North Carolina has the unique opportunity to pioneer state-level maternal health legislation. On April 1st, 2021, NC representatives Zack Hawkins, Julie von Haefen, Carla Cunningham, and Vernetta Alston filed House Bill 488. This bill directs the North Carolina Department of Health and Human Services (NCDHSS) to explore the scope of current doula services statewide, promote the availability of these services, and ultimately provide coverage for doula support under the Medicaid program (H.B. 488, 2021). If these measures are adopted, North Carolina would be the fourth state to provide statewide coverage for the use of doulas under Medicaid, behind Oregon, Minnesota, and New Jersey (Nguyen, 2021). Oregon and Minnesota, two states that forged the way with doula legislation, have faced, and continue to face, hurdles in the successful implementation of their interventions (Chen, 2018). To be successful, North Carolina must learn from the legislative shortcomings in Oregon and Minnesota, financing the intervention so doulas are adequately paid for their services and do not face financial barriers when meeting state Medicaid registration and licensure requirements. Further, North Carolina has a tremendous amount to gain from implementing Medicaid-covered doula services, including improving birth outcomes for mothers and infants, lowering costly medical interventions during delivery – such as cesarean sections – and potentially creating financial savings for the state’s Medicaid program.
Compared to other developed countries, the United States is far behind in terms of maternal health (OECD.stat, 2021). There is also a wide variety in maternal and child health outcomes within the United States. North Carolina, as of 2019, was ranked 30th out of the 50 U.S. states with 27.6 maternal deaths per 100,000 live births (United Health Foundation, 2019). North Carolina ranked even lower for infant deaths, sitting at 41st out of 50 states with an infant mortality rate of 7.3 deaths per 1,000 live births in 2019 (United Health Foundation, 2019). Within these statistics lie vast disparities between races and social classes. Non-Hispanic Black women are more than three times as likely to die from pregnancy-related complications as non-Hispanic white women in the United States (Petersen et al., 2019). These trends are also seen among non-Hispanic American Indian and Alaska Native women, whose pregnancy-related mortality ratio is more than twice that of non-Hispanic white women (Petersen et al., 2019).
Rates of maternal mortality for minority populations in North Carolina follow these striking trends. Aggregate pregnancy-related death ratios from 2012 to 2015 displayed a death rate for non-Hispanic Black mothers that was 1.6 times greater than the rate for non-Hispanic whites (Small et al., 2020). Moreover, many pregnancy-related deaths are preventable, as demonstrated by a survey conducted by the Maternal Mortality Review Committees (MMRC), which found that 63.2% of pregnancy-related deaths from nine different states could have been averted (CDC and USDHHS, 2017).
At the root of the disparities in maternal and infant mortality are structural and social determinants of health. Examples of structural racism and institutional policies, according to Crear-Perry et al. (2021), include “Jim Crow, the GI Bill, redlining…, [and] mass incarceration – historically based features of an overtly oppressive U.S. society that have endured and adapted over time and continue to shape contemporary access to health-promoting resources and opportunities necessary for optimal Black maternal and infant health outcomes” (p. 231). Doulas seek to dismantle these structures within maternal health, working inside of a health system that can be overtly racist to maximize positive birth experiences for both mother and infant.
A doula serves as a professionally-trained birth companion who provides emotional, physical, and psychosocial support throughout the peripartum period (Gruber et al., 2013). Emotional measures include reassurance and praise, while physical measures include comforting touch and massage, warm baths or showers, and encouraging mobility and position changes (Bohren et al., 2017). Although nonclinical in nature, doulas are expected to build team relationships with nursing staff and physicians in order to encourage communication between patients and medical caregivers (Gruber et al., 2013).
While developing an open line of communication with providers is crucial, a doula primarily serves the mother’s best interests. Gruber et al. (2013) highlighted this in their literature review, stating that, “A doula serves as a mother’s advocate, providing a woman a sympathetic but informed ear for the choices that the birthing staff may ask her to make during the birthing process” (p. 50). Medical providers may, at times, encourage mothers to accept interventions focused primarily on the mother’s comfort – even if these interventions run counter to the birthing process and could negatively impact the health of the mother or baby (Gruber et al., 2013). When women disagree with their providers in how care proceeds, this can impact their birth experience. Vedam et al. (2019) in their research found that “30% of Black and Hispanic primiparous women and 21% of white women who delivered in hospitals in the US reported that they were treated poorly because of a difference of opinion with their caregivers about the right care for [themselves] or [their] baby’” (p. 3). When a doula accompanies a woman through the birth and delivery process, they can challenge the power dynamics in the delivery room, ensuring that the mother’s voice is appropriately heard and that her decisions on how to proceed with care are closely followed without retribution.
Protecting women in marginalized communities, specifically women of color, is especially critical to a doula’s work. As stated previously, women of color face considerably worse maternal health outcomes, and doulas must act to voice their preferences and prevent unnecessary or unwanted birth interventions. This critical work is highlighted through the “By My Side Birth Support Program,” which provides doula support to women, many of whom are faced with high rates of comorbidities and poverty, in New York City neighborhoods (Thomas et al., 2017). The highly successful program consists of three prenatal home visits with a doula, in addition to support during labor and delivery, and four postpartum visits (Thomas et al., 2017). Mothers accompanied by By My Side doulas experience considerably reduced rates of preterm birth and having low birth weight infants, nearly halving the rates experienced by women in the program area (Thomas et al., 2017). These positive findings are further supported through client interviews, with one client stating that “[The doula] didn’t push anything on me. She gave me the information, and then I chose what I wanted” (Thomas et al., 2017, p. 63). These findings further underscore the importance of providing doulas to women, especially those who are at high risk of experiencing maternal morbidity or mortality. The By My Side doulas are simultaneously attempting to disrupt and dismantle a “rigid, biased, and … racist medical system,” with the ultimate goal being to provide better birth experiences for their current patients and those that come after (Fox, 2021, p. 4).
The impact of empowering mothers and providing social support during delivery extends far beyond improved psychological well-being. Doula support has real and significant impacts on many physical aspects of labor and delivery, as well. Numerous studies have highlighted the positive impacts doulas have on birth outcomes (Campbell et al., 2006; Thomas et al., 2017; Gruber et al., 2013; Kozhimannil et al., 2013). Gruber et al. (2013) stated that “Studies examining the impact of continuous doula support report significant reductions in cesarean births, instrumental vaginal births, need for oxytocin augmentation, and shortened duration of labor” (p. 50). Thomas et al. cited remarkably similar findings adding that doulas lower preterm birth rates, increase rates of initiation of breastfeeding, and increase the overall satisfaction with the birth experience (Thomas et al., 2017).
Many of the comorbidity reductions are quite significant. In a study that employed a theoretical model consisting of 1.2 million women having two births, continuous support by a layperson during the first birth resulted in fewer cesarean births, decreased costs, and increased quality-adjusted life years (QALYs) for the first and subsequent births (Greiner et al., 2019). According to Greiner et al. (2019), “Women with support from laypersons had 71,090 fewer cesarean births, 35 fewer uterine ruptures, 9 fewer hysterectomies, and 16 fewer maternal deaths, which saved $364 million with 2,673 increased quality-adjusted life years” (p. 538). These significant reductions provide better birth experiences for women overall, while also reducing riskier and more costly medical interventions.
The reduction in costly medical interventions has the potential to reverberate throughout North Carolina’s Medicaid program. Take the rate of cesarean sections in the state, for example. According to the Kaiser Family Foundation, as of 2016, 54 percent of all births in North Carolina were funded by Medicaid (Kaiser Family Foundation, 2019). Of all births in the state, nearly one third were conducted via cesarean section at an average cost of $16,224 per procedure in 2016 (Johnson et al., 2020). That same year, the average cost of a vaginal birth in North Carolina was $11,197 (Johnson et al., 2020). If doula services reduce the rate of cesarean sections by an estimated 28 to 56 percent for full term births, this would create of significant savings for the Medicaid program in North Carolina (Muza, 2017). Chen (2018) highlighted in her literature review estimates of potential savings for states, stating that “state Medicaid savings from avoiding cesarean deliveries could exceed $2 million in most states” (p. 1). Medicaid reimbursable doula services make sense from a health care perspective, providing better birth outcomes to women, and from a financial perspective – potentially passing on thousands of dollars of savings per mother. Further, introducing doula coverage in North Carolina’s Medicaid program will likely have additional benefits down the line, as improved maternal and infant health may reduce future state-funded health interventions.
North Carolina has recognized the importance of integrating doula services into pregnancy care teams in the past. The North Carolina Institute of Medicine’s (NCIOM) Task Force partnered with the NCDHHS in 2019 to provide a series of recommendations to improve maternal health outcomes in the state, one of which centers on expanding coverage for certified doula care, following the Center for Disease Control and Prevention’s (CDC) recommendation to do so in 2013 (North Carolina Institute of Medicine, 2020). Birth Partners, a hospital-based, volunteer doula program in North Carolina provides access to compassionate doula support, free of charge, to anyone delivering at the University of North Carolina Medical Center (Lanning and Klaman, 2019). Based on patient feedback, collected through surveys following delivery from mothers who received doula care through Birth Partners, 96.34% were satisfied with doula care and 100% of the labor and delivery nurses who responded agreed or strongly agreed that doulas served as critical members of the maternity care team (Lanning and Klaman, 2019). Surveys of doulas serving in the operating room through the same program reflected similar results and levels of satisfaction for mothers with scheduled cesarean births (Lanning et al., 2018).
House Bill 488 provides the perfect opportunity for the North Carolina legislature to follow through on the recommendations made by the NCIOM’s Task Force and the NCDHHS. The bill seeks to provide doula services to Medicaid-eligible women, thus ensuring increased access to those who may not be able to afford doula services otherwise (H.B. 488, 2021). Outlined within the bill are steps that need to be taken to meet general Medicaid requirements. Medicaid, according to Platt and Kaye, must cover a standard set of services but can also offer optional services as long as federal guidelines are met (Platt and Kaye, 2020). One of the required guidelines is that services must be provided or recommended by a licensed practitioner (Chen, 2018). North Carolina has every intention of following this requirement – as the bill states that the NCDHHS will “partner with doula training programs and childbirth education organizations … to help set standards for the attestation, training, and certification of doulas in North Carolina” (H.B. 488, 2021). The bill also outlines plans to develop reimbursement strategies and the creation of a bill of standards for doulas with these organizations (H.B. 488, 2021). It is these frameworks in which North Carolina must exercise caution and learn from intervention implementation challenges in Oregon and Minnesota.
Each state took a different approach in complying with Medicaid guidelines on licensure and reimbursement practices for doulas. Minnesota mandates that doulas work under the supervision of a physician or another Medicaid qualified health professional to receive reimbursements (Chen, 2018). Oregon allows doulas a more independent track, requiring that they register for their own National Provider Identifier Number and enroll as an Oregon Medicaid Provider (Chen, 2018). As a positive, in both scenarios’ doulas are able to be reimbursed through the Medicaid program. However, a significant downside in both states is the cost required to follow through with the mandates. As of 2018, in Minnesota, registration fees were $200 and mandated training costs, required for certification, were up to an additional $800 (Chen, 2018). In Oregon, the Oregon Health Authority approved training program for 2018 cost $800 (Chen, 2018). These required costs to be a Medicaid reimbursable provider create a barrier further inhibiting low-income doulas from entering the field and practicing. Further, the costs are simply too high if the ultimate goal is to provide women with doulas who come from similar backgrounds and communities. According to Chen (2018), “For doulas to be effective in providing culturally appropriate and patient-centered care for Medicaid enrollees, they must be recruited and trained in greater numbers from the same communities in which their services are most urgently needed” (p. 8). North Carolina, when creating guidance for doulas to become Medicaid reimbursable providers, must ensure that low-income doulas are not excluded from practice are a result of certification and licensure costs.
Additionally, a lack of funding for the programs in each state impacted the uptake of the intervention, as both states provided too little funding for too few visits to be truly impactful. Minnesota reimbursed $411 for seven visits with a doula, including one for labor and delivery (Mehra et al., 2019). Oregon’s intervention also had this shortcoming, providing $350 for four “maternity support visits” and an additional visit for labor and delivery (Mehra et al., 2019, p. 217). North Carolina is already addressing one of the identified issues, planning to provide four antenatal visits, a visit for labor and delivery, and an additional seven visits during the postpartum period (H.B. 488, 2021). Mehra et al. (2019) underscore that “Black and publicly insured women are almost twice as likely as White and privately insured women, respectively, to report desiring but not having access to doula support” due to high cost (p. 217). Even when access is provided through Medicaid, as seen in Oregon and Minnesota, “uptake has been minimal because reimbursement rates are below the cost for doulas to provide services” (Mehra et al., 2019, p. 217). Communities that would see the most significant benefits of providing a Medicaid reimbursable doula program are therefore left out, as this reintroduces a cost barrier. Therefore, the success and failure of this intervention for North Carolina truly does hinge on guaranteeing that House Bill 488 is effectively financed and properly pays doulas for their services.