Utilizing Doula Care to Support Substance Use Disorder in the Postpartum Period

June 28, 2023 | Maria Gabriela Ruiz, Ramya Dronamraju

Substance use disorders (SUD) contribute heavily to adverse maternal health outcomes in the United States. More than 1,200 pregnant and postpartum people died of a drug overdose in 2020, with overdoses involved in more than one in six pregnancy-associated deaths that same year. The postpartum period is a perilous time for birthing people experiencing SUD, with the greatest risk of death related to SUD in the first 90 days and an elevated risk for a year postpartum. Despite this, postpartum people experiencing SUD are less likely to receive critical care. Additionally, many lose contact with the healthcare system due to the incomplete transition from obstetric to primary care and loss of insurance coverage that affects the continuation of treatment during this critical time.

Pregnant people experiencing SUD also face substantial barriers to care perpetuated by stigma and fear of Child Protective Services involvement and other legal repercussions. Not seeking and adhering to obstetric care increases the risk of postpartum complications. Expanding the maternal care workforce to include postpartum doulas can help mitigate that fear and improve maternal health outcomes through patient advocacy, emotional support, and individualized care.

Postpartum doulas provide culturally respectful, family-based services emphasizing support through emotional and physical care, infant feeding support, advocacy, referrals, and help navigating parenthood and tending to a newborn. This support can increase parental self-efficacy and adherence to treatment for those experiencing SUD, leading to lower rates of postpartum depression and, subsequently, improved health outcomes.

How States Fund Doula Care

Funding is a main barrier to providing and accessing doula services. However, there are diverse methods of appropriating funds to support doula programs at the state, county, and city or community levels:

• Medicaid. Oregon, New Jersey, and Minnesota, for example, are covering doulas through their Medicaid plans under preventative care. Some states, such as Florida and Nebraska, reimburse Medicaid recipients enrolled in managed care plans as an expanded benefit. In Virginia, doulas are also covered through Medicaid and can be reimbursed through independent practice and billing, joining an agency or practice, or enrolling as an MCO provider.
• Block Grants. In Pennsylvania, the Philly Loves Families Doula Support Program offers SUD-centered doula care through a referral-based program that utilizes Title V state funds to support birthing people experiencing SUD. This program fully covers doula services for up to one year postpartum and includes access to support groups, lactation support, and continuous education support throughout program participation.
• Federal Grants. Massachusetts’ Moms Do Care EMPOWER (MDC) and EMPOWER program uses federal grant funds to serve pregnant and postpartum people experiencing SUD through a team of postpartum and prenatal doulas, nurses, clinical providers, and recovery coaches. The postpartum doulas working with these teams offer physical and emotional support, home visitation, assistance with breastfeeding, and help navigating the postpartum period while experiencing SUD. Many of the doulas working on these teams are also in recovery, offering lived experience.
• Blended Funding. Through a combination of state and federal funding, the Illinois Department of Human Services/Division of Substance Use Prevention and Recovery developed a pilot program that focuses on family-based services to support pregnant and postpartum individuals experiencing opioid use disorder. These family-based services include access to a Doula Certified Peer Recovery Specialist, a person in active recovery with certifications in doula training.
• Private Organizations. North Dakota uses grant funds distributed by a private foundation aimed at mitigating the effects of the opioid crisis to fund their Don’t Quit the Quit (DQTQ) program. Based at the University of North Dakota, DQTQ supports pregnant, postpartum, and breastfeeding people experiencing opioid use disorder in rural parts of the state by increasing access to care and providing postpartum doula coverage. DQTQ is working to increase access to medications for opioid use disorder for pregnant and postpartum people and raise awareness about the unique needs of this population. Additionally, North Dakota’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is participating in DQTQ to offer additional support, treatment, and referral options—all to provide continuity of care.

Leveraging funds to support doula-based programs and subsidize doula services can help increase access to those services. States that have not yet expanded Medicaid can utilize several other innovative methods to finance access to doulas. Additionally, including language in proposed policy that explicitly states the value of postpartum doulas as medical service providers could be valuable in ensuring coverage of those services.

Recommendations for State and Territorial Health Agencies

• Consider incorporating postpartum doula support into the care team for pregnant people experiencing SUD by exploring the creation and implementation of doula programs, as well as finding ways to mitigate the financial burden on families who seek these services. Developing specialized programs and reducing financial barriers can lead to more inclusive and comprehensive care and equitable access to services improving outcomes for postpartum people with SUD.
• Support the doula workforce through Medicaid reimbursement and other innovative models of payment. Implementing innovative financing methods is essential to overcoming financial barriers and increasing availability of services. Medicaid reimbursement of doula services not only recognizes the valuable contributions doulas make to maternal health, but also helps make their services available to low-income and underserved populations.
• Increase provider and patient awareness to increase the uptake of doula services. This is a crucial step to empower expectant individuals with valuable information and support they need to make decisions that impact their care. It also equips healthcare providers with a broader understanding of the benefits doulas bring as allies on the maternal care team.
• Consider partnering and collaborating with doulas and community health organizations early in program and policy development. Engaging doulas with lived experience in the policymaking process ensures equity and sustainability. States can partner with local and national doula organizations, forging relationships with the community-based perinatal workforce, evaluating existing doula programs, and communicating with states that have successfully implemented doula programs, such as those mentioned earlier.