Washington state doulas are celebrating the announcement of a Medicaid reimbursement rate of $3,500 per birth, the highest in the nation. This milestone comes after years of painstaking lobbying by advocates.
Doulas support pregnant people before, during and after birth by providing physical and emotional support as well as important information about pregnancy and childbirth. They are key advocates during a stressful and potentially dangerous time in a person’s life, while also offering auxiliary support that often isn’t provided by the Western medical system.
Historically, nearly all societies had skilled midwives, doulas or other practitioners of traditional medicine who had deep expertise in birthing and perinatal care. These people, often the sisters, nieces, aunts or grandmothers of the community, guided pregnant individuals through birthing and administered culturally appropriate treatments and medicines.
However, in the late 19th century, birth care shifted from at home to hospitals in the U.S. The transformation replaced traditional caregivers with licensed physicians and midwives, who were predominately white. Reproductive justice advocates argue the exclusion of doulas has disproportionately harmed Black, Brown and Indigenous communities, leading to a loss of traditional knowledge and poorer health outcomes.
To rectify these historical injustices, doulas, perinatal medical providers and other pregnancy health advocates across Washington came together to form the Doulas for All coalition in 2018. That year, the group successfully lobbied for legislation authorizing Apple Health — Washington’s version of Medicaid, the program that provides health coverage for low income individuals — to cover doula care. But since most doulas were not credentialed, they were unable to easily receive reimbursement. Professional certification from credentialing organizations like DONA International can cost hundreds of dollars and take at least 16 hours to complete.
In 2022, the Washington Legislature passed House Bill (HB) 1881, which created an alternative credentialing pathway for doulas trained in ancestral traditions of perinatal care. This change allowed them to receive the same certification as doulas who go through a more formal education process. HB 1881 also eliminated fees for doula certification and renewal.
To receive the state-issued credentials, a doula must either have completed a certified doula training program or submit three letters of recommendation attesting to their competency and knowledge. Doulas must also affirm their duty to provide culturally congruent care, defined as respecting and upholding their client’s cultural practices related to birth. Practicing doulas are also required to complete 10 hours of continuing education every two years to renew their certification.
The lower-barrier credentialing system established in HB 1881 is aimed at recognizing the work of Black, Brown and Indigenous doulas, who out of care for their communities often put in long hours for little to no pay.
“It’s great for birthing folks, but it’s also great for the practitioner side,” said Paris Nelson, the strategic development and policy manager at Fourth Plane Forward and a member of Doulas for All. “Now they have a workforce development opportunity to gain a livable wage and be able to expand their services to support lower-income [people] and/or individuals that may not otherwise be able to access these care services.”
In order to ensure the most equitable implementation of HB 1881, the Doulas for All coalition stayed in constant communication with the Washington State Department of Health (DOH) and state legislators. Senait Brown, the policy director of Surge Reproductive Justice, said that at one point the coalition had to get a provision passed in the state budget within five hours to ensure enough money was set aside for doulas.
Brown said advocates had contentious negotiations with DOH and legislators over the definition of cultural congruent care and the amount of compensation doulas could receive from Apple Health. Washington’s 2024 supplemental budget adds more than $800,000 in additional funds for doula reimbursement. Brown added that when legislators initially proposed $2,000 in Medicaid reimbursement, the Doulas for All coalition pushed back.
“$3,500 was the lowest that we were willing to accept, even though it’s the highest in the country, sadly,” Brown said. “The fact that we got that is brilliant, and it should have been $4,500. It should keep going up.”
California has the second-highest doula reimbursement rate, ranging from $1,500 to $3,100.
In addition to implementing Medicaid reimbursement, the coalition also won funds for a new doula hub, a professional network that will help doulas navigate insurance paperwork and other bureaucratic hurdles.
The new Apple Health doula reimbursement rate could dramatically expand the number of pregnant people who can access comprehensive perinatal care. According to the DOH, more than 47% of all births in 2018 were covered by Medicaid.
“There’s a huge quote that is often said in the [Doulas for All] space: It’s that doula care should not just be a privilege, but it should be a standard of care,” Nelson said.
Doulas for All believes expanding doula care in Washington could significantly improve maternal and infant health outcomes, especially among Black and Indigenous communities.
Brown said she had a difficult pregnancy in the middle of the COVID-19 pandemic when she was split between Chicago and Seattle. Her doula helped her navigate 18 months of post-pregnancy complications. Additionally, Brown said, that if it wasn’t for the intervention of a Black midwife, she might not have survived.
“The one Black midwife — the only one that was allowed in birth centers because in Illinois home births are illegal and white women are the only ones that don’t get criminalized so there’s not a lot of Black people that do it — was the person who sent me to the emergency room,” Brown said. “That’s probably why we’re here today.”
A 2023 maternal mortality review panel report by the DOH found that 80% of pregnancy-related deaths between 2014 and 2020 in Washington could have been prevented. The state has an average of 15.9 pregnancy-related deaths per 100,000 live births, which is lower than the national rate of 18.6. In that six-year time span, 68% of the people who died were insured by Medicaid.
The report also showed staggering levels of disproportionality in maternal mortality. While non-Hispanic white people had an average of 13 pregnancy-related deaths per 100,000 live births, Indigenous people had an average of 84 deaths per 100,000. Both Pacific Islander people and Black people had an average of 36 deaths per 100,000 live births. The largest cause of pregnancy-related death was suicide, followed by hemorrhage and infection.
Stephanie Courtney, the founder and executive director of the Spokane-based nonprofit Shades of Motherhood and a member of Doulas for All, said this disparity is rooted in the white-supremacist origins of modern gynecology.
“I think it starts with the mothers of gynecology, Betsy, Anarcha and Lucy,” Courtney said. “Three Black slaves that were on three different plantations, who suffered a severe tear [in the reproductive system] that caused them to be seen as useless. They were sent to Dr. J. Marion Sims, also known as the butcher of gynecology, and he did surgery torture on these three Black women, plus other women, without anesthesia, because he felt that Black women did not feel pain.”
For Courtney, Medicaid reimbursement is just the first step toward reproductive justice and repairing the harm done to Black, Brown and Indigenous communities.
“There [are] reparations that need to be paid,” Courtney said. “In my area, I had to start a doula workforce development program because we had no doulas of color. We have one doula of color, who speaks Spanish, who is crucial to the ground. … This really is a time for our communities to not only apologize, but to make it right within an industry. It wasn’t that Black doulas and Black midwives didn’t want to exist. They were forced out, and some people were violently pushed out.”
Guy Oron is the staff reporter for Real Change. He handles coverage of our weekly news stories. Find them on Twitter, @GuyOron.
Read more of the April 17–23, 2024 issue.