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Virginia Invests in Doulas to Improve Maternal Health Outcomes

This blog was written by Abena Asare, a 2021 Emerging Leaders of Color Fellow.

The United States is facing a maternal health crisis with poor maternal health outcomes. Across the country, states have adopted many strategies to address maternal mortality and morbidity. One state policy strategy to promote racial equity in maternal health outcomes is Medicaid coverage of doula services. In January 2022, Virginia became the latest state to expand coverage for community doula services for Medicaid beneficiaries. Community doulas can begin enrolling in the state’s Medicaid program in spring of 2022.

Doulas are trained professionals who provide continuous physical, emotional, and informational support to pregnant people before, during, and shortly after childbirth. Research shows that doulas can help improve the birth experience and reduce disparities in poor birth outcomes for both the mother and baby. Nationally, there has been a growing interest in expanding the maternal health workforce with an investment in doulas. In September 2021, the U.S. Department of Health and Human Services announced an investment of more than $3 million in supplemental funding to increase the availability of community-based doulas.

With the approval of its State Plan Amendment (SPA) in October 2021, Virginia became the fourth state in the country to roll out a doula Medicaid benefit following New Jersey, Minnesota, and Oregon. Each state’s benefit is distinctive with varied licensing requirements, reimbursement structures, and billing procedures. The benefit is the result of calls by former Governor Ralph Northam to eliminate disparities in Virginia’s maternal mortality rate by 2025. Policymakers crafted the benefit using recommendations from a doula workgroup that included a variety of stakeholders, such as community-led doula organizations. The efforts were part of a larger state Maternal Health Strategic Plan which included numerous state policy recommendations.

The framework for Virginia’s SPA and reimbursement structure was the result of intentional conversations held with a diverse set of stakeholders in the state. Virginia’s Office of the Secretary of Health and Human Services (OSHHR) facilitated multiple workgroup meetings over the course of one year. During this time, the group met to discuss the steps of the certification process, collect data on current reimbursement rates for maternal health services across the country, dissect various training materials to ensure cultural relevance and sensitivity, and identify recommendations, including appropriate reimbursement rates for Virginia’s doula Medicaid benefit. The doula workgroup meetings included people with lived experience, doulas, licensed practitioners such as obstetricians/gynecologists and certified nurse midwives, several organizations including managed care organizations, the Virginia Hospital and Healthcare Association, and the Medical Society of Virginia, along with state agency partners including Virginia Medicaid and the Virginia Department of Health. In developing the SPA, Virginia Medicaid collaborated with New Jersey Medicaid on best practices, lessons learned, challenges, and areas of opportunity for policy advancement.

A key pillar of Virginia’s process was ensuring that doulas were brought to the policymaking table, including engaging community-led doula agencies and doulas of color to capture their ideas. The OSHHR took the time during the monthly workgroup meetings to hear from doulas who were currently in the field and leverage the ability to address their concerns, challenges, and hopes for the Medicaid benefit. They were also able to hear from and work with providers in the state and get a better understanding of how this benefit could be useful for pregnant people throughout the state.

Virginia’s doula Medicaid benefit will primarily be operationalized through the state’s Medicaid managed care (MMC) service delivery system. Services can be reimbursed from the date of confirmed conception through 180 days after delivery, contingent on the beneficiary maintaining their Medicaid eligibility. To be reimbursed for services, community doulas need to complete training which must include core competencies such as perinatal support services, labor support, community-based/cultural competency training, and care coordination. All community doula trainings must be approved by the Virginia Department of Health (VDH) and doulas who complete the training need to be certified by a state certifying entity designated by VDH.

Virginia’s doula Medicaid benefit includes a unique payment structure which encourages and incentivizes continuity of care. Virginia’s reimbursement structure includes:

  • Services for standard care include up to eight prenatal/postpartum visits and attendance at birth with a reimbursement rate of $859.
  • A $100 payment incentive for postpartum follow-up visits.

To receive the incentive payments, doulas need to have performed at least one postpartum visit. A $50 value-based incentive payment can be received by the doula if the client is seen by an obstetric clinician for one postpartum visit. A second $50 value-based incentive payment can be received if the newborn is seen by a pediatric clinician for one visit after birth. With 1 in 3 pregnancy-related deaths occurring between one week and one year after childbirth, these incentive payments have the potential to improve postpartum outcomes for mothers and babies.

Virginia’s doula Medicaid benefit was intentionally designed to address disparities in maternal health outcomes within the state. The intentionality behind Virginia’s process is evident throughout — from the selection of the workgroup members to the reimbursement structure, the state’s efforts reflected their commitment to racial equity and inclusivity.

Through the Maternal and Child Health Policy Innovation Project (MCH PIP), funded by the Maternal and Child Health Bureau within the Heath Resources and Services Administration, NASHP continues to support states including Virginia in their efforts to address inequities in maternal health outcomes.

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Abena Asare is pursuing her MPH concentrating in maternal, child, and adolescent health at University of California, Berkeley and graduated from Wellesley College in May 2018 with a BA in psychology and health and society. She is passionate about health equity and addressing the determinants of health that influence race-based disparities in outcomes for birthing people and children. In 2021, Abena partnered with Virginia Medicaid officials through NASHP’s Emerging Leaders of Color (ELC) Fellowship Program to support the development of the state’s doula benefit. To help shape more equitable systems and policies, NASHP’s ELC Fellowship aims to empower emerging state health policy leaders from communities of color to lead the development and administration of state health policy informed by their lived experiences. NASHP connects ELC Fellows with a community of support, guided learning opportunities, and hands-on experience in state government.

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