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Center suggests policy changes that could reduce Missouri’s high maternal and infant mortality rates and racial disparities

Written by Kim Furlow, communications manager for the Institute for Public Health

A new policy brief published by the Center for Health Economics & Policy at the Institute for Public Health reports that the state of Missouri has below-average outcomes for maternal and infant health as well as significant racial disparities. The brief cites emerging research shows that doula care can help reduce these outcomes; however, doula services are not currently funded through Medicaid in Missouri.

“If their work could be reimbursed by Medicaid in a way that facilitates flexibility and retains the strong connection to community,” says the brief’s lead author, Ethan Bradley, “we could see an impact on Black maternal and infant mortality, newborn intensive care admissions, and other metrics.” 

The center has collaborated with area doula service providers and WashU colleagues to publish recommendations addressing these issues in “Medicaid Reimbursement for Doula Services: Definitions and Policy Considerations”. The idea of a brief on this topic stemmed from a pair of Transforming Healthcare in Missouri meetings in Summer/Fall 2021 during which health care providers, researchers, economists, and policymakers convened to generate and discuss ideas for Medicaid maternal health policy reform. The brief itself aims to “explain the opportunities provided by doula care, summarize the current training and credentialing options of doula organizations in Missouri, and identify policy considerations.”

Doulas are trained professionals who provide continuous support to mothers and families before, during, and after childbirth. Research is cited showing that doulas are beneficial for improving the health outcomes of mothers and infants; however, “the challenge for authorizing Medicaid payment for doula care is that this form of care operates outside of traditional clinical provider organizations.”

Co-author Okunsola M. Amadou, CPM, founder and CEO of Jamaa Birth Village, champions what she terms Culturally Congruent Community Based Doulas (CCCD), a “non-traditional” doula, who supports mother and family improving their overall well-being as a unit. According to Amadou, CCCD’s “enter care from a holistic perspective addressing root issues related to systemic and historical social determinants of health, which have ripple effects from mother to baby and the family”.

The brief leverages the expertise of Amadou and co-author Hakima Payne, MSN, RN, CEO of Uzazi Village, both of whom provide regional doula training and services. Of particular significance is research citing that Black women are four times more likely to die of a pregnancy-related cause than are white women (88 deaths per 100,000 live births.)   Asked about disparities witnessed through her work, Amadou notes that “community-based doulas are working for little to no pay because they want to support pregnant people in their community, being disrespected in hospital settings by providers who refuse to acknowledge them and honor them as professionals.” The two experts explain how community-based doulas follow “a multifaceted approach that empowers women of color, mitigating discrimination, racism, loss of autonomy, and preventing other harms to communities that have been neglected by the medical system.”

“The key point that I’d like policy makers to take away from this [brief] is that pregnant, low-income and marginalized people deserve access to doulas,” says Amadou. “And the doulas who serve them deserve to be paid their worth.”  Payne adds, “It’s important to issue this brief now because our state [policymakers] are having conversations now about how doulas should be compensated for their work. We want to ensure that the voice of community is represented in those conversations.”  She and Amadou have concerns that without their participation, conversations will continue to center white-led doula organizations that, according to Amadou, “just tag on diversity statements” without recognizing that Black-led doula organizations have developed a specific curriculum based upon their expertise in tackling racial disparities. Payne also notes the importance of avoiding policies that would result in “burdening [doulas] with restrictions and heavy regulatory barriers.”

The policy brief acknowledges that five states currently reimburse for doula services in their Medicaid programs: Maryland, Florida, New Jersey, Minnesota, and Oregon.

Lead author Bradley, a Brown School MPH candidate, says the brief recommends that Missouri Medicaid create a doula reimbursement model which prioritizes local, community-based, culturally congruent doulas in its reimbursement structure; and, that Missouri’s managed care organizations develop closer relationships with the doula organizations leading this space in order to understand how to facilitate their growth.

In addition to Bradley, Payne and Amadou, co-authors include Abigail R. Barker, PhD, and Jesse A. Davis, MD, MBA. Read the brief. The Center for Health Economics and Policy at the Institute for Public Health advances evidence-based research to improve health and work with policy makers and public health leaders to drive more equitable health policy. Read more center policy publications.