Michigan Medicaid to reimburse for doula services starting in 2023

By Sarah Rahal, Detroit News / November 27, 2022

One of the biggest mistakes a pregnant woman can face is going to the hospital too early, but doulas like Kirsten Johnson can help.

"It starts a bit of a clock with some providers or staff. After hours of being there with no change in dilation, they start talking about inducing to move things along. From a medical standpoint, they want to get the show on the road," said Johnson, co-founder of Detroit Doulas. "Doulas consider these scenarios and help determine when is best to go because the alternative can be a slippery slope that can lead to mental traumatization from the experience."

Starting next year, Michigan Medicaid will begin reimbursing for doula services and create a division to support doula workers, which leaders hope will positively affect social determinants of health, and decrease health and racial disparities in the state.

Doulas are trained to provide non-clinical emotional, physical and informational support to pregnant women and their families before, during and after birth. Doula support is a safe and cost-effective intervention to improve birth outcomes, said Dawn Shanafelt, director of the Michigan Department of Health and Human Services' Division of Maternal & Infant Health, who is leading the initiative.

Research, which has been supported by the American College of Obstetrics and Gynecology, and the Centers for Disease Control, have shown that doula services may reduce infection and birth complications, decrease medical intervention including Cesarean delivery, shorten labor and producing healthier babies and healthier moms.

"But in Michigan, we don't have equitable access to doulas. To correct that, the Medicaid reimbursement will go into effect in 2023. Otherwise, accessing doula care requires paying out of pocket or finding one working under a grant, which is really limited," said Shanafelt. "With the inequities that exist and are apparent in our data across the board, it is essential that we have this. It's a great step forward."

Michigan Medicaid will begin reimbursing for doula services provided to individuals covered by or eligible for Medicaid Insurance and doulas eligible for reimbursement must be Medicaid-enrolled and listed on the MDHHS Doula Registry.

Doula services can range from $700 to $2,000, depending on the duration and extent of services, and Medicaid reimbursements will be adjusted based on individual health claims. The reimbursement means more women will be eligible for service, especially in areas of Michigan where the birth rate lags.

"When you look at the statistics, Black infants are 2.6 times more likely to die in Michigan in their first year of life than White infants," said Farah Hanley, Michigan's chief deputy director for health. "Our maternal mortality rates are 4.5 more times higher in Black women than White, and to address this, we've proposed doulas as a Medicaid benefit."

Meanwhile, the state health department is launching the Doula Advisory Council to inform the advancement of doula services in Michigan.

Those interested in serving on the council will advise the state on policies, applications and resource documents with the goal of making doula services accessible to families and increasing the Medicaid enrolled doula workforce. It will work to expand the workforce by creating opportunities for individuals statewide to receive approved doula training. Advisory council members will work on education content and offerings to benefit the state's awareness of doula services and promote access to doula care.

The Michigan Doula Advisory Council will include representation from doulas across the state. Priority will be given to developing a diverse council membership that represents various communities and settings.

To be considered for appointment to the council, applications must be submitted to MDHHS-MIDoula@michigan.gov. before 5 p.m. Dec. 15.

Hanley recently attended the National Association for State Medicaid directors conference in Washington, D.C. There, she said, several states were making strides toward doula equity.

"In fact, there are 33 I think of our 56 Medicaid programs, including the states and territories where we have expanded that 12-month postpartum coverage, a lot of them are doing lot of things we did, which is building off of the Medicaid benefit," Hanley said.

The state health department is also hiring two doula specialists to serve different geographical focus areas. Both positions will work in the Division of Maternal and Infant Health with internal/external partners to increase equitable access of doulas to Michigan families covered by Medicaid.

Doula specialists will develop and maintain the registry of Doula Medicaid providers; develop, coordinate and promote doula training programs to increase access to certified and trained doulas and educate the public and professionals on the benefits. Lastly, they will support and coordinate the Doula Advisory Council to engage maternal and infant stakeholders and coordinate doula services in Michigan.

For every 1,000 Michigan live births, more than six infants die before reaching their first birthday, according to the state health department. Michigan experienced a significant decline in infant mortality during the early 1990s, but during the 2000s the infant mortality rates remained around 7.9 deaths per 1,000 births. The total number of Michigan infants who died between 2010-2020 was 8,324, or 700 deaths in 2020 alone.

Along with the statewide statistics, medical leaders will be keeping a close eye on Detroit, which has a struggling infant mortality rate.

From 2013 to 2019, the infant mortality rate for Black infants in Detroit worsened, while the infant mortality rate for white infants improved. Detroit’s infant mortality rate plunged from 16.7 deaths per 1,000 live births in 2018 to 11 per 1,000 live births in 2019, representing a one-third rate reduction.

They also noted a promising closing of the disparity between Black babies and white babies dying before their first birthday. In 2018 the rate was 18.9 per 1,000 for Black babies compared to 6.4 for white babies. In 2019, that gap closed dramatically with a rate of 12.3 for Black babies and 9.7 for white babies.

Birth Detroit works to connect families to a doula, regardless of their ability to pay for one, but that effort is challenging to cover and unsustainable without support, said Elon Geffrard, co-founder and program director of the maternal health practice.

"Doulas don't just coach a person through labor. Doulas remind parents of their rights as a human. Doulas help families find the best care options for them," Geffrard said, "including the factors that create safer pregnancy and birthing conditions."

Why is it different?

Doulas work with mothers months ahead and the weeks leading up to the birth, provide the mother with all of her options, including at-home, at a birthing center, and/or unmedicated births. Doulas are not the alternative to a hospital staff but provide physical and emotional support aimed at preventing distressing situations.

Johnson of Detroit Doulas took her first doula courses at Lifespan Doulas, a training school based in Ann Arbor, and joined forces in 2019 with a classmate, Alexandria Idziak. Together, they launched Detroit Doulas in February 2020. They had only a handful of clients before the pandemic lockdown but by the end of that summer, business became busy and that has continued since, she said.

"If you are wanting an unmedicated birth and you are in a space that is set up for that, it changes how you are approached by the medical staff. If you have a doula, there's a stark difference," Johnson said. "In the last few years I've seen that medical staff are now treating doulas as assistants rather than being in the way. Hopefully, this acknowledgement and outreach will allow more good collaborative experiences."

So far, Johnson and Idziak have assisted in 25 births this year with another seven scheduled. One of the biggest mistakes they help mothers avoid is going to the hospital too early.

Doulas improve informed consent because "People have more choice than they realize," Johnson said.

"The experience can be very overwhelming. I remember having my daughter in 2013 and from the moment I arrived, I had dozens of questions and the nurse wasn't always around. I can only imagine how often I would have been hitting my hospital button to ask questions because you don't know what's normal," she said. "Without my doula, I would have been the most annoying patient."

Locally, the Southeast Michigan Perinatal Quality Improvement Coalition, which represents the city of Detroit and Wayne, Oakland and Macomb counties, focuses on addressing inequities. The coalition has been utilizing doula services for a while, Shanafelt said. Other organizations providing doula services for a long time include Black Mothers' Breastfeeding Association and Focus: Hope. Volunteer groups, where many people receive their first trainings, include Southeast Michigan Doula Project and New Beginnings Advocacy and Doula Services. The state expects to partner with them to spread the word.

"Creating more opportunities for individuals to have a doula of their choice reimbursed will make doulas the integral members of perinatal health they should always be," Geffrard said.