Over 50 years ago, a pediatric researcher named Dr. John Kennell conducted a study and found that women who were supported in birth by a doula or midwife had drastically positive outcomes compared to standard hospital care.
Using information from over 100 cultures across the world, Kennell found that ancient childbirth-support techniques could still be effectively applied in modern life.
In the years since those findings, a gap in care has growing across the nation and is especially pronounced in the Midwest. As of 2022, 35% of U.S. counties were considered maternal health deserts. The March of Dimes, which supports expectant mothers, said that means more than 1,100 counties do not have a birthing facility or obstetric clinician.
To fill this gap, doulas and midwives have once again emerged to provide prenatal and postnatal care.
As defined by DONA International, an organization dedicated to serving prepartum and postpartum mothers, a doula is a trained professional who provides physical, emotional and informational support to their client before, during and after childbirth to help them achieve the healthiest experience possible.
And their efforts seem to work. A study published by the National Institute of Medicine found that women receiving Medicaid with doula support saw a 52.9% decrease in the risk of cesarean surgery and a 57.5% decrease in rates of postpartum depression/postpartum anxiety.
Research highlighted by the federal assistant secretary for planning and evaluation hows that providing expectant mothers with doula and maternal health services can greatly improve the outcome of childbirth.
But despite their proven impact on the health of expectant mothers, access to midwives and doulas is still out of reach for many, limited by policy gaps, cost and lack of awareness.
Support with lasting change
Many people hear “doula” and think of an emotionally calming person who just provides emotional “soft support” during birth, said Kimberly Costello, CEO of the Doula Foundation and president of the Missouri Doula Association. But doulas do much more than that.
Before birth, they teach expectant mothers about physiology and what to expect during the labor and delivery process. They are often present for the birth and educate their clients on each step of labor. Once a baby is born, doulas can assist with the postpartum period by aiding with lactation techniques, helping take care of a new baby’s siblings, and coordinating things like transportation to pediatrician appointments or meal prep for parents who have their hands full.
Costello said all of these aspects save lives and protect families from dangerous health outcomes.
“You’re able to educate them in a way that they know their risks,” she said. “They know the signs to look for to go into a doctor's appointment or to go into labor and delivery without it becoming emergent or having to end up in an emergency C-section because they waited too long—because they didn't know the signs and symptoms and they didn't have that education.”
Preventative care and education are pillars of doula work, Costello said. They both aim to improve health outcomes and prevent high-risk complications.
Unlike a doula, a midwife is a medical professional who can be used in a hospital setting and has the ability to administer medications, while still being present to monitor postpartum life.
The use of midwives has gradually risen since the 1980s, from 1.1% of mothers utilizing the service to 12% in 2020. Lara Rivera, a certified nurse-midwife at Lawrence Memorial Hospital in Kansas, said she has noticed an increase in the use of doulas and midwives during her time there.
“Instead of being a passive recipient of care, they’re wanting to be actively involved in their care,” Rivera said. “I think that doula care is more prevalent now because women are getting to hear about different options.”
Even with the benefits of doula and midwife services, one major barrier remain—the cost. To combat this, lawmakers in 21 states proposed bills in 2026 to include doula and midwife coverage under health insurance plans. Those states are Alabama, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Massachusetts, Minnesota, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Rhode Island, Tennessee, Virginia, Vermont, West Virginia and Wisconsin.
Two Indiana bills fail in committee
In 2022, Indiana was ranked the third-worst state for maternal mortality in the country. From 2018 to 2022, for every 100,000 births, 30 women died. In an effort to combat these statistics, legislators recently proposed two bills regarding doula coverage.
Senate Bill 155, proposed by state Sen. La Keisha Jackson, D-Indianapolis, would have implemented a training program for doulas and allowed them to be reimbursed by Medicaid. The bill failed to pass its first reading in the Senate Health and Provider Services Committee.
“Access to quality maternal care should not depend on where you live or what you earn,” Jackson said in a news release promoting the bill. “These recommendations move us closer to ensuring that every woman in Indiana receives the care, compassion and follow-up she deserves.”
House Bill 1049 would have given state employees coverage for doula services under their health insurance plan. The bill was scheduled for review in the House Insurance Committee in December during a special session but was not heard.
The topic isn’t new to the General Assembly. Similar proposals were introduced in 2024 and 2021 but did not advance beyond initial committee review. Much of the conflict surrounding the legislation stems from the fact that doulas are not required to hold an official license.
Despite repeated proposals in recent years, legislation expanding the scope of coverage for doula and midwife services has yet to advance in the General Assembly, even as Indiana remains ranked in the bottom 20% of states.
Missouri push for services to be covered by insurance fails
Five bills that would have allowed private insurance coverage for doula and midwife services failed in Missouri’s General Assembly. The bills would have made the services more affordable for more families and created opportunities for mothers to be supported before, during and after birth.
Those positive financial impacts would be felt not only by families but also by insurance companies, which would have to cover less long-term and emergency care.
“We're saving you money on preterm and low-birth-weight deliveries. We're saving children from going into the NICU (neonatal intensive care unit),” said Costello. “And then we're preventing pregnancy-associated deaths because we're in the homes getting that early access to health care.”
For doulas, insurance reimbursement would mean a higher wage and the ability to sustain their work. This is especially valuable, she said, because doulas can physically and mentally handle only so many clients at a time.
“You can only take, you know, three to four births a month because you could be there for continuous labor support. We just had one this weekend that was a 36-hour birth. So, if she's at a birth continuously for 36 hours, then she can't take on five, 10 births a month because they would overlap,” she said.
According to Dreaming Tree Women’s Care, a home birth and midwifery service in Kansas City, Missouri, a flat-rate charge for the birth of a child is $5,500. The cost includes comprehensive prenatal and postpartum visits, in-home support, lab work, newborn screenings and more.
Being able to bill insurance would allow fairer compensation to doulas, Costello said, ensuring they can continue the valuable work they do.
The four House bills—1820, 1949, 3168 and 3169—had first and second readings and were referred to the Emerging Issues Committee in mid May. Senate Bill 1229 was heard in the chamber’s Insurance and Banking Committee on Feb. 24 but did not receive further action during the session.
Kansas program includes access to maternal care
It’s been over a year since Kansas was selected to participate in the Transforming Maternal Health Model program. One of the goals was to improve access to maternal health care in the state and to improve the quality of maternal care offered through Medicaid.
Jodie Mayfield, a certified nurse-midwife and founder of Lawrence Birth and Wellness, said she has shared suggestions with the program's project manager to improve access to doulas and midwives. That includes better reimbursement from the state for those who accept Medicaid.
“The problem being is that nobody has our back. We’re on our own, and so they have to reimburse us more to look after the people with a lower insurance type,” Mayfield said.
In 2024, Kansas doulas became recognized as non-physician providers, making their services eligible to be covered by Kansas Medicaid. The expansion would cover about $1,295 in prenatal visits, assistance at labor and delivery, and postpartum visits. In Kansas City, doula services cost around $1,500 but can increase based on the level of care.
Mayfield said it’s up to each provider to decide if they accept Medicaid insurance and that sometimes midwives and doulas don’t accept Medicaid because of the lack of proper compensation.
“You have to decide personally as a business or a professional whether you want to take that insurance type if you’re able to. It’s nice to, but not everyone can,” she said. “It is very important to have health equality for people to choose where they want to go.”
Poor reimbursement rates from Medicaid have been an obstacle for access to doula and midwife services in the Kansas City area, even leading to the closure of birthing centers in 2024. New Birth Company in Overland Park closed in October 2024, partly due to the $6,000 operation cost of providing its services and the $1,295 Medicaid reimbursement rate.
Axios reported the average in-network cost is $11,400 for vaginal deliveries and $15,200 for Caesarean sections. Kansas is slightly higher at $12,400 and $16,100, respectively.
No bills in this year’s legislative session would have improved access to midwife or doula services. However, cities like Kansas City have chosen to provide access to natal care through things like the KC Doula Program, which provides free doula services to families. The program, now in its second year, gives $15,000 per awardee to local doulas in their mission to provide care for local families.
While doulas and midwives can help address gaps in obstetric care, cost continues to limit access—leaving many families without support in more than 1,000 counties in the nation where care is already stretched thin.
This story was produced through the Statehouse Reporting Project, a collaborative effort by collegiate journalism programs across the country. It was reported by Chloe White from Franklin College, Zoe Naylor from the University of Missouri and Arien Roman-Rojas from the University of Kansas.
Award-winning TSF reporter White is a senior at Franklin studying multimedia journalism, incoming executive editor of The Franklin News and past editor of literary magazine The Apogee. She led this reporting effort exploring the growing use of midwives and doulas.
Naylor graduated from the University of Missouri in May. She is pursuing a career covering local government and writing feature stories.
Roman-Rojas is a senior studying journalism and political science. She is the Opinion editor for KU's student newspaper, The University Daily Kansan.
