Two years after Frankie Robertson gave birth to her son, an experience she described as fairly uneventful, she got pregnant again. At the time, she was the director for the Louisiana chapter of March of Dimes, a nonprofit that aims to improve maternal and infant health. She had a decade’s experience in health policymaking, community education, and national advocacy, but that knowledge and expertise did not prevent the harrowing nature of her second pregnancy.
When she went in for her first ultrasound, the doctor noticed she had a dangerous condition in which the placenta blocks the birth canal. And on top of the medical concerns, she had screened positive for depression about two months before she learned she was pregnant. She underwent an emergency cesarean section three months early, and her daughter was in the Neonatal Intensive Care Unit for 26 days.
Throughout her turbulent pregnancy, Robertson kept thinking about the work she was doing through March of Dimes: studying health equity issues and drawing attention to the Black maternal health crisis.
“Here I am, a Black woman at 41,” Robertson said. “And everything I’m teaching about, everything that I’m talking to the media about, everything that I am breathing, living from the inner part of my core, wanting to change things, all of a sudden, this has happened to me, right? And I’m like, ‘This is how this happens.’”
Her difficult pregnancy inspired her to complete doula training and eventually to lobby for the passage of House Bill 272, which mandates private health insurance reimburse doula services up to $1,500.
Authored by Representative Matthew Willard and passed with bipartisan support, the bill will become law on Tuesday (Aug. 1), but will not impact insurance policies until Jan. 1, 2024. While nine states and Washington D.C. offer doula care under Medicaid, Louisiana will soon become one of two states to cover doula care through private insurance (Rhode Island, which also includes Medicaid coverage, became the first in 2021).
Unlike midwives, who assist pregnant people during childbirth, doulas provide a different kind of service. Victoria Williams, an outreach director for the Birthmark Doula Collective, defines a doula as a “non-medical physical, emotional, mental, and spiritual support person that provides education advocacy to families who are in the preconception, all the way to postpartum.
Medical organizations, including the American College of Obstetricians and the Centers for Disease Control and Prevention, have documented doula services' benefits: lower cesarean section rates, shorter labor hours, and fewer complications during and after birth. And while advocates and representatives believe this bill will improve the health of pregnant people and infants, they also see it as a baby step in the context of the maternal health crisis.
The bill comes when a maternal health care crisis that disproportionately harms Black women, is likely to worsen due to the overturning of Roe v. Wade. It also comes out of a legislative session that struck down a series of other bills pushed by reproductive justice advocates, including exceptions to the abortion ban for cases of rape and incest, and bills pushed for by doctors, including legal clarifications on miscarriage treatment.
“It is by far one of the best things that came out of the 2023 session,” co-author of the bill Rep. Delisha Boyd, said.
‘Not a great state if you’re a pregnant woman.’
The idea for the bill dates to Willard’s 2019 campaign for state representative. Knocking on doors and talking to people in his district clarified the importance of prioritizing maternal health. He learned the troubling statistics — that Louisiana has the highest rate of maternal mortality in the country and a third of the state’s parishes are maternal health deserts, without an OB-GYN; that Black women are four times more likely to die pregnancy-related deaths than their white counterparts. “Overall, Louisiana is not a great state if you’re a pregnant woman,” Willard said.
During his campaign, he spoke with Lori Jupiter, a civil district court judge in New Orleans who also works as a doula, and she suggested that he look into doula and midwifery services as one way to help address the maternal health crisis.
Willard authored a bill in 2021 that guaranteed health insurance coverage for midwifery services and established a “Doula Registry Board,” which allowed the birthing community to start working with the insurance industry so as to prepare for the passage of the 2023 measure. Robertson represented birth equity organizations — RH Impact, the Institute of Women and Ethnic Studies, and the March of Dimes — as a strategist and lobbyist.
“One of the reasons that I think we got [the insurance industry] to come to the table is because, you know, access to doula care can improve birthing outcomes and when you have better birthing outcomes, it’s actually cheaper on the insurance industry, even even with them paying for a doula and a midwife and a doctor,” Willard said. “That will still be cheaper than if you have a preterm delivery who has to stay in the NICU for a week or two.”
Public versus private coverage
While the new law will guarantee doula coverage for those with private insurance, these services are not guaranteed for publicly insured individuals, concerns advocates. Robertson emphasized that the bill can potentially be “a big game changer” when it comes to doula access.
She noted that Medicaid providers had the option to revise their benefits packages last year, and all but one of the six organizations modified their services to reimburse doulas. But the reimbursement rates for publicly insured individuals are much lower than those on private insurance. For instance, Medicaid provider AmeriHealth Caritas Louisiana typically reimburses doula services up to around $500, a third of what private insurance companies will pay when the new law kicks in.
“With Medicaid, there’s much inequity there,” Robertson said. “It’s a cause for concern. If you’re serving a person, you’re serving a person.”
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