Access to Doula Support Is a Key Piece of Maternal Health Equity
Providing doula coverage under Medicaid could increase access to this birthing support resource and help bridge inequities in maternal outcomes.
black woman pregnant doula in hospital
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A young pregnant person, who will go by the name Diana, struggled with alcohol use and mental health issues, including depression. She was challenged by her lack of resources and lived with her mother. But Diana told her prenatal care provider that she was determined to be more present for her child. Her provider helped her match with a woman companion through the Birth Sisters Program, a doula program at Boston Medical Center (BMC). That Birth Sister recognized that Diana needed a safe, healthy place to stay during her pregnancy and postpartum period, and so she helped her navigate and find resources that were available to her. Ultimately, Diana was joined by her doula during her labor and had a vaginal birth and delivered a healthy baby. But the doula's role wasn't done. She helped Diana breastfeed after Diana communicated her hope to do, despite the many challenges in her daily life.

Julie Mottl-Santiago, DrPH, CNM, told Diana's story—which is not the patient's real name—while testifying at a hearing for the Massachusetts Joint Committee on Public Health to advocate for bills H.2372 and S.1475, an act relative to Medicaid coverage for doula services. The bill would allow patients with MassHealth coverage to access doula care, which is not currently covered.

Mottl-Santiago is a nurse midwife in the OB/GYN department at BMC, recently stepping down as the director of midwifery services to focus on research and policy around maternity care services. Without her Birth Sister, a doula, she testified that Diana risked not connecting with available resources, laboring alone, and not breastfeeding.

"Providing doula coverage for MassHealth beneficiaries will ensure more birthing people, regardless of income or race, have access to this critical resource," she said.

How doulas could close outcome gaps for birthing people of color

Doulas are nonclinical support workers who provide physical, emotional, and informational care for pregnant, birthing, and postpartum people. Those needs can take many forms, including culturally competent care support, navigation of the healthcare systems and community resources, emotional support, and health literacy, among others.

Maternal health and birth outcomes are a health equity issue. In the U.S., Black women are three to four times more likely to experience a pregnancy-related death than white women and are more likely to experience preventable maternal death. A 2018 CDC report showed major racial gaps in maternal childbirth mortality, with 37.3 deaths per 100,000 live births for non-Hispanic Black birthing persons, compared to 14.9 among non-Hispanic whites.

Moreover, hospitals that primarily serve Black patients perform worse on birth outcomes, including non-elective cesarean births. Overall, people of color report lower satisfaction about communication with their medical providers than do white people.

The Birth Sisters program specifically serves pregnant people with medical and social risk factors for poor outcomes, and 70% of its clients are Black or Hispanic. These clients are matched by language and cultural preference to a doula, or Birth Sister, for peer support. Testifying about the program, Mottl-Santiago explained how its doulas affected birth outcomes.

"Published outcomes for our programs showed reduced cesarean birth rates—one factor that contributes to severe maternal morbidity both for current and future pregnancies," she said. "The program also improves breastfeeding rates, which reduces acute and chronic disease risk for infant and mother."

Mottl-Santiago plans to publish a paper in fall 2021 about a study on the cost-effectiveness of the Birth Sisters program and found, via an economic analysis, that the program shows a positive return on investment. Mottl-Santiago and her colleagues said that community doula programs are a "high-value innovation," in advocating for Medicaid reimbursement.

Doulas are just one piece of maternal health equity advocacy

Last year, a bill passed in the Massachusetts legislature, championed by Representative Liz Miranda of Boston, to establish a special commission that will investigate and study methods to reduce racial inequities in maternal health in the commonwealth. Among other agenda items, the commission will gather data and make recommendations of accessibility and affordability of doula care and the diversity of maternal healthcare providers.

But implementing community doula programs and advocating for Medicaid coverage for those programs is just one piece of a rejuvenated focus on maternal health justice at BMC, bolstered by its Government Advocacy office—and across the state.

BMC experts join others from the commonwealth as part of the new special commission to help give a holistic look at maternal health, including Renée Boynton-Jarrett, MD, ScD, a pediatrician, social epidemiologist, and founding director of the Vital Village Community Engagement Network; Tejumola Adegoke, MD, MPH, an OBGYN and director for Equity & Inclusion at BMC; Jo-Anna Rorie, PhD, MSN, MPH, CNM, a certified nurse midwife and collaborator with Healthcare Without Walls, Inc.'s Bridges to Moms program; and Craig S. Andrade, RN, MPH, DrPH, a former critical care, public health, and ward nurse at BMC and now the associate dean of practice and director of the Activist Lab at Boston University's School of Public Health.

The first official meeting of this commission was in June 2021, and it was, in part, a listening session for Western Massachusetts. There will be a similar session for the Greater Boston area in the future.

“Even with the best institutions in the world right here in the Commonwealth, maternal mortality is still a public health crisis that impacts all women, but particularly Black women who die at twice the rate of white women in Massachusetts,” said Rep. Miranda, who hails from Roxbury and represents part of Roxbury and Dorchester, in a press release. “This legislation allows us to approach the maternal mortality crisis as both a racial justice and public health issue by seeking to understand both the socioeconomic determinants of health while also tackling the issue of racism head-on. Maternal justice is racial justice."