Kaosarat Aina and her husband Ibrahim Odugbemi had plenty of reasons to be nervous as their son’s due date grew closer: They’re first-time parents. The couple is from Nigeria and navigating the very different and complex United States health care system. Pregnancy and birth can also be a dangerous time, particularly in Indiana, which boasts one of the nation’s highest maternal mortality rates.
Aina had a birth plan: She wanted an unmedicated, vaginal birth with a midwife. But Aina’s cervix didn’t dilate as expected during labor. After about 20 hours, she was only two centimeters dilated. During the first stage of labor, which in the best-case scenario is hours shorter, the cervix dilates up to 10 centimeters.
Instead of waiting for her labor to progress at home, Aina got to the hospital and stayed there because her baby’s heartbeat was fluctuating.
“It looked like baby was not tolerating the contractions so well, so [he] had to be under close monitoring,” Aina said. “It was shocking and heartbreaking.”
Aina was comforted by her doula, Kristi Pietz. Pietz is not a medical provider; she’s trained to work with clients during pregnancy, childbirth and postpartum. Doulas provide support and advocate for their client’s medical care preferences in the delivery room.
Pietz had led the couple through childbirth education classes in the months prior and was with them through Aina’s 48-hour labor and delivery. In the delivery room, Aina said Pietz made the birth feel collaborative. Pietz discussed the couple’s options and suggested trying different positions to make Aina more comfortable as her labor dragged on. The couple’s son, Iretomiwa, was born safe and healthy on Feb. 4.
Research shows doulas can play an important role in obstetric health care, such as providing support to patients that may lead to shorter labors and fewer cesarean births, which carry risks like infections and longer recovery times.
In Indiana, some lawmakers saw the benefit and responded by approving legislation for doulas to be reimbursed through Medicaid. The state also provided more than a million dollars in grants to increase patient access to doulas.
But some who championed those initiatives say progress has been slow, and that the state isn’t living up to its promises – which could leave people who need doulas most without access to their services.
“We're not respected for the job that we do and for the data and statistics that proves that we help … birth outcomes,” said Kelli Brien, a South Bend-based doula of over 15 years.
New law, same problems
In 2019, state lawmakers passed legislation that would allow doulas to be reimbursed through Medicaid. Nearly forty percent of Indiana births were financed by Medicaid in 2020, and that year nearly three-quarters of women who died within one year of pregnancy were enrolled in Medicaid, according to the state department of health.
Indiana was only the third state to expand Medicaid coverage to doula services. As of late 2022, eight states and Washington, D.C., are actively providing Medicaid coverage for doulas, according to the National Health Law Program’s Doula Medicaid Project. Another six states, including the Midwest states of Illinois and Ohio, are in the process of implementing Medicaid coverage for doulas.
But the 2019 Indiana law allowed for reimbursement to happen rather than be required. It was unclear how doulas could be reimbursed, as no budget funds were allocated to the legislation expanding Medicaid access.
So instead of accepting Medicaid, many Indiana doulas operate small businesses or work as independent contractors. Kristi Pietz co-owns Rebel Doulas and doesn’t bill Medicaid for her services.
“Even though Medicaid might cover doula care, we're not able to bill for it independently unless we've jumped through certain hoops or we have certain relationships,” Pietz said. “So, it's not necessarily accessible in the ways that most doulas work.”
Pietz’s clients pay $900 to $1,100 out of pocket for her services, which can include childbirth education, attending labor and delivery, and postpartum visits, as well as on-call support by text and phone throughout the pregnancy. She also works with nonprofits that foot the bill.
Pietz recognizes her services are expensive for some. But she’s attended births even longer than Kaosarat Aina’s 48 hours – some longer than 80 hours. She has to be on call over holidays. And she needs to make a living wage to support her own family.
Without grant programs, doulas like Pietz and Brien worry those who need them most can’t afford their work.
“What happens is that there's so many families who can't get service,” Brien said.
In Indiana, doulas can be reimbursed for some services through Medicaid if they are certified as community health workers, according to Indiana’s Family and Social Services Administration, which oversees the state’s Medicaid programs.
“This way of being reimbursed requires doulas to be employed by an IHCP [Indiana Health Coverage Programs]-enrolled billing provider and to deliver services under supervision,” FSSA spokesperson Michele Holtkamp wrote in an email. Those providers include physicians, physician assistants and advanced practice nurses.
Questions remain about a state-mandated doula advisory board
In 2022, lawmakers created a 13-member state doula reimbursement advisory board to study and make recommendations for an appropriate Medicaid reimbursement rate. The provision was part of a social services package that lawmakers passed along with a near-total abortion ban.
But in the 10 months since the law took effect, no board members have been appointed, and the group has never met, Indiana House Republicans spokesperson Erin Wittern confirmed.
“Legislative appointments are expected in the coming weeks,” Wittern said in an email.
The law did not specify when the board must make its recommendations to the General Assembly, or the next steps lawmakers will take with that information.
Some lawmakers who focus on maternal health are also frustrated at the lack of urgency on behalf of the Republican-led legislature. The legislature passed its two-year budget in the spring, which did not contain funding specifically for doula care.
"It's really sad, because we know that doulas help turn the tide in maternal health,” said State Rep. Vanessa Summers (D-Indianapolis), who created the legislature’s Maternal Health Caucus in 2020. “I just think it's sad that we can't get the powers that be to realize how important this is and how important it is to save women.”
Summers said she is unsure if the legislature “will heed the advice … of the advisory committee,” if and when those recommendations are released.
A million-dollar solution falls short
An earlier legislative push to address the state’s maternal and infant mortality crisis was the Safety PIN (Protecting Indiana’s Newborns) grant fund. The program, established by law in 2015, awards millions of dollars every year to nonprofits, hospital systems and other organizations that work to reduce infant deaths, particularly in marginalized communities.
One of the first grant recipients was “Speak Life: Here to Stay,” a program designed by doula Brien focused on providing pregnancy and postpartum services to Black and Hispanic pregnant women in Elkhart, St. Joseph, LaPorte and Marshall counties in Indiana. At the time the grant was awarded, Northern Indiana had some of the highest rates of infant mortality in the state, with Black infants close to three times as likely as White infants to die before their first birthdays.
The initiative was administered through South Bend nonprofit Community Wellness Partners, and Brien would serve as the maternal child health coordinator.
“That's where they had me plug in all the information on my end of how this would work, how the program would be set up, what should be done with the doulas, what that looks like in the community,” Brien recalled.
Side Effects Public Media submitted a records request for contracts and budgets related to the Speak Life grant. The documents show that the first of two contracts awarded Community Wellness Partners $1,079,915 for work from January 2017 to the end of December 2018.
“The Speak Life initiative proposes to reach 1,000 unduplicated participants of the entire project periods in multiple community touch points as well as the traditional home visit setting,” the project’s scope of work document reads.
A second contract for an additional $880,031 expanded the program into Cass County from 2018 through 2019.
“Historical performance has shown success within the targeted community for the Speak Life: Here to Stay Initiative and … establishing new relationships though the community is on-track to maintain a pattern of reducing infant mortality within the Midwestern region,” the description of the program within the contract reads.
However, progress reports to the state show the program struggled. It was difficult to find a “high quality workforce,” according to the reports, and despite receiving close to $2 million from the state, there weren’t enough funds to hire doulas to meet the waitlist of clients.
“The volume of referrals Speak Life receives has become an issue. We need additional staff to cover the amount of families that need entrance into the program,” one report reads.
In fulfilling Side Effects Public Media’s records request, the state did not provide detailed budgets from the program, so it’s unclear what the grant funds were spent on.
The nonprofit Community Wellness Partners also went through executive leadership changes. Eventually, the state transferred management of the grant to the Indiana Minority Health Coalition. IMHC was brought in to provide stability, which was also important after the start of the COVID-19 pandemic, said Tony Gillespie, the organization’s vice president of public policy and engagement. The program was renamed Community Doula Services.
“The State Department of Health felt that the program was so important and needed to put it somewhere," Gillespie said. “And so that's how we ended up here.”
From 2017-March 2021, Speak Life/Community Doulas Services had 235 total participants, according to a report provided to Side Effects Public Media through a public records request – about one-fifth of what was promised in Speak Life's original grant proposal to reach 1,000 unduplicated participants.
“It hurts my heart because this [the Speak Life initiative] was meant to be something that served women. This was meant to be something that served the community. There should be thousands of women who are getting resources … the doulas should be getting professional development,” Brien said.
As of April 2023, the Community Doula Services program has had 447 total participants.
Brien left the program she designed in 2019 after Speak Life’s transition to management under IMHC. In the years since, she’s felt her responsibility is to advocate for other doulas. She knows doulas aren’t the silver bullet to improving maternal and infant health outcomes. But she said doulas could make more of a difference if provided pathways to payment through Medicaid rather than relying on grant funding, which makes it difficult for doulas to make a living.
“We're not going to move the needle on infant mortality if we're stressed out, overworked, underpaid, underappreciated,” Brien said. “I want doulas in Indiana to understand and know that they deserve better … and that we need to fight for this profession."
Side Effects Public Media is a health reporting collaboration based at WFYI in Indianapolis. We partner with NPR stations across the Midwest and surrounding areas — including KBIA in Missouri, Iowa Public Radio and WFPL in Kentucky.