More Washington companies offer doula services in health benefitsFree

For a small but increasing number of Washingtonians – including, possibly, people covered by Medicaid – doulas at birth could be covered by their medical insurance. Doula support has become increasingly recognized as a way to improve birth outcomes and equity in pregnancy care. But advocates say universal access remains a far-off goal.

A few major employers now offer doula coverage as a paid benefit, and – after a push from a coalition of local birth workers – Medicaid reimbursement is in the works for Washington. Birth-justice advocates say more reforms in access to doulas are needed to offset medical racism and undo the harm of long-standing health inequities.

In October, Walmart, the nation’s largest employer, began offering a doula support benefit to almost all its employees, including more than 20,000 in Washington. Microsoft is also piloting a doula benefit through Premera Blue Cross, available to employees in King and Snohomish Counties.

“For us, a company supporting doula access is a step in the right direction for supporting pregnant people,” said Rokea Jones, community engagement specialist with Open Arms Perinatal Services, which offers doula support and community education resources to pregnant and parenting people throughout King, Pierce and Snohomish counties. But the ultimate goal, she said, is even more expansive and inclusive access.

According to leading doula certification organization DONA, a doula is “a trained professional who provides continuous physical, emotional and informational support to their client before, during and shortly after childbirth to help them achieve the healthiest, most satisfying experience possible.”

For too long, said Jones, a doula herself, access to doula support has been framed as a privilege or additive service. Jones says that’s a myth.

“When really, as long as there have been people birthing, there has been someone to support them.” For clients navigating birth, she said, “I’m that sister, neighbor, friend, cousin, auntie that is trained in this work, but it’s also really, really here to hold your hand and walk you through this process.”

For Jones, birth is “a rite of passage.” For doulas, “It’s a part of life that we show up to support and to make sure that people come out on the other side whole and ready for this new identity that they carry.”

Research shows that having access to one can improve birth outcomes – which is especially critical for people of color, who face disproportionate rates of maternal mortality. “We believe that everyone should have access to a doula, whether or not they can pay, or whether or not a company’s able to provide it,” she said.

This support has the potential to save lives, and to ameliorate long-standing racial disparities in maternal and infant mortality. In the U.S., Black and Alaska Native and American Indian women face disproportionate rates of pregnancy-related death, and in Washington, they’re more likely to give birth to babies of low birth weight. Doulas in the Pacific Northwest have provided new parents a greater sense of control over their own care as well as ballast against medical racism, said Jones.

“Particularly in my practice, I often remind families, ‘Hey, you are the primary member of your care team,’” she said. “‘You get to make the decisions here. Yes, our medical providers are trained. This is their specialty, so to speak. They’ve spent many years learning this situation, but you know your body best.’”

The benefits of this kind of advocacy are well-documented. The American College of Obstetricians and Gynecologists, the nation’s leading professional organization for obstetrician/gynecologists, recommends the presence of a doula or other support person as one way to limit the need for interventions during birth.

In a 2019 review of clinic evidence, the group found that support people like doulas helped people have shorter labors, better pain management, fewer assisted vaginal births, and greater satisfaction among patients with their birth experiences.

Despite the financial and health advantages of access to doulas, it’s still rare for companies to provide it in their medical coverage. But as the police killing of George Floyd in 2020 sparked demands for reform of many systems through the lens of racial justice and equity, medical coverage for doula support has been seen as one way to address health inequities. According to the Centers for Disease Control and Prevention, Black women are almost three times more likely to die from a cause related to pregnancy than white women. Research posted by maternity care advocacy group Every Mother Counts showed that the presence of a doula improves pregnancy outcomes and can therefore help reduce Black maternal mortality and other perinatal racial disparities.

Some companies have explicitly framed their new maternity policies in terms of equity. When in March 2021 CVS announced a new paid doula benefit for its employees of up to $1,200 a year, the health care and pharmacy chain overtly stated that its new coverage option was “an outgrowth of CVS Health’s work to help solve disparities in maternity care.” Melinda King, a doula employed as a nurse with CVS, told the company in a blog post that she hoped the benefit would ensure a greater sense of agency for Black women navigating pregnancy and birth.

Microsoft also introduced that benefit in 2021, according to The Washington Post. A spokesperson for the software company declined to be interviewed by Crosscut for this story, but confirmed that the benefit covers a $1,000 reimbursement allowance for doulas through Microsoft’s Health Connect Plan, which is available to employees in the Puget Sound region.

When Walmart announced its doula support benefit in October, it became the largest employer nationwide to offer one. The retailer is the biggest employer in the U.S., with over two million employees, 23,231 of whom work in Washington. (By contrast, CVS employs 300,000 people nationally, putting it closer in scope to Microsoft, which employs just over 220,000.)

Before launching its national benefit, Walmart offered it to employees in Georgia, Louisiana and Illinois as a pilot. A health plan that gives access to doulas is now available to most of the retailer’s employees, with the exception of those in Hawaii. Walmart covers up to $1,000 for doula services during pregnancy. Walmart vice president of physical and emotional wellbeing Lisa Woods said on the company’s website that she hoped it would help employees who live in areas where maternity care access is in short supply – or nonexistent. “Doulas are especially important in health care deserts where access to care may be limited,” she said. These deserts could grow as maternity care units shut down in states like Idaho in the fallout from Dobbs v. Jackson Women’s Health.

Medicaid access in Washington

Birth advocates in Washington have also made progress on trying to ensure access to doulas for low-income Washingtonians. The Doulas for All Coalition, which is led by queer, trans, Black, Indigenous, and people of color birth-justice advocates, has pushed for and taken steps toward getting Medicaid reimbursement for doulas, which would extend access for more than half of births in the state. Over the summer, the coalition – which includes Open Arms – started working with the state Department of Health to create a credentialing pathway for birth doulas, the first step toward reimbursement under Medicaid. The coalition has plans to lobby for additional legislation, including budgeting consideration, this winter. If passed, enrollments could start by summer.

But even with possible Medicaid reimbursement in the future and a handful of corporate plans broadening access to doula support, a wide swath of Washingtonians will still have to pay out-of-pocket. And in other states without strong resources for doulas, many are doing their work for free. “A lot of folks in between are trying to figure this thing out,” said Jones.

There are few examples of how mainstream insurance and health care systems can incorporate doula support, which is highly individualized and often culturally specific. Still, said Jones, the evidence is clear, and medical and systems can and do catch up. “We have enough research,” she said. “We have enough science to know that there are some things that just work. And so if we can understand that, our systems are there trying to get it right.”

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