• Doula input was solicited but not used as a basis for the policy. The State held several listening sessions with doulas before drafting its policy. All of the concerns that follow were shared during those listening sessions, but none of them have been included in the policy. Doulas are the experts on our profession and we feel frustrated that our input and clear direction on crafting policy was ignored. We request that the state return to conversation with doulas to establish a clearer understanding of the profession and the unique demands and time commitment of our role.

• The birth attendance reimbursement level is drastically out of line with reality and will result in zero to extremely minimal uptake. The proposed reimbursement rate of $350 per birth is so drastically low that we can only assume that the State has a fundamental misunderstanding of the support provided by doulas. We were advised going into Medicaid conversations that “every professional complains that Medicaid rates are too low,” but we also know that other professionals receive at least enough reimbursement to provide a basic living wage to the service provider. Doulas provide continuous support during a birth. We can have only one client in labor at a time, and we provide support both at home and at the birth location. It is not unusual that in working with a first-time parent or a VBAC client, a doula may provide 24 hours of birth support, and several times a year a full-time doula might even have a client in labor for 36-48 hours. Again, except for short breaks to eat or use the bathroom, doulas remain continuously with the client for that time, and may need to call in a backup doula if they reach the point of exhaustion. No human, much less a valued professional, can be asked to work for 24 or more continuous hours for such a substandard rate.

Further, the proposed policy does not take into account the on-call nature of doula work and the compensation that should accompany that availability. To make ourselves available 24/7 to a client, be willing to leave any family gathering, our own medical appointments, or a treasured date night on a moment’s notice is taxing and deserves fair compensation. The deeply personal nature of doula work is part of what helps us to improve outcomes. Having a person at your birth who knows your history, your trauma, your fears, and your heart is deeply important and that means that doulas are not “rotational” — one or two doulas get to know a family intimately, and that is who attends the birth. Our on-call availability needs to be addressed in a higher compensation level.

In addition, doulas also provide frequent text and phone support to clients that is not reflected for reimbursement in either the birth attendance fee or the fees for prenatal or postpartum visits. This support can add up to hours each week for a client, especially if there are complexities happening with the pregnancy, birth preparation, or in the client’s life generally. If this phone and text support is not going to be specifically reimbursed, it should be reflected and accounted for in a higher birth attendance fee. Phone and text support is not just a nicety that doulas provide and which could be eliminated — it’s again a crucial part of how we improve outcomes.

 Knowing that families who face racism as a risk factor in their birth are often best served by a culturally matched doula, it is deeply concerning that the state would ask these doulas to work for such a substandard wage. If we are asking Black and Indigenous doulas to step up and help solve the maternal and infant mortality crisis, we must pay those doulas a fair living wage for their work.

 We point you to the recently adopted Medicaid policy in Rhode Island, which offers $1,500 reimbursement per “package”: prenatal visits, the birth, and postpartum visits as a global fee. This is a reasonable and fair compensation goal for Michigan and should be a model for our state. If the State of Michigan prefers to keep the birth fee and visit fees separate, we propose a birth attendance fee of $1,200, with an additional $600 birth attendance fee available to a back-up doula if the original doula is present for 24 hours and requires backup assistance because the baby is still not born.

• The fee proposed for prenatal and postpartum visits need clarification. Doula prenatal visits typically last for one to two hours. That amount of time is needed for the processing, preparation, and resource connections that doulas need to do with families. Although a rate of $75 per visit would be very low for a 60-120-minute visit, it is minimally acceptable. However, an official at Priority Health Medicaid recently pointed out to us that the policy does not make it clear whether the fee of $75 includes ALL prenatal and postpartum visits, or if it is per visit. If the $75 is a global fee to include all visits, this is unacceptable as it averages only $12.50 per visit (if six visits are completed), which does not even reach minimum wage for a 1-2 hour visit. This issue requires clarification and could be addressed by adding “per visit” after $75 in the policy.

Further, the State has attempted to lump in childbirth education and lactation support with doula prenatal and postpartum visits. This is not acceptable or accurate to our profession. Childbirth education is a separate training and certification process and not part of the doula scope of practice. A typical childbirth education class is 12 hours or more. High-level breastfeeding consulting is not part of the doula scope of practice (we offer basic lactation support for common, simple challenges). Lactation professionals’ rates are typically much higher than what a doula would charge for their services, as it is a very specialized support that, like childbirth education, requires specialized training. These services should absolutely be funded, but not lumped in with doula prenatal and postpartum visits. We ask that the State either develop two separate line items for childbirth education and breastfeeding support or eliminate those items from this proposal (with the intent of creating a separate policy).

• Licensed provider referrals/recommendation. Under “Covered Services,” the state outlines that “Doula services must be recommended by a licensed healthcare provider.” Presumably this refers to a certified nurse-midwife or obstetrician. We strongly oppose any such requirement. The nature of doula work is that we advocate for our clients and their needs. Even when doulas are fully within their scope and treading carefully, a coercive or racially biased health care provider does not always respond well to this advocacy work. The most (implicitly or explicitly) biased health care systems and providers would be the least likely to provide their patients with a referral for a doula — the exact patients who need doula care the most. It is imperative that doula support for families not require a referral. In order to improve outcomes, there must be direct access to doulas, who work directly for the family (research shows that hospital-based doula programs, for example, do not improve outcomes, likely for this and other reasons).

• Certification expansion. While we are not completely opposed to the idea of certification requirements, they can pose a challenge for some Black and Indigenous doulas who have a different perspective on the nature of doula support as more peer-to-peer. We recognize, however, that we are working within a colonized system and certification may be required to receive reimbursement. However, the list of certifying organizations should be expanded to include certifying bodies recommended by Black and Indigenous doulas. Specifically, it is critical to include doula certifications and credentials created and led by Black and Indigenous doulas as they center culture and traditional practices for and by Black and Indigenous communities. We urge the State to go back to the doula community to identify those certifying organizations. Further, the inclusion of toLABOR on the list is mystifying, as this organization is not currently functional or active in the doula world. The other organizations listed are at least respected and active doula certifying organizations.

• “Clinics that may be billing on behalf of the doula.” This definition also needs clarification. For example, would a doula agency or group constitute a “clinic”? Doulas typically work independently or as part of an agency or group.

 • “Diverse doula advisory council.” The doula advisory council should be formed before the approval and implementation of the proposed policy, not after. We request the immediate formation of the council to consist of currently active, long-time doulas from a variety of regions in the State. These doulas should be publicly recruited and not privately appointed by the State. Public recruitment avoids the risk of an “echo chamber” that can be created if the State works only with a select few doulas who may not at all represent the work, experiences, or needs of doulas statewide.

• “Provider criteria.” The State requests that the qualified doula be at least 18 years of age and hold a high school diploma or equivalent. However, some community based doula programs, especially those seeking to provide culturally matched doulas, may have doulas on their team who are teenagers (such as teen-to-teen support at a high school), or who did not complete their high school education. Doula certifying agencies typically do not have age minimums nor do they require a high school education. This is a peer-to-peer profession and we see no reason to limit the pool of potential doulas in this way. We suggest eliminating this portion of the criteria.

 Again, we’d like to thank the State for your interest in reimbursing doula services for Michigan families who receive Medicaid. We share your goal “to improve birth outcomes, address social determinants of health, and decrease existing health and racial disparities for Medicaid beneficiaries.” However, to reach the goal of widespread — or even minimal — uptake by doulas, major changes are needed. Families will not be served if the compensation and other requirements of the proposal do not allow doulas to effectively do our work. 

We look forward to those changes and thank you for your attention to our concerns on behalf of families and doulas. We remain available for questions and support as you revise the coverage details.