This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Research has shown that birthing people who use a birth doula are less likely to need drugs used to augment labor contractions, request pain medication, or have a cesarean birth — and more likely to consider childbirth a positive experience.

"We ... know that having a doula improves the birth experience," says Jennifer Torres, manager of the Michigan Public Health Institute Office of Women's Health and Birth Equity. "Doulas are a really important support for birthing people in navigating the medical maternity system."
Jennifer Torres.
Doula support has been shown to improve outcomes around vaginal birth, duration of labor, infection rates, use of analgesics, and Apgar scores, which score how well babies are doing at one and five minutes after birth. With positive outcomes like these, the Michigan Department of Health and Human Services (MDHHS) has been bolstering support for Michigan doulas through its Doula Initiative. The initiative's first step was to expand Michigan’s Medicaid program to cover doula services for pregnant people starting in January 2023.

"The coverage is still somewhat limited, but at least it makes doulas a lot more accessible to more people who need that support," Torres says. "I think this is a really important change and I'm really happy to see it happening in our state."

The Doula Initiative also is launching an online doula registry, where pregnant folks can find a doula in their area who accepts Medicaid clients. Its Doula Advisory Council promotes equitable access to doula services across the state and works to expand the doula workforce. And MDHHS is also encouraging more Michiganders to become certified doulas through approved programs listed on its website and by offering resources to existing doulas, including continuing education opportunities.

What do doulas do?

Shonte' Terhune-Smith is a doula health educator, lactation consultant, and birth doula practicing in Genesee County through her own small business, You Overcoming Lactation Obstacles (YOLO). She believes that Medicaid coverage of doula services will open doors for people who previously found doulas financially out of reach.  

"I feel like it will definitely impact those birth outcomes for families of color, especially if they are able to get the support that they need," Terhune-Smith says. "With a doula, women are more empowered during their birthing process. They're more informed about the choices that are available to them. There's someone there that's outside of the health system that can support them in their decision making."

While the doula’s role doubles down during labor, most doulas establish a relationship with the families they serve during the pregnancy. They get to know the family, establish what the family expects from the birth experience, and lay a foundation of support that carries through the birthing process. When the birthing parent goes into labor, the doula stays by their side, suggests positions to labor more effectively in, makes the parent physically comfortable, and offers vital emotional support.

"Doulas make sure that the laboring person is heard, remind the laboring person of what her plans or hopes are, and provide advocacy for those preferences and how to best support them," says Joanne Bailey, director of Nurse Midwifery Service at Michigan Medicine. "Doulas definitely do not have a medical role. And that's wonderful. There are midwives, doctors, and nurses who are assessing and managing labor. The doula’s role is support for the laboring person and their family or support people."

Doulas help decrease disparities

Making doulas available to more Black and Indigenous families can help reduce racial disparities in pregnancy and birth outcomes, which continue to be glaring. The March of Dimes' most recently compiled data relates that Michigan’s Black babies were nearly three times as likely to die during their first year of life than white babies. In addition, three times as many Black mothers in Michigan died from pregnancy-related causes than white mothers.

For birthing parents classified as socially disadvantaged and at higher risk for poor birth outcomes, those who had doulas throughout their pregnancies were four times less likely to have a low-birth-weight baby, two times less likely to experience a birth complication, and much more likely to initiate breastfeeding. Having a doula during pregnancy and labor even provides benefits after the birth, as birthing parents with doulas are less likely to experience postpartum depression and anxiety.

"Having Medicaid reimburse doulas is essential to reducing some of our disparities," Bailey says. "The way that hospitals are set up, it's very hard for pregnant families to develop a relationship with the people that will be caring for them during labor and birth. If the doula is there, that is a familiar person who knows them, at least a little, and can help them navigate through the medical system."

Low reimbursement rates may create barriers

While Michigan doulas are thrilled that more pregnant people will have access to doulas thanks to the state's expansion of Medicaid coverage, they have also taken issue with the low reimbursement rates that Medicaid currently offers. These low rates are discouraging many doulas from accepting Medicaid clients and prompting others to limit the number of Medicaid clients they take on, as the reimbursements do not cover their costs of doing business.  

"The feedback from the doula community is that the reimbursement rates are low," Torres says. "They’re not really high enough for it to be a sustainable source of income for doulas. When reimbursement rates are low, it limits the impact because it limits the number of people who will register as providers."

Terhune-Smith has received grant funding in the past that allowed her to accept clients who could not afford a doula. To date, she has not signed up to accept Medicaid clients.

"You have to think about all of the other things a doula has to cover, like being able to pay your backup doula. I do more than just two prenatal check-ups and I'm more than available after a birth, as well," she says. "Are people really getting paid for what they offer? Well, I think that's something that has to be looked into."   

Terhune-Smith also worries that heavier client loads may cause doula burnout.

"There will probably be an increased number of families that sign up for doula services," she says. "As much as families have to be selective about who they pick to be their doula, I believe doulas also have to be equally selective about how much they take on."

She also has concerns about hospital systems offering doulas to patients with Medicaid. Traditionally, doulas’ effectiveness has come about because they work for and advocate for the birthing family, not for the health system.

"As community doulas, we need to think about where this is going to take us," Terhune-Smith says. "I believe families need to be able to trust that the doulas in their communities are doing what's best for them as the family. Even though this is a great opportunity for our families, I still feel like doulas need to come from within the community."

Torres hopes that as more Medicaid parents choose to enlist a doula, the data will not only reveal better health outcomes for parents and babies but also show cost savings for hospital systems. C-sections cost approximately $3,000 to $4,000 more than vaginal births. Costs of caring for a low-birth-weight baby in the NICU can be several thousand dollars a day.

"One of the potential benefits is that as we get more of the data about outcomes for people who use a doula through the Medicaid program, then that will show that not only does this have improved outcomes, but it also has cost savings," Torres says. "Then we might get more of the private payers on board. That would be great."

At any rate, Medicaid coverage for doula services is a giant step forward in providing little Michiganders a better start at a healthier, happier, and more equitable life.

"When I come on duty and hear that people have their doulas with them, I know they're getting all the support that they need," Bailey says. "I know I have a great partner and that we're working towards helping the family have the absolute best experience possible — for mom and baby to be healthy, but also for it to be a really positive experience."

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Photos courtesy of the subjects.