This is part of a series from The Lily that examines how the role of doulas intersects with private and public insurance, race, socioeconomic status, policy and the medical community.

After protests spawned a national conversation about racism last summer, CVS Health began to take a hard look at what the company was doing to address disparities.

In July, CVS Health announced that it would invest about $600 million to “advance employee, community and public policy initiatives that address inequality faced by Black people and other disenfranchised communities.”

The company decided to focus on several areas with major disparities, including maternal and child health, said Joanne Armstrong, the chief medical officer for women’s health and genomics at CVS Health. Throughout the fall and winter, Armstrong met with employees to learn more about their birth experiences. Armstrong and her team also reviewed research about doulas, who support people during pregnancy, childbirth and the postpartum period. Numerous studies connect the presence of a doula to positive maternal health outcomes. Although the number of states that cover doulas under Medicaid is slowly growing, coverage through private insurance is still relatively rare. People usually pay for a doula using their own money, limiting who has access to birth support.

In January, CVS Health — which employs about 300,000 people nationwide — rolled out a new benefit for eligible employees and their partners: $1,200 per year for doula services. All CVS Health employees — from retail to office workers — who work at least 30 hours per week are eligible for the benefit. They may choose any doula who has attended doula and cultural competency trainings.

Tanya Echols hadn’t heard of a doula before meeting with Armstrong and other colleagues to talk about her journey as a mother. After learning more about the role of a doula, Echols said having one would have helped her “tremendously” during her pregnancies. Echols had her first child, Gabriel Alexander, when she was only about five months pregnant. He died within an hour of his birth on Sept. 4, 1995. Doctors later told Echols she had an “incompetent cervix” — or weak cervical tissue that can lead to premature birth.

When Echols became pregnant with her second child, she had a lot of questions and dealt with anxiety. Looking back, having a doula would have helped her “make sense” of what was happening at that time, said Echols, who later gave birth to a daughter in 1998 and a son in 2001.

Echols wishes a doula had been available to her then, she said.

Echols, now 47, is the director of service operations at Aetna, one of the nation’s largest health insurance companies. (CVS Health acquired Aetna in 2018.)

It’s too early to say whether CVS Health will expand beyond its employee base to offer doula services through its commercial plans, Armstrong said.

CVS Health’s headquarters are in Rhode Island, where advocates are fighting for state lawmakers to pass legislation that would require Medicaid and private insurers to cover doula services from pregnancy to up to one year postpartum. The language of the legislation cites racial disparities in maternal health and that the use of doulas can be cost-effective.

Ensuring that people have access to doulas irrespective of insurance type is key, said Rhode Island doula Quatia Osorio: “I’m intentional to get rid of the misnomer that it’s only poor Black people who have these adverse effects.” Black women are more likely to die of pregnancy-related causes than other racial and ethnic groups, regardless of education level.

Rhode Island doula Quatia Osorio is a facilitator for Chocolate Milk Cafe. (Quatia Osorio)
Rhode Island doula Quatia Osorio is a facilitator for Chocolate Milk Cafe. (Quatia Osorio)

The doula bill in Rhode Island failed in 2019 and 2020, but Osorio and other advocates are optimistic about 2021. In early May, state senators voted in favor of the bill, which is still moving through the House.

Despite previously opposing the legislation, America’s Health Insurance Plans — a national trade association — has not taken a position on the bills this year. Blue Cross Blue Shield of Rhode Island recently said it supports the legislation’s goal of making “doula services more widely available and covered by Medicaid and commercial plans.” In a statement provided by a CVS Health spokesperson, the company said it is supportive of “increased access to doula services,” but declined to say whether it supports or opposes the legislation in Rhode Island.

Doulas offer nonclinical services, which is challenging for private insurance companies that typically work with licensed medical providers, said Megan Sowa, director of health and benefits at the consulting firm Willis Towers Watson.

Companies can offer employees benefits outside of their health plan, as CVS Health does. This method is becoming more prevalent, according to Sowa.

“Many employers are interested in supporting family benefits as a whole, inclusive of doulas, as part of their diversity, equity and inclusion initiatives,” she said.

Some doulas fear that standards imposed on their profession by government entities and insurance companies will limit their autonomy and affect how they serve clients. But if Medicaid can establish a process that works for doulas and patients, it will “throw gasoline on the fire for private insurance,” said Averjill Rookwood, a doula and family benefits strategist. Change can occur in other ways, too, Rookwood said: If enough employers want to include doulas in their health plans, insurance companies will have no choice but to figure out how to make it happen.

Premera Blue Cross found a way to administer a new doula benefit through Microsoft’s Health Connect Plan, which is only available to employees who live in Washington state’s King and Snohomish counties. (A global company, Microsoft’s headquarters are located in Redmond, Wash., in King County.) At the beginning of 2021, Microsoft started offering eligible employees and their dependents $1,000 to put toward doula services.

When Hollie Sherfey, 25, found out about the new doula allowance, she was pregnant with her second child. In the months before discovering the new benefit, Sherfey and her husband had disagreed over whether to hire a doula. After going through a difficult labor and severe postpartum anxiety about three years before, Sherfey wanted the extra support. But her husband was hesitant for financial reasons: Doulas in the Seattle area can cost up to $2,500, and the Sherfeys are a single-income family.

“That’s a really big chunk of money for us,” said Sherfey, who moved to Washington state from California in 2019 after her husband landed a job at Microsoft. “We’re just kind of starting off our life.”

Knowing that their health plan would pay for half the cost, Sherfey hired two doulas, Mariah Falin and Gina Cantatore, for $2,000 total. Falin and Cantatore use a partnership model to ensure that someone is available when clients need them.

The support and resources her doulas provided before, during and after the birth of her son is one of the reasons she didn’t have postpartum anxiety again, Sherfey said: “For me, it made all the difference.”

It’s important for companies to think about how the postpartum period can affect employees’ well-being, said Alyssa Veneklase, who co-owns Gold Coast Doulas, an agency based in Grand Rapids, Mich. Postpartum mood disorders and sleep deprivation can affect fathers, too.

That’s partly why Veneklase and her business partner, Kristin Revere, decided to pitch their agency’s birth and postpartum doula services to Pioneer Construction. About 82 percent of the company’s workforce is male, according to Yvonne Bedolla, Pioneer’s director of human resources. If employees are distracted or experiencing fatigue, it can lead to injury or death, Bedolla said.

“I’ve been up on these buildings with guys who are 40 stories high, walking on steel beams, who have an infant at home and they got three hours of sleep last night,” said Veneklase, who worked at Pioneer for almost eight years before pursuing her career as a postpartum doula.

Pioneer employees also travel for work, leaving some partners home alone with infants. Postpartum doulas offer a wide range of support, including staying the night so that parents can rest, doing laundry or teaching parents how to care for newborns. They can also watch for signs of postpartum mood disorders and encourage parents to contact a medical professional if they’re experiencing postpartum complications.

Several months after listening to Veneklase and Revere’s presentation in 2019, Pioneer announced that eligible employees and their dependents would be reimbursed up to $2,000 for doula services from the prenatal period to one year postpartum.

After experiencing success with Pioneer, Gold Coast Doulas tried to work with other businesses, including private insurance companies, but the pandemic forced them to put their plans on hold.

The coronavirus pandemic has also heavily impacted pregnancy and birth experiences. Although Mandy Garber, 36, hadn’t considered hiring a doula for her second pregnancy, the “anxiety of the unknown” during the pandemic began to take a toll on her. Her husband wasn’t allowed to accompany her to prenatal appointments, and she wasn’t sure which provider would be at her birth. During labor and delivery, the hospital would allow one support person — and a doula. (Nationwide, additional friends, family members and doulas have been shut out of many hospitals because of covid-19.)

Mandy Garber with her children. (Family photo)
Mandy Garber with her children. (Family photo)

When she was about eight months pregnant, Garber contacted her insurance company to see whether doula services were covered. During a live chat, a representative assured Garber that her health plan would reimburse her as long as the doula was certified. Garber then hired a doula through Birth First Doulas, an agency in Portland, Ore.

After being diagnosed with preeclampsia and learning that she would have to be induced, Garber cried on the phone as her doula, Liz Haebe, listened to her concerns: “She felt like a best friend ... who knew what was going on and had been through this before.”

“Her job and her presence were priceless,” said Garber, who gave birth to her daughter, Quinn, on Jan. 28.

But when Garber submitted her claim to Regence BlueCross BlueShield of Oregon, it was denied. The company eventually determined that there had been a mistake but agreed to honor the original conversation Garber had with a representative. Garber — a pediatric occupational therapist who decided to stay home with her kids after her caseload dwindled — gets her insurance through her husband’s employer. She expects to be reimbursed $900.

Garber’s story reflects the importance of simply asking insurance companies about doula coverage, Birth First Doulas co-owner Rebecca Durlin Smith said.

“The more parents who ask, the more they see that there’s interest and demand,” Durlin Smith said. “The client’s voice is the loudest voice.”

Durlin Smith and her business partner, Brooke Noli, have also seen an increase in the number of clients who use Health Savings Account or Flexible Spending Account funds to pay for doula services. Noli said that when they first became a doula in 1999, few people were talking about private insurance coverage or using an FSA to pay for their services.

As more people learned about the benefits of having a doula, Noli said, the question became, “What are the options for payment?”

“All women should have access to anything that’s going to improve their outcomes,” Noli said.

Rookwood, the doula and family benefits strategist, said that when it comes to improving maternal health, it’s important to make sure companies are supporting their employees holistically by offering benefits such as paid parental leave and funds for fertility treatment.

“I’m going to be a proponent of doulas forever, but doulas care about the 360-degree view of their clients,” Rookwood said.

This doula series is funded by the O’Brien Fellowship in Public Service Journalism at Marquette University. Marquette University and administrators of the program played no role in the reporting, editing or presentation of this project. To learn more about this reporting project, click here.

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