When Alysha Warner was pregnant with her daughter, the Parma, Ohio, woman got support from a doula — a trained professional who helps people during pregnancy and postpartum.
She said her doula supported her by taking her to most of her doctors appointments, and remembers a scary time during her pregnancy.
“I remember going to the hospital because I was showing signs of a major headache and high blood pressure. She was there and she advocated, she asked questions, and she never left me by myself,” said the 30-year-old mom of three.
Warner’s doula, Marie McCausland, has worked in the Cleveland area for three years. She became a doula because she had a difficult pregnancy too.
“I had nearly died when I had my son and it sparked my movement to the maternal health advocacy space and I felt there was a need for better support in the Cleveland area,” McCausland said.
McCausland is also chair of the Ohio Doula Advisory Group, which falls under the Ohio Board of Nursing, and has been working to expand access to doula services in the state.
Starting this fall, doulas will be able to get paid up to $1,200 per birth by Ohio Medicaid, thanks to rule changes that passed in 2023 in the state budget.
Over half of all births in Ohio are covered by Ohio Medicaid, so the rule change has the potential to dramatically increase access to birth support.
The new system to pay and certify doulas is being created by the Ohio Board of Nursing.
But doulas on the advisory group are questioning the rules that the nursing board is drafting and are worried their concerns aren't being heard.
Why Medicaid Coverage?
Ohio ranks among the highest for maternal and infant mortality in the country. Asccording to the CDC, Black women in the U.S, like Warner, are three times more likely to die during or shortly after childbirth than white women.
Research, like a study from the Journal of Perinatal Education has shown that doula access could help address these disparities. The study also showed that mothers who had support from doulas were less likely to have complications during and after childbirth.
Ohio Medicaid covered over 746,000 women of reproductive age as of April 2024.
Medicaid coverage would make doula services more accessible for low-income families, said Natasha Takyi-Micah, who has researched the subject for Cleveland-based Center for Community Solutions.
“With the help of doulas, we can reduce maternal mortality rates, especially for black women, and for infants too,” Takyi-Micah said.
The role of the Ohio Doula Advisory Group
In October, doulas will be able to formally become Medicaid providers.
However, McCausland said there are still some major concerns which are title protection and disciplinary actions against doulas.
"The Board of Nursing wants to be able to have title protection over the term certified doula and fine any doula who says they're a certified doula if they don't get this certification through the board of nursing,” McCausland said.
But she said doula-certifying organizations, like Doulas of North America (DONA International), already exist. Other certifying organizations in the state include ROOTT in Columbus and Birthing Beautiful Communities in the Cleveland area.
In a statement to WYSO, the Board of Nursing said title protection should be addressed through the Ohio legislature. The board’s role is to enforce the law the legislature makes.
“Our job is on the fast track as the legislature has tasked our team with putting the rules in place by 10/3/2024," the statement said.
In a recent letter to the Board of Nursing, doulas in the advisory group also cited rigid rules, which they said are punitive. This includes rules that say the board "may impose one or more of the following sanctions on an individual who applies for or holds a doula certificate: deny, revoke, suspend, or place restrictions on a doula certificate, or reprimand or otherwise discipline a holder of a doula certificate.”
Sunday Tortelli, another member of the Doula Advisory Group, said these disciplinary actions for doulas are excessive, as doulas provide non-clinic advisory services.
“The rules are in alignment with someone such as a nurse who has much more clinical responsibility than does a doula,” Tortelli said.
The Road to a Fall Deadline
Medicaid requires approval of certification by the state board of nursing for doulas to qualify for coverage.
Maureen Corcoran, Ohio Department of Medicaid director, said some regulation is needed.
“You have to set up this kind of a regulatory oversight mechanism to work with one of the boards that has a nearby kind of clinical experience,” Corcoran said. “You don't want the doulas under the plumbers and pipefitter board, for example, right?”
Brandy Davis, another researcher from the Center for Community Solutions, said it is important to keep doulas engaged and make sure the new rules are fair.
“We don't want to have a situation where they just sort of say, okay, I don't even want to practice anymore, because this process has been more difficult than what it's worth,” Davis said.
A Board of Nursing spokesperson told WYSO that although the rules process can be taxing, they are making progress.
Doula assisted mothers are 4X less likely to have a low birth weight baby (one of the leading drivers of infant mortality), and 2X less likely to experience a birth complication involving themselves or their baby, according to the Center for Community Solutions.
“Providing doulas with Medicaid provider status is an extraordinary and necessary opportunity to support Ohio’s infants and mothers,” they said.
As an October deadline approaches, moms and birthing people like Warner will continue to need doula services.
“She explained to me what the severity was of pre-eclampsia,” Warner said about her experience with her doula. “I'm thankful she showed me how severe your health is when you're pregnant.”
Doulas with the advisory group hope a fair compromise will be reached.
“My concern about that is if we are embarking on something that has glaring problems that are visible already, that we may be setting this program up for failure," Tortelli said.
