Executive Summary: State of Maternal Health
As maternal mortality in the United States continues to climb, Medicaid coverage of doula services has emerged as a promising policy solution. Doulas provide emotional and informational support to expecting moms which helps to reduce birth complications. They also help to address the racial disparities observed in maternal health outcomes. For these reasons, there has been a national push to include doula services in maternal health services. Because Medicaid covers approximately 42 percent of births, advocates nationwide are calling for Medicaid programs to reimburse doula services to help ensure that beneficiaries have access to quality, equitable pregnancy and delivery care and address our country’s maternal health crisis. Medicaid reimbursement of doula services would be particularly impactful in Tennessee where 44 percent of births are covered by Tennessee’s Medicaid program, TennCare.
Scope of the Problem: Racial Disparities in Maternal Health Care
Black and Native women feel this crisis more acutely, as they are three times more likely to die during childbirth than white women. In 2023, the U.S. Department of Health and Human Services launched a civil rights investigation into Cedars-Sinai Medical Center after Kira Johnson died in 2016, hours after giving birth to her second child. Following her C-section, Kira’s husband Charles Johnson noticed blood in her catheter. Charles pled with medical staff for hours to attend to his wife but to no avail. Doctors finally took Kira into surgery ten hours later, but by that point, Kira had hemorrhaged three liters of blood into her abdomen and died. Kira’s story is just one example of the discriminatory treatment of Black women by some providers.
Multiple federal agencies have identified areas where implicit bias impacts the quality of care that patients receive. The National Institute of Health found that providers were less likely to identify expressions of pain or discomfort in Black faces, making them less likely to believe that their Black patients were in pain. This is consistent with many Black mothers’ reports that providers devalued or ignored them during their delivery. In 2022, the Tennessee Department of Health reported that discrimination contributed to 1 in 3 pregnancy-related deaths. Community-based doulas can mitigate these effects because they reflect the patients they serve, allowing them to both connect with moms and advocate for their needs.
Policy Recommendation: Medicaid Coverage of Doula Services
While there are many necessary economic and social interventions to address the maternal health crisis, there is considerable evidence that expanding access to doula care is a promising strategy. In 2022, the White House called for expanded access to doula care, proposing state Medicaid agencies include doula care as a covered service. Currently, 21 states are actively reimbursing for doula services or undergoing implementation, and an additional 20 states have taken adjacent actions. In Tennessee, the legislature has taken steps towards this policy change, but more support is needed to move forward.
Policy History in Tennessee
In 2022, Senator London Lamar (D-Memphis) introduced SB 2150 which, as introduced, would have implemented TennCare coverage of doula services. However, she and proponents of the bill had to settle for a less impactful compromise due to political pushback. The bill was amended to merely study the benefits of doulas even though the benefits are already thoroughly documented in research and the several Medicaid-doula reimbursement pilot programs across the country. In 2023, Senator Lamar tried again to pass TennCare coverage of doula service, but her colleagues chose to instead pass adjacent legislation which created a “Doula Advisory Committee.” In 2024, Senator Lamar is again sponsoring a bill (SB 1739) to allow TennCare coverage of doula services. The bill is currently being reviewed by the Senate Health and Welfare Committee, though it is not expected to pass as introduced. It is imperative that legislators enact TennCare coverage of doula services because interim measures only delay women from receiving the quality of care they so desperately need.
Fiscal Incentives
Some lawmakers have expressed concern about the costs of implementing this policy, but investing in doula care upfront will reduce healthcare spending down the line. Research supports that doula care is a cost-saving measure in maternity care. Doula care lessens healthcare spending by reducing the rates of C-sections, preterm births, epidurals, and associated medical complications and chronic conditions. They also increase the rates of breastfeeding and spontaneous vaginal births which similarly reduce spending.
Incorporating doula care into maternity practices could reduce the prevalence of C-sections by 40 percent. In Tennessee, this could mean more than $17.8 million in annual TennCare savings. Similarly, NHeLP found that 25 percent of preterm births could be prevented under the care of a doula. Preterm birth is defined as a birth prior to 37 weeks of gestation. On average, preterm births cost 3.7 times more than full-term births. Research strongly supports that the reduction of C-sections and preterm births alone make Medicaid coverage of doula services a cost-effective policy, and emerging research continues to point to other opportunities for savings.
Policy Challenges
A persistent challenge to Medicaid reimbursement of doula care is adequate reimbursement rates. Historically, states that have enacted Medicaid reimbursement of doula services have adopted a reimbursement schedule for doulas that is similar to the one for doctors and midwives, but this is a flawed approach. Doulas spend significantly more time with their clients than clinicians, as they are frequently on call 24/7 for months before and after a mother’s delivery, and they also provide emotional and informational support to clients outside of scheduled appointments. As a result, doulas can often only serve one to three clients per month. This is drastically different from clinicians who often care for dozens of patients at a time. An equitable reimbursement rate must consider the differences in the care that doulas and clinicians provide.
A low reimbursement rate can stifle legislative progress, as doulas may elect to not serve Medicaid recipients. For example, while Oregon was one of the first states to adopt Medicaid coverage of doula services in 2014, its initial reimbursement rate of $75 resulted in less than 2 percent of births being supported by doula care. The Tennessee Doula Advisory Committee is tasked with setting an appropriate reimbursement rate and is expected to give its recommendation in 2025.
It is important to recognize that doulas are not the ultimate solution to our nation’s maternal health crisis. They represent just one piece of what must be a coordination of economic and social supports for expecting parents. In addition to covering doula services, Tennessee should pursue paid family leave and Medicaid expansion. Still, TennCare reimbursement of doula services promises a better and healthier future for moms and babies.