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June 16, 2022

Saving Women’s Lives While Addressing Delivery Care Staffing Shortages and Increasing Capacity to Provide Culturally Centered Care: Expanding Medicaid Coverage for Doulas and Midwives

This Bulletin is brought to you by AHLA’s Hospitals and Health Systems Practice Group.
  • June 16, 2022
  • Natalie Birnbaum , Nixon Gwilt Law

Across the United States, reproductive health care is increasingly inaccessible. As federal abortion protections are stripped away, states are passing laws that not only ban abortion, but also impede access to maternal health care. Simultaneously, the United States boasts the highest maternal mortality rate of all developed nations. For Black women living below the poverty line, maternal death rates are significantly higher, reflecting deeply embedded structural racism in our health care system and country at large. Emphasizing culturally centered care in maternal health care can help rectify birthing inequities and decrease maternal mortality in the United States.

The United States Is Facing an Ongoing Maternal Health Crisis

The United States is the only country in the world with an advanced economy and an increasing maternal mortality rate; in fact, it is one of only 13 countries worldwide where this rate is rising. Black women are three to five times more likely to die from pregnancy-related complications than White women. The COVID-19 pandemic has further exacerbated these inequities. These communities have been speaking out for decades against health care settings that lack representation, are rampant with implicit bias, and with doctors and providers that minimize their concerns. In terms of access, 2.2 million women of reproductive age live in “maternity deserts'' that lack maternal health providers altogether. The pandemic has led to more scarcity in health care systems, leading to staffing and funding shortages in hospitals and cuts for OBGYN services, particularly hitting hard in rural areas.

Community-Based Birth Workers as a Solution to Birth Equity

Emphasizing culturally centered health care by increasing access to community-based based birth workers is one way to direct public health efforts in order to change the trajectory of this crisis. Culturally centered health care focuses on the patient and addresses interpersonal barriers by employing staff, such as doulas and midwives, who share linguistic and/or cultural backgrounds with patients and thereby can more easily build relationships and trust through sensitive and respectful interaction.

Doulas are nonclinical professionals trained to provide physical, emotional, and informational support to mothers in the prenatal, birth, and postpartum periods. Doulas can help create birth plans, advocate for women during prenatal appointments, and provide support like breath work and massages during labor. Midwives provide medical care and can be trained to practice in birthing centers or home births without the presence of physicians or in hospitals alongside physicians.

Multiple studies demonstrate better outcomes for birthing people who have doula and/or midwife support, including lower rates of maternal and infant health complications, lower rates of preterm birth and low birth weight infants, and lower rates of non-vaginal birth, which are associated with higher rates of maternal mortality and severe maternal morbidity. This is particularly true for Black and non-White mothers. Additionally, doula support is linked to reduced rates of postpartum depression and anxiety as well as increased positive feelings about the birth experience and ability to influence one’s own pregnancy outcomes. Increasing access to community-based birth workers can also help fill shortages in hospitals and maternity deserts.

The Affordable Care Act (ACA) Helped Improved Access to Community-Based Birth Workers, but Barriers to Access Remain Significant

Medicaid currently covers over 40% of birthing mothers in the United States and plays an even larger role among Black, American Indian, or Alaska Native and Native Hawaiian or Other Pacific Islander women, covering over two-thirds of births. The ACA Medicaid expansion increased coverage for low-income adults, who are predominantly women of color. The ACA also helped increase access to culturally centered care by increasing Medicare reimbursement to Certified Nurse Midwives (CNMs) from 65% of what physicians received for the same services to 100%.

While the ACA expansion was a step in the right direction, insurance coverage of midwifery remains a barrier to the people who need the support most, including Medicaid enrollees. In fact, only 10% of births are attended by midwives and for Medicaid enrollees and Black and minority women this number is significantly lower. This is in part due to the limited coverage of Medicaid for community-based birth workers beyond CNMs. Both Certified Professional Midwives (CPMs) and Certified Midwives (CMs), who deliver in homes and outside of hospital settings, and doulas are excluded from Medicaid reimbursement. Furthermore, regulations and reimbursement for midwives and doulas vary from state to state. For example, only 13 states have elected to cover CPM services for Medicaid beneficiaries. This means that the majority of community-based birth workers are not covered under Medicaid and therefore remain out of reach for enrollees and those who need them most.

Increasing Access to Midwives and Doulas Through Medicaid Expansion and Grassroots Involvement

During this May’s Black Maternal Health, lawmakers introduced the Mamas First Act, which extends the breadth of the ACA by amending the Social Security Act to allow doulas, midwives, and tribal midwives to be reimbursed by Medicaid. Meanwhile, state policy makers are moving in parallel directions. As of December 2021, four states are actively reimbursing doula services through Medicaid, including Florida, Minnesota, New Jersey, and Oregon. Additionally, eight states are starting to implement doula coverage laws: California, Washington, DC, Illinois, Indiana, Maryland, Nevada, Rhode Island, and Virginia. Several other states said that they have plans to begin coverage in 2022 or are considering adding doula benefits in the future.

As federal and state policymakers take these important steps forward, they must be proactive in including doulas and midwives in the process. For example, in 2018 the New York State Doula Pilot Program, which was created without the input of local community-based birth workers, failed largely in part because the Medicaid fee-for-service reimbursement rates offered were not at a livable wage. Other states, like Oregon, are course correcting, after finding similar failures in uptake.

In early June, Oregon’s State Medicaid Agency announced they will submit a State Plan Amendment to the Centers for Medicare & Medicaid Services to raise reimbursement rates from $350 to $1500. The Oregon Doula Association explained in a press release that although Oregon was the first state to create a Medicaid doula pathway, low rates meant that few doulas participated and low-income families remained underserved, making it impossible to eliminate health inequities for birthing families. Other primary concerns for community-based birth workers include avoiding over-regulation of practices and overly complex reimbursement procedures and emphasizing community education.