West Virginia has some of the worst birthing outcomes in the nation. The WVCBP has previously focused on racial disparities in infant and maternal mortality, but the state must also address infant and maternal morbidity, or serious health complications that do not result in death. These are far more common and have a significant bearing on quality of life in the short- and long-term. The emotional and physical cost of morbidity in a family or community is astronomical and difficult to quantify, but stories have begun to uncover the true depths of this issue. Experts have also begun breaking down the financial costs to individuals and insurance providers. To reduce these numerous costs and promote health equity, experts seek policies that will address adverse birthing outcomes and experiences.
One of the most cost-effective ways to address infant and maternal health outcomes is by making doula care more accessible. Doulas are trained birth workers who provide non-medical support throughout pregnancy, during childbirth, and after the end of pregnancy. They act as support for pregnant persons, ensuring that their questions are answered, their needs and desires are represented, and that they feel comfortable and safe. Studies show that having doula support can improve both birth and post-birth outcomes.
Over the past several years, lawmakers have introduced legislation that would require the state’s Medicaid and/or PEIA programs to cover doula services. Legislation introduced during the 2023 West Virginia legislative session that would have extended doula services to Medicaid recipients was estimated to cost the state about $85,000 annually. Those funds would also pull down additional federal dollars for a total cost of $340,000. Several states are in the process of improving doula access. About one-quarter of state Medicaid programs already cover doula services, including those in Maryland and Virginia.
While West Virginia faces a relatively low cost to make doulas more accessible to families, the benefits are immediately apparent. The National Health Law Program (NHeLP) conducted a study that measured the cost-effectiveness of doula care coverage. It found that having a doula present throughout pregnancy and postpartum significantly improved birthing outcomes. These outcomes include fewer cesarean sections and pre-term births, as well as lower rates of postpartum depression and anxiety and higher rates of breastfeeding. Further, the study also found significant cost savings for health insurance providers that cover doula services.
The two most common birthing complications that NHeLP analyzed are cesarean sections (c-sections) and preterm births. The WVCBP analyzed potential savings to the West Virginia Medicaid program, concluding that having a doula coverage program could save the state at least one million dollars annually by reducing the likelihood of these occurrences.
A c-section is a surgical delivery of an infant through an incision. Over one-third of babies born in West Virginia were delivered via c-section between 2018 and 2022, slightly higher than the national average. C-sections are medically necessary in many cases. In others, especially in low-risk pregnancies, they are often elective or scheduled. Having a doula present can reduce c-sections in low-risk pregnancies by providing education, avoiding inductions, and advocating on behalf of their patient. Preventing these procedures can reduce infant and maternal risks of injuries, hemorrhages, and embolisms. NHeLP found that doulas reduced the likelihood of a c-section by 40 percent compared to births without doulas. On average, c-section births cost Medicaid programs an additional $4,500 compared to vaginal births.
Preterm births refer to births before 37 weeks of gestational age. Between 2018 and 2022, just over 12 percent of infants born in West Virginia were born prematurely; roughly 70 percent of those babies had a low birth weight, which is a primary concern for preterm births. Preterm births and low birthweights caused 13 percent of infant deaths in the state in 2021. Roughly 17 percent of Black babies born in West Virginia had a low birth weight, compared to just nine percent of white babies. That same year, Black infants in West Virginia died at a rate 2.5 times higher than white infants.
These newborns often face difficulty breathing, heart problems, digestive problems, and more. Often, these babies must stay in the neonatal intensive care unit for extended periods, where they are closely monitored. Having a doula can reduce the number of preterm births and low birthweights by providing education and emotional support, both of which reduce anxiety and stress. Decreasing stress levels also curtails postpartum depression and anxiety and increases breastfeeding success, supporting healthy babies in the critical first few months of life. Doulas are associated with a near-25 percent reduction in premature births. Medicaid programs pay over $40,000 in additional funds to ensure the wellness of these infants compared to full-term births.
In 2021, West Virginia’s Medicaid program covered the births of roughly 8,100 infants, representing nearly half of births across the state. The program plays a meaningful role in connecting West Virginia families with critical and otherwise inaccessible pre- and post-natal care. Nationally, about six percent of pregnant people utilize doula services. Based on this estimation and the figures provided by NHeLP, West Virginia could have saved at least $927,000 in 2021 by covering doulas—nearly a three-to-one return on investment compared with the estimated cost of the program.
With more resources and education about the benefits of having a doula, West Virginia could save even more. If even one in five pregnant people sought doula care, it could amount to over $3 million in savings to the state Medicaid program annually, while costing less than $250,000 in state dollars.
To be clear, these estimates are conservative—they only account for direct savings associated with c-sections and preterm births. Accounting for factors like lost productivity, maternal and infant health complications, and other factors could generate significant additional savings. Still, these figures are compelling, especially with the low cost to the state. These savings, alongside the well-documented health benefits to new parents and infants, make it clear that implementing doula care in West Virginia could significantly improve health outcomes. Enhancing doula accessibility would help make West Virginia a better place for families.
