Heartache in the Heartland

Postpartum depression and other perinatal mood and anxiety disorders may indirectly drive maternal mortality through suicide and substance use,¹²Heck et al., “Maternal Mortality Among American Indian/Alaska Native Women: A Scoping Review.” highlighting the need for more accessible doula care for Oklahoma women.

This fall, the Centers for Medicaid and Medicare Services and Child Health Insurance Program approved the reimbursement for tribal traditional healing provided by Indian Health Service facilities in Arizona, California, New Mexico, and Oregon.¹³Centers for Medicare and Medicaid Services, “Biden-Harris Administration Takes Groundbreaking Action to Expand Health Care Access by Covering Traditional Health Care Practices.” Including doula care services and Indigenous doula care, this groundbreaking change will expand access to doula care to improve healthcare quality and outcomes for Indigenous women. Similar programs are needed in Oklahoma, where we have one of the highest populations of Indigenous people in the nation.¹⁴Sanchez-Rivera, et al., “Detailed Data for Hundreds of American Indian and Alaska Native Tribes.”

The U.S. Department of Health and Human Services and the Health Resources and Services Administration recognized the clear advantages of community-based doula services by providing 4.5 million dollars for hiring, training, certifying, and compensating community-based doulas in fifteen states, not including Oklahoma.¹⁵U. S. Department of Health and Human Services, “Health Resources and Services Administration Announces Availability of New Funding to Support Community-Based Doulas.” While these programs break down barriers to doula care in other states, there remain many barriers to accessing affordable doula care in Oklahoma.

A major barrier is cost. Though SoonerCare, Oklahoma’s Medicaid insurer, and TriCare, insurance for military families, reimburse doula care, most other insurers do not.¹⁶Oklahoma Healthcare Authority, “Doula Services.” While insurance reimbursement is helpful, doulas need specific skills to apply for reimbursement and deal with insurance bureaucracy. Many doulas run their own businesses and may not have this skill set, making reimbursement difficult. Additionally, the rate is often lower than what doulas receive through self-paying clients.¹⁷Roux, “Issue Brief, Expanding and Diversifying the Doula Workforce: Challenges and Opportunities of Increasing Insurance Coverage.”

In addition to reimbursement issues, other barriers to accessing doula care abound. Families are not always familiar with the doula role and the services provided and may not know how to access doula care. With many maternity care deserts located in the Midwest,¹⁸Knocke, et al., “Doula Care and Maternal Health: An Evidence Review.” many Oklahoma families lack access to maternity care¹⁹March of Dimes, “Maternity Care Desert.” which may include doula care. This lack of exposure to doula care, as well as a lack of awareness about doulas in general, contribute to inaccessible doula care for pregnant and/or parenting families.

Birth providers and hospital systems are often unfamiliar with the doula role.²⁰Roux, “Issue Brief, Expanding and Diversifying the Doula Workforce: Challenges and Opportunities of Increasing Insurance Coverage.” Doulas are not typically hospital staff and may face barriers to the implementation of doula care in a system unfamiliar with their services. Nurses and other hospital staff may not be familiar with the doula role and may be resistant to doula care.²¹Darvish, et al., “What do Community Doulas Think About the Future of the Doula Workforce?” Sadly, many nurses and hospital staff may create a difficult working environment for doulas.²²Kang, et al., “Characterizing the Utilization of Doula Support Services Among Birthing People of Color in the United States: A Scoping Review.”

Additionally, it is unknown how many doulas are currently working, how many doulas are needed, and the geographic distribution of doulas in Oklahoma. This lack of tracking doula-related data potentially creates another barrier to doula care through lack of availability and awareness. Comparatively, this barrier is a non-issue in many other states. Therefore, the Oklahoma doula workforce, and other healthcare-related workforces, should start gathering data.
Much work is needed to address maternal mortality in the heartland. Action is needed in the individual, community, system, and state levels. The health-related benefits of doula care can be seen on all levels and is one factor that can potentially improve maternal mortality. Innovative ways to raise awareness, improve access, and breakdown barriers to doula care are needed, and to do so, advocates in the heartland must take a multilayered approach. Table 2 outlines our recommendations. Using a multilayered approach will raise awareness, improve access, and breakdown barriers to doula care and ultimately improve maternal and infant/child health outcomes.