Date of Defense:
May 13, 2020
Maternal and child health (MCH) outcomes in Trenton, NJ tend to be worse than county (Mercer), state, and national averages. Trenton has a population of less than 85,000 people, 50.5% Black, 36% Hispanic. The median income is $35,524 ($77,027 in the county) and the poverty rate is 23.1% (U.S Dept. of Labor, 2019). Many residents are immigrants and nearly 40% speak a non-English language at home (U.S. Census, ACS). Families in Trenton face many barriers to accessing maternal health services; there is only one prenatal clinic that accepts Medicaid and no hospital that has a labor and delivery unit within the city.
Throughout NJ, MCH inequities are evident along racial and economic lines. In 2015, the teen birth rate in Trenton was nearly six times higher than the state average. Around 10% of babies are born with low or very low birth weight and nearly 11% are born prematurely (2015). In Mercer County the infant mortality rate is nearly twice that of the state average and the mortality rate for Black infants is over three times as high (Children’s Futures, 2018) (NJSHAD, 2018).
Studies show that doulas help reduce cesarean sections and low-birthweight babies, as well as increase rates of breastfeeding. This means that families who can afford doula services may have inequitably positive birth outcomes. Doulas are professionally trained birth workers who traditionally support women and their families during prenatal, birth, and postpartum. Doula services are often expensive and not covered by medical insurance. Community doulas are doulas who typically work with younger, lower-resourced women and may be from the communities in which they serve. There are many types of doulas: prenatal, postpartum, birth, abortion, end of life; doulas support women and families through these life events. Doulas are important because they often act as patient advocates (Advancing Birth Justice, 2019).
Many states have or are attempting to pass legislation and budgets that would allow Medicaid to cover the cost of doula services and train more women as community doulas. Prior to 2019, states with Medicaid coverage for doula services (MN and OR) have experienced low participation primarily due to low reimbursement rates, limitations on who can submit claims, and weak referral and support networks for community doulas. Adequate implementation of doula services in a state Medicaid plan would afford more women access to this birth resource, potentially improving birth outcomes for this population. Doulas will not be the answer to the systemic racism in our healthcare system that has led to inequitable birth outcomes; however, broader access to doula care may improve health outcomes for more mothers and babies.
During my field experience from June to Sept. 2019 with the Children’s Home Society of NJ (CHSofNJ), I sought to better understand legislative and public policy process and current MCH policies in NJ. This included proposed policies with the goal of reducing maternal mortality and morbidity in communities of color. I also wanted to explore how these policies compare to other states policies, understand the system of Medicaid at the state and federal level, and ultimately provide recommendations for Medicaid implementation of coverage for doula services.
To achieve these objectives, I first conducted a literature review of current and proposed state MCH policies and on doula implementation experiences in other states (MN, OR, and a NY pilot). I compiled a comprehensive policy brief of all MCH-related bills for use by Trenton MCH partners. Through this process I also met and spoke with key doula stakeholders from MN, OR, MA, NY, CA, and NJ to refine recommendations for doula implementation by Medicaid. Some best practice topics include: reimbursement amounts, mode of claim filing, minimum training and certification requirements, minimizing barriers to entry, and professional development and capacity building to work with diverse communities. I validated the stakeholder comments with academic sources and by connecting with doula training/certifying organizations to compare rigor and cost. These recommendations were then compiled in a public comment submission to the New Jersey Department of Human Services (DHS), which manages Medicaid in NJ.
Near the end of my field experience, my site preceptor and I meet with Medicaid leadership at NJDHS to discuss these recommendations. Through this meeting, we learned that NJ Medicaid is committed to making doula implementation a supported program rather than just a means for reimbursement. We were the first community group that Medicaid had spoken to about this initiative. Later, we joined the same directors in a statewide convening of doula stakeholders. Currently, all of our recommendations are being strongly considered or implemented.
This project was timely with doula services having been recently included in NJ state laws and budgets. The public comment period on the proposed amendment was open during my field experience, which allowed for an easy way to communicate our recommendations. To better understand the broader policy and legislative landscape, I researched the state Medicaid waiver process and observed legislative hearings and votes.
The CHSofNJ is a non-profit organization that has been a community-based provider of MCH services to women in Mercer and Ocean Counties since 2002. In 2019, CHSofNJ implemented a new community-based doula program for Hispanic women in Trenton. Through this program, over a dozen Hispanic women completed a 20-session HealthConnect One training. My policy-based project became part of the long-term sustainability plan for this program. If organizations can one day bill Medicaid for doula services, CHSofNJ will be able to employ more of women, full-time and with benefits, without relying solely on grant funding. Additionally, women who complete the doula training will also be able to independently bill Medicaid for their services.
Lessons Learned, Recommendations, and Conclusion
It is incredibly valuable for public health professionals to understand and participate in the policy process. While good public health policies can be hard to achieve, they are the best way to sustainably maintain programs over time. I learned that political timing is very important. I could not have done this work without the precedent set by other groups, making doula services more accessible in their states and the strong leadership in NJ that supports and funds MCH work. My field work was fortunately timed after funding was allocated to Medicaid to cover doula services and during the planning period for implementation. State health officials often want to make the most educated and evidenced decisions but may not have the time and staff dedicated to doing this research.
Individuals or organizations who would like to enter into or continue to do work around Medicaid doula implementation should leverage resources and stakeholder experiences from other states. Low uptake of utilization in states that include doula services in their Medicaid plans should not be a deterrent for other states to pursue the same goal. Resources such as the Advancing Birth Justice Report and The National Health Law Program’s Doula Medicaid Project as well as learnings from other states were invaluable to our work in NJ. It is also important to have diverse and dedicated local stakeholders to provide input and help form an advisory committee. The doula service delivery model must be a continually supported; an advisory committee will help ensure that doulas are able to bill Medicaid without major barriers and for a fair wage, that there will be continued professional development opportunities, and that doulas and providers can better work together to improve health outcomes.
Broad access to doula services through Medicaid can have a significant impact on health outcomes for women and infants, particularly in communities with many socioeconomic challenges such as Trenton. Doulas may impact spending on healthcare, but more importantly improve the pregnancy experience for many women and their families. While doulas can act as patient advocates, they will not be able to significantly impact the inequitable health outcomes we see in our system today. Improving access to doulas is one of many positive steps we must take in order to improve the health of women and children.