In 2019, we published a letter in direct opposition to the New York state bills attempting to regulate doulas, and in full support of autonomy for doulas in their practices. Our position on these matters has not changed. However our support of doulas and their work has been tested. As we have adapted the response to meet the growing demands imposed on doulas, we have worked and continue working with state-based health departments to provide documentation of the Doula Trainings International program. In some cases this has facilitated their approval of DTI doulas to work with Medicaid clients. To be paid for their work, doulas are asked to become either credentialed or registered with states. These are not processes we are in support of or wish to devote our limited resources to, however ultimately we must do what is best for birthing folks: expanding access to doula care is what we're about. We do not want doulas, and particularly DTI doulas, to be strong-armed into taking an additional training they feel is unnecessary. We stand by the integrity of the rigorous program DTI offers.
Doula Trainings International is currently an approved training for Medicaid in Colorado, Maryland, Michigan, Minnesota and Nevada (birth), and is also approved in the District of Columbia. In January 2025, DTI received partial approval in the state of Virginia.*
The state of California does not require doula training from any particular organization, and the state of New York provides a couple of pathways which are inclusive of doulas who have trained through us.
*In Virginia, the state certification board has imposed requirements regarding doula training curriculum. They require a fully approved training to teach the following:
- 2 hours must be in Maternal and Infant Health Concepts and Approaches
- DTI has 40+
- 10 hours must be in Lactation anticipatory guidance and support
- DTI has 15
- 20 hours must be in Service Coordination and System Navigation
- DTI has 5, plus plenty of opportunity to receive guidance on these subjects directly from our educator team. We did not apply for this category.
- 8 hours must be in Health Promotion and Prevention
- DTI has 2. We did not apply for this category.
- 5 hours must be in Advocacy, Outreach and Engagement
- DTI has 39, however we did not apply for this category because the content we teach fits more closely into the next two categories.
- 2 hours must be in Communication
- DTI has 16
- 8 hours must be in Cultural Humility and Responsiveness
- DTI has 23
- 5 hours must be in Ethical Responsibilities and Professionalism
- Ethical responsibilities are a core value which guides our community and we trust our community members. We did not apply for this category.
To say we are frustrated by these requirements would be an understatement. As you can gather, there are 4 categories above which DTI did not qualify for. We cannot help but wonder whether we are one of the few organizations who chose to fill out the application with 100% transparency.
Unfortunately the issues for doulas who wish to serve Medicaid clients, or who already do, are numerous. Let's highlight a couple of the most severe:
- Inability of the doula to decide which training works best for them. (See above, specific curriculum requirements which do not necessarily improve the doula's knowledge or experience.)
- In many states, the reimbursement rate is far below market rate. For instance, in the state of Virginia, doulas are reimbursed $859 for eight prenatal and postpartum visits and presence at labor/delivery. Factoring 12 hours of labor support plus 8 hours minimum of additional visits, while $53/hour might seem like a fair wage, it does not factor in the tremendous on-call element of our birth doula role, or speak to the reasons birth doulas work on a flat rate model.
- Doulas spend countless additional hours supporting their clients and running their businesses. Now states are adding the hours it takes to figure out billing processes, filing bills correctly, etc. just to get paid weeks or months after work has already been completed, if they get paid at all.
- The state of Virginia requires training organizations to pay fees in order to be considered for their credentialing process.
The bottom line is that we will continue supporting our doulas with what they need in the best ways we can. We will communicate with and ask questions of the departments responsible for making these decisions. We will give input whenever key stakeholder meeting invitations are extended, and we will keep tabs on the incredible resource, Doula Medicaid Project offered by the National Health Law Program, on behalf of our doulas.