There’s a Good Reason Medicaid Covers Doulas

When Marie Holmes was pregnant with her daughter in 2014, she knew she wanted a doula to support her during her labor. It wasn’t easy to swing it—money was tight because Holmes, a New York City public school teacher at the time, would have to go on unpaid leave after her daughter’s birth. But because her first birth had been so difficult, she prioritized hiring a doula. She found the perfect person: Theresa McCaffrey, who was a friend of a friend. 

Unlike her first birth, Holmes’s labor was quick, and soon after Theresa arrived at her home, it was time to leave for the hospital. Holmes, in such pain she could barely walk or speak, squeezed Theresa’s hand as she inched her way down three flights of stairs to the street. Holmes says that if not for Theresa, she doesn’t know how she would have made it down the stairs of her home. Her wife later told her that they probably would have had to call an ambulance.

By the time she got to the hospital, Holmes was fully dilated. But her midwife, who Holmes had expected to meet her there, never showed; later, Holmes found out that the after-hours answering service had never called her. Instead, Holmes’s care was taken over by two obstetricians she’d never met. When it came time to push, Holmes leaned against Theresa, who braced against her with the full strength and weight of her body.

Though Holmes lost a significant amount of blood, she didn’t need a transfusion, and her daughter was born healthy. But because Holmes was “profoundly anemic” when she was discharged, she was advised to return for bloodwork. 

While recovering, Holmes says that talking with Theresa about the birth helped her to process becoming a mother for the second time, and to “make sense of what happened.” There’s nothing like hearing from someone who was there, she says. 

Still, Holmes says she also would have benefitted from a postpartum doula who could have come to her home to give her a hand. (While some doulas focus only on providing support during birth, some also care for mothers during pregnancy, postpartum, and even during miscarriage, stillbirth, and abortion.) Holmes’s wife was only able to take off two weeks from work, leaving Holmes alone to care for their newborn and their 4-year-old while recovering from childbirth. 

“I just felt so overwhelmed,” says Holmes. But her health insurance didn’t cover doulas, and paying for a postpartum doula cost too much out of pocket to even consider hiring one. Even washing her hair seemed like an ordeal, because she was “trying to keep things afloat,” so going to the hospital for blood work was out of the question, she says. 

Doula Care and Medicaid

Until recently, neither private insurance nor Medicaid covered doula care. In the U.S., doula care has been perceived as a “luxury,” says Twylla Dillion, executive director of HealthConnectOne, a nonprofit that trains community-based doulas, peer lactation counselors, and community health workers to address inequities and improve maternal and child health during pregnancy, birth, and postpartum. Now, 46 states and the District of Columbia have taken some steps to implement Medicaid coverage of doula care, including passing a law requiring coverage or, in some states, piloting a Medicaid program that covers doula care, according to Amy Chen, Senior Attorney in the National Health Law Program. 

Louisiana and Rhode Island require that private insurers cover doula care, which is the “logical next step” following Medicaid’s implementation, says Chen (though Louisiana does not yet have Medicaid coverage of doulas). Another three states are implementing laws that require private insurance coverage, and two more require private insurance to cover doula care for some public employees.)

That Medicaid reimburses doulas at all is thanks in part to each state’s having expanded Medicaid coverage to last for a full year following birth. The first year is a critical window for maternal health; the majority of maternal deaths occur postpartum, not during pregnancy or birth. Expanded coverage makes it possible for mothers to continue to use Medicaid to pay for a variety of postpartum appointments—including doula care—that are important to treating and stabilizing conditions, such as cardiovascular problems, which can be exacerbated by pregnancy and birth. And part of what has driven doula coverage, says Chen, is the country’s “truly abysmal rates of Black maternal mortality and morbidity.”

But the new administration’s attacks on research on racial disparities in health, as well as potential cuts to Medicaid with Thursday early morning’s passage of Trump’s horrifying megabill, may curtail that coverage.

Though Chen cautions against predicting what may happen if Medicaid funding is gutted, she says it’s possible that states that have implemented coverage may roll back existing benefits, such as reimbursement rates or the number of allowable prenatal or postpartum appointments. Or they may find other ways to reduce the “scope of services or nature of the benefit.” It would not necessarily be easy for states to do so, Chen says—they would need to submit a request to the Centers for Medicare and Medicaid Services—but it is possible. 

But states piloting coverage, she says, may decide that the pilots—or the benefit overall—are too expensive to implement. 

***

On their own, doulas cannot address the maternal health emergency. But evidence shows that continuous labor support improves birth experiences and birth outcomes, including lower rates of c-sections. Studies specifically of Medicaid recipients have also shown that doula care reduces cesarean rates. In that way, say Dillion and others, doulas are “an asset to hospital systems.” And by advocating for people who’ve just given birth, and witnessing the care that they receive, doulas can disrupt negative patterns of care and the sometimes dehumanizing systems that fail to recognize or respect patients’ autonomy—particularly during labor and birth.

Those outcomes matter not only for the new parents’ lives, but also for their financial impact, which is essential to justifying a Medicaid-covered program: Cesareans cost more than vaginal birth. And because one of the single biggest predictors of a future cesarean is having had one in the first place, investing in doulas can also potentially save costs on future births—and prevent the downstream consequences of cesarean sections, which include more complicated and dangerous subsequent pregnancies. Medicaid currently pays for about 40 percent of all U.S. births.

The support that doulas provide is similar to the kind of support that free women in the U.S. enjoyed from other women in their communities during the era of social childbirth, before birth moved into the hospital from the home 100 years ago. But over the past century—even as new technologies, antibiotics, blood transfusions, and safe cesarean sections have made birth safer for mothers and babies—that support came to be seen “as a commodity,” says Susie Finnerty, a community doula, board member of the Rhode Island Birth Worker Cooperative, and director of RhodeIslandbirth.com. “Birth options and good care shouldn’t be commodities,” she says.

Nearly anyone can benefit from a doula, but doulas are particularly important to the lives and health of mothers from marginalized communities, who comprise a disproportionate share of women who die or suffer serious harm during and after pregnancy, and during childbirth. In fact, Black women are the only group for whom rates of maternal mortality did not decrease in 2024. And because Black women are more likely than women from other groups to have a cesarean, even if they are low-risk, doulas’ potential to protect Black maternal health outcomes and reduce cesarean rates is especially important. 

Yet only about 6 percent of births in the U.S. involve a doula, in part because of the costs of hiring one. Women who hire doulas are disproportionately white and tend to be from higher socioeconomic backgrounds. (Even for women from these groups, as Holmes’s experience demonstrates, hiring a doula can be a financial stretch.) And because it can be difficult to sustain, financially—one of the leading reasons doulas leave the profession—doulas in the U.S. are also disproportionately white, middle-aged, and upper-middle-class. 

But sources say that building and sustaining a diverse doula workforce is critical for families from every community to access the culturally congruent support they need. “It’s a lot easier to talk to somebody who understands you, someone you know through a few degrees of separation,” says Dillion. 

In principle, Medicaid and private insurance coverage of doulas “takes money out of the equation for the family” so that every mother can have a doula, says Finnerty. Done well, this coverage can also function as a tool to diversify the doula workforce, by making doula work financially sustainable, and therefore accessible, to people from a diversity of socioeconomic communities, says Finnerty. 

But in practice, Medicaid coverage of doula care varies widely across the U.S. Each state’s particular processes shape whether and how doulas become—and remain—Medicaid providers, and how well the program succeeds. The most successful states, Chen says, work in close partnership with doulas in their program’s design and implementation.  

Making Doula Work, Work

Doulas do not provide clinical or medical care, so they are not licensed. Nor is there a single educational pathway to become a doula. Some learn through apprenticeship, others through training that focus on teaching core competencies such as childbirth education and prenatal and lactation support. 

But to become a Medicaid provider, doulas must go through state-sanctioned training and credentialing processes—even if they are already working as doulas. These processes, which can be laborious and differ in every state, can inadvertently sideline doulas, says Dillion: They may mandate a single way to earn that credential. Or they may lack provisions for grandmothering in doulas who aren’t certified, but are deeply competent, because they learned through apprenticeships and have provided services for decades. 

In the early to mid 20th century, when states began to implement new licensing requirements of midwives—some of which included bag inspections and English reading tests, which didn’t necessarily have anything to do with the skills needed to attend birth safely. These conventions were used to push out Black, Indigenous, and immigrant midwives from administering to women giving birth, resulting in a tremendous loss of talent, knowledge, and care. “We can’t allow it to happen with this profession,” says Dillion.

Denise Bolds, a New York–based Black birth doula, doula trainer, and founder of Black Women Do VBAC, notes that some certification processes include requirements that doulas be of a certain age or capable of lifting 50 pounds. “There are doulas out here who are mentally and physically disabled, but still able to work,” she says. “What is that going to do but further marginalize marginalized people?”

Billing is another difficulty, according to doulas and advocates. Some Medicaid managed care organizations require that doulas bill in 15-minute increments. That works “if you’re a podiatrist,” says Jill Wodnick, a doula and maternal health policy expert at Montclair State University. But applying these “payment mechanisms” to the emotional and social labor—and value—doulas provide prenatally, during labor, and postpartum is complex and challenging, she says.

In that way, Wodnick says, trying to fit caregiving into a billing code system is emblematic of the ways that our society undervalues and misunderstands caregiving. It’s also challenging, she says, that the process asks doulas as peer support educators “to do what most medical providers and facilities don’t even try to do without a billing specialist.” (Doula collaboratives, like the one Finnerty co-founded, work together on billing and can make the process less onerous; they also advocate for reproductive justice, birth options for families, and other community-based and legislative work, of the type set out by the Perinatal Doula Act.) 

Bolds adds that if there’s an error in billing, the bill is “kicked back” to doulas, which “delays payment.” And even when a bill is accepted by a state’s Medicaid program, it can take months to see payment, which makes it difficult for doula work to be sustainable. “I can’t wait three months for maybe $900 after taxes,” says Bolds, who is based in New York, and who recently chose not to recertify as a Medicaid provider. “Not when eggs are $9.” 

Compensation varies by state—Washington State is among the most generous, reimbursing doulas for nine visits and for care during birth, for a maximum of $3,500. Of course, not all states’ rates cover as much as Washington. And even with compensation from public and private insurance, it can be hard to make a living wage; Finnerty notes that there are doulas who drive Uber to support themselves.

And while Chen observes that reimbursement rates have improved over the past couple of years, in some states, low rates and waiting long periods to get paid make it tough for doulas to provide care for Medicaid families. “It’s not something that’s lucrative, and once again it’s impacting women of color,” says Bolds. “Women of color are paying the price to support women of color.”

“Our Whole System Still Has More Work to Do”

Doulas, while crucial, offer only one element of improving birth outcomes for mothers and babies. “We need to look at the broader picture,” says Chen. “Whether that means changing the way we approach birth, how doctors are trained, or addressing racism at a broader social level.” It’s essential, she says, “to keep our eyes on that even as we work to expand access to this specific benefit.”

Morgan Miles, Executive Director of Giving Austin Labor Support and a board member of the Texas Doula Association made a similar point. A person may have a doula and still “end up with a cesarean,” she says. “That’s not saying their doula did something wrong. Our whole system still has more work to do.”

Moreover, doulas are caring for mothers in a field that’s already strained, says Bolds. A chronic nurse shortage means that doulas may be the ones doing postpartum wellness calls, she points out, or other tasks that nurses once did—but at a much lower wage than nurses earn. At the same time, notes Dillion, the nursing shortage is yet another reason why doulas are so critical; particularly in busy hospitals, they may be the advocate who steps out into the hall and says, “We need a nurse in here.” 

Doulas also play a critical role in rural areas, where families may be hours from a hospital—a growing concern as more rural hospitals and obstetric units close because of falling birthrates and financial and staffing challenges. In those places, explains Miles, doulas can help assess and advise whether families need to make an urgent, 200-mile trip to the emergency room or suggest a televisit or a phone call in between doctor visits.     

Someone to Be Your Village

Doula care may seem new, but in fact doulas have supported women in childbirth for millennia. Before birth moved from the home to the hospital, women—those who were not enslaved—experienced childbirth with a midwife and with the women in their communities by their side. Early labor “probably took on something of the character of a party,” writes historian Laurel Thatcher Ulrich in her book Good Wives: Image and Reality in the Lives of Women in Northern New England, 1650-1750. The expecting mother provided food and drink, including “groaning beer” and “groaning cakes,” to the women who stayed with her during labor. These women provided support, expertise, and kept the house going—cleaning, cooking, and caring for older children. As Ulrich has written, a mother might conceivably give birth in the arms of another woman—an image that evokes Marie Holmes’s labor, with Theresa quite literally behind her. 

Other mothers rely on doulas’ verbal support: When Geovanna Hinojosa had her baby at a Connecticut birth center in 2023, her husband, midwife, and doula, Chelsea Munkelt, were by her side. To have someone “to be your village—that was everything to me,” she says. “Having her there and telling me how strong I am—you don’t know you need it until you’re hearing it.”