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Kansas Medicaid doesn’t cover birth doulas, but one contractor is footing the bill to help moms

Doula Janice Ingram talks to Anna Ferguson at a postpartum visit at Ferguson's home. Ferguson had experienced some complications following the birth of her youngest daughter and Ingram was there to check in on her.

In Kansas, the number of severe complications during labor and delivery has increased. For moms of color or women enrolled in Medicaid, the numbers are even higher. One of the state’s Medicaid contractors is now providing doula services to help.

Janice Ingram was not always a doula, but she always had a big heart for helping people.

That led her to leave her work in criminal justice four years ago for a career that would marry her calling to help vulnerable people with her master’s degree in business and leadership. And that’s when she heard about doulas.

“Do I need to go back to school?” Ingram said. “What do I need to do? I just want to help moms.”

Ingram jumped into birth work at a crucial time for Kansas moms. A study from the Kansas Maternal Mortality Review Committee shows between 2016 and 2020 severe maternal morbidity, which is when a person experiences extreme complications during labor and delivery that impact their long or short-term health, increased by 6.4% annually.

A Kansas Medicaid provider is trying to remedy this by covering doula services for its clients, but Ingram and other doulas said there are still hurdles to overcome with issues like timely payments.

Doulas serve as a pregnant woman’s biggest cheerleader and a coach to support moms through labor and delivery. Services vary on a case-by-case basis, but generally, the doula is there to offer advice before and after birth.

“You're kind of like a counselor,” Ingram said. “You're a therapist. Sometimes you may need to be their mother, if they're young.”

According to Ingram, women of color are often not listened to in clinical settings. That's another reason she felt compelled to become a doula. As a Black woman herself and mother of five, Ingram has had her fair share of birth experiences. And now as a doula, she’s helped at least 40 moms.

Ingram said she views herself as an advocate for all of her clients and for Black moms, she has to kick it up a notch.

“A lot of them (moms of color), if they didn't have an advocate in the space, it could have went really badly really fast,” Ingram said.

Moms of color in Kansas and women on Medicaid or from low-income zip codes disproportionately experience the brunt of these pregnancy complications. Non-Hispanic Black women experience severe maternal morbidity at rates 83.5% higher than non-Hispanic white women.

Studies show that doulas can help. A report by the National Institutes of Health found moms who use doulas are two times less likely to experience birth complications and four times less likely to give birth to an underweight baby.

Janice Ingram stands outside her home in Blue Springs, Missouri. As a doula, Ingram serves women on both sides of the state line. Recently, she has been providing doula services for moms enrolled in UnitedHealthcare's Medicaid coverage in Kansas.

Bringing down the ‘wall’

To help combat the alarmingly high cases of maternal morbidity and mortality in Kansas, one of the state’s three private Medicaid providers stepped in. In 2022, UnitedHealthcare began offering doula services to Black moms on their Medicaid plan in Wyandotte County, Kansas.

The first program was developed by Lucia Jones Herrera, who is associate director for social determinants of health and oversees maternal strategies for UnitedHealthcare. Jones Herrera said doulas are important players in the birthing world and improve clinical outcomes.

“That doula is a fantastic partner,” she said. “The mom will probably need less medication, will feel safer.”

Jones Herrera, who was an emergency room nurse before she launched her career as a community health worker, said as the health care system modernized, it pushed people like doulas to the margins.

“We kind of evolved … a wall between what happens inside the clinical system and what happens outside,” she said. “So a lot of the work that I do has to do with trying to integrate those worlds.”

Jaima Saunders sits in her mom's home in Kansas City, Kansas, where she meets some of her doula clients. Saunders said she is driven to help Black moms in Kansas City, Kansas, where she is from, because of the disparities they are facing.

‘Something as simple as listening’

For the 2022 program in Wyandotte County, Jones Herrera enlisted Ingram. Ingram recruited the help of two other area doulas and they began accepting UnitedHealthcare Medicaid clients.

One of the doulas that Ingram helped recruit is Jaima Saunders. Saunders got her start as a doula in the spring of 2021. But a few years before that, there were a couple things that propelled her into the birthing space as an advocate.

First, in 2019, Saunders was struggling through a pregnancy with her youngest daughter. She said during her pregnancy, she was doing a lot of journaling and reading.

“And I stumbled upon an article regarding Serena Williams,” Saunders said.

Saunders read about Williams almost dying after giving birth to her daughter, showing even the famous Black tennis star faced challenges.

“Solely because her nurse wouldn't listen to her,” Saunders said. “That was really alarming.”

Saunders said the history of Black women being disregarded in health care has deep roots. The man who is credited with inventing the speculum and dubbed the “father of gynecology” performed experiments on Black enslaved women.

“I'm telling this story because I really think that's where it stems from,” Saunders said. “Just not being listened to in health care as a person of color. I think it just stems from history.”

Earlier this year, UnitedHealthcare’s national team reached out to Jones Herrera to see if she thought Kansas would be a good state to expand doula coverage for all of UnitedHealthcare’s clients on Medicaid. Kansas became one of five states taking part in the pilot.

UnitedHealthcare partnered with The Doula Network, a national program to help with billing and management.

It isn’t easy work

On a chilly day earlier this month, Ingram drove to Overland Park, Kansas, for a postpartum visit with one of her clients. Anna Ferguson had just given birth a few weeks earlier and had experienced some health complications. Ingram was there to check in on her and make sure she was taking care of herself.

Ferguson is a mom of seven daughters. Ferguson is a birth worker herself, and this was her first time using a doula. Her UnitedHealthcare Medicaid covered Ingram’s services.

Ferguson said with Ingram’s help, her most recent birth was the calmest despite everything she was facing in her personal life.

“My husband left like five months ago, and I just don't have the support,” Ferguson said through tears. “It was just good to have somebody who validated my preferences and how I wanted to birth. ”

For some providers, accepting UnitedHealthcare Medicaid clients hasn’t been easy. Ingram, who works as a doula full-time, said she was having trouble getting paid during the initial Wyandotte County pilot program. Before UnitedHealthcare expanded the program for the entire state of Kansas, Ingram had stopped accepting Medicaid clients temporarily while she waited for the payment issue to resolve.

When the 2023 statewide pilot program started, Ingram resumed taking Medicaid clients. But she said payment still remains an issue. She and other doulas are required to complete at least five pre- and post-natal visits, and they aren’t paid until after the services are complete.

In some cases, especially if the doula gets involved early on in the pregnancy, Ingram said it can take nine or more months to get paid.

“As doulas, they feel like we can wait and get paid for our work at the end, which I don't see how that's fair,” she said. “Because we're putting in work throughout the pregnancy.”

And For Ingram and many other doulas, their work does not stop after normal working hours and is not confined to the five-visit window. Ingram said she fields calls and texts from anxious mothers-to-be at all hours of the day. And a lot of times, those extra hours go unpaid.

“Attorneys get paid by the hour, whenever they go file paperwork at the courthouse. They're clocking those hours,” Ingram said. “That's time I have to take away from my children and my family.”

Doula Jaima Saunders shows off various items she uses to make pregnant women more comfortable before and during labor and delivery. During their birth, Saunders does things like play soft, tonal music, soak the mom's feet and use massage tools to help ease the pain.

More work to be done

Jones Herrera from UnitedHealthcare said there is still work to do to improve the program for doulas.

“There is still a need for capacity on both sides to make this work more seamless,” Jones Herrera said.

According to the National Academy for State Health Policy, as of August 2023, 10 states and Washington D.C. cover doula services through their state Medicaid programs. Advocates want that number to grow.

In Wichita, Kansas, the Kansas Birth Justice Society, a non-profit led by Black and brown women, is pushing for doula care to be covered by all health insurance providers.

On Monday in a release, the organization announced the launch of the Kansas Doula Alliance. That group will advocate for fair and adequate coverage and partner with hospitals to make clinical settings more doula-friendly.

Saunders said she is encouraged by the progress.

“It's motivation, because it's a disparity. So if moms are already dying … the least you can do is give them that companion,” she said.

Ingram couldn’t agree more. She said moms on Medicaid generally are the people who need doula care the most. But it’s hard work, and the payment delays mean she’s had to carefully plan taking Medicaid clients.

“It turns into a lot of running. It turns into a lot just to get a decent livable wage to do it,” Ingram said.

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