This piece is published in collaboration with Echoing Ida, a Forward Together project.

Earlier this month, Choices in Childbirth and Childbirth Connection, a program of the National Partnership of Women and Families, released a report and advocacy toolkit called Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health.

Since Choices in Childbirth released its previous report on doula care and the Affordable Care Act, not much about maternal health or coverage of doula care has changed. Between 2014 and 2015, the United States dropped from 31st to 33rd in Save the Children’s annual Mothers’ Index, which “assesses the wellbeing of mothers and children in 179 countries.”

Despite spending more on pregnancy-related care than any other nation, the U.S. health-care system continues to fail mothers and babies, especially those of African descent. Black women are three times more likely to die from pregnancy-related causes than white women (42.8 versus 12.5 per 100,000 live births).

Furthermore, there has been little policy change that would support improved maternal health outcomes. For example, a 2014 Medicaid Services Rule revision allowed reimbursement of preventive services recommended by a physician or licensed provider, including those provided by non-licensed service providers such as doulas. Only the states of Oregon and Minnesota have taken legislative action since then to provide doulas with Medicaid reimbursement for their services. Logistical challenges and a lack of clear guidance for implementation from the Centers for Medicare and Medicaid Services means states would have to invest in configuring new policies and procedures for doula reimbursement.

This is bad news for Black women and Black doulas alike.

Like so many other things about the U.S. health-care system, insurance coverage restrictions on doula care creates unnecessary hurdles for women seeking assistance during childbirth and those who provide care.

As noted in the Overdue report, doula care is associated with reductions in the likelihood of medical interventions during labor and delivery such as epidurals and cesarean sections. It is also associated with shorter labors, higher newborn health indicators, positive birth experiences, and increased breastfeeding initiation. Black women—who suffer disproportionately from negative pregnancy-related outcomes—could benefit the most from insurance coverage of doula care.

Cost is a significant barrier to receiving doula support, and lack of insurance coverage makes it difficult for Black women to make a living from providing doula care.

Shantae Johnson is a nutrition policy specialist for racial and ethnic approaches to community health in Oregon, and a doula trained by the International Center for Traditional Childbearing. She says that she has had difficulty getting paid as a doula and instead volunteers her services for free.

“I had a hard time developing a business model. I’ve been paid once and that was $100 to provide postpartum support,” Johnson told Rewire in a phone interview.

Johnson, who has experience as a single mother in school trying to make ends meet, did not feel comfortable charging clients referred to her from social service programs. “I was using my own food stamps and resources to bring food for [clients] and make food for postpartum mothers. I would have to ask my family to babysit my kids. It became a burden in a way. [Because I wasn’t being paid] my family didn’t see value in my doula work, so I eventually lost the support I had to even do it.”

Johnson is one of few doulas who live in a state that has legislation regulating Medicaid coverage of doula care. Oregon and Minnesota Medicaid plans allow coverage for doula care but have experienced challenges with implementation, as the Overdue report notes. In Oregon, doulas must partner with a Medicaid-enrolled licensed practitioner who is only reimbursed $75 for doula support during a single labor and delivery, although these licensed practitioners can choose to provide the doula more than $75 for their services. Johnson volunteers with the Oregon Office of Equity and Inclusion’s Traditional Health Worker Commission to help advocate for improved Medicaid reimbursement of doula care.

In the absence of a national policy on reimbursement for doula services in both public and private insurance, many mothers who choose to have the physical and emotional support and health-care advocacy a doula offers must pay out-of-pocket. There are a small number of community-based programs that offer doula support at no or low cost to women who could not afford it otherwise. But grant funding for these programs is limited and inconsistent.

In an email to Rewire, Nan Strauss, director of policy and research at Choices in Childbirth, explained, “A number of programs have started but had to close their doors when the time period for their grant was finished, with repercussions for doulas, women, and communities. To make a difference for the population as a whole, funding for doula support needs to be woven into the fabric of the payment system.”

The Overdue report recommends that states take advantage of the Medicaid rule allowing reimbursement of doula services or that they mandate both public and private insurance provide comprehensive coverage of doula care.

Funding for doula support could be covered through cost savings to the health-care system. The Overdue report explains that doula care could prevent nearly one-third of cesarean sections, saving over $2.3 billion annually. Beyond these immediate savings related to labor and delivery, doula care could reduce long-term expenditures by minimizing complications during labor and resulting follow-up care and by increasing positive postpartum behaviors such as breastfeeding, which is associated with a number of health benefits.

While insurance coverage of doula services could save money and enhance the birth experience and outcomes of women who receive that care, it will not eliminate the racial disparities that persist in the United States. True health equity requires new and numerous efforts to remove social, systemic, and institutionalized factors that preclude healthy pregnancies and safe labor and delivery for Black women. Insurance coverage of doula care is a solid step in the right direction that could particularly benefit Black mothers and service providers.

“Doula support will only be widely available when doulas get fairly paid for their work by both private and government payers,” Strauss aptly stated. “Until then, we have an inequitable model where the ability to pay out of pocket or the generosity and donated or discounted labor of a doula determines whether or not a woman can have access to evidence-based practices.”