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Doulas are about to get a big boost in New York State — but not everyone is on board.
Doulas are trained nonmedical professionals who provide physical and emotional support to pregnant women during and after pregnancy; studies have shown they can reduce the chance of complications for mothers and babies.
To expand women's access to doulas, New York’s Department of Health is launching a pilot program on March 1 to allow Medicaid to help cover their services in Brooklyn and Erie County. Since the announcement of the pilot program in November, the doula community in New York has been buzzing about the opportunity to serve more clients — but many doulas and advocates for maternal health have also criticized the program as being inadequately funded and offering a reimbursement rate that is too low for doulas to make a living. Similar concerns have emerged in Minnesota and Oregon, the only other states to offer Medicaid coverage for doulas.
“We are committed to continue working with doulas on implementing this pilot program and look forward to expanding these important services to more women throughout the state,” said Caitlin Girouard, the press secretary for the governor.
What will New York's doula pilot program provide?
Unlike midwives, who are health care providers, doulas act as birth coaches and do not replace medical practitioners. They are trained in the birthing practice and complete a certification process. Benefits for mothers include shorter labors, lower rates of Cesarean sections, fewer requests for pain medication, improved assessments of newborn well-being and greater likelihood for breastfeeding, according to Choices in Childbirth, a nonprofit that advocates for equity in maternal health care.
New York’s doula pilot program includes coverage of four prenatal and four postpartum visits, plus labor and delivery, for which doulas would be reimbursed a total of $600 by Medicaid. Hiring a doula in New York City can cost $250 to $4,000, based on their experience level, so in many cases, Medicaid would not cover the full cost of the service.
“Even if you do one-hour visits, that’s seven hours right there already. And then most people’s birth is going to be at least 10 hours,” said Yael B. Yisrael, the owner of Flatbush Doulas, who has been a birth worker for six years. Doulas can be on call for weeks in advance of the birth and spend days without rest supporting clients in active labor. According to Yisrael, failing to pay a livable wage incorrectly “assumes that you don’t have to survive, too."
"It’s a business and it’s not that I can’t be passionate and caring and loving, but I have two children and they also deserve to be able to eat," she said.
The New York governor’s office said that reimbursement rates and covered services are subject to change as the program progresses.
Brooklyn and Erie County represent the state’s highest number of Medicaid births and infant mortality rates per capita. Though maternal mortality affects all women, black women are 12 times more likely to die from pregnancy-related complications than white women in New York City, based on data from the city's Department of Health. Black mothers are three to four times more likely to die than white mothers, according to the Centers for Disease Control and Prevention. Birthing complications persist regardless of socioeconomic status, as illustrated by both Beyoncé and Serena Williams’ distressing stories last year about their own birthing experiences.
“Doulas, midwives and alternative health practitioners have long been a part of maternal and family health in communities of color," New York State Assembly Member Tremaine Wright said in a statement. She represents a district in Brooklyn where the program will be implemented. "Capturing these important practitioners in Medicaid repayment is a major recognition and will go a long way to increase healthy births.”
When Catherine Francis was expecting her daughter in 2016, she believed that doulas were “kind of preserved for Upper East Side or Jewish women,” but she decided to seek out low-cost support anyway. She hired a doula from Ancient Song Doula Services, an organization in the Flatbush neighborhood in Brooklyn, with a mission to empower pregnant women from marginalized communities and train providers to offer high-quality care to all patients, regardless of their ability to pay.
Francis described her birthing experience as "wonderful" and credited her doula for being supportive, but also objective. "It was helpful to have somebody to hold me accountable to what I wanted. Sometimes when you have people that are really close to you in those spaces, it can be easy to fall short."
Where the program could fall short for birth workers
Many doulas said their work is not highly profitable — they often take on a mix of well-off clients paying full price and low-income clients who pay what they can afford, and sometimes they work for free. The Medicaid reimbursements could help, but the billing process could be intimidating to doulas who are new to the system, and it may take as long as six months to receive payment for their services, said Ancient Song Doula Services founder Chanel L. Porchia-Albert.
“For the doulas who want to do the work in populations where individuals are receiving Medicaid, it may be something they can do maybe once a month, with the expectation that they aren’t going to get reimbursed right away,” Porchia-Albert said.
Simone Toomer, a full-time doula with New York City’s By My Side Birth Support Program, wants to ensure that doulas serving low-income communities are trained in how to serve families that may be coping with housing or food insecurity, which many Medicaid recipients do.
“We, as doulas of color, are sometimes getting the short end of the stick by wanting and having a passion to work within our own communities," Toomer said.
People gained awareness of the issue of maternal mortality after a wave of personal stories and news articles were shared on social media. Since then, interest in doula care has gone up. At Ancient Song, requests for services have skyrocketed. To keep up with community demand, they ramped up the number of birth and postpartum doula trainings that they offer year-round. Enrollment tripled, and, by December, they had trained 209 new doulas.
“Half the time we can’t even serve people because we don’t have the capacity to be able to do so, but we don’t turn anyone away,” Porchia-Albert said.
Porchia-Albert said that turnover has been high among doulas and that financial burden is often the given reason for stopping.
At the Brooklyn Birthing Center, the city’s last free-standing center of its kind, midwives regularly work alongside doulas from Ancient Song and other sources. But director of midwifery Trinisha Williams said that the Medicaid pilot program does not do enough for patients nor providers.
“It just needs a lot more work in order for us to really reach the people that we wanted to reach,” Williams said.