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Every time she has given birth, Lancour, of Duluth, says she has felt unable to ask for the postpartum help she needed. 

“In labor, it can be so rushed, everything is so fast. I wanted to know what it's like for the first time to breastfeed my child. I've never breastfed before,” she said.

As she reflects on her births, Lancour wonders now if having a doula — a non-medically trained professional who supports clients physically and emotionally through the childbirth process — might have been the answer. Especially if that doula, Lancour said, was Black, like her. 

"I've always experienced birth as kind of violent,” Lancour said. “And when I was introduced to doula birth, it was something that I felt like every woman should have access to, to have a support in the community."

Lancour recently participated in a free, four-day doula training with the hopes of offering the service to clients in Duluth, where she’s from.

The training is organized by Everyday Miracles, a nonprofit based in Minneapolis that helps clients connect with doulas. Blue Cross and Blue Shield of Minnesota, the state's largest nonprofit health insurer, pays for the program. The training is aimed at recruiting more doulas of color — who represent a sliver of the already small doula workforce.

Behind the effort is a growing body of research that suggests that doulas can have a positive impact on birth outcomes. 

Pregnancy support from someone who isn't a family member or a hospital employee can have positive outcomes during and after birth, said University of Minnesota public health professor Katy Backes Kozhimannil, who has studied the role of doulas in the birth process.

"Everything from higher levels of satisfaction and feelings of agency to things like lower rates of preterm birth, lower use of pain medication and lower rates of surgical birth when it's not needed,” Backes Kozhimannil said.

But in spite of those positive outcomes, doulas remain financially and logistically out of reach for many pregnant women — especially women of color, she said. 

Research shows that women of color and their babies face higher rates of death and more medical problems during childbirth — disparities that are connected to generations of institutional racism embedded in the health care system.

Doulas could help improve birth outcomes, especially when doulas share racial and ethnic backgrounds that are similar to their clients, said Ashley Kidd-Tatge, doula and outreach coordinator for Everyday Miracles.

"There's something so important about having somebody come into arguably the most vulnerable space and time,” she said. "Having somebody who looks like you, in the birth room can make a difference medically, emotionally, physically, spiritually, on every level."

Researchers haven't yet investigated whether doulas have an impact on death rates and medical complications among pregnant and birthing women, said Backes Kozhimannil. 

But she sees an important role specifically for more doulas of color in helping pregnant people of color who have been marginalized within the health care system for generations. 

Backes Kozhimannil points, for instance, to

 that shows a higher rate of breastfeeding among mothers of color who employed a doula. 

Easing the path into parenthood matters even more for people of color, she said. 

"It matters, especially for Black and Indigenous folks who are birthing in a system that we know suffers [from] structural racism, and that we know produces inequitable outcomes, not just at childbirth, but across the lifespan,” Backes Kozhimannil said. 

Still, access to doula care is uneven even though the state’s Medicaid program, called Medical Assistance, has covered the service since 2013. 

The program serves a disproportionate number of people of color, but very few of those clients use the doula benefit. 

"Something wasn't working. And we needed to try to understand what was going on,” said Amy Bloomquist, director of population health design at Blue Cross.

The health insurer partnered with Everyday Miracles to find out what was holding the program back. 

What they discovered was a tangle of challenges and barriers. 

For starters, Medicaid reimburses doulas $47 for each visit and less than $500 for each birth. Bloomquist said that's roughly a third of what people pay out of pocket for the service. 

"You only have so many slots in your calendar. And when you can get less than $500 for a slot versus $1500 for a slot,” she said. “It's a no brainer.”

So, Blue Cross doubled doula pay for births covered by Medicaid — still not quite as much as a private pay patient, but closer. 

And it worked with Everyday Miracles to submit more claims at regular intervals, so doulas would be paid throughout the process, instead of one payment at the beginning of the relationship with their client and another when the baby is born. 

These are big improvements because babies show up whenever they want to, said Debby Prudhomme, director of Everyday Miracles 

"Doulas do very, very valuable work. It is hard work. It's a lot of time. It's putting your life on hold,” she said. 

But Prudhomme said that reimbursement rates are still too low.

"The fact remains, you can train doulas all day long. If they can't make a livable wage, we're not taking that barrier away,” she said. 

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Small towns pay the price

In addition to low reimbursement rates, there are too few doulas of color in Minnesota, especially in rural areas. So working with Blue Cross, Everyday Miracles organizes free, four-day doula training programs aimed at expanding the workforce — like the one Lancour attended. 

Joining Lancour in the training was Oyate Nixon. She had a doula for the birth of her child who was familiar with Indigenous traditions. Nixon, who identifies as Native American, said it improved her birth experience and she wants to share that support with her clients. 

"I'm excited to have that sigh of relief when they see me walk through the door and they're like, 'Wow, she's Native, too.' You know, it's like, it's that automatic sense of relativity between us that I think is very important to them feeling comfortable and, and supported."

Kozhimannil, whose research influenced the state's decision to expand Medicaid coverage to doula services, said the Blue Cross model shows promise. 

"I'm so happy to see the attention to greater investment in doula services, the attention to racial and geographic equity in the distribution of doula services. I think this is an example of things going well."

At the end of the year, Bloomquist says Blue Cross will analyze its work to find out if more of its Medicaid members used doulas. The insurer will tweak the program based on what it learns. 

But Bloomquist said one thing won't change: Those higher reimbursement rates for doulas are permanent. 

Correction (June 16, 2022): This story has been updated to correct the amount Medicaid reimburses for doula work.

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Minnesota is among a handful of states that cover doula care for people on Medicaid. Though researchers say doula services could help shrink health inequities for pregnant women of color and their babies, few women use the benefit. Standing in their way is a tangle of challenges.

To tackle maternal health disparities, one MN insurer looks to doula care

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