Doula care, increasingly recognized as a beneficial support during pregnancy and childbirth, is now covered by Medicaid in 26 states and Washington, D.C., according to research by KFF Health News. Despite this formal expansion, many low-income parents face significant hurdles accessing these services due to administrative burdens and low reimbursement rates, leaving an important support system effectively out of reach for some of the most vulnerable families.
What Happened
In 2022, Virginia became the fourth state to implement Medicaid reimbursement for doula services as part of efforts to reduce the state’s high maternal mortality rate. This policy followed advocacy to improve birth outcomes and provide expanded support to Medicaid recipients. While doulas like Taja Iglesias, founder of The Momager Co. in Alexandria, are committed to bridging care gaps, she and others report that complex certification and billing processes, combined with limited reimbursement, significantly restrict the number of Medicaid-accepting doulas. A review in June 2024 found only 19 doulas in Northern Virginia accepted Medicaid payments, despite a large Medicaid-eligible population.
Key Facts
Perinatal doula services typically include pregnancy education, labor advocacy, and post-delivery support such as lactation assistance and recovery help. Virginia Medicaid covers up to eight doula visits per pregnancy, with all but the first session limited to one hour. The state reimburses doulas $859 for the full pregnancy, with an additional $100 when prenatal and postpartum doctor visits are attended. However, the Medicaid reimbursement rate is uniform statewide and does not reflect regional living cost differences, such as in Alexandria, where costs are approximately 32% higher than the state average.
A study published in 2024, analyzing data from 2022 to 2024, found that fewer than 1% of Medicaid births in Virginia involved doula services during the first two years after implementation. This low utilization indicates the challenges in converting coverage into actual access. Certification fees range from $75 to $150, which some doulas report as a prohibitive upfront cost considering the modest pay and administrative burden involved.
What This Means
While Medicaid coverage of doula care represents a promising policy advancement addressing maternal health inequities, the real-world impact remains limited by structural barriers. Low reimbursement rates disincentivize doulas from enrolling as Medicaid providers, particularly in higher-cost areas, restricting the availability of culturally competent and continuous support that doulas typically provide. Additionally, the paperwork and referral requirements further complicate timely and widespread access.
This gap is notable because doula care has been linked in prior research to improved breastfeeding rates and diminished maternal anxiety, factors that can contribute positively to maternal and infant health outcomes. The constrained access means many Medicaid-eligible families may not receive these benefits, perpetuating disparities in perinatal support and outcomes. It also reflects broader challenges in integrating supportive, non-medical health workers into formal healthcare financing systems.
Background
Doula care is designed to provide continuous physical, emotional, and informational support to parents before, during, and after childbirth. It complements but does not replace medical care provided by obstetricians or midwives. Several states have moved to Medicaid coverage for doula services as part of maternal health strategies, motivated by the United States’ comparatively high maternal mortality rates, especially among low-income and minority populations.
Virginia’s 2021 legislation mandated Medicaid coverage of doula services and allowed an additional companion in the delivery room beyond family members, aiming to improve birth experiences and health outcomes. Policymakers hope that enabling doula access contributes to reducing maternal deaths and complications during the perinatal period.
Analysis
Researchers such as Desirae Leaphart Mensah of George Mason University have emphasized that the Medicaid doula program’s potential is undermined by logistical challenges. Interviews with doulas revealed that cumbersome certification processes and low reimbursement have resulted in many providers opting out of Medicaid participation. Kenda Denia, executive director of Birth in Color, highlights that payment rates do not match the scope of doula work, which often includes home visits and extensive time commitments not compensated adequately by Medicaid.
What Remains Unclear
The trajectory of doula utilization under Medicaid programs nationally remains to be seen, as few states have had such programs long enough for comprehensive evaluation. It is also unclear how policy adjustments regarding certification processes, reimbursement rates, or coverage scope might change doulas’ participation and patient access in the near term.
What Comes Next
Virginia’s ongoing doula task force, co-chaired by doulas including Iglesias, is actively exploring policy reforms to streamline certification and increase compensation. Other states considering Medicaid doula program implementation are monitoring these developments. Meanwhile, some doulas continue to offer services outside Medicaid to reach low-income parents, relying on fundraising or private support.
Sources
This article is based on reporting and publicly available information from the following sources:
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