Nearly 4 million U.S. women give birth each year, and approximately half of these births are financed by state Medicaid programs. About 99 percent of American infants are born in hospitals, at a total cost of more than $27 billion annually. The treatment intensity provided in a typical hospital-based childbirth in the United States has drawn scrutiny in past years, and particularly so over the past several weeks.

In the June issue of Health Affairs, Jessica Taylor Goldstein, an obstetrics-trained family physician, offered a personal perspective on this issue in her Narrative Matters essay, “Amid Fears And Controversy, A Doctor Chooses A Home Birth.” In it, she cites the “desire for physiologic childbirth with limited medical intervention” as a motivation for her decision to give birth at home.

In another recent piece published June 4 in the New England Journal of Medicine, obstetrician Neel Shah highlights differences in maternity care policies, practices, and recommendations between the United States and the United Kingdom, suggesting that low-risk pregnant women may actually be better off giving birth in Britain, where new national recommendations support greater access to home birth and midwife-led care.

At a time of growing pressures toward cost-containment within the health care system, the search for solutions to achieve the triple aim (quality improvement and better population health, at a lower cost) is increasingly urgent. According to another article in the same issue of Health Affairs, in which Sherry Glied and colleagues analyzed employee compensation in the health sector, compared with other sectors, cost containment would likely “require using fewer or less skilled employees to produce a given service.”

In the context of maternity care in the United States, there is a need to address the twin concerns highlighted by these recent publications: greater access to normal, physiologic birth and creative adaptation of the workforce to meet patient needs while reducing costs.

Additionally, it is imperative to consider these two challenges in the context of equity, which is not explicitly mentioned by either Goldstein or Glied and colleagues. There are longstanding, pervasive racial/ethnic and rural/urban disparities in maternal morbidity and mortality as well as access to maternity care services.

Complex socio-demographic and historical factors perpetuate the challenges women of color and rural women face in achieving what obstetrician and bioethicist Anne Lyerly calls “a good birth,” a birth experience characterized by personal agency and security, connectedness, respect, and knowledge.

Current Policy Efforts

One policy effort with the potential to ameliorate equity concerns while improving care and reducing the costs of childbirth is currently being taken up by Oregon and Minnesota. These states have expanded Medicaid coverage to include doula services for pregnant beneficiaries. A doula is a trained professional who provides physical, emotional, and educational support—but not medical care—to mothers before, during, and immediately following childbirth.

Support from a doula is associated with lower cesarean rates, as well as fewer obstetric interventions, fewer complications, less pain medication, shorter labor hours, and higher scores on the APGAR test (which determines how well the baby is doing outside the womb).

In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released a consensus statement which explicitly states: “Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”

Access to Doula Services

Given the strength of the evidence and the endorsement of doula care by professional associations, it’s important to consider why only 6 percent of U.S. women who give birth have support from a doula. First, hiring a doula is expensive. Most private doulas charge $700-$1,500 per birth, putting doula care outside the financial reach of many mothers.

Secondly, doulas are not evenly distributed geographically, and many women in rural areas of the United States—where half a million babies are born each year—don’t have a doula nearby. Finally, there is limited diversity within the doula workforce, which can create cultural barriers to access. Most doulas are white upper-middle class women, and most of their clients are white upper-middle class women.

Low-income women and women of color, which are the groups of women at highest risk of poor birth outcomes, are also the most likely groups to report wanting, but not having, access to doula services. The major evidence gap for policymaking is not whether doula care supports positive outcomes but rather how policy efforts can best ensure access to evidence-based doula support and whether and how particular policy strategies more effectively produce value and potentially reduce disparities in birth outcomes.

The Role of State Medicaid Programs

State Medicaid programs are in a uniquely powerful position to address equity issues highlighted by tragic and persistent disparities in birth outcomes, alongside the other concerns raised by Goldstein and Glied. Efforts to expand Medicaid coverage to include doula services have the potential to improve access to low-intervention, physiologic birth and also to reduce costs of maternity services for all women. However, for policy change to be effective, it must be informed by the experiences and wisdom of the community it aims to serve.

In 2013, Minnesota passed legislation requiring Medicaid payment for doula services. We (the authors of this post) are currently studying the effects of this law in partnership with community- and hospital-based organizations that provide doula services.

In November 2014, we conducted four focus groups with pregnant Medicaid beneficiaries from diverse backgrounds to document their knowledge of doulas, ability to access doula services, and barriers to access. The insights that emerged from these focus groups shed light on the intersection between doula support and potential cost savings from relying less on specialty-trained providers or resource-intensive procedures. For example, one respondent stated:

“Having doula support would make it better — having [a chance to ask] questions instead of going to the doctor or the hospital over and over again. Sometimes you don’t really need to go to the doctor … sitting for hours to have [the] ER doctor tell you something your doula could have told you.”

Despite the legislation, Minnesota has had significant challenges implementing Medicaid reimbursement of doula services. In April 2015, we sent letters to the CEOs of all of the managed care organizations in the state that participate in Medicaid to solicit their input on implementation.

Respondents noted several key challenges regarding network development, billing, and consumer outreach. We also interviewed practicing doulas and doula program administrators.

Top concerns that emerged from our analysis of feedback and input from patients, providers, administrators, and payers include the following:

  1. There is a lack of awareness of doula coverage among Medicaid beneficiaries, maternity care clinicians, and health care delivery systems.
  2. Low reimbursement rates ($411 per birth) are a significant barrier to entry for doulas, an obstacle to sustainability and retention of doulas serving Medicaid beneficiaries, and a financial feasibility challenge for doula program administrators.
  3. Doulas have had difficulty becoming enrolled providers with the state’s Department of Human Services and with managed care organizations.
  4. Medicaid programs must pay licensed providers in order to receive federal matching funds. Because doulas are not licensed in Minnesota, doula services must be provided under the supervision of a licensed clinician and billed through that clinician’s National Provider Identification number in order to be reimbursed by Medicaid.

These barriers are not insurmountable, however, and doulas are working closely with administrative agencies and legislators to address these challenges in Minnesota. Other state Medicaid programs have the potential to both improve outcomes and possibly save taxpayer dollars through coverage expansion to include doula services. It’s not a straightforward path, but it may well be worthwhile.

If states consider this route, Minnesota’s lessons may inform their efforts. It is possible to create policy change that heeds the call of Goldstein to “empower women in their birth experience whenever possible,” and of Glied and colleagues to “improve productivity, producing the same services with fewer, or less costly, labor inputs.”

Further, we can do this while enhancing equity in the birthing experience and improving outcomes for all women. Moving ahead, states should look to the evidence base on labor support provided by doulas, and—importantly—consider the importance of equity concerns and engage all voices in the processes of policymaking and implementation.

Author’s Note

For more information on the early implementation of Minnesota’s legislation allowing Medicaid coverage of doula services, please see the authors’ interim report to the state Department of Human Services, published July 1, 2015.