Health Insurance and Doulas

By the end of 2024, 23 US states and the District of Columbia were providing Medicaid insurance coverage to enable expectant mothers to use doula services, and most of the remaining states were running pilot projects or considering doula coverage¹. In the US, Medicaid is a safety net insurance program that covers people who have low income, and is designed to help people that are elderly, disabled, or pregnant. Medicaid is administered at the state level, hence Medicaid programs can vary quite a bit across the country. About 1 in 5 adults relies on Medicaid to cover health insurance costs, and 41% of all births in the US are covered by Medicaid².

The word “doula” comes from the ancient Greek word for “female servant” or “female slave.” Nowadays, the word doula describes a support partner for a pregnant person. Doulas provide a wide variety of services that are educational and supportive, and help mothers to advocate for the birth that they want³.

A doula is not another type of midwife, this is an important distinction. A midwife has the medical training to deliver babies when there are no serious complications that require an obstetrician. The service of a doula is not a medical role, it is a supportive role. Your doula will be there for you throughout your pregnancy and the post-partum period, not just in the hours around birth. This can be especially important in healthcare systems where the mother does not know which doctor or midwife will be on shift when the delivery happens; your doula is a constant presence who will be there for you.

Studies have shown that expectant mothers who work with doulas have better birth outcomes. For example, the published results of a pilot study that enrolled 1809 mothers in Brooklyn, New York, found that mothers working with doulas had much lower chances of preterm birth (5.6% vs 11.9% of controls, P<.0001) and notably fewer babies of low birthweight (5.8% vs 9.7% of controls, P=.0031)⁴. In state after state, pilot studies that provided doula support for moms on Medicaid have shown multiple health benefits, such as a 40% reduction in C-section births, 10% reduction in the use of pain medications during labor, and 20% higher adoption of breastfeeding⁵.

Clearly doulas have many benefits, but what is the cost to benefit aspect of doula services? Mothers who are not enrolled in programs that provide free doula support can expect to pay between $1500 and $2000 out of pocket for doula services⁵. However, from the perspective of Medicaid, doula services literally pay for themselves in terms of lower medical bills, especially fewer bills for medical emergencies. For example, the reduction in pre-term births (defined as birth before 37 weeks gestation) saves $41,964 in Medicaid payments per birth⁵. And that is just one type of complication which can be prevented or ameliorated with doula support. When you add up all the healthcare savings thanks to better outcomes for the 1.5 million births covered by Medicaid (in 2021), doulas can save Medicaid over $2 billion per year⁵.

The question really becomes, not why is Medicaid paying for doulas, but why aren’t all private health insurance plans paying for doulas?

The National Health Law Program (NHeLP) has the most comprehensive and up-to-date state database on Medicaid coverage of doula services¹. More expectant parents should be more aware of the benefits that doulas can provide. Like cord blood banking, doula services are an optional add-on to the birth experience that can provide peace of mind and facilitate access to more treatment options.

Despite their undeniable success, the Medicaid doula programs could stand to be improved in some ways. One problem is that there are no national standards for licensing doulas. Several states are setting up their own certification programs for doulas that are authorized to work with their state Medicaid program⁵. Another problem area is the reimbursement paperwork for covered Medicaid services, which can be a headache for doulas to navigate⁶.

On the horizon, the big unknown is how the Trump administration’s drastic cuts to federal spending will impact Medicaid health insurance in general. While Medicaid is administered at the state level, over half the funding for Medicaid is supplied by the federal government. The federal contribution is largest in those US states with the lowest average income: Mississippi gets 77% of its Medicaid funding from federal support, and Medicaid covers 57% of births; in Louisiana the federal support for Medicaid is 68% and Medicaid covers 61% of births^7,8.

The Republican political party wants to cut billions of dollars from federal support for Medicaid⁹. One proposal is to simply cap the federal funding given to states, regardless of the needs of state residents. Most possible scenarios converge on the conclusion that many people will lose Medicaid health insurance. Downstream, this will also impact doctors and hospitals that serve poor communities, driving them out of business and creating healthcare deserts^10,11. It remains to be seen if the Medicaid doula programs survive these budget cuts.

References

1. NHeLP’s Doula Medicaid Project: Current State Efforts at Expanding Access to Doula Care. National Health Law Program. Accessed 2025-02-20
2. Rudowitz R, Burns A, Hinton E, Mohamed M. 10 Things to Know About Medicaid. Kaiser Family Foundation. Published 2023-06-30  
3. Sprague B. What is a doula anyway?!? Parent's Guide to Cord Blood Foundation Newsletter Published 2013-09
4. Thomas MP, Ammann G, Onyebeke C, Gomez TK, Lobis S, Li W, Huynh M. Birth equity on the front lines: Impact of a community-based doula program in Brooklyn, NY. Birth Issues in Perinatal Care. 2023; 50(1):138-150.
5. Eastburn A, Hubbard E, Mitchell A. A Cost-Benefit Analysis of Doula Care from a Public Health Framework. National Health Law Program. Published 2024-01
6. Rubin B. Now Reimbursed by Medicaid, Doulas Adjust to a More Complicated Future. Medium. Published 2024-09-23
7. Peter Peterson Foundation. How Do States Pay for Medicaid? Health. Updated 2024-02-05
8. Kaiser Family Foundation. Medicaid State Fact Sheets. State Health Facts. Published 2024-08-14, but data on Medicaid births date from 2022
9. Emerson J. The states that would be the hardest hit by Medicaid cuts. Becker's Healthcare. Published 2025-02-26
10. Nguyen A, van Meijgaard J, Kim S, Marsh T. Mapping Healthcare Deserts. GoodRx. Published 2021-09
11. Kane A. My Firing Represents the Death of Public Service. Medpage. Published 2025-03-07