The Massachusetts Medical Society (MMS) is a professional association of over 25,000 physicians, residents, and medical students across all clinical disciplines, organizations, and practice settings. The Medical Society is committed to advocating on behalf of patients, to provide them a better health care system, and on behalf of physicians, to help them provide the best care possible. In pursuing those ends, the MMS strives for health equity, advocating for vulnerable patients especially during time periods most critical to their health. H.1240/S.782 requires MassHealth coverage for perinatal doula services, which would include providing physical, emotional, and informational support, but not medical care, during and after pregnancy, labor, childbirth, miscarriage, stillbirth or loss. Establishing Medicaid coverage for doula services is an important step toward eliminating maternal health inequities and would improve the health and health care of such peripartum patients. Accordingly, and for the reasons below, the Medical Society wishes to be recorded in strong support of H.1240/S.782, An Act Relative to Medicaid Coverage for Doula Services.
The Medical Society is committed to combating the rise in maternal morbidity and mortality and the racial disparities therein. The United States has the highest maternal mortality rate among developed nations and is the only such country whose rate is on the rise, with a 26% increase in maternal mortality rates between 2011 and 2014. Racial disparities in maternal mortality are staggering, with African-American, Native American, and Alaska Native women dying of pregnancy-related causes at approximately 3 times the rate White women in the United States. Research has shown that these disparities persist, even when controlling for factors like income, prenatal care, and maternal age.
In Massachusetts, where a Black birthing individual is twice as likely to die from pregnancy-related complications than a white person, overall rates of pregnancy-associated mortality increased 33% from 2012 to 2014 alone, the most recent period for which data is publicly available. These disparities are seen in other aspects of maternal and infant health. Severe maternal morbidity (SMM) involves unexpected complications of labor and delivery that result in significant consequences to the birthing person’s health. According to the Massachusetts Department of Public Health (DPH), the prevalence of SMM nearly doubled in the Commonwealth from 2011 t0 2020, with Black non-Hispanic birthing people consistently experiencing the highest rates of labor and delivery complications among all races and ethnicities. While infant mortality in the Commonwealth, a state rich in public health history and innovative insurance reform, is among the lowest in the nation, that number belies pervasive disparities that exist across the Commonwealth. According to the Centers for Disease Control and Prevention (CDC), while Massachusetts has one of the lowest infant mortality rates (IMR) of 3.6 deaths per thousand live births in 2019, low-income communities and communities of color have IMRs that are nearly double the statewide average. In fact, rates of infant mortality among Black infants (9.5) were more than two times that of Whites, while Hispanic infant mortality rates (2.7) were 1.5 times higher than Whites, according to the most recent data available from DPH. We are long overdue in having policy change to address this in real, frontline ways.
The proposed legislation, H.1240/S.782, An Act Relative to Medicaid Coverage for Doula Services, is important for Massachusetts birthing persons. First and importantly, it provides coverage for a no-harm intervention that will reduce cesarean section and improve birth experiences. Second, it establishes a Doula Advisory Committee to work with MassHealth and the Department of Public Health (DPH), to establish competencies and a registry of certified doulas, which will be crucial to the success of the program. Importantly, this committee will also be charged with developing strategies to develop a diverse workforce which represents the diversity in our Commonwealth and addresses the issue of wage equity for these important members of the maternity care team. This bill will address doula support across the reproductive health spectrum and will bring the voices of those with lived experiences of all kinds of birth loss and birth harms to the conversation. While we as physicians may understand that we can provide compassionate care to our patients, doulas represent the community and culture with whom pregnant persons can relate and support people through reproductive trauma in different ways than physicians can. Doulas become part of our health care team, integrated with nurses and physicians and midwives and lactation counselors, but are different than each of us in those roles and offer something unique.
The first US doula study was published by the Journal of the American Medical Association in 1991 and demonstrated the unequivocal benefit of doula services. Thus, the evidence for doula care is not new. More recently, a Cochrane review in 2017 showed that women who experienced continuous labor support with a doula had a statistically significant reduction in cesarean sections, operative vaginal deliveries, and low five-minute APGAR scores. Moreover, birthing patients were less likely to report negative feelings about their birth. In light of these findings, the researchers found that doula care would not only improve health outcomes and patient experience, but would also likely be a cost effective intervention when the financial savings from reduced cesarean rates were realized. Additionally, in 2019 the American College of Obstetrics and Gynecology (ACOG) supported the use of continuous labor support as a tool to improve obstetric outcomes. In a joint statement with the Society for Maternal Fetal Medicine, ACOG noted that doulas were “probably underutilized” as a tool to reduce primary cesarean section rates.
It is uncommon for private or public insurance to cover this important service. As an out-of-pocket medical expense reaching $2,000 in many Massachusetts locations, most patients do not have access to doula care, exacerbating health disparities. Eleven states, plus the District of Columbia, are actively providing Medicaid coverage of doula services. In Massachusetts, it is time that our policies caught up with the evidence. The MMS commends MassHealth’s proposed rule change to regulate and cover doulas. However, without the passage of H.1240/S.782, there are limitations to what MassHealth can do on its own to foster workforce development for doulas and ensure certification of these non-medical professionals in a system designed for health care providers. Moreover, this legislation gives the Commonwealth an opportunity to guarantee a future of access to affordable and high-quality doula services for individuals with MassHealth coverage.
Several organizations including Cambridge Health Alliance, University of Massachusetts Medical Center, Boston Medical Center, Baystate Medical Center, and Mass General Brigham among others, have implementing programs to provide labor support to their birthing population. These programs should be available to all pregnant patients in the Commonwealth, regardless of their site of delivery. To spread best practice and sustain the programs already in existence, and to further work towards racial equity in maternity care, we must establish public coverage of doula services for MassHealth beneficiaries.
The twin pandemics of COVID-19 and racism have been devastating for Massachusetts families. As we recover from the traumas of these experiences, getting extra care and connection is more critical than ever. Our national shame of the racial inequities in high maternal morbidity and mortality, and high infant mortality requires transformational solutions. This bill is just one aspect of a larger set of policies that are needed to move us along the path towards a new standard of excellence in maternal and infant health in the Commonwealth. We therefore urge the prompt passage of H.1240/S.782, An Act Relative to Medicaid Coverage for Doula Services.
View a PDF version of this testimony here.
