Doulas: Nonclinical birth workers who are trained to provide physical, emotional, and informational support to pregnant people in the prenatal, birth, and postpartum periods.
Community Doulas: Nonclinical birth workers who provide culturally sensitive pregnancy and childbirth education, early linkage to health care, and other services such as labor coaching, breastfeeding support, and parenting education.
Midwives: Trained birth workers who provide care during the prenatal, birth, and postpartum periods. Midwives may be trained to practice in birthing centers or home births without the presence of physicians or in hospitals alongside physicians. There are several pathways to the midwifery profession, including certified nurse-midwives (CNMs), certified midwives (CMs), certified professional midwives (CPMs), and traditional midwives.
Background and Context
Community-based providers, including doulas and midwives, have assisted pregnant people in the United States for several centuries.
Historically, people of color, including Indigenous people and Black people, have relied on midwifery services as a cultural practice and because of systemic barriers in health care that caused transgenerational trauma. Black midwives have reported viewing midwifery as a linkage to their African roots, the diaspora, and to current challenges faced by Black people when seeking maternity care.
The United States health care system has historically not reimbursed services provided by doulas and midwives. Supporting and growing a diverse perinatal workforce is essential to recognizing the existing birth knowledge within communities of color, supporting cultural concordance, and reducing racial disparities in maternal mortality and morbidity.
States are increasingly recognizing these provider types and developing training, certification, reimbursement, and billing policies.
Incorporating doulas and midwives into maternity care services for Medicaid members has the potential to:
Improve outcomes
Reduce costs
Improve equity
Perinatal care from doulas and midwives is evidence-based and shown to reduce costs.
A meta-analysis of 26 studies found pregnant people who receive continuous support during childbirth:
- Are more likely to have a vaginal birth
- Are less likely to have a Cesarean delivery
- Have babies who are less likely to have low five-minute Apgar scores (an immediate post-birth measure of an infant’s clinical status)
- Did not experience adverse outcomes
Recognizing doula services can lead to improved birth outcomes and reduced costs.
- Studies from Minnesota, Oregon, and Wisconsin show Medicaid reimbursement for doula services has the potential to save costs.
- Research indicates doula support can lead to Medicaid savings when reimbursed at an average of $986 per birth.
Midwife-led models of care are associated with:
- Increased likelihood of vaginal delivery
- Decreased likelihood of preterm birth (before 37 weeks)
- Decreased likelihood of infant mortality
It is estimated that increasing the percentage of pregnancies with midwife-led care to 20 percent (from the current 8.9 percent) over the next 10 years could lead to $4 billion in cost savings.
To learn more, check out Expanding the Perinatal Workforce through Medicaid Coverage of Doula and Midwifery Services.