Doula Fees and Health Benefits plans

This is a topic that I am actually hoping to write a longer piece about, hopefully for publication in a parenting magazine of some variety, but until I get around to finding someone who wants to print it, I figure a short post might get people talking and thinking.

Given what the research on doula support has unequivocally shown – that women who have doulas for their births have significantly higher rates of satisfaction with their births, fewer unnecessary procedures or medications and lower rates of postpartum mood disorders – there are many people out there, myself included, who believe that every birthing woman should have a doula, just as every birthing woman in Ontario has a doctor or a midwife to attend their births. In addition to a woman’s feelings of satisfaction, and no doubt in some cases, connected to it, is the fact that doula-attended births also have significantly lower rates of medical intervention. Statistically speaking, women who have doulas have shorter, less painful labours and are significantly less likely to request pain medications, require assistance with forceps or a vacuum extractor or have Caesarean births. Obviously, first and foremost, this is great for the women (and their babies) who can afford to hire doulas, but it is also great news for the health-care system. The cost of administering an epidural is about $2000.00 and a Caesarean birth costs two to three times more than a vaginal birth. When you consider that most doulas charge a fee that is somewhere between $500 and $1000 per birth, you can see how they could potentially save our healthcare system a lot of dollars, even if that healthcare system were paying for them. Which, in Canada, it is not.

When midwifery was first legislated and regulated as a profession in Ontario in 1994, one of the criteria that the groups who had been fighting for it were insistent upon was that it be accessible, meaning that there could be no restrictions based on a person’s financial constraints. In this province (though not in every province with regulated midwifery care) regulation came hand in hand with provincial coverage, meaning that women now have equal access (from a financial perspective) to both midwives and obstetricians. Now there are hopes that a similar arrangement might be developed for doula care. This would make the profession much more visible, as well as accessible. In the meantime though, what are you to do if you want a doula, but can’t afford the fees?

Well, there are a few options. Many new doulas will provide services for very low rates or even for free while they work towards certification. For couples with very low incomes, groups like doulaC.A.R.E. can sometimes match them with a doula willing to do the odd volunteer gig for those in need. Many doulas, especially very experienced ones, will not work for free though as there is a common perception that doing so de-values the work that we do. Also, given the intimacy of the doula-parent relationship, it is unfortunate that lower-income couples often don’t have the same options as their wealthier peers in terms of selecting their own doula, someone that they feel a connection to and comfortable with. While having any doula is virtually always better than having none at all, this is hardly ideal, especially given that people don’t usually have the option of selecting a particular doctor or midwife either because of the realities of demand.

At the moment, the only option in Ontario for having some or all of your doula fees covered, is to submit a claim to your private health insurance company, if you have benefits either individually or through your employer. In the US, Doulas of North America (DONA) was  recently successful in getting a number of third party health insurance providers to explicitly agree to cover doula services, as most already did for massage therapists or acupuncturists, for example. In the States it was a slightly simpler argument to make though, since those insurance companies would also be on the hook for the epidural if there was one, or the costs of the Caesarean if there was one, etc. In Canada, because our public healthcare system covers the doctors, the epidurals, the surgeries, etc. there is less incentive for private health benefits providers to cover doulas since they have nothing to gain by their clients avoiding these interventions. Despite this, there are ways to have labour support covered by your health benefits plan.

The easiest way is probably the least accessible unfortunately. For those with health spending accounts or ‘flex dollars’ built into their plans, it’s usually just a matter of submitting your claim form along with an itemized invoice from your doula (NB: some providers require that the doula be certified by a doula training organization such as CAPPA or DONA, so if you’re planning on pursuing this route, be sure to check with your provider before selecting a doula, so that you can be sure to find someone who is certified if necessary). Often your prenatal classes can be covered in this way as well. It’s not the norm though for benefits plans to include these spending accounts and unfortunately, those who do tend to have them are typically those with higher incomes who would be more likely to be able to afford a doula either way (why do things always seem to work out this way in our economy?).

The second option is more commonly available, but limits your choice of doula somewhat. Registered massage therapists can choose to be trained in massage for labour and many also undergo doula training so that they can offer a full package of labour support to pregnant massage clients. This is something that the College of Registered Massage Therapy in Ontario acknowledges as within the scope of practice for RMTs. On the other hand, most doula training organizations do not support this overlap and feel that RMTs who are also doulas should not wear both hats at once, so to speak, so it is a bit of a grey area. In any case, if you can find an RMT who does double-duty as a doula, they can invoice you for the full gamut of labour support services and your benefits plan will cover it to the extent that it covers treatments from registered massage therapists. This may not cover the whole cost, as many plans only provide for a few hundred dollars of coverage per year from an RMT, but it may take the sting out of your doula fees somewhat.

Ideally, as we move towards better and more individualized maternity care in Ontario, it would be fantastic to see the doula profession regulated and funded by the government. In the meantime, if you’ve got benefits, check with your provider to see if there is some way that you can have them cover your doula fees, either by using one of the strategies I’ve outlined above or by having them make a special case for you (in particular, if you have special circumstances surrounding your birth, this might be more of a possibility). Even if you’re certain that they will not cover doula costs, call them and ask anyway. It wasn’t so long ago that acupuncture wasn’t covered either and now it tends to be a standard item in most plans. This is largely because of popular demand. I recently spoke with Bill Walker, Manager of Individual Products at Blue Cross about the issue and he had this to say, “…at the end of the day, the rationale (behind what services are covered) is the demand for it. If companies really are getting customer demand for it, I believe they would begin looking at providing some kind of coverage.”

If you’re a doula, recommend that your clients (or even potential clients interviewing you) inquire with their providers about coverage. The more people asking for it, the more likely we’ll see it ‘on the menu’ in the near future.

If you don’t have benefits and the cost is a factor for you, you can search doulamatch.net, a directory service where doulas list their rates, as well as their willingness to work for free or on a sliding scale.

Do you know of any other ways to have doula fees paid for? I would love to hear any suggestions that people might have so that I can recommend them to others.