To close racial and ethnic birthing outcome disparities, Medi-Cal is expanding access to maternal health services — most notably, doula care.
Doulas — trained professionals who provide physical, emotional and informational support to patients before, during and after childbirth — are essential to closing these disparities for parents and infants, as doula care can help improve birth outcomes and reduce C-sections, epidurals, premature deliveries, low birthweight, anxiety and labor length.
A maternal health overview
Alongside more doula care, first added to Medi-Cal in January 2023, newly expanded services include a birthing care pathway for members from conception through 12 months postpartum, dyadic care which serves the parent and child together, postpartum mental health treatment, licensed midwife services, culturally-specific community health resources and other benefits for pregnant members, including some over the Medi-Cal income limit.
Medi-Cal eligibility has also been extended from 60 days postpartum to 12 months postpartum, with premiums eliminated for families.
As Medi-Cal covers about half of all California births and nearly 5% of all U.S. births, this expansion is “transforming the maternal health landscape” statewide, said Erica Holmes, benefits division chief at the California Department of Health Care Services (DHCS). She spoke during a June 4 ethnic media briefing organized by EMS.
In California and much of the U.S., maternal disparities are starkest for Black mothers.
The California Department of Public Health (CDPH) reports that Black mothers are nearly four times more likely to die than white mothers from pregnancy-related causes and at a 1.7 times higher risk of preterm birth. Black babies are twice as likely to die before their first birthday as white babies.
CDPH data also shows that California’s 2020 maternal mortality rate was 18.6 deaths per 100,000 live births — a 45% increase from a rate of 12.8 in 2019, while the rate for Black mothers was three times higher than the rate for white, Asian, and Hispanic mothers.
The mortality rate for those with Medi-Cal in 2021, before the expansion of services, was 2.8 times higher than for those with private health insurance.
According to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, “one of the most effective tools to improve labor and delivery outcomes” — including reductions in pain, Cesarean deliveries, and labor length — “is the continuous presence of support personnel, such as a doula.”
“To reduce access barriers, Medi-Cal members now don’t need a separate, written referral to get a doula; they can use our regularly updated doula directory,” which includes ethnicities and languages spoken, to get care directly from doulas, who get the highest Medicaid reimbursement in the nation, said Holmes.
As of May 31, 2024, DHCS has approved 455 doula applications, with 336 of these being individual doulas, rather than group doulas.
Two doulas’ stories
“For so many years, in order to do the work, we had to focus on the outcome at the exclusion of the income, what we were investing,” said Kairis Chiaji, a doula for over 25 years who founded Children of the Sun Doula Project, worked a DHCS doula pilot program in Northern California and now works as a Medi-Cal doula in Sacramento.
By developing the doula benefit with DHCS through policy advocacy and implementation advice over the past two years, “we finally have the ear of state decision-makers to shift away from treating pregnancy as a pathology to be cured,” she continued. “To move our state into understanding that leveraging community relationships is crucial to maternal health, that pregnancy is just not the body producing a baby, disconnected to what comes before and after, is historic.”
Once an 18 year old man, in the hospital with a girlfriend with a baby, wasn’t feeling safe with the care they were getting,” Chiaji said. “I went, and immediately there was a shift. The questions they were asked changed, and that they were being asked at all. The dad’s role in his family was protector, but how do you protect someone when you don’t know what is supposed to happen or not?”
Over 80% of U.S. pregnancy-related deaths are preventable, she said, adding that “As a doula, we’re able to fill the gap by amplifying the voices of families, recognizing issues before they reach a crisis.”
“The origin of the Greek word ‘doula’ can mean ‘woman who serves’ or ‘slave,’ but we’re not slaves. We serve our community, and thanks to our great state, we don’t have to work for free,” Chiaji continued. “I witness miracles for a living … If you had asked me 10 years ago, if this would have been possible, I’m not sure I would have believed it.”
“One of the ways this is so unique to California is its focus on community care,” said Khefri Riley, co-founder and director of Frontline Doulas — serving over 700 families, mainly African American, through community programs in LA County — and a Medi-Cal provider who worked with DHCS to build doula services. “Having given birth on Medi-cal over 20 years ago, none of this was available then.”
“Doulas are likely to encounter families with socioeconomic hardships impacting perinatal health, but they also typically come from the communities they serve, and can connect them to the resources they need to prevent adverse outcomes,” she explained. “We cannot afford to have one more demise when it’s unnecessary.”
In one Frontline Doulas program, “we had a younger mother in transitional housing who was birthing alone and facing the threat of having her baby taken away,” Riley continued. “Our doula was able to help her avoid a Cesarean by voicing her needs to the health care team because the mother didn’t want to be on her back anymore … and we connected her to community resources so she could keep her baby and recover postpartum.”
“After we’ve given birth, we’re in such a vulnerable time; we still need to be taken care of,” she added. “While we cannot put this maternal health crisis solely on birth workers’ backs, what we can do is understand the evidence-based impact that doulas have by their very presence alone, by centering the voices of birthing individuals … that’s why this benefit is so historical.”
