Ohio doulas are sounding a warning, saying a new process meant to encourage the profession to improve infant and maternal mortality outcomes in the state may actually be making it harder for doulas to perform their life-saving jobs.
Doulas are people who help pregnant women and advocate for them through a pregnancy, birth and after.
On Wednesday, doulas from around the state are gathering in Columbus for a meeting of the Doula Advisory Group.
Many doulas are going to voice their complaints about how state lawmakers and the Ohio Board of Nursing have been rolling out a new process to certify doulas, and to suggest ways to improve it.
“That doula, that support person is there to give emotional, physical, and even educational support," said Jamaica Gilliam. "One of the biggest things that we say for our clients, for the folks that we serve, is that we want your birthing experience to happen with you versus to you.”
Gilliam is a doula who works in the Cincinnati area. She's the executive director and founder of Blaq Birth Circle. She said the process started out good, and that the state was interested in what doulas had to say.
“We were actually really excited that this was a thing that was happening. There was a point where about eight to 10 other states that had already had Medicaid reimbursement for doulas. So we were really excited that we were getting on board," Gilliam said.
Doulas aren’t required to get certified to offer their services in Ohio, but the certification is supposed to be a pathway to get doulas paid through Medicaid. Doulas can receive up to $1,200 per pregnancy they work on. That’s $600 per birth and up to $600 for the prenatal and postpartum visits. The idea is to connect more people to doulas, and to make their services accessible to everyone.
Marlene Anielski, executive director of the Nursing Board of Ohio, said doulas are a part of the state’s strategy to bring down the rate of infant and maternal deaths.
“We want to do as much as we can to promote that profession, because we know that has a direct impact on the health of the mom and health of the baby," Anielski said.
Over the last few years, the state also increased Medicaid coverage for pregnant women to 12 months and added lactation consultation to covered services.
Doulas can be particularly helpful in communities of color, where infant mortality rates are higher.
Anielski said the state's goal is to have six or fewer infant deaths per 1,000 births in the state. She said the figure is at 14 per 1,000 births for Black babies, and at five per 1,000 births for white babies.
“This has been something that the governor and the governor's office has been very adamant on wanting to be a priority as the infant mortality and maternal mortality of Ohio, especially in Black and Brown communities," Gilliam said. "We are trying to let them know, 'hey, this is not working out the way that you wanted it to work out.'"
So far, only 200 doulas have been or are in the pipeline to become certified in Ohio and eligible to get their services reimbursed by the state’s Medicaid system.
There are tens of thousands of births in the state each year, and about half are covered by Medicaid.
“I do think we need thousands in the state," Anielski said. "I just think we need all of them to work for the safety of all Ohioans, to reduce infant mortality.”
But, the process is actually forcing some doulas out of the profession.
“There are hospital systems that are saying to doulas that if you don't have that certification, then you are not welcome here," Gilliam said.
The original language of the law bars doulas from calling themselves "certified," unless they are certified by the state’s board of nursing.
“Which is also ridiculous because that was something that we said in the beginning that said, like maybe we shouldn't use these particular words and language, because it's going to make it seem like all of the other certifications are obsolete," Gilliam said.
There are other organizations that certify doulas.
Organizations like DONA International make sure doulas have professional experience and training.
The Ohio certification is supposed to only be required for Medicaid reimbursement, but some hospitals changed their policies after the law passed.
Doulas lobbied the nursing board to lobby lawmakers to change it. And it worked. A change in the language takes effect in April.
Anielski gives credit to the doulas for getting the language changed.
But lawmakers also changed the structure of the doula advisory body, calling it a group instead of a board and putting a member of the nursing board in charge instead of an elected doula.
Anielski said the nursing board is doing what they can to work toward the common goal of saving lives, but said the doulas are expecting too much from their advisory role.
“They want to have us lobby and change the law for them to have more authority. They want us to tell hospitals they have to hire all doulas. That is not within our authority," she said.
But Anielski admits they’ve been able to elevate some of the doulas' concerns in other ways, like getting that language changed in the original law. And getting an amendment allowing advisory group members to attend virtually, so they don’t have to leave clients or children behind to come to Columbus.
“We want participation from everybody, and that's how you make good decisions when you have everybody's input, as long as we are following the law, whatever the law tells us to do, and as long as the advisory group understands what the Ohio Board of Nursing scope is regarding the advisory group," Anielski said.
Gilliam said doulas had to make noise to get their concerns addressed with the original language of the bill, demonstrating that they should be closer to the process and not further from it.
She said lawmakers made other changes, which passed at the same time, that work to undermine the doulas' place, and water down their influence.
“And we don't need another barrier, but I feel like we have said 'This is not working.' And the Board of Nursing has just said, 'Well, basically we'll figure it out. We'll have to figure it out.' And that's just not gonna work in this community," Gilliam said. "So there's barriers to becoming certified in the first place.”
Gilliam said the law is trying to treat doulas like clinical providers, but doulas aren’t offering clinical services.
“In all honesty, I just think that the system wasn't thought out very well. And I think that the intention was for it to be thought out. But I think when it comes to the state of Ohio, when it comes to regulating different bodies, that they think very medically,” Gilliam said.
Anielski said the board of nursing is available to help doula groups work through the application process, and that there are training videos available online. She said they've also reached out to hospital systems with a fact sheet to help explain what the state's certification process does and doesn't do.
At Wednesday's meeting, the agenda includes a discussion of updates to the application process and a plan to address the removal of uncertified doulas from hospital systems.
It will be the last meeting before the chair is removed and replaced with someone from the Ohio Board of Nursing.
