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While several states are in the process of implementing Medicaid coverage for doula services, only a handful of states are actively providing that coverage. In this episode, host Deitre Epps, founder and CEO of Race for Equity, is joined by Averjill Rookwood, founder of The Corporate Doula, and Amy Chen, senior attorney at the National Health Law Program, to discuss the importance of accessible doula coverage and the National Health Law Program’s Doula Medicaid Project.
We are the Maternal Health Learning and Innovation Center, a network of maternal health equity experts and organizations working to make real change for women and birthing people in the U.S.
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Deitre: Welcome to the Maternal Health Innovation Podcast, season two. I'm your host Deitre Epps. I'm the founder and CEO of Race for Equity, where we advocate for equity to play a central role in the work of every organization, agency, institution and system who are all dedicated to improving the quality of life of the populations that we serve. This podcast is created by the Maternal Health Learning and Innovation Center. Episodes are released weekly, so be sure you are subscribed. In this podcast, we listen to maternal health innovators about ways we can implement change to improve maternal health in the US.
In this episode, we'll be discussing Medicaid and doula care with two passionate and influential guests in the maternal health space. First up is Averjill Rookwood, founder of the Corporate Doula, which provides doula services for modern families and their employers. Thanks for joining us Averjill.
Averjill: Thank you for having me.
Deitre: Next we have Amy Chen, senior attorney at the National Health Law Program, which fights to advance access to quality healthcare for low income and underserved populations. Welcome Amy.
Amy: Thank you.
Deitre: All right. Thank you both for being here today. I'm really excited about this conversation we're going to engage in, and I think we'll start with Averjill. Averjill, can you provide some context of what you're doing at the Corporate Doula? We'd love to learn more.
Averjill: Absolutely. I've spent 20 and more years, in human resources, running benefits departments for Fortune 100 companies, and it got to the point where I was always having employees come into my office and tell them, to tell me about all the hoops that they were having to jump through to be a parent in the workforce.
And regardless of your socioeconomic status, most parents are working. So I kind of combine my two loves with my doula education, which then moved to my doula work, along with my corporate benefits, knowledge and experience. And yes, I serve individual, parents who are having a child, but another kind of arm to the corporate doula business is consulting with employers, hospitals, systems that be, to kind of help cultivate, create design, family friendly or doula friendly specific benefits programs.
Deitre: Thank you for sharing and we're excited to learn more about that. Amy, can you tell us about the National Health Law Program's, doula Medicaid projects? For example, what states are currently reimbursing for doula services?
Amy: Sure. So, I'm part of the National Health Lab Programs Reproductive and Sexual Health team, and since 2018 I've been leading our work around Medicaid coverage for doula care. So a couple years prior to that, we had launched our doula Medicaid project, as you said. And as part of the project, we really are working to try to improve health outcomes for Medicaid enrollees by expanding access to full spectrum doula care for pregnant and postpartum people who are enrolled in Medicaid, who want access to a doula.
A lot of what we do is not just tracking state efforts, but also trying to work with doulas and advocates in states that are implementing or looking to implement me Medicaid coverage for doula care programs to really try and make those programs sustainable, equitable, and inclusive. I can share that, you know, we've been tracking these bills since 2019. There's def definitely been a clear increase in the number of state bills in 2020, 2021, and 2022. as of right now, and this is current as of I think this month. There are six states that are currently providing coverage in various ways.
So Florida, Maryland, Minnesota, New Jersey, Oregon, and Rhode Island. There are eight states, including eight states and Washington DC that are currently at various stages of, of implementing coverage. So many of these will are set to begin Medicaid coverage for doula care this year. Some of them, such as California where I'm based, are set to begin in early 2023.
And then there's about another half dozen states that are taking some adjacent action. So, for example, some states have legislation that's related to ultimately implementing Medicaid coverage for doula care. Some of them have, are convening doula advisory boards. Some of them have sort of legislation around stakeholder work groups.
So I think a lot of things happening all across the country. super exciting and happy to talk about, you know, any of those in more detail.
Deitre: Thank you. So when you, when you mention more detail, what stands out for you as something that's exciting about this time in Medicaid and doula coverage that brings you joy in the work to say, yes, it's going forward. What brings you some joy around this Medicaid coverage and doulas?
Amy: Yeah, so I will say that one thing that has been encouraging is that traditionally, you know, two of the states that have had Medicaid coverage for doula care for quite some time for several years, Oregon and Minnesota, originally the reimbursement rates in those states were lower. they were not, you know, not really close to market rate.
In Oregon in particular, the original reimbursement rate was only $75. It was later increased to $350 per pregnancy. And I think super exciting, just this past May, the State Medicaid agency announced that they were, after years of advocacy from doulas and other, you know, policy advocates and maternal health advocates in the state are increasing their reimbursable rate to $1,500.
And so along with Rhode Island, which also passed a bill for coverage of doula care, both in Medicaid and private insurance. For Rhode Island, their reimbursement rate is also $1,500 for Medicaid. So those two states now, Oregon and Rhode Island are at the higher end. in terms of the reimbursement.
So I would love, what I would love to see is for more states to be looking at those two states, the $1,500, and looking at that as a starting point, for reimbursement and maybe even going higher. And in particular for Oregon, I think the lesson learned there, you know, one of the big reasons why they did choose to increase the reimbursement rate is because the uptake of the benefits has been low.
And I think there's been really an acknowledgement on the part of doula's, advocates, and ultimately the state Medicaid agency of that if they want the benefit to be successful, one of the things they really need to do is increase that reimbursement, make it sustainable for the doulas, providing that care.
So I'm really hopeful that going forward with more of these states in the process of implementing coverage, that they'll kind of look to, you know, look to this sort of lessons learned in Oregon and really try to get those reimbursement rates up and have those be, you know, equitable and sustainable for the doulas.
Deitre: Yeah, that's very hopeful, to see that states can learn from one another and even learn from their own work and talking to doulas about, what reimbursement rate makes sense. Amy, can you talk a little bit more about that $1,500 reimbursement rate, just for those who are curious, like some people may or may not know about the work of a doula, how it, what, what you might need to keep in mind when, when you're reimbursing doulas.
Can you talk a little bit more about the $1,500 reimbursement rate and what states and listeners may wanna think about as they're considering reimbursement rates for doulas.
Amy: Yeah, so you know, I think one thing, you know, one piece of the sort of implementation process is that many state Medicaid agencies, you know, they don't already incorporate doula care as, you know, part of maternal healthcare. So doulas are really having to come into these states as really new Medicaid providers.
And so I think one piece that, you know, states really need to consider is kind of the whole public education, right? So in many conversations that I've had, even with stakeholders and sort of advocates in the maternal health space, that people are still get confused about a doula.
People think a doula is the same thing as a midwife. People think doulas are delivering, delivering the baby, which is not the case. And so I think there is kind of a confusion about that piece, and I think what comes in around the reimbursement rate is, I think because people don't totally understand the work that a doula does, they don't understand why, why their reimbursement rate has to be, you know, depending on some ways of looking at it, you know, relatively high as compared to say, like rate of like a doctor midwife for, for like an individual appointment or something like that.
So, you know, I will say that, I'll give a plug here for the advancing birth justice report that came out of New York. There's a really terrific portion of that report that talks that kind of breaks down why doula reimbursement rates cannot be pegged or cannot be sort of, cannot be related to, to doctor and midwifery rates. And I think it, there's a chart in that report that does a really good job of sort of breaking it down in a very common-sense way.
You know, this is the amount of time that a typical a doctor or even midwife spent with a pregnant person throughout the pregnancy and then during labor and delivery, this is the time that a typical doula. And so for me, I, I've had, I have three kids. I had doulas at all three of my births. Loved my OB. My OB was, you know, there for maybe 10, 15-minute appointments, very fast prenatal appointments.
You know, she was there again at like the very last 30 minutes. Like literally as the baby was coming out. That's when the OB came in. My doula came to my house right when I first started having contractions, stayed with me that whole time, went with me to the hospital, stayed through the labor and delivery, stayed through the postpartum period, you know, made sure that the latching and sort of breastfeeding was initiated.
It was such a longer period of time, and so if you look at this in the great section of the report is this chart that sort of breaks down how many hours, you know, the do spent with the pregnant person throughout that entire pregnancy versus how many hours the, you know, typical OB or midwife. And so I think when you look at it from the hours, then there's maybe a little bit more justification or understanding about why the reimbursement rate would be higher.
And then secondly, my OB probably had dozens of other patients at the same time that I was seeing her, right. A doula. And I think, I'm sure Averjill can talk about this some more from her own direct experience, but it's very, very difficult for a doula to take on more than two, maybe three clients a month because they're on call for those clients, you know, during the month of, you know, whenever the due date is, they're often sort of available 24/7 by text often or you know, email. And so I think just the nature of the services provided and the work that the doula does is just fundamentally different.
Deitre: It is, and it's so important for, as states are considering reimbursement rates for doulas, to keep this in mind about the, the role of the doula, the hours that a doula works over the course of a pregnancy, and then even postpartum, right? Even thinking about postpartum. Thank you, Amy, for sharing your own personal experience with doulas because it's obvious that it's not only important to you as an advocate and a policy maker, but also personally, that's an important part of the conversation.
So, is there anything else you wanna share that comes to mind for you before we move to talking to Averjill a little bit about, doulas and the role in specific.
Amy: You know, I would just say like, you know, a couple of final points that I like to share for advocates. You know, doulas in any state or even, you know, policy makers who are doing this is, you know, first, as I mentioned earlier, I really encourage states to try to get this right from the get go so they don't have to do a lot of cleanup on the back end.
In Oregon, for example, you know, even though, you know, the original kind of bill for Medicaid coverage for doula care, I think it was originally passed in like maybe 2016 or 2017, but there've been a lot of cleanup legislation that has taken place over the years to try to improve upon that benefit.
And so I think it really behooves states to try to get it right from the beginning so they don't have to subsequently do a lot of cleanup. You know, and I think also we've seen this in many states that are implementing coverage, including here in California where I am, that it's really, really critical for the state Medicaid agencies and other agencies that are implementing Medicaid coverage for doula care to really make sure that every step in the process, there are doula groups that are already serving low income and Medicaid, rollies, community based doula groups, doula groups that are led by black doulas and other doulas of color to really be front and center. Not just, sort of giving input or advice, but really in helping to craft the policy language, figuring out how it's implemented, that there'd really be a real partnership there.
And then lastly, you know, as firm as my faith is in the power of doulas to positively impact the lives of their clients, I also know that in the end, we really can't put it all on their backs. Right? So doulas can definitely help, I think, mitigate the impacts of racism on their clients of color by advocating for them in the face of individual racism, institutional racism, structural racism. But at the end of the day, that racism is still gonna be there, right? So I think, you know, all of us who are doing this work have to, I feel like, really remember this and remember it continued to do, work in other ways to try to seek out and eradicate racism in, in all of its forms.
Deitre: Thank you. So as we think about Medicaid and maternal health and doula coverage, Averjill, how do you talk to employers, for example, about providing doula care for their teams? Are there any lessons that you've learned from the corporate space that can be leveraged into the public space?
Averjill: I really kind of use it in the reverse. Because there's no company out there. If you take the many, many reports and many, many stats that companies like to collect, when you look at that, it's really a mirror of what's happening in society. So that fuels the public, public health. Type of work and consulting that I do.
And then it, you know, circles right back into making a case for the, the corporate work. These same people that are being helped in the quote unquote community are going to work every day, and this is a benefit that's being created, and I completely agree with Amy. This benefit cannot be created without doulas being front and center, because there is a real lack of understanding what doulas actually do, and how that can be woven into benefits in the public space or the private space. so it's really telling the story of, let me tell you what these numbers mean. So you, you know, you, you have what I like to call million-dollar babies every year at, employer.
Why, why did this birth cost you the company millions of dollars. And that can, that same case study can be brought to public health. Why did this baby cost taxpayers cost us in general, a million dollars? Because there were certain things that were lacking, maybe prenatally. Or some, something that was lacking in labor and delivery or something that was lacking in postpartum.
And that doula, if we're talking about doula care specifically, is kind of a gatekeeper, kind of that person to raise the flag, that guide, to help that family get where they're supposed to get to mitigate not only. You know, extra dollars being spent, but your health. We we're really the gatekeeper, for the health, safety and the lives of mothers, mothers of color specifically, and their children.
Deitre: And so as you're thinking about comparing the corporate space to the public space, and we know that women and birthing people on, who happen to be on Medicaid, the outcomes can be significantly worse for those who are Medicaid in terms of maternal health. can you speak a little bit about why would it be important for a state to consider, you know what, maybe we do need to reimburse for doulas for a cost saving measure. Can you say a little bit about that?
Averjill: first of all, let's talk about the presence of that, employee of that person in the working space. So if there are things that go wrong and there's no support, decisions have to be made to leave, right? That, that working space, that's a cost to that employer, and that's a detrimental cost although that decision had to be made for that family. They now lose that income.
Then there may be public assistance that's now needed to, to take the place of the working income that had to be left. So it's, it can be a, a vicious cycle, rather than having, you know, help come from both directions, from a public health direction and have it be further supported by the leaves of absence that are available to you at your job.
Because if you are a retail worker, if you are a. Anything from retail worker to corner office VP, you should have access. The real key is access. You asked Amy a question earlier, like what are some of the things that are exciting? Yeah, it's twofold. On the doula side, it's being able to earn an actual living and be available, because this is what you can do for on a full-time basis.
But from the client or the employer or, the Medicaid recipient point of view, It's about access. If there are more doulas that are there available to give you the care that you need, and it's a new care model, a continuous care model, this is not what Amy experienced from her OB, like this is something that is hours and hours of care, and that hours and hours of care makes a difference in the outcome.
It's been proven in peer reviewed research. Volumes and volumes of this at this point, that it makes sense and it saves money. There are soft costs and there are hard costs that are in black and white.
Deitre: So it. That you're ending on that black and white. Because what stands out for me for first and foremost is the cost of human life and the tragedy that people who are pregnant are dying either during pregnancy, during childbirth, or just after. And so let's speak a little bit about when a person is pregnant and on Medicaid and what difference that doula might make in that person's life, and that family's life who may have a family member lost through, maternal mortality.
Either one of you who would like to speak first about like what is the impact on life, and on wellbeing when we ha bring in a doula, especially for pregnant people who are on Medicaid
Amy: You know, I can speak a little bit about in, in California there have been quite a few pilot programs and many of the pilot programs have been, aimed at Medicaid rollies, and many of them have also been aimed at specifically addressing, Perinatal birth, disparities. And so, you know, even if they haven't been Medicaid focused, you know, some of them have been focused on Black, pregnant and birthing, individuals and families.
And so I will say that, you know, many of those pilot programs have had evaluations. You know, sort of interviews with the people who have participated and in some cases interviews also with family members. And I think what we've seen is, you know, for the individuals and families that were able to have the support of a doula, especially for many of them, for whom this was their first time having a doula, but this was not necessarily their first birth.
They really did share that they just had a great, they felt greater autonomy, you know, they felt a greater sense of. Greater sense of control over what was happening with them and their bodies throughout the course of the pregnancy, but then also, especially during the labor and delivery. I think in general there was a much higher levels of sort of satisfaction and happiness with their birth experience.
And you know, these are all sort of, I'm sort of talking more about like the qualitative pieces as well. And I think what was also super interesting is that I remember in some of the interviews that we did with the doula pilot programs, some of them said, you know, in some cases we did have one of the, you know, one of the, the, the, the clients who were enrolled in the doula pilot program who did end up having to have an emergency cesarean birth, which, you know, obviously not planned an emergency cesarean birth, but even in those situations, the clients said, but I felt supported by my doula, right? Like, I knew that I wasn't alone. And you know, even though this was unexpected and it's not what we had been planning for, I really felt like the support of the doula helped me get through it. And I still had a positive birth experience, even though it was this unexpected, you know, sort of unexpected outcomes.
So I think that was really powerful. You know, even in situations where, you know, things went sideways a little bit. Having the support of the doula really, I think really, really helped empower those individuals who are part of the pilot program to, to, to really feel like they, they had a better experience. And then, of course, you know, for most of the pilots, I think we don't have evaluations yet for, for all of the pilot programs, but thus far for the ones that have been able to crunch their data, there's also, you know, positive findings around lower rates of cesarean birth. You know, I think higher rates of, breastfeeding initiation and then also higher rates of, of parents coming in for the postpartum appointment.
And, you know, that, that first p you know, pediatric appointment, I think lower. Of preterm birth. So you know, all of those other kind of quantitative like data benefits that, that we also hear about for doula care.
Deitre: Averjill, yes. Can you speak a little bit to why is it important for, people who are pregnant and who are ex birthing to have a doula, especially when they're, a Medicaid, recipient?
Averjill: Well, I'll answer that question, as a doula who has Medicaid clients down here in Florida and it makes a huge difference. I think the words that come to mind is education, empowerment and advocacy. And those are things like Amy was saying, even if it's not the first child, it is a big difference, to them.
They feel educated. So things are explained to them that in that 10-minute doctor's appointment, didn't have time for, what are these baby medications? If I do have to be induced because of my hypertension, what will that induction look like? Exactly. Okay. And what are the choices I have and types of induction?
What are the questions that make sense for me to ask at that time? It's just something about knowing that there's someone there that has. Taught you or given you information that you can advocate for yourself. But in the instances where you're not ab able to advocate for yourself, now your partner and family has been educated and your doula is there for you.
These are, maybe a service that they would not be able to afford to get on their own. but they are not lacking because of the Medicaid, benefit that's available to them. It is, makes such a difference and in the postpartum, completely priceless. Labor and delivery, of course is important, but the forgotten phase is that postpartum phase.
So at three o'clock in the morning, and this is happening, and I'm a first-time mom, I've never seen this before. Oh my gosh, let me text my doula and I could readily tell them, you need to get up and go to urgent care immediately, or, Okay, that's normal. The poop is supposed to look seedy. It's nothing wrong,, you know, so it, it's having that and.
It, it's, it was surprising to me, entering the world of, of doula care, how low the statistics were for breastfeeding, initiation and sustainability, and it's because folks who are having babies now had moms that had them in the seventies and the eighties and nineties, and they were working. They didn't have time for this.
They don't have the advisement. Grandma can't tell you exactly what to do. Mom can't tell you exactly what to do because they always gave you a bottle. So here you are trying to do it. Who do you access for? Your doula is your first person to ask the question. and so we see, we definitely see differences in breastfeeding and how long, getting to their breastfeeding goals or maybe even surpassing them.
So I can just say from a doula's point of view, it makes all the difference, especially in the areas of education and their own empowerment.
Deitre: Thank you. And, and we, we know that there are challenges with clinicians, providers listening to the voice of, African American, Black, indigenous women and low and, and birthing people who are of low income particularly need that type of support that a doula can provide, where their voice is heard. And we know that it's not just women of low birthing people who are low income, because even if we think of the example of Serena Williams, who is extremely wealthy.
And who also had a case where she was not listened to as a, who identifies as a Black woman, and was not listened to, in her, post native, early post-partum or perinatal period. So there are unfortunately many stories of when women. And birthing people are not listened to during, their pregnancies and during their birth experiences.
So I appreciate both of you in sharing just some of the reasons why it's important, but when you think about the, urgency of this issue, right? We recognize that it's important, but why is it urgent that we think about Medicaid and doulas?
Averjill: Because mothers and babies are dying. And we have access to, we have knowledge of a service that can mitigate that. And so we get caught up in all this red tape, caught up in lack of understanding, caught up in what's the bottom line? The bottom line, as you said earlier, is the loss of human life. So for me, that's the urgency.
So if I can be the catalyst, the bridge that helps, you know, the business of it and the practice of it, understand and meet somewhere in the middle to get this done, happy to do it, but that's the urgency for me.
Amy: Yes, absolutely I would. Yeah, I mean, I think exactly what Averjill said. I also think in terms of this moment, you know, we are seeing, obviously across the country, there's attacks in many states and at the federal. Laundry, reproductive and sexual health access, especially, you know, post OBs position, after the Supreme Court decision.
And I will say that with that being said, I do think that state efforts at addressing maternal mortality and in particular maternal disparities and care is one area where I've seen, you know, efforts that reach across the aisle. Like, I do think that this is something that in many states, it is a bipartisan issue.
If you look at the map of the states that have passed Medicaid coverage for doula care or who are looking at implementation, it really is, across the board. It's not just, you know, it's not just progressive states that are considering this. And so I do think that this is, you know, also there's obviously, there's been this urgency, honestly.
So I think it's, it's good that, you know, now I think, states and legislators are really looking at implementing these programs. And I think also there's, at least right now in terms of this sort of political moment, there is still kind of bipartisan support for improving the health outcomes of, of, you know, moms and babies.
Deitre: Thank you. I wanted to; I wanted us to think a little bit about what's not working right? Because it's not only important to recognize what is working with Medicaid and doulas, but are there any warning signs or things to avoid that you could think about, Amy, that you've seen states do that you would highly recommend that they not do that because it doesn't work and, and possibly could be harmful.
Amy: Yeah. You know, I think, as I mentioned earlier, I think there are some states or maybe some state Medicaid agency efforts that have not been as good about incorporating and, you know, involving doulas who are in that state in, in those communities, in designing and implementing the program is, I think those have been challenging because the, you know, these are the people who are gonna be your workforce, and so if you don't involve them in those conversations and you, you know, just kind of pass legislation or pass regulations and just expect them to fall in line, I think that that's gonna be really, really challenging when it comes to actual implementation and sort of roll out of the program.
So I think that has been one thing that I think has been difficult and even, you know, I would say even in states, that where they have tried to make an effort to involve doulas. You know, I think in some cases that has also been challenging. State Medicaid agencies, you know, some of them I think are good at working with state stakeholders. Some of them are not. But I think, you know, it's not just a listening session or sort of like a getting input.
It really needs to be a partnership and that implementation, and I think it's, you know, state Medicaid agencies don't always work in, in quite that way. So I think that has been a big challenge. I think another challenge is, is for the doulas themselves, this is also a different, you know, kind of like a whole new realm for them.
So many doulas who are just sort of taking private pay clients are, you know, they're really just entrepreneurs. They have their own business and, you know, they'll enter into maybe their own contracts with their individual clients, but it's a very different ballgame to be a Medicaid provider, right? There's like, you know, other paperwork involved. There's sort of billing to figure out. And so I think that has been another challenge in some states, I've seen doulas who would like to be, you know, would like to provide services to Medicaid enrollees, where states are implementing programs.
Try to figure out some way to maybe come together as a coalition or as a co-op, you know, and try to find some ways to, to kind of help address some of those bureaucratic or administrative challenges, but still retain their autonomy and still retain, you know, their kind of core values as practicing doulas. So I think, you know, those are some of the challenges that, that, that I've seen in some of the states that I've, I've been talking with.
Deitre: Thank you, Amy. Averjill, anything you'd add?
Averjill: Yeah, what I'd add to that is, not overregulating, what it means to be a doula and providing services and making it a scary place to, to enter that arena because I think we, doulas are not midwives, but what has happened to midwives is a cautionary tale for doulas where the granny midwife, that apprentice midwife, has really been made illegal.
You know, we don't see that anymore. And so what we don't want as doulas, is to now have to completely change how we get educated and how we practice in order to provide this care. Right? So I think that's something that, I, I maybe has been done wrong or we're, we're cautious of it, not of being done wrong and might prevent some people just outta fear of even entering the arena and maybe choosing to leave doula care altogether.
Another thing is not understanding a Medicaid agency is not understanding who all the stakeholders are. So we've been talking about making sure that doulas are, front and center, but what about the insurance companies that, that are behind all of this care as well? So I can say specifically for the state of Florida, we have some Medicaid insurance companies that do, who do offer livable wages as a doula and others that are severely lacking, much like these early states, that were offering, you know, 200 and, and slightly above.
And so that causes confusion because what happens is, you know, oh, I'm with Medicaid insurance Company X, and they are offering doula care. And another one might not be, and people jump, that causes break in your care, because now you're risking, you're trying to jump to doula care, but now you're risking maybe midwife, or maybe your OB is not covered under that and you didn't check that before you left. So what happens then? You know, so there's. Understanding who all the stakeholders are, when setting up the programs, I think is super important going forward.
Deitre: Thank you. And that's certainly a culturally responsive approach, understanding, engaging all the stakeholders from the beginning. It would be remiss me if I did not mention the work that each of us is connected to in California through the California Department of Healthcare Services, where they have engaged, a doula advisory group, as the benefits team, comes together to understand and to consider, what does it take to have a doula benefit that is supportive and proactive.
And it comes with its challenges, engaging the community and hearing the voice of all of the stakeholders, including the Medicaid providers, is a challenging process that takes time. What timeframe, do you think that, as states begin to consider, bringing on doulas and Medicaid, what timeframe should they look at too that they could begin starting this process and ending it and having a great benefit for doulas, and for, people who are on Medicaid.
Averjill: I think timelines need to include a launch and a look back date. As well. So it's not just let's get it to market and you know, it's live, it's all right, we're checking this every month, looking at the numbers, look at the utilization. If we're talking a state, you know, where in the state is this being utilized and why is it not being utilized over there?
So there's this whole back-end piece that is where the benefits sometimes falls apart all the work that you did. So I would say if you're not willing to invest, two years, 18 months to 24 months of from planning to communication to reporting to say, Okay, we have now launched this properly, then you're not ready to do this.
Amy: Yeah, I would agree with that. I think, in some states I think they sort of hope they could just kind of push a button, like add doulas to, you know, the computer system for Medicaid, providers and, and have it be done. But I think, as I mentioned, like I think it's, it's really a whole new program that has to be built up to incorporate doulas as a new Medicaid provider, figure out what doula care is gonna look like for the pregnant and you know, birthing people in that state.
I, I will say also that, that especially the piece around the partnership takes a long time, right? So some states pass bill, you know, pass legislation and then kind of you tried to put together a partnership with the doulas and then are sort of implementing care. But in some states, interestingly, you know, even before there was legislation that was introduced, you know, the doulas or you know, some doula group or some, some group of doulas and advocates have already started having those meetings and discussions with the state Medicaid agency.
And sometimes those discussions can take a very long time, right? Because they're kind of trying to figure out like, oh, what would certification look like? Oh, like if we had a series of requirements that doula is needed to meet in order to be eligible reimbursement, like what would be a sustainable, inclusive way to think of those? And I think those conversations, to be thoughtful, really take a long time. So, you know, for, for me, I, I am saying that some states are taking longer to get to the point where the benefits are actually being provided. But I actually think it's better to take a long time and be super thoughtful about it, make sure that all the voices are included, that, that work is really done in partnership.
If that takes two years, three years, and in the end you have a really terrific, sustainable, equitable, and inclusive program that you're not gonna have to go back over time and, you know, keep trying to fix and sort of like, put Band-Aids on. Like, I would love to see like that program, you know, sort of have a program to maybe a longer time to get set up, but then just be up and running and, and just be, be golden. So, but I think states are, are definitely gonna be different I think in, in sort of how they roll out the coverage.
Deitre: I often encourage folks to remember that equity is a slow, long journey and process that we all want to hurry up, right? We want to get there quickly, but it's taken hundreds of years for us to get to these institutions and systems and inequities that we've, we find ourselves in. So it's gonna take time to dismantle the systems that have been put in place to really advance equity. What do you see changing in the next five to 10 years?
Averjill: Awareness, and, and that awareness helps systematically. Cause like you said, you could let doulas in the door, but what does that mean? If the clinicians that are in the hospitals or in the perinatal space don't know how to best work with doulas... there's tension there, and that's not what we're all there for.
We're all there for that pregnant person to have a lovely and healthy delivery and go home with that baby. so right now, like in Miami-Dade County, we're doing a lot of work to raise awareness with clinicians, and that's all kind of clinicians. You, you podiatrists need to know about what a doula does, because there are cases where they need to make that referral, right?
So, It's, raising the awareness with clinicians on what doulas do, and how they can be woven into prenatal care, as well as the business part of it too. Like, how do you properly pay? So we talked about earlier, I'm not familiar with the study that Amy talked about yet, but you know, it's very easy to find that with your OB you're spending 10, 15 hours total, including the birth.
But with a doula, 50, 53 hours. And so how do you pay for that? You know that, having the awareness of what a doula does help you set up equitable payment structures because you have a deep understanding. So awareness is what I'm hoping is gonna change in the next five to 10 years, and that will seep into the entire system of having a baby
Amy: Yeah, I like that. I, I also think that, you know, in many cases there are other circumstances or, you know, other instances in which benefits have come out, sort of rolled out to Medicaid enrollees, and then after some time private insurance has picked that up. And so, you know, another thing that, that I'm hopeful for in like kind of the five-to-10-year span is that as states have rolled out Medicaid coverage for doula care, people in the private health plans are like, hey, I want that too. Right?
And so, you know, in California for example, a couple of the pilot programs that I mentioned earlier were pilot programs that were run by Medicaid managed care plans. So I am hopeful that that, you know, if we are at like five to 10 years, that we'll see a growing number of states start to roll out doula care as a requirement or as a benefit also in in private plans as well.
Deitre: The question I'd have for you as we, both of you, as we close out, what resources are available for people to learn more about, Medicaid and doulas, and in case they would like to go beyond today's podcast.
Amy: Yeah, so I can mention, you know, the report, it was the Advancing Birth Justice report. It's written by, I think, Village Birth International, Ancient Son Doula Services and every mother counts in New York. And I think maybe we can include like a link in the show notes. I think it's a great, it's a great resource and it really came out of some challenges implementing a pilot pro, a doula pilot program in New York, in, I forget, I think it was like 2018. That's a great report and I always recommend that one. for people who are interested in learning about where states are, we have a great, sort of state implementation chart on our website at the doula Medicaid project page, as well as some additional resources.
One that I can mention since I think I've brought it up a couple of times is we did a series of interviews with 10 of the doula pilot programs taking place here in California between 2019 to the present. And so I think there's a lot of. We have some publications around both challenges that they had in implementing those doula pilot programs, lessons learned, and then also summaries just so that people could learn a little bit more about kind of the scope of each of those programs. So happy to share all of those links.
Averjill: Those are great resources and I, what I would say to people trying to understand a little bit more is its very state specific right now. There's no, you know, federal, everybody's under the same rules. So I think that just needs to be understood as you enter the arena and then look specifically what's going on in your state. and it could be sometimes as, as small as what's going on in your municipality. You know, so it can get that nit and grid sometimes. So, look locally and then expand from there.
Deitre: Thank you both for your conversation, your dialogue, your insight, and your wisdom on today. how can our listeners connect with you?
Amy: Anybody can email me; I can share my email address in the notes as well. That's fine. You know, and happy, you know, myself and my colleague Alexis Robles-Fradet. We answer questions. We, you know, provide technical assistance for doulas and other stakeholders, so, you know, happy to provide support for you if you're trying to look at some of these efforts in your state and sort of share information of what people in other states are doing as well.
Averjill: You can just go to the corporate doula.com and contact me. There and I'll be happy to, to give back to you in whatever way you need.
Deitre: Okay, and my name is Deitre Epps. You can reach me at deitre@race4equity.com. That's race the number four equity.com. We also have a website where you can connect with me on LinkedIn and other places as well. Most importantly, I want to thank you all for taking time to join us today to share your experiences, and thank you all for listening.
For more podcasts, videos, blogs, and maternal health content visit, the Maternal Health Learning and Innovation Center website. We are at maternalhealthlearning.org and we want to hear from you. Tell us what you want to hear more of, review our podcast and share with like-minded innovators. We've got some great episodes recording now, so be sure you're subscribed. Let's keep on talking. Tag us in your posts using #maternalhealthinnovation. I'm Deitre Epps, and we'll see you again next week on the Maternal Health Innovation Podcast. Take care everybody.