Starting as early as spring 2024, doulas will be available at no cost for members of MassHealth, the state’s Medicaid insurance.
“It’s a big step in that there was nothing before and now there's something,” said Lorenza Holt, who has been training doulas and working in doula services for 30 years. “It’s a good first step. But the work is just beginning.”
Now that the framework is in place, the next steps are getting doulas enrolled in MassHealth and informing members about their services.
Doulas are non-medical professionals who provide emotional, physical and informational support to people giving birth. Doula services have been linked to improved health outcomes during labor and delivery, fewer preterm births and higher parental satisfaction with births.
But they’ve often been treated as a luxury, with the majority of Massachusetts parents paying out of pocket for their support.
State officials hope the MassHealth doula coverage will help cut down on maternal health care disparities.
Severe complications around childbirth have nearly doubled in the last decade in Massachusetts. What was most troubling to officials at the state health department is that disparities have also gotten worse: Black people giving birth are now two-and-a-half times as likely to have complications than white people, compared to twice as likely a decade ago.
“Because the evidence on doula care is so strong and doulas make such a difference, sometimes there can be this tendency to kind of expect doulas to solve the maternal health crisis — which is, of course, unrealistic and unfair,” said Sarah Hodin Krinsky, MassHealth’s deputy director of perinatal and maternal health policy.
Other MassHealth efforts to address health outcomes include expanding midwifery services and remote blood pressure monitoring, she explained.
About 25,000 people on MassHealth give birth each year. Krinsky said she would like to see a day where there are enough doulas enrolled that any MassHealth member can use their services.
But many doulas and health advocates worry that doulas won’t sign up to be covered by MassHealth. They say the compensation rate of up to $1,700 is too low — a rate that includes birth and hours of additional visits in the months before and after delivery.
How much doulas charge for their service in private practice varies widely, but many doulas in Massachusetts have reported struggling to make a living wage.
“Everybody wants to see improved outcomes, but nobody really wants to pay for what this is doing,” Holt said. “It’s not enough compensation, it’s not enough hours, it’s not enough.”
Krinsky pointed out that the $1,700 rate is “one of the highest in the country among states that cover doula services through Medicaid” and that MassHealth increased the pay after receiving feedback on prior drafts of the regulations.
Many doulas and health advocates hope the Massachusetts Legislature will take another step forward to expand and support the doula workforce. A bill before the House and Senate would create a workforce development fund, as well as an advisory committee that would work with MassHealth to continually give feedback on the program. The concern is not only having enough doulas but having doulas who live across the state and share diverse backgrounds with MassHealth’s members.
Amy Chen, who leads the Doula Medicaid Project at the California-based National Health Law Program, was thrilled to see that MassHealth patients who want a doula won’t need to get a referral from their doctor to qualify for coverage — one of only three states to do so, according to Chen.
“It might not sound like that big of a deal, but in the big scheme of things, it’s yet one more hoop that Medicaid enrollees would have to jump over in order to get these services,” she said. “All pregnant people should have this if they want it,” she added.