A Conversation About Doulas, Medicaid, and Effective Support Services

There are ways to improve maternal health outcomes. Research shows that doula care can support healthier pregnancies and contribute to better outcomes for mothers and babies. What are some ways that states can expand doula coverage for people on Medicaid?

These are all topics that Dr. Darrell Gray, president of Elevance Health's affiliate health plan in Maryland, and Dr. Tiffany Inglis, Carelon Health's national medical director for women’s and children's health, discussed in this recent conversation.

Listen to find out how these two leaders are working to support healthy pregnancies and babies — and how doula service can provide much needed support to pregnant people and even bring about measurable improvements in maternal health outcomes.
 

Full Transcript:

Intro

Welcome to Elevance Health. Today we're talking to visionary changemakers about how they're contributing to healthier communities and connecting people to the care and support they need to lead healthier lives.

Darrell Gray

Good morning, good afternoon, good evening, depending on the time in which you are listening. My name is Dr. Darrell Gray, and I have the pleasure of serving as chief health equity officer at Elevance Health. I'm here with Dr. Tiffany Inglis who is medical director of clinical programming and population health here at Elevance Health, and Tiffany has a special focus on maternal health. Tiffany, can you tell us a little bit about what you do and your team? And also can you define for us again what we mean by maternal health?

Tiffany Inglis

Thank you, Darrell for having me. It's a pleasure to be here and would love to start with the question regarding maternal health and defining that a little bit. It's such an important definition. We often hear the pregnancy and the delivery episode, and we don't think about the fact that that starts so much earlier and the care leading up to becoming pregnant through that pregnancy, through the delivery, and then into the postpartum space, which we know extends well into that year. And then also how much it means to the child from that pregnancy and incorporating that whole family's health as we enter that space of becoming a family unit. And then in our work, we focused so much the last couple years on understanding our pregnant population better, understanding the impacts of all of the parts of their health, how it impacts their pregnancy and the development of that family unit. And really valuing the understanding that all of the pieces have such an important role to play, whether that be behavioral health, physical health, social wellbeing, geographical location, all of the different pieces, parts, race, ethnicity, all of those things and their role in what happens and the experience as you go through pregnancy and into that family unit.

Darrell Gray

And Tiffany, last time we got together, we talked about some of the strategies that are really improving access and outcomes amongst pregnant people across the nation, and particularly through that continuum you were just speaking of in regards to maternal health. And one of those things we very briefly highlighted was utilizing doulas. Now, we didn't go into detail during our last discussion, so I want to give us the opportunity to expand upon that a little bit. Can you first start with telling us what doulas do?

Tiffany Inglis

Doulas are non-medical trained professionals who provide continuous educational, physical, emotional support to both women and their birth partners before, during, and after childbirth, right through that maternal health timeframe. And really it works to help those people achieve the healthiest, most satisfying experience possible. They really help to empower women. They really help to serve women, to learn how to find their voice and advocate for themselves and what they want from that pregnancy, and then also help them. The focus is often on self-care and understanding what those things mean throughout that pregnancy journey. And then I think there's a few different types of doulas. Community based doulas are really those doulas that are local to the community that pregnant people live in, and they really can help with cultural gaps, language, understanding what the social environment may be like, and then helping them to translate that into the healthcare system that can be confusing for so many people. And then really leading to outcomes associated with better engagement, better satisfaction, and then better outcomes. And that's really why we've focused on trying to improve access to doulas is understanding that this is a space where we can really, really impact positively those feelings we hear from so many women that are impacted, especially those women that are impacted by disparate outcomes in pregnancy.

Darrell Gray

And Tiffany, what I'm hearing you say is that doulas play an incredibly important supporting role to the care team in having that optimal outcome that is culturally relevant, that meets birthing people how and where they need to receive care to have that kind of optimal experience in childbirth. If I'm also understanding you correctly, doulas are not the practitioners who are delivering the baby, but they walk hand in hand with the birthing person throughout that journey. Is that correct?

Tiffany Inglis

Yes, that's a hundred percent correct. They're not the delivering providers, they're really the support person to help connect them to that delivery provider, whether that be a doctor or a midwife in that scenario.

Darrell Gray

Now, we at Elevance Health have conducted some really interesting research around doula care. Can you talk about that and what you found?

Tiffany Inglis

There's some national data that had shown that there's likely an improvement in outcomes with women who've received doula care. So we said, let's look at our own data and let's double click, I would say, into that area. And so what we did was we evaluated three programs across three of our markets and looked at the women who used doula services and how did it impact their pregnancy outcomes? And it was really interesting. So what we found was that they had a lower risk of C-section. They had lower risks of behavioral health diagnoses in the postpartum space compared to women with similar demographics, but who did not use a doula. And then there was a lower proportion of low-birth-weight babies. So those are babies that are born very small and often have needs in that immediate post-delivery space. And then they had lower NICU admissions for infants. So really showed extremely important impacts to both mom and baby when we wrapped that mom with supportive care, culturally relevant care, and give her the voice to really empower her to speak through her pregnancy. The interesting part is that the earlier our pregnant person was engaged with the doula — so those who engaged in the first trimester with doula and had that consistency through the pregnancy — had the largest impact on reduction of the risk of C-section. So again, confirms that it's that support and that understanding of the healthcare journey.

Darrell Gray

Whether or not a birthing person engages with a doula is often dictated in regards to reimbursement for those doula services. And not all states provide Medicaid reimbursement, for example, for doulas. How can that change?

Tiffany Inglis

I'm a doctor, not a policy expert by any means, but our public policy institute really took a look at that and they've identified different ways that states can move forward covering doula care within their Medicaid programs. And there are a few different options, and they've gone different pathways. One of those choices that the states can amend their Medicaid plans to allow non-licensed practitioners, such as doulas, to provide and be reimbursed for services if recommended by a physician or another licensed practitioner, another care provider. The second option would be the states can enact 1115 demonstration waivers, which can be used to test different benefit designs of new models for delivering care. This includes paying doula services. A third option states can use their managed care organization contracts to require doula services for beneficiaries or to pilot doula initiatives in specific regions. And then finally, one of the last choices, they can wrap doula coverage into a state federally required effort to improve the quality of healthcare delivery outcomes, population health. And this includes addressing health equities and maternal health, which we talked about. The data shows that the doula services do provide that. And then it also falls under a state's managed care quality strategy. So lots of different choices and varied choices, but they do have lots of options.

Darrell Gray

It seems like common sense somewhat. Given the positive impacts of doulas on outcomes, hospitalizations, healthcare costs, it just seems to make sense for doula care to be covered under Medicaid, don't you think?

Tiffany Inglis

I think it does, and it shows how much we can do by just providing people that support structure and when you just need to meet them where they are, provide that support structure. I agree. It just makes sense. Why wouldn't we do that?

Darrell Gray

Well, you heard it here first. Dr. Inglis, thank you so much. This has been such an enlightening and engaging discussion, and I hope our listeners are able to not only just hear and learn, but really to now be able to be proponents of this information to be champions in their networks, their circles, to be advocates for what we've been talking about today. Mainly our discussion this time has been around doula care and the opportunities to improve outcomes and advance health equity for our birthing people with utilization of doulas. Thank you so much for your time, Dr. Inglis.

Tiffany Inglis

Thank you so much. Have a great day.