{"id":58956,"date":"2023-07-19T15:00:22","date_gmt":"2023-07-19T22:00:22","guid":{"rendered":"https:\/\/lapost.us\/?p=58956"},"modified":"2023-07-19T15:00:22","modified_gmt":"2023-07-19T22:00:22","slug":"benefits-of-medi-cal-coverage-uncertain-for-doulas","status":"publish","type":"post","link":"https:\/\/lapost.us\/?p=58956","title":{"rendered":"Benefits of Medi-Cal Coverage Uncertain for Doulas"},"content":{"rendered":"
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By<\/span>Selen Ozturk<\/a><\/div>\n<\/div>\n<\/div>\n
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Doulas in California are divided as to the benefit that inclusion in Medi-Cal can offer them.<\/p>\n<\/div>\n<\/div>\n

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A pregnant woman with a doula.<\/figcaption><\/figure>\n<\/div>\n<\/div>\n
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While policymakers have championed the Medi-Cal Doula Services Benefit, the benefits of inclusion for doulas are ambiguous.<\/p>\n

The program, which went into effect on January 1, 2023, provides families enrolled in the state\u2019s Medicaid program with the services of a doula, a trained non-medical professional who provides physical, emotional and informational support to clients before, during and after childbirth.<\/p>\n

Doulas throughout California \u2014 the vast majority of which work independently for uninsured pay \u2014 are mixed, however, as to whether and how much participation in the low-income health insurance program helps them provide this support.<\/p>\n

Juliana Birnbaum, a Marin County doula who has practiced since 2012, said that this systemic inclusion of birthwork eases the central challenge that her clients face: accessibility.<\/p>\n

\u201cUp until this Medi-Cal change,\u201d she said, \u201cpeople had no choice, unless there was a volunteer program available at the time of labor, but to pay doulas out-of-pocket. This is made harder by the fact that doula relationships start ideally before labor, in the second trimester. Because hospital care is based on shifts, you rarely have someone with you from the beginning through the end.\u201d<\/p>\n

Though fees are often out-of-pocket,\u00a0doula care saves<\/a>\u00a0$58.4 million from the $26.2 billion ($51,600 per baby) spent on preterm delivery in the U.S., and prevents 3,288 preterm births annually.<\/p>\n

When a hospital system does not prioritize the birthing patient through continuity of care, Birnbaum continued, \u201cit can be in the interest of care providers to suggest interventions to make a profit. But in a costly intervention like a C-section, too, there can also be risky outcomes, especially when it\u2019s left to whoever happens to be on-call when a woman gives birth, rather than to an advocate for their interests.\u201d<\/p>\n

Rising maternal mortality rates<\/h2>\n

This neglect can often be fatal: California Department of Public Health\u00a0data<\/a>\u00a0shows that California\u2019s 2020 maternal mortality rate was 18.6 deaths per 100,000 live births \u2014 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.<\/p>\n

Although Medi-Cal funds over half of California births and nearly 5% of all U.S. births, the\u00a0mortality rate<\/a>\u00a0for those with Medi-Cal in 2021 was 2.8 times higher than for those with private health insurance.<\/p>\n

In light of this, the benefits of doula care are well-supported: the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine\u00a0report<\/a>\u00a0that \u201cone of the\u00a0most effective tools to improve labor\u00a0and delivery outcomes\u201d \u2014 including reductions in pain, Caesarean deliveries, and labor length \u2014 \u201cis the continuous presence of support personnel, such as a doula.\u201d<\/p>\n

Lack of training<\/h2>\n

Nevertheless, the incorporation of this support in Medi-Cal may hinder it, says Neri Life Choma, who operates San Jose-based birth support center Birth Coach Method and has been practicing since 1999.<\/p>\n

For one, no universal doula training system exists. California does not require doulas to earn a certificate; Choma estimates that most work without one. In place of a certificate,\u00a0Medi-Cal allows doulas<\/a>\u00a0to enroll through five years of experience and three letters of recommendation from licensed providers, community-based organizations, or enrolled doulas.<\/p>\n

This lack of a requirement for hospital-adjacent training may oppose doulas \u2014 and their clients \u2014 to the system intended to aid them.<\/p>\n

\u201cIn Israel, where I trained, you worked for a year, 100 hours of hospital shifts. Here you can be done in a few weekends, maybe online. At the hospital there\u2019s no culture of teamwork in place, you may be intimidated from the start,\u201d Choma said.<\/p>\n

\u201cI see the result often in recently trained doulas,\u201d she added. \u201cThey position themselves as the resistance to the medical system, and their job is to rescue their clients from it. But this instills fear, not empowerment. I don\u2019t tell a mother that her providers don\u2019t have her best interests at heart but examine how her providers\u00a0are<\/em>\u00a0contributing to her wishes and values.<\/p>\n

\u201cPatient-centered advocacy is not done through resistance but collaboration,\u201d she continued. \u201cIf a client wants something, I ask: \u2018How comfortable do you feel going back to the clinic and sharing it with your doctor? If I see hesitation,\u00a0then<\/em>\u00a0we need to discuss it.\u201d<\/p>\n

Low pay for doulas<\/h2>\n

Although institutional standards of care for doulas may position them away from what Choma deems \u201cfight-or-flight thinking,\u201d enrollment in Medi-Cal may not help this.<\/p>\n

For one, coverage would lower doula pay. Governor Newsom\u2019s\u00a02021-2022 budget<\/a>\u00a0originally set reimbursement to $450 per birth; practically minimum wage, given the extensive prenatal support involved.<\/p>\n

Even the\u00a0$1,154 per birth<\/a>\u00a0set by the 2022-2023 budget is lower than the market rate for doula work in most regions of California, which can run between $1,500 and $3,500 (and as much as $5,000 for very experienced doulas). The highest rate statewide is $1,500, currently provided through Medicaid in Oregon and Rhode Island.<\/p>\n

Accordingly, participation in the program is low. In Los Angeles County, which is roughly three times larger than any other in California by population (currently about 10 million),\u00a010 doulas<\/a>\u00a0had enrolled out of a total 25 applications as of April 2023.<\/p>\n

Patient centered trust<\/h2>\n

Lower pay, said Choma, not only limits doula services but the relationship of trust which these services build: \u201cThe heart of doula work is prenatal. The message is that birth does not begin with the experience of delivery, but with physical, mental, and emotional preparation for it. Medical providers want this too, but the health system is often short-sighted in connecting the dots.\u201d<\/p>\n

Per example she cites the\u00a0ARRIVE trial<\/a>, a 2018 study published in the New England Journal of Medicine which concluded that inducing labor electively (i.e. with no medical reason) before 39 weeks would reduce caesarian rates to 19% from 22%, but wouldn\u2019t reduce baby deaths or complications.<\/p>\n

\u201cBased on this,\u00a0providers started inducing<\/a>\u00a0mothers early, despite the risks involved,\u201d Choma explained. \u201cBut what\u2019s the goal, to reduce caesarians to zero or to reduce maternal and baby deaths and interventions in general?\u201d<\/p>\n

\u201cDoulas reduce caesarian rates too\u201d \u2014 anywhere from 28% to 56%,\u00a0research shows<\/a>\u00a0\u2014 \u201cbut the relationship we have with our clients lets us see holistically how we get there. If Medi-Cal is involved, it must support this relationship,\u201d she concluded.<\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

BySelen Ozturk Jul 19, 2023 Doulas...<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16],"tags":[],"class_list":["post-58956","post","type-post","status-publish","format-standard","hentry","category-health"],"_links":{"self":[{"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/posts\/58956","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/lapost.us\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=58956"}],"version-history":[{"count":1,"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/posts\/58956\/revisions"}],"predecessor-version":[{"id":58957,"href":"https:\/\/lapost.us\/index.php?rest_route=\/wp\/v2\/posts\/58956\/revisions\/58957"}],"wp:attachment":[{"href":"https:\/\/lapost.us\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=58956"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/lapost.us\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=58956"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/lapost.us\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=58956"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}