This year, through MassHealth, more than 700 moms had doulas by their side through labor thanks to a new benefit.
Having a doula had one very practical impact for Cecilia Milligan: she could understand her medical care better. She’s Deaf, and in the chaos of the delivery unit, sometimes couldn’t understand what the doctors and nurses wanted her to do. The hospital provided a virtual ASL interpreter on an iPad, but medical staff would sometimes stand in front of the screen.
“They were in the way, not paying attention,” she told GBH News, thinking back seven months to when she gave birth to her son. “It was really frustrating, because I’m having to deal with the contraption while I’m trying to figure out which way they want me to move.”
She was glad to have a doula in her corner. The doula helped her through labor, reminding her of breathing techniques. And, in their visits before Milligan went to the hospital, the doula took time to explain what the experience would be like and use her beginner American Sign Language to sometimes fingerspell.
Milligan’s case is an example of how broader access to doulas can help meet parents’ cultural and language needs. Hospitals have long been required to provide interpreters, but officials hope pairing patients with doulas who come from a similar background and speak the same language will give them an effective advocate. The ultimate goal is to cut down on maternal health care disparities, since people of color and with some disabilities have more complications during labor.
Though officials and longtime doulas recognized the potential benefits of covering doula services for people on MassHealth, the state’s Medicaid insurance, they were worried about building up the workforce. Since the program’s launch last December, about 150 doulas have enrolled — three times what MassHealth officials were hoping for by this summer.
Deu Almeida, the first doula who enrolled, saw the coverage as a “huge opportunity” to expand doula services and launched her company Doulas of the Diaspora in January. So far, she’s trained 50 new doulas of color.
“A lot of people want a doula who looks like them — who understands their culture, or who shares a racial or ethnic identity. So that’s really important,” Almeida said. “And I felt like in order for us to serve the population who needs it most ... it was really important for me to address this issue.”
Improving health outcomes
Doulas are non-clinical professionals who provide emotional, informational, physical and advocacy support for pregnant moms. They meet with parents multiple times before the birth to make a plan and talk through what could happen, offer support through the childbirth itself, and then have more visits after to provide help with things like breastfeeding.
Pregnant people who have doulas are less likely to have C-sections or preterm births, and report higher rates of breastfeeding and better experiences during labor.
Milligan believes having a doula should be available to everyone, no matter what their insurance is. Public insurance plans in 18 states and Washington, D.C., cover doula services, according to the National Health Law Program. A smaller but growing number of states require that private insurance companies cover doula services, too. She believes it’s especially important for single moms, as well as Deaf and disabled moms.
“Especially in the Deaf community, those who are single moms — or that have challenges with communication” struggle to learn about resources, she explained. With the doula, “I started to get more access to information she would share with me. ... From there, just having her to provide that comfort and support, I was able to, like, ‘OK.’ Do my own research, or ask the right questions to the doctors about my health. I started to feel a little better from there.”
Parents with some disabilities are more likely to have severe complications during childbirth in Massachusetts, a state report out last year shows. Health outcomes are the same for parents with and without hearing disabilities, but they’re worse for people with vision, mobility, and intellectual disabilities.
The racial gap is only getting worse, too: health outcomes for birthing parents worsened across the board from the early 2010s and got disproportionately worse for Black parents in Massachusetts. Black parents are now about 2.5 times more likely to have a severe complication during childbirth than white parents.
Those bad outcomes and experiences are why UMass Memorial Health’s Dr. Cherise Hamblin, an OB-GYN, is working to get more doulas in delivery rooms with Black moms. UMass Memorial Medical Center is participating in an eight-week training program for doulas this fall, and the hospital is building up a list of local doulas to recommend to their patients.
“I could do the best that I can, and it will still not be enough to move the needle or to change the experiences and the outcomes that I see patients who look like me, and have similar backgrounds to me, are facing,” said Hamblin, who serves as medical director of the hospital’s doula program. “And that is because, at the root of racial health disparities, is racism. And racism is pervasive.”
She said given the lack of diversity in medicine, cultural competency training only goes so far. But she believes doulas — specifically, Black doulas — can help.
“We have nowhere to go but up,” she added.
Training new workers and expanding support
As the workforce grows, officials are closely watching that question of cultural and linguistic compatibility.
More than 40% of the enrolled MassHealth doulas reported speaking a language other than English, as of last month, a MassHealth spokesperson said. They report speaking a dozen different languages in addition to English — mainly Spanish and Portuguese.
But, for instance, only one reported speaking Mandarin and Cantonese, even though it’s spoken in about 12% of Massachusetts’ low-income households where English isn’t primarily spoken. Just one person reports any competency in American Sign Language, too.
To Sarah Krinsky, MassHealth’s deputy director of perinatal and maternal health policy, there isn’t a magic number of trained doulas to reach.
“Ultimately, it’s about equitable access to doula care,” Krinsky said. “So that’s really where I think the kind of North Star goal is, is really about: ‘How do we make sure that our members have access to doula care that meets their needs?’ Which is something that I think goes well beyond the pure number of doulas.”
MassHealth is tracking the demographics of doulas enrolled and also checking patients’ insurance claims for any complications to make sure the program is working as they’d hoped, a spokesperson said.
The MassHealth program pays about $1,700 per client. While many doulas say the reimbursement rate should be higher, those who used to attend births for free to help low-income families are now enrolling to at least get paid for that time.
“A lot of my stuff would end up being pro bono,” Kiara Grinkley, who’s been working as a doula since 2018, told GBH News. “And MassHealth putting this program out has really opened up the doors.”
An agency called Birthing Gently has had a roster of dozens of doulas who volunteered their time at local hospitals for the last decade, pairing with the most vulnerable clients to give them extra support. But, by mid-November, the agency will only have doulas certified under MassHealth, founder Tara Campbell said.
She’s glad to see doulas moving up in Massachusetts.
“It’s becoming more professionalized and respected by providers,” she said.
One of the challenges is that there’s no specific certification process for doulas. But a growing number of programs, including UMass Memorial Health, are training doulas now.
As the workforce grows, doulas are keeping an eye toward longevity, too. That’s why Almeida formed a collective where doulas share their experiences and, crucially, act as backups for each other in case they can’t get to a client’s birth.
“So that they don’t just come into the field, take a couple of births and then leave,” she said. “We want doulas to be doulas forever. We want them to be able to be in practice, but we need to be able to offer the support — both financially, administratively and socially — for them to be able to do this work.”
