Advancing Equity in Maternal Health with Virtual Doula Care

Despite advancements in medical care, maternal morbidity rates are rising in the U.S., and Black birthing people disproportionately experience adverse outcomes, including maternal mortality.¹ Policymakers have highlighted the importance of addressing the maternal health crisis and stark racial disparities. One potential strategy highlighted in the White House Blueprint for Addressing the Maternal Health Crisis is to increase access to doula care.² Doulas are non-clinical professionals who offer physical, emotional, and informational support during pregnancy, delivery, and postpartum. They also help parents navigate the healthcare system and mitigate the impacts of racism by encouraging parents to self-advocate in interactions with healthcare professionals. Several systematic reviews have shown that doula support can reduce cesarean birth rates and premature deliveries and improve breastfeeding initiation and birth experiences.³ Recognizing these benefits, 12 states now provide coverage for doula services in their Medicaid programs.^4,5

Although doulas have historically used telephone calls and text messaging to enhance communication, they generally worked with clients in-person.⁶ However, many fully virtual and hybrid (in-person and virtual) doula services that use synchronous video visits have emerged in recent years. While virtual doula services were initially delivered out of necessity in response to the COVID-19 pandemic, the care model remains common.⁷ In this Viewpoint, we review the advantages and limitations of virtual doula services and discuss their potential to address the maternal health crisis.

Current Offerings

In recent years, several virtual doula services have emerged, with both individual doulas and doula organizations offering virtual options. Services offered by larger organizations vary on several dimensions. Some organizations such as Pacify Health offer fully virtual, on-demand doula services while others such as National Baby Co offer options to be seen in-person or virtually depending on client preference. Some organizations employ doulas directly while others such as The Doula Network match clients to community-based doulas. Organizations such as Mae Health provide culturally competent care for Black parents while others serve the general parent population. Further, organizations differ on which stages of the perinatal period are supported and whether they offer services beyond doula care (e.g., lactation support, behavioral healthcare).

To date, access to doula services has been limited in the U.S., with greater utilization among higher-income, predominantly white, individuals.⁸ This is largely because doula services are seldom reimbursed by insurance and there is low public awareness of the doula role.⁵ While some organizations providing virtual doula services require clients to pay out of pocket, others are in-network with select payers. Others contract directly with Medicaid plans, employers, and public health agencies to provide services to a population of parents. While coverage for doula services is growing across Medicaid programs, coverage remains rare among commercial payers. Currently, Rhode Island is the only state that requires commercial insurers to cover doula services, and six states (California, Indiana, Massachusetts, Missouri, New York, and Virginia) are considering this requirement.⁹

Advantages over Traditional Doula Support

Visits that involve birth planning, education, breastfeeding support, or that can engage a birthing individual’s partner as a physical proxy (i.e., the doula guides the partner on positioning the mother for comfort) may be conducive to virtual care.^6,7 Video visits are less costly and more convenient than in-person visits for both parents and the doulas serving them. Further, virtual services not only have the potential to bring doulas into communities that lack them (e.g., rural areas); they can bring diverse doulas into communities that lack workforce diversity, thereby facilitating racially concordant care. Another advantage is that virtual doula care can support a care model that involves ongoing, on-demand interactions outside of scheduled visits.

Furthermore, offering virtual services has distinct advantages for doulas who struggle with burnout. Doulas who spend less time commuting may be able to serve more parents and obtain better work-life balance. Productivity gains may in turn allow doulas to serve a larger share of low-income parents who may pay on a sliding fee scale or have visits that are poorly reimbursed. The doula workforce is ultimately strengthened by having a pathway for some doulas, including those with family caregiving responsibilities or with chronic illnesses, to deliver virtual care.

Drawbacks

While virtual visits may work well for many types of doula-client interactions, virtual birth support may be inferior to in-person support.⁶ Birth support is an intimate and physically rigorous job, with doulas guiding clients through physical comfort measures and intense movements. Qualitative research has suggested that some doulas find “attending” births via telehealth to be lower quality.⁷ Some observed that without a physical presence, it is harder to establish trust with clients, develop rapport with clinicians in the birthing room, recognize a client’s discomfort, and intervene on their behalf.⁶ Further, not all parents have broadband access, devices, or the digital literacy to navigate virtual platforms. These challenges related to the digital divide may be particularly acute in rural areas and among disadvantaged populations, including those with limited English proficiency.

Data on the effects of virtual doula care is scarce. No research has assessed impacts on birth outcomes, whether or to what extent virtual visits can substitute for in-person care, or the ideal amount and sequencing of virtual visits within hybrid care models. This represents a significant gap in the literature given that states and payers that cover doula services must determine whether and how to reimburse for virtual services. To date, states have had inconsistent approaches to virtual care. For example, California allows all doula visits, including labor and delivery, to occur via telehealth. In contrast, Oklahoma and Maryland specify that while several types of doula visits can occur via telehealth, labor and delivery services must be in-person. Research is needed to determine the impact of virtual doula services on access, satisfaction, and birth outcomes. Such evidence could inform reimbursement decisions and identify strategies to improve the uptake, cultural competence, and effectiveness of these services. If research suggests that virtual doula care is equivalent to in-person care, it should be offered to all birthing people. In contrast, if it is found to be inferior in some respects, it may be appropriate to use virtual care as a targeted intervention to support those who would otherwise have no access to any doula care or to culturally or racially concordant doula care.

Doula services have numerous benefits, particularly for Black birthing people, who are more likely to report discrimination and coercion by healthcare professionals.^5,6,8 Yet despite the benefits, less than 10% of U.S. births involve doulas due to barriers such as cost, workforce shortages, and low public awareness of doula care.¹⁰ Virtual doula services have the potential to increase access to doula support and may become an important tool in addressing the maternal health crisis. When making reimbursement decisions, it will be important to specifically assess virtual doula services rather than simply aligning with larger trends in the healthcare system towards embracing virtual care. Informed by research, virtual doula care should be reimbursed in a manner that recognizes its limitations for different types of supports and populations as well as leverages its profound strengths in increasing access.