. Robin Kelly (D-Ill.) introduced legislation calling for $50 million in federal funding to build up the doula workforce through grants to schools and training programs.

• This workforce performs the emotional check-ins that catch problems health care too often misses, Kelly said.
• "Hundreds of thousands of moms are afraid that their pain will be discounted and their anxieties ignored," she said.
• Her bill also calls on the Department of Health and Human Services to issue guidance to state Medicaid programs on doula coverage — something relatively few programs provide now.
• At least 10 states and Washington, D.C., already cover doula care through Medicaid, though reimbursement rates vary. Other states have expressed interest in adding those services.

Meanwhile, community-based efforts are expanding access to doula care, with encouraging results.

• A program in Tulsa, Oklahoma, lowered the preterm birth rate for participating Black women to 8.9% between 2019 and 2022, according to data shared first with Axios. That's roughly half the state average for Black women.
• The program, run through the Tulsa Birth Equity Initiative, also cut low birth weight instances down 55%.
• The results add to a growing body of research showing doulas can improve birthing experiences and outcomes.
• Health insurers and state health officials have reached out about replicating the program in other parts of the country, said Kimberly Butler of the George Kaiser Family Foundation, which is the program's primary funder.

Between the lines: Companies have also expressed more interest in covering doulas in their health benefits as options for OB-GYN care and birthing centers for their workforces dwindle, said Elizabeth Mitchell, CEO of Purchaser Business Group on Health, which represents companies like Amazon, Boeing and Wells Fargo.

• Last summer, Walmart added doula reimbursement to health coverage. CVS and Microsoft both added a doula benefit in 2021.
• "Now a lot of our members want to start paying for doulas. We're actually even exploring a partnership to train doulas because the workforce constraints are so significant," Mitchell said.

The big picture: The U.S. maternal mortality rate has shot up from 20.1 deaths per 100,000 live births in 2019 to 32.9 in 2021, according to the CDC. The rate is more than double that for Black women, at 69.9.

• Doula advocates say they can help fill in important gaps in a maternal care landscape that's been worsening for decades.
• Poor reimbursement and staffing constraints have led birthing units to close and OB-GYNs to relocate. At least 89 obstetric units closed in rural hospitals between 2015 and 2019, per the American Hospital Association, and many more have closed since.
• That problem is likely worsening, the New York Times recently reported, as OB-GYNs leave or give up practicing in states that have passed strict anti-abortion measures in the past year.
• The March of Dimes estimates up to 6.9 million women live in areas with low or no access to care.

What they're saying: "It was safer for me to have a baby. And my baby's 39," said Kelly, the Illinois congresswoman.

Reality check: Doulas alone can't solve the maternal mortality crisis, said Omare Jimmerson, executive director of the Tulsa Birth Equity Initiative.

• But many groups spearheading doula programs take a multi-pronged approach to fixing the maternal care system. Jimmerson's organization also focuses on hospital quality improvement.
• And the Purchaser Business Group on Health's members are also considering funding birth centers and changing reimbursement so they can be viable, Mitchell said.
• "The system is just failing so dramatically that they are looking to play a new role," Mitchell added.