The discussion around offering state-funded doulas to low-income pregnant people might be headed back to the Georgia legislature, advocates and lawmakers say.
Supportive legislators are planning to introduce a bill that would allow the state’s Medicaid dollars to fund doula services in an effort to reduce maternal deaths in Georgia. The state has among the worst maternal death rates in the nation, and the majority of pregnancy-related illnesses between 2018 and 2020 occurred in Medicaid patients.
Doulas aren’t medical professionals, but they provide information and emotional support for pregnant people, aiding their medical decisions and experience during pregnancy, birth, and postpartum. Skeptics say they worry that doulas could interfere with a safe birthing process, and they want to ensure doulas are properly trained.
But those in favor of Medicaid reimbursement are concerned that, if skeptics get their way, doulas would face unnecessary red tape through stringent credentials put in place by the state.
Democratic state Rep. Park Cannon of Atlanta, who has supported past efforts to get Medicaid-funded doulas passed by the legislature, says she plans to introduce legislation in the upcoming session. She said skeptics’ fears about the birthworkers are unwarranted.
“Whether a doula is credentialed or not, a doula is an emotional and physical support person who does not cross the medical line,” she said.
A maternal mortality report released earlier this year by the state Health Department shows that Black women are twice as likely to die from childbirth, with most of the deaths having to do with cardiovascular complications like embolisms and cardiomyopathy. But race wasn’t the only factor that significantly affected a woman’s likelihood of pregnancy-related death. Among those whose insurance status was known, 60% of women who died were Medicaid payers.
Securing a doula can be cost prohibitive. Some charge thousands of dollars for postpartum and prenatal services. But one study published in the American Journal of Public Health showed that doula care could decrease Medicaid birthing costs, since doula-supported births were less likely to result in costly cesarean deliveries.
A number of states have implemented Medicaid coverage for doula care. In Georgia, a pilot program for Medicaid-funded doulas ended this year. Sponsored by Healthy Mothers Healthy Babies, a coalition that advocates for birthing rights, the program called for two prenatal support visits, labor and delivery support, and two postpartum visits for pregnant participants. The majority of participants were Black and living in urban areas.
Most patients said they felt their doulas respected their cultural needs, encouraged decision-making, and respected their ideas and choices. The insurers who participated in the pilot, which ended in March and included Amerigroup, CareSource, and UnitedHealthcare, said doula services were valuable for their clients and lowered the risk of maternal and infant mortality.
Cannon works as a doula herself and says the support she provides for her patients is invaluable. But when it comes to introducing doulas into the space of policy to solve maternal mortality, things get tricky, advocates say.
“Some clinicians started to look at doulas as if we were attorneys who were there to nitpick their clinical decision-making, when, in fact, we are the opposite,” Cannon said.
Doula certification processes can be time-consuming and costly. Take the certification process at DONA International, for example, which is the largest community of credentialed doulas in the nation. Aspiring doulas have to complete DONA-certified training, which can be hundreds of dollars. You also have to purchase study materials and attend at least three births, which has been difficult during the COVID-19 pandemic because of hospital restrictions.
Cannon believes for pregnant patients without income, a doula can look different.
“If you are a low-income, pregnant, young person in Georgia, your version of a doula might be a doula-in-training, might be your cousin who works at a clinic,” Cannon said. “And so the hypervigilance around credentialing is going to be a barrier as we move doulas to be covered by Medicaid.”
For Republican state Rep. Darlene Taylor of Thomasville, who serves on the House’s Public Health Committee, certifications are necessary for anyone who is going to have a hand in ensuring a baby is delivered safely.
“We have to be responsible and make sure that you’re getting somebody that is certified, that’s been trained, that knows what they’re doing,” said Taylor. “I’m all for whatever’s going to help … but we’re gonna have to look at who they are and who’s providing the service.”
A stringent emphasis on the education requirements for practicing doulas concerns former Democratic Rep. Renitta Shannon. Her overall worry is a general approach to doula care that may not allow for Black doulas to bring their own cultural expertise to the practice.
“If you go and regulate them, the struggle around that has been, how are you going to do that?” Shannon said. “Are you going to set up hurdles that are so high that it makes it nearly impossible for Black people to become doulas at the rate that white people can?”
Part of the challenge in adopting Medicaid-funded doula services is convincing lawmakers who represent rural communities of the benefits, advocates said. Rural Georgia is an area where Black people experience some of the worst outcomes of maternal care, but the practice of hiring a doula is more common in the metro-Atlanta area than in the state’s rural counties. In fact, only 7% of participants in the Medicaid doula pilot program were from rural areas.
“There are 79 counties in Georgia that don’t even have an OB unit,” said Madison Scott, director of policy and research at Healthy Mothers Healthy Babies. “We find that there’s a lot of confusion about what [a doula is] … and what are the benefits that they bring.”
Taylor said she believes certification should be part of any doula-related legislation, but she isn’t too concerned with where doulas get their certifications from.
Naima Bond, a doula who participated in the HMHB Medicaid pilot, said there were pros and cons to the process, but her only worry about certification is if the state legislature prevents certification from various organizations.
“The only way I see it putting up red tape is … if they are requiring you to only certify with four or five specific doula organizations,” which would be limiting, Bond said. Still, if the state funds doulas for Medicaid recipients, she believes there needs to be baseline requirements for training, because “everybody practices differently.”
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