In a significant move to address racial and ethnic disparities in birthing outcomes, Medi-Cal is broadening access to maternal health services. They center their attention around doula care.

In a media briefing on June 4, hosted by Ethnic Media Services, a panel of experts digs deeper on how Medi-Cal is improving its maternal health care, honing in on how doula care is such a significant aspect of it.

Speakers

  • Erica Holmes, Chief, Benefits Division, Department of Health Care Services (DHCS)
  • Kairis Chiaji, Medi-Cal doula provider
  • Khefri Riley, Medi-Cal doula provider

Doulas are trained professionals who offer physical, emotional, and informational support to patients before, during, and after childbirth. Their role is crucial in closing disparities for parents and infants, as they contribute to improved birth outcomes and reductions in C-sections, epidurals, premature deliveries, low birthweight, anxiety, and labor duration.

Maternal Health Initiatives

Alongside the increased emphasis on doula care, which was added to Medi-Cal in January 2023, newly expanded services encompass a comprehensive birthing care pathway for members from conception through 12 months postpartum. This includes dyadic care that serves both the parent and child together, postpartum mental health treatment, licensed midwife services, culturally-specific community health resources, and additional benefits for pregnant members, including some who exceed the usual Medi-Cal income limit.

Medi-Cal eligibility has also been extended from 60 days postpartum to 12 months postpartum, with premiums removed for families. Given that Medi-Cal covers approximately half of all births in California and nearly 5% of all births in the United States, this expansion is a statewide transformation in the maternal health landscape, according to Erica Holmes. 

In California and across much of the United States, maternal health disparities are most pronounced among Black mothers.

The CDPH reports that Black mothers are nearly four times more likely to die from pregnancy-related causes than white mothers and face a 1.7 times higher risk of preterm birth. Black infants are twice as likely to die before their first birthday compared to white infants.

CDPH data also reveals that California’s maternal mortality rate in 2020 was 18.6 deaths per 100,000 live births, representing a 45% increase from a rate of 12.8 in 2019. The mortality rate for Black mothers was three times higher than that of white, Asian, and Hispanic mothers.

In 2021, prior to the expansion of services, the mortality rate for those on Medi-Cal 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 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 lists ethnicities and languages spoken, to get care directly from doulas, who receive the highest Medicaid reimbursement in the nation, said Holmes.

As of May 31, 2024, DHCS had approved 455 doula applications, with 336 of these being individual doulas, rather than group doulas.

Stories from Two Doulas

“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 with over 25 years of experience who founded the Children of the Sun Doula Project, participated in 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 providing 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 added. “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.”

“An 18-year-old man, in the hospital with a girlfriend with a baby, wasn’t feeling safe with the care they were getting. 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. “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.”