Victoria Dash spent $1,200 for a birthing coach because she didn’t know the state of New Jersey would have paid for it.
As a parent buying formula that cost $50 a can, the Mount Laurel mom of three said it was frustrating considering how dear the money was to her and her family.
“We spent the first six months of my daughter’s life on a hunt for formula,” said Dash, 28. “And if I had that extra money, I could have just been like, ‘Here, take the money.’”
In New Jersey, where dozens of women die each year during childbirth, the state hopes birthing coaches will help low-income moms have better outcomes during their pregnancies.
Yet thousands of moms who qualify for the benefit don’t even know it exists, and many birthing coaches — called doulas — won’t work with the program, citing a complicated application process, billing problems, low reimbursement rates and a lack of outreach.
“It’s heartbreaking,” said Giovonna Clifton, a community doula in Deptford Township. “It makes it very hard for these mothers that could use a support.”
Gov. Phil Murphy’s administration said it is aware of the problems and is working with doulas to address them.
‘We need to do better’
Doulas have no medical training but support women before, during and after pregnancy, helping them navigate the hurdles of childbirth. They are a bridge between the mother and the medical profession, helping them frame questions for their doctors during pregnancy, manage pain and communicate concerns during delivery, and breastfeeding and care for their infant after birth.
Research shows that women who use doulas are four times less likely to have a low birth weight baby, two times less likely to experience a birth complication and significantly more likely to initiate breastfeeding.
In New Jersey, there were 131 deaths or 26 per 100,000 live births from 2018 to 2022, exceeding the national average of 23.2 deaths per 100,000 live births, according to the Centers for Disease Control and Prevention.
Still, of the approximately 30,000 low-income women who gave birth in New Jersey through the state’s Medicaid insurance plan last year, just 203 or less than 1% used a doula, according to the state Department of Human Services.
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“It tells the state of New Jersey, ‘OK, we need to do a better job in marketing and in raising awareness about this program,’” said Angela Neal-Barnett, a doula researcher and professor at Kent State University. “We have to get the word out about doulas and what they do and how they can benefit your physical and mental health and your baby’s mental and physical health. That’s just a fact.”
Kiaerra Banks, of Camden, couldn’t agree more. Banks had her daughter in October during a painful labor, where doctors used forceps to deliver the baby. At the time, she had heard about doulas but had no idea her Medicaid insurance would cover her having one. Looking back, she wishes she had enlisted a doula to speak up for her during delivery.
“It was painful,” Banks recalled of her delivery. “Maybe if I had a doula, they wouldn’t have had to use forceps.”
The state Department of Human Services said it informs pregnant women with Medicaid of their benefits, including information on free access to a doula, and regularly promotes the coverage on its social media accounts.
In addition, some Medicaid insurers said they assign caseworkers to pregnant women who inform them about their eligibility for a doula.
But experts say it’s not enough.
Why doulas won’t sign on
In 2021, New Jersey became one of the first states in the country to allow Medicaid reimbursement for birthing coaches, a move advocates applauded.
Concern began in 2018 when New Jersey ranked 47th in the nation for its high maternal mortality, with 23.8 deaths per 100,000 live births, according to America’s Health Ranking, a national nonprofit that ranks health outcomes across the United States.
The following year, First Lady Tammy Murphy created Nurture NJ, an initiative to address the high maternal mortality rate.
In giving moms on Medicaid access to doulas trained in CPR, cultural competency and privacy laws, officials sought to improve outcomes.
The Strategic Plan was “designed to make transformational change in a system that has historically failed our mothers and babies — especially our mothers and babies of color,” read a 2021 news release on Nurture NJ.
But that hasn’t happened, doulas say, noting that some of them have avoided signing up for the program because it is too cumbersome to navigate.
“They don’t want to take Medicaid not because they don’t want to service the client,” said Iyonia Guinyard, a doula at Kind Comforting Births in Burlington Township. “But if you know you’re going to have a constant issue getting reimbursed, now your private clients become more enticing.”
Few doulas, low access
The numbers tell part of the story. According to astate doula directory, 98 doulas are approved to accept Medicaid in a state of 9.3 million people. That’s nowhere near the 3,000 to 4,000 doulas that advocates estimate are needed.
“If there’s not enough doulas who have either signed up as providers in general or if there’s not enough doulas in network for that specific Medicaid managed care plan, then there’s going to be an access problem,” said Amy Chen, a senior attorney at the National Health Law Program who tracks Medicaid doula reimbursement nationwide.
Ashley Joyce witnessed the problem first-hand. Joyce, 34, was delighted when she learned that Medicaid would pay for a doula. But there were only two near her Gloucester County home — one didn’t return her call, and scheduling conflicts prevented the single mom of two from working with the other.
Joyce eventually found a doula. And she’s glad she did. She delivered a 7-pound, 14-ounce boy in April. Though she called the birthing experience “terrible,” she said having a doula was very helpful.
“She went to one of my doctor’s appointments with me and was trying to advocate for me, just going naturally and not being induced,” she said.
‘It’s too much’
To accept Medicaid payments, doulas must hold or obtain one of five state-approved certificates, said Jodi Green, executive director of the New Jersey Doula Learning Collaborative, which supports doulas.
Afterward, they must fill out applications for the five Medicaid providers the state works with to provide insurance coverage to low-income residents — Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan and Wellpoint. Green said the applications range from a few pages to dozens of pages long.
Angelica Broxton, a doula at Karasi Birth in Bloomfield, said it’s too much.
“There’s like a lot of steps to it, too,” she said. “So I just don’t know how much time I can commit to all of that.”
For those who can get past the certification and application process, then there’s navigating billing and payment, which some doulas say is so complex and slow that they won’t accept clients with Medicaid.
“Billing is probably the most daunting thing ever,” said Kayla Lloyd, a doula at Abounding Love Doula in Sicklerville.
Doulas complain that they don’t know how to complete the paperwork, which requires adding the proper codes before moving through to payment.
Tom Wilson, with Horizon Blue Cross Blue Shield of New Jersey, said Medicaid companies are required topay doulas in a timely manner but can’t help with billing.
So, doulas are on their own.
Green said doulas typically earn between $1,500 and $2,500 when they work with private clients. But the state pays $1,165 per client. Under state law, those bills are supposed to be paid within 45 days. However, doulas say it often takes months to receive payment because they constantly have to resubmit paperwork that was filled out incorrectly.
“Speaking to other doulas in the community, I was finding out how long it was taking for them to get reimbursed and how little they were getting paid,” said Christine Becerra, a doula at Your Family Doula Services in Caldwell. “It gets to the point where I’m not gonna go through all these hoops to get paid like a small amount of money.”
The state and Medicaid providers said they’ve tried to address the problems by creating more certification programs, shortening the application and having point people walk providers through the process.
“Although the community doula workforce started small, the maternal health community in New Jersey is working together to support more doula training and to streamline processes that help doulas enroll and serve our community,” said Tom Hester, a spokesman for the state Department of Human Services. “NJ FamilyCare is working closely with the Department of Health, the Doula Learning Collaborative, and other community partners to broaden the doula workforce in New Jersey.”
Hope for New Jersey
Nationally, 12 states and the District of Columbia reimburse for doulas under Medicaid. While experts say most have not published usage figures, they acknowledge lower enrollment of certified doulas and the pregnant women using them. Several states, including Colorado and Washington State, have passed legislation and allocated fundsto improve the reimbursement rate and help with billing and outreach.
Advocates say there’s hope for New Jersey, which didn’t benefit from as many lessons learned as states that began reimbursing for doulas after the Garden State.
“It’s a very complex system,” said Jill Wodnick, a doula childbirth educator at Montclair State University. “But It doesn’t mean that we can’t reimagine it.”
Several insurance companies say despite the small numbers, they’re seeing more women use doulas — and that’s a positive sign.
“We believe that the utilization of doula services will grow over time,” Catherine Cantone, a spokesperson at Wellpoint, said.
Milly Menos with Horizon, agreed.
“You see the growth year-over-year already,” she said.
Meanwhile, Victoria Dash and her husband, Joseph, said they are thankful that doula Xiomara Gittens was there when their daughter was born.
The couple recalled how Victoria Dash suffered a seizure during childbirth in January 2022. Gittens jumped into action, alerting the medical staff that Victoria was in trouble and that the baby was coming.
“She literally saved my life,” Victoria Dash recalled.
Her husband agreed, praising their doula. “She was the one that caught the baby coming after the nurse said the baby wasn’t there.”
The Dashes are disappointed that so few women know about the doula benefit, but they hope that will change.
“We have to do better getting that out there,” Victoria Dash said. Having a doula “can quite literally save your life.”
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Amira Sweilem may be reached at asweilem@njadvancemedia.com.
