Studies show moms with doulas have far better health outcomes than those without doulas—but only three states allow Medicaid (which pays for nearly half of all U.S. births) to cover doula care: Minnesota, Oregon and New Jersey.
Illinois just missed its chance to become the fourth.
A maternal health care bill that would have allowed Medicaid to cover doula services and mental health screenings for new moms, which was proposed by Sen. Cristina Castro and passed the Senate with bipartisan support, stalled in the House as the state legislative session closed last week.
However, Castro said that a provision that extends Medicaid coverage of existing postpartum health services from 60 days to 12 months did make it into the Illinois budget, which was signed by Gov. J.B. Pritzker and goes into effect July 1.
That's especially significant since Medicaid covers exactly 50 percent of births in Illinois. Still, maternal health experts say that doula care is an essential part of pre- and post-birth health care.
"For me this is an issue of justice," said Qiddist Ashe, a Chicago-based doula who received her doula training and certification in Oregon, where doula care is covered by Medicaid, "by making sure that Black birthers in particular, regardless of income or access, can have support in this way."
Every year around 700 U.S. moms die from pregnancy-related complications, and Black women are much more likely to die from pregnancy-related complications compared to white women. Nationwide, the ratio is almost three to one. In Illinois, it's six to one. Even worse, though racial disparities often shrink as people of color gain more income, that's not the case for maternal health. Regardless of class or education level, Black women are equally as likely to die from pregnancy-related complications as lower-class white women.
"The Illinois Department of Public Health revealed last year that there are significant differences in pregnancy mortality rates for women based on their race, ethnicity, age, location of residence, insurance type, et cetera," said Castro in a phone interview. "We do a great job with the baby, but we do a terrible job in taking care of the mother."
Castro's bill, known as the Improving Healthcare for Pregnant and Postpartum Individuals Act, addressed several recommendations from the Illinois Maternal Morbidity and Mortality report in late 2018, including covering depression screenings before and after birth and creating or expanding doula programs. The greatest challenge, according to Castro, was persuading her colleagues that the provisions were worth the cost in a cash-strapped state. She expects to propose a similar version of the bill again next year.
"We're all concerned about costs on the front end, [but] think about the long run," said Castro. "You can't put a price on a life. We could save so much if we could just be more proactive in care versus reactive."
The cost for a doula in Illinois can be upwards of $1,000 (with rates around $30 an hour), based on listings found on doula listing website Doula Match in April and May 2019. But births with severe complications on average cost about four times as much as those without complications—$73,000 compared to $18,000, according to the state's maternal health report. From 2016 to 2017, hospital charges related to severe maternal morbidity totaled $107.5 million in the state.
Despite outpacing all other countries on health care spending per person, the U.S. maternal mortality rate is the worst among developed nations—and it's rising as other developed nations' rates decline. Meanwhile, doula care is gaining more attention nationwide. Since 2009, 12 state bills relating to doula care have been signed into law, while eight have been proposed and haven't been signed into law, according to the National Health Law Program. (The New Jersey bill was just signed last month.) Six Congressional bills, including the MOMMIES Act by Sen. Cory Booker and the Maternal CARE Act by Sen. Kamala Harris, were proposed in the last session and didn't pass. Variations of both have been reintroduced in Congress this session.
Doulas are birth coaches who advocate for pregnant women. They work with moms to create a birth plan that details who moms want in the room during labor, what medicine the mom prefers, how the mom prefers to birth her child and more. Though doulas are not medical professionals, the work they do is essential, as it can be difficult for moms to advocate for themselves while experiencing pain during birth.
National Institutes of Health studies show doula-assisted moms are two times less likely to experience birth complications involving themselves or their baby, are more likely to breastfeed and four times less likely to have low-birth-weight babies. The studies also show these women can forgo epidurals and avoid cesarean sections, which carry higher risk of complications. In addition to medical benefits, moms with doula support feel less stressed and have increased confidence in navigating their pregnancies.
Marillac St. Vincent is a family services organization with centers on the North and West Sides of Chicago, which has offered doula services since 1995. Today, the organization offers doula care at no cost to moms ages 12 to 25 in their pregnant and parenting teens program called Project Hope on the West Side.
"[It's] good to have the doula there as an extra layer of support with the knowledge the doulas have and the emotional support they're able to provide, not just to the participant but the family members also; it's appreciated," said Laronda Castine, Project Hope program manager.
In Project Hope, moms receive doula care until six to eight weeks after birth. According to its website, all moms in the program created birth plans with doulas and 90 percent of expecting moms had doula-assisted births. The doula care is funded through a public-private partnership organization, Ounce of Prevention.
Ashe, the Chicago-based doula, completed her training in Oregon, which along with Minnesota and New Jersey is one of three states where doula services are covered under Medicaid. (New York state is running a pilot program and Indiana had passed a bill this year, but funding was stripped in the final days of the legislative session.)
While not all doulas necessarily welcome government intervention into their work, Ashe said she experienced firsthand how including doulas in the state's medical system improved access for low-income women.
"A lot of how it works is that nurses, social workers, doctors [in Oregon] will now refer their clients to doula groups and I think that is the really beautiful thing," she said. "Going to births in Portland, there's a great sense of collaboration and between physicians, midwives, other care providers and birthworkers like doulas… It also allows birthworkers to be able expand their care to people who need it, while still being able to sustain themselves."
In Minnesota, a study published in 2016 showed Medicaid beneficiaries with doula support had lower rates of preterm births; cesarean section rates for full-term births were 56 percent lower in the state compared to Medicaid recipients in other states without doula care. In Oregon, Medicaid recipients with doula care have similarly positive birth outcomes, though each state is still adjusting its doula coverage process to better reimburse doulas.
Considering racial health disparities, making doula care accessible to women of color is especially important to Ashe, a Black woman. "A big piece of what I wanted to do in my birthwork and in my practice [is] include education, ritual, healing tools, especially from across the African diaspora so that the people I'm working with are also able to reclaim some of that as their own," she said, "to change the culture that doulas are not just for rich white women. This knowledge came from us. We have ownership over it, too."
Doula care and Medicaid coverage are just one piece of the puzzle when it comes to lowering maternal mortality rates. So far this year, state lawmakers have introduced more than 80 bills to address the issue. Proposed changes include everything from creating maternal mortality review committees to uniformly collect maternal death data to establishing state-covered maternal peer support programs.
"We always talk about [how] we need to reduce cost, but sometimes in health care we also need to have preventative care and be proactive versus reactive," said Castro, who proposed the Illinois bill. "In the end we want to do what's right for the moms and make sure the mom is happy and healthy to raise her child."
This story was produced by City Bureau, a civic journalism lab based in Woodlawn. Learn more and get involved at www.citybureau.org.
Read all stories in our special Maternal Health Issue here.
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