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Rhode Island joins a handful of states that extend Medicaid coverage to doula services, among them Illinois, Minnesota, New Jersey, and Oregon. Reimbursement rules for private insurers in those states vary. Other states have less aggressive doula legislation or pilot programs granting access to some groups. Federal lawmakers, including Representative Ayanna Pressley, have introduced legislation intended to improve birthing outcomes for Black women specifically, but progress is slow.
Black doulas in Massachusetts describe a skewed landscape where their services are accessed primarily by clients who are either financially comfortable or in crisis — rarely anyone in between. Several hospitals offer programs that provide doulas at no cost to pregnant people who are socially isolated or otherwise particularly at risk — for reasons ranging from sexual assault to criminal justice system involvement. Private practice clients, though, come from almost another world. Black doulas say they serve many Black families, but most of their clients, regardless of race, work in white-collar professions. Though families with more limited budgets sometimes manage to make the investment, doulas say a law like Rhode Island’s would make it easier to reach many more families.
In the Massachusetts Legislature, a 2020 bill proposing Medicaid coverage for doulas failed to make it out of committee. But another bill establishing a committee to lay out racial disparities in maternal care and investigate solutions made it through, and in January, Governor Charlie Baker signed it into law. Massachusetts doula She-Tara Smith is passionate about what she does but recognizes the obstacles she and her colleagues face. “I always say it’s like we’re operating within the system that’s the bigger Goliath,” Smith says. “We can fight all day long to change the system, but it’s not going to happen overnight.”
A mother to three — including a 10-month-old who coos in the background during our phone interview — Smith thinks about that system often as a doula and parent. No matter how joyful the birthing experience, there is “a little bit [of] despair for your Black children living in a world that’s so racially unjust,” she says. “That’s not something necessarily that a doula has any charge over. We talk, we process, and you have another listening ear. … But we can’t take that away.”
That bigger picture is why holistic health interventions are so important, says Brittney Butler, a social epidemiologist at Harvard’s François-Xavier Bagnoud Center for Health and Human Rights. Access to such care must be equitable, she says, to avoid what often happens: pregnant people getting blamed for not tapping into a given health intervention they’re unable to access.
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