Doulas push to make their services more widely available

When Maria Rossi started working with at-risk teens in Washington County almost two decades ago, she quickly spotted inequities that low-income pregnant people face in accessing prenatal and postpartum care.

As a caseworker at Washington County Mental Health Services, she had pregnant clients, many of whom were covered by Medicaid, the joint federal and state public health insurance program. She recalled encountering “enormous differences” between families who could afford to hire her as a private doula and the young people she was working with.

“That population just had no access at the time to childbirth education. They had no access to all of the sort of warm and fuzzy things that people with resources do like taking a yoga class. They often didn’t have transportation to their prenatal appointments,” she said in a recent interview. Many of them, she added, were in addiction recovery, requiring “a whole other layer of special care.”

Rossi saw a need for doula services and started offering some of the clients her services for free and soon pitched the idea of a special program to make such care available to at-risk and underserved people.

Today she runs The Doula Project, which has provided all Washington County families with free doula services since 2021 thanks to a mix of federal and grant funding. “People have just really been so grateful and happy to have the service here,” said Rossi.

Now, she is among those urging Vermont lawmakers to expand statewide access to doula services.

A bill to pave the way

Fourteen states have implemented Medicaid coverage for doula care and many others have efforts underway, according to the National Health Law Program’s doula Medicaid bill tracker .

Advocates have been pushing the state to provide Medicaid coverage for doula services for years. Prior efforts to provide the benefit in 2014 and 2019 failed.

A bill making its way through the Vermont Legislature this year made another attempt at doing so. In its original form, S.109 would have required Medicaid to pay for doula services, but the legislation has since turned into a study .

Doulas are non-clinical professionals trained to support pregnant people and their families before, during and after a birth. Doulas are not currently licensed or regulated in Vermont. The revised bill tasks the Office of Professional Regulation with exploring the process for professional certification or licensure, a federal requirement for Medicaid allocation. The report, due in 2025, could lay the groundwork for state regulation, legislators backing the bill explained.

Proponents of S.109 also see it as the first step toward the ultimate goal of requiring Medicaid to cover up to $850 for doula services.

The Senate passed the bill on March 13, and it’s now under review in the House Committee on Health Care. Its sponsors are optimistic it will pass this session.

One of those sponsors, Sen. Martine Larocque Gulick, D-Chittenden Central, told VTDigger she had a positive experience using a doula for herself years ago “so it was something that felt near and dear to my heart.”

“I was fortunate to be in a position of privilege and to have the financial wherewithal to afford a doula for both of my births,” Gulick said. “But I’m well aware that not everyone can do that.”

‘Work worthy of payment’

Those pushing for expanded doula services have made the case that doulas can play a major role in improving maternity care and addressing inequities in maternal and infant health outcomes – particularly for marginalized groups.

They brought research to lawmakers to support their case, citing, for instance, a 2023 study outlining how doulas help create to a more positive birth experience with better outcomes. Doula-assisted mothers were four times less likely to have a baby with low birthweight, two times less likely to experience a birth complication and significantly more likely to initiate breastfeeding. Beyond the birthing, research notes that doulas help connect families to essential social services such as housing, food assistance and transportation.

The United States outranks most other developed nations in its overall maternal mortality rate, at 23.8 deaths per 100,000 live births in 2000, versus single digits per 100,000 for comparable countries . That U.S. rate is significantly higher among Black people, more than double, according to the U.S. Centers for Disease Control and Prevention.

The country’s rate of maternal mortality — defined as a death during pregnancy or up to 42 days following its end — worsened during the Covid-19 pandemic. The CDC tallied 1,205 maternal deaths in 2021 , a 40% increase from the previous year and one of the highest since 1965, according to NPR .

Recent comparisons among the states found Vermont’s maternal mortality rate over time to be among the lowest , though the annual numbers are too small for that comparison to be statistically significant. According to the state’s Maternal Mortality Review Panel, Vermont recorded an average of two or three deaths each year since 2012, though the number also spiked during the pandemic, with six deaths recorded in 2022. The majority were directly related to substance use, according to data presented to Vermont lawmakers.

Advocates make the case that doulas are a cost-effective way to improve pregnancy outcomes. In Vermont, the services can cost from $1,200 to $2,000, depending on where one lives, according to Rossi.

That’s a fraction of the cost of a normal hospital birth without complications, which ranged last year from $9,771, in Morrisville to just under $25,240 in Burlington, or a cesarean birth which ranges from $20,276 in Morrisville to $33,762 in Burlington, according to spokesperson Rebecca Copans from Blue Cross and Blue Shield of Vermont. Those numbers reflect the total cost of care as paid by the insurer and the member.

BCBS of Vermont is currently running a pilot health equity program on doula-supported births with a goal of closing the gap on maternal health inequities, Copans said. The 30-person study will reimburse a participant up to $1,000 for expenses incurred to hire a doula.

Limited to BCBS members, the pilot has 10 spots for white people in a high-risk pregnancy (filled) and 20 for Black, Asian, Pacific Islander, or Hispanic people or refugees. Nine spots are still open, she said. It’s an effort to gauge if offering coverage for doula services would benefit the entire member population, according to a recent presentation .

Martha Churchill, the lead midwife at the University of Vermont Medical Center for 15 years, created a volunteer-run doula service for families there in 2019 and also provided testimony in favor of expanding and funding doula care, which she said is “largely mental health care.”

“Doula care is intimate, compassionate, educational and advocacy work,” Churchill wrote to lawmakers. “This work is worthy of payment and accessibility by everyone who desires it.”

‘A long way to go’

While the health care system is focused on medical decisions, “the piece that’s missing is human companionship and connection and safety and trust,” said Sarah Teel, research director at Voices for Vermont’s Children, who also provided testimony in support of S.109. “It’s very very common for birthing people to say that they’ve had traumatic experiences during childbirth,” she said.

The Covid-19 pandemic, opioid crisis and homelessness are affecting pregnant people and infants in tragic ways in Vermont, said Rossi. When people are bouncing between motels, don’t have consistent prenatal care or have high levels of depression or untreated perinatal mood disorders, even having a birthing plan can be a luxury. And that’s where doulas can greatly help, she said.

As a small state, Rossi thinks Vermont is positioned to set the stage for what good reproductive health looks like. From an equity standpoint, however, “Vermont does have a long way to go in terms of providing access to pregnant and parenting folks,” she said. “And this is a way to do that.”

The demand for doula support is robust in Washington County, she said, with 26% of pregnant people using The Doula Project last year, a percentage that “would be higher if we had more doulas,” she told lawmakers during a Jan. 23 hearing.

Geographic equity in doula access is also an issue, according to Rossi. Advocates for expanding services have said there are doula deserts in Rutland, Bennington, Windham counties and in the Northeast Kingdom.

Among the 147 Washington County families that The Doula Project has served since 2022 is Sage Rollins, 25, who delivered her second child two weeks ago.

The Montpelier resident said she used doulas for both her pregnancies.

They helped her with making plans, securing rides, going out to get stuff she needed at home, finding parent groups, bath time and using pressure points to lessen pain during labor. They even had a donation system going for things new parents may need, such as car seats.

Her first pregnancy was scary, Rollins recalled, and the extra support from her doula helped her feel “that everything was going to be OK.”

She started working with a doula a couple weeks into her second pregnancy and is still working with one postpartum. “Everything actually went really well,” she said. “They’re there just to listen and be another support.”

Read the story on VTDigger here: Doulas push to make their services more widely available .