Background
In the U.S. today, Black women are nearly three times more likely to die during childbirth as White women. One potential remedy to address this and other disparities in maternal health outcomes, which has gained recent attention, is the integration of midwives and doulas into the U.S. healthcare system. Doulas are trained professionals who provide physical, emotional, and educational support before, during, and after childbirth. While their role is non-medical, doulas often enhance maternal outcomes by reducing stress, increasing patient satisfaction, and lowering the need for interventions like Cesarean sections. Midwives are licensed healthcare providers who manage pregnancy, childbirth, and postpartum care. Unlike doulas, midwives perform clinical duties, including monitoring fetal development, conducting births, and providing postpartum care.
Community-based midwives and doulas, particularly those who serve Black, Indigenous, Latinx, and LGBTQ+ communities, play an essential role in supporting populations disproportionately affected by adverse maternal health outcomes. These birth practitioners provide critical culturally relevant care that reflects the cultural values, communication styles, and traditions of their patients, filling gaps in treatment that general hospitals do not address. Despite this, their integration into mainstream healthcare has faced obstacles.
The current regulatory landscape for midwives and doulas is complex and varies widely by state. Some states require licensing, training, and specific scope-of-practice guidelines for midwives, given that they provide medical care. Regulations on doulas are less stringent, but still differ state-to-state. Regulatory variation affects insurance coverage and reimbursement, creating inconsistent support for integrating doulas and midwives into mainstream care nationwide.
Pros of Integration
Proponents argue that integrating midwives into the U.S. healthcare system could significantly improve maternal and infant health outcomes, particularly in underserved communities. Establishing a nationwide credentialing system would standardize qualifications and scope of practice, ensuring consistent, high-quality care across states. This approach would address disparities caused by restrictive state-specific regulations, which currently limit midwives’ ability to practice. Under current guidelines, midwives oversee only about 8% of U.S. births. Research shows that healthcare systems with greater midwife involvement report better maternal and infant health metrics, including higher rates of vaginal deliveries, fewer C-sections, and reductions in preterm births and low-birthweight infants. Nationwide credentialing policies could enhance collaboration between midwives and traditional medical providers, creating a more cohesive maternity care model. These measures would expand access to midwife and doula care and optimize care delivery nationwide.
Rather than establishing a national credentialing system for doulas, proponents of doula integration point to solutions like reimbursement policies, standardized training programs, and partnership programs with healthcare centers. Reimbursement policies would increase insurance coverage of doula care, which could significantly increase low-income families’ access to doula services. Nationwide training programs could ensure consistent qualifications and high-quality care, ensuring that families who opt to receive doula services can expect a certain standard of care. Proponents also hold that national training programs are uniquely poised to recruit trainees from underserved populations, which would expand the pool of trained professionals serving diverse communities. Additionally, much like credentialing programs for midwives, collaboration programs between doulas and hospitals could embed doulas within care teams and strengthen the continuity of care for birthing families.
State regulations for doulas and midwives vary widely, creating disparities in access and care quality. Proponents advocate for nationwide standards for Medicaid and private insurance reimbursement to establish a uniform baseline for coverage of doula and midwife services. Proponents of nationwide coverage point to the example of Rhode Island, where demand for doulas among high-risk pregnant clients increased significantly after the state expanded its coverage guidelines for doula services. However, given that few doulas currently accept insurance, consistent certification and reimbursement processes are necessary to ensure that expanded coverage effectively connects patients to providers. Collaborating with doulas to design reimbursement structures that reflect their unique services– such as extended client access and billing for long labor–would ensure proper recognition and compensation for their work. Standardized insurance policies, supporters argue, would promote equity, reduce administrative burdens, and enable consistent, high-quality care across states.
Cons of Integration
Opponents argue that regulating and standardizing midwives and doulas may undermine their autonomy and ability to advocate for birthing people, particularly those in underserved communities. While formalizing doula services with official billing codes could expand insurance coverage, critics warn it could also introduce conflicts of interest and compromise patient-centered advocacy. Regulation under hospital systems or boards could stifle advocacy due to fears of repercussions such as losing credentials or hospital partnerships. Michelle Drew, a maternal health historian, highlights that nationwide regulation of midwives and doulas risks repeating the historical erasure of Black birthing practitioners. Critics also warn that credentialing programs could reduce the already limited pool of doulas, counteracting efforts to expand care access amid rising maternal mortality. They worry that standardizing care through rigid oversight may ultimately compromise the culturally tailored, client-focused support that doulas and midwives provide.
Critics also argue that integrating midwives and doulas into mainstream healthcare systems raises challenges related to medical oversight, liability, and professional dynamics. One significant concern involves the potential for malpractice or birth injuries, especially in high-risk scenarios where midwives or doulas prioritize natural birth over necessary medical intervention. Some say this tension can lead to critical disagreements with medical professionals, persuading patients to refuse essential care and endangering maternal and infant health.
Resistance from medical professionals complicates the integration of doulas and midwives into traditional healthcare settings. Studies indicate that the role of doulas and midwives is often unclear to providers, leading to tension in healthcare practices. Many obstetricians assume that doulas and midwives “work against the hospital” because they advocate for their clients’ birthing preferences. Only 48% of obstetricians agree that doulas improve maternal and newborn outcomes. Moreover, doulas often report feeling unsupported by physicians, labor and delivery nurses, and other clinicians, which hinders collaboration and limits their effectiveness. Critics warn that integrating doulas and midwives into healthcare settings could exacerbate provider conflict and add unnecessary stress to patient experiences.
Conclusion and Future Outlook
Integrating midwives and doulas into the U.S. healthcare system requires consideration of the complex benefits and drawbacks to standardized care While proponents argue that nationwide standards for training, certification, and reimbursement will expand access to crucial midwife and doula services, critics warn that these solutions risk limiting practitioner autonomy and adding tension to healthcare workspaces. Moving forward, efforts to integrate doulas and midwives into mainstream services through insurance coverage expansion, hospital partnerships, and investments in community-based programs must balance the need for integrated birthing care with the need for an autonomous and diverse workforce of doulas and midwives.
