When Maria Rossi first started working as a doula 15 years ago, she immediately noticed a startling contrast in who was able to access her services. “It was so stark, the differences of what’s being offered to people who had means versus those who didn’t,” she said.
That’s important because the benefit of doulas lies in their ability to work outside of the traditional medical establishment, she said. Rossi said doulas address the emotional needs of clients, rather than offering clinical medical services.
Rossi started the doula program at Washington County Mental Health Services 12 years ago because she wanted to provide more birthing resources to Vermonters who aren’t white, are experiencing poverty, live in a rural area or struggle with substance abuse.
For years, doulas across the state have told lawmakers their services can bridge the gap in resources. They’ve pointed to research that shows pregnant people who use doulas are more likely to have positive birthing outcomes.
And they’ve asked lawmakers to make their services more affordable.
Now, a new law signed by Gov. Phil Scott Monday, creates a roadmap to having Vermont Medicaid cover up to $2,100 in doula services. The state and federally funded insurance program would specifically pay for doulas to work with people before, during and after birth. The law also creates a certification program for community-based doulas who serve lower income and under-resourced populations.
The time around birth can be very powerful, but has the potential to be traumatic, Rossi said.
From 2012 to 2023, 29 people died from pregnancy complications in Vermont, according to an annual state report. Across those cases, researchers found that rural counties in Vermont have a maternal mortality rate three times higher than in Chittenden County — and 83% of Vermonters who died during the perinatal period were insured by Medicaid.
Nationwide more than 80% of pregnancy-related deaths in the United States are preventable, according to the Centers for Disease Control and Prevention. National data also shows huge racial disparities. Black people are more than three times likely to die from a pregnancy-related cause, according to the CDC.
Those statistics, along with input from doulas, inspired the law.
If all goes as planned, a pregnant person working with a state-certified doula could have their expenses covered by Medicaid. But officials at the Department of Vermont Health Access, which operates the program, have “significant concerns regarding funding and implementation” of the law, said Alex McCracken, a spokesperson for the department.
First, state officials must figure out how to certify doulas. The Office of Professional Regulation, which operates under the Vermont Secretary of State’s Office, is tasked with developing the certification process and carrying it out. The office wants a training standard that will teach doulas how to address the distinct needs of underserved populations, said Jennifer Colin, the office’s general counsel.
Once the certification is designed, the Department of Vermont Health Access must seek federal approval to change its Medicaid plan by July 1, 2026. But health officials worry the “community-based” doula certification program as envisioned by the law won’t meet federal standards, McCracken said.
In early May, McCracken cautioned lawmakers against any amendments to the state plan “given the current volatility and uncertainty in the federal environment.” Just days later, President Donald Trump announced billions of dollars in cuts to Medicaid’s federal funding.
Upon signing the bill, Scott gave those concerns a platform.
“Outstanding operational concerns must be addressed before we seek to amend our Medicaid plan,” Scott said in a statement. He urged lawmakers to address any unresolved administrative stumbling blocks next year.
Lawmakers who worked on the legislation understand those concerns. Sen. Martine Laroque Gulick, D-Chittenden-Central, the bill’s lead sponsor, said she’s optimistic state agencies can work together to get everything ready for federal approval.
Officials at the Office of Professional Regulation supported the bill and are excited about its passage, Colin said. She said state officials across agencies can work together to create a certification the feds will green-light.
Creating a certification process aims to strike a balance between public protection and maintaining accessibility, Colin said.
To Rossi, accessibility is what the profession is all about.
Doulas that could be certified under the new law are “usually serving a higher level of need, and a more marginalized population,” she said. Rossi describes her work as more of a “behavioral intervention” that addresses a client’s emotional needs.
Rossi sees the law as an important step in closing gaps in access birthing resources and improving maternal care. She said the issue is timely as some hospitals in Vermont consider closing birthing centers in response to expensive healthcare costs.
Lawmakers recently passed another new law aimed at expanding options for pregnant people. The legislation creates a licensure process for freestanding birthing centers and reduces regulatory barriers for them to open. The law also directs state administrators to seek Medicaid coverage for their services, and requires private insurers that cover maternity services to include freestanding birth centers as providers.
Doulas are essential in rural communities where there are fewer health care resources, Rossi said, and research shows their services prevent birthing complications and make cesarean sections less likely — ultimately lowering hospital costs.
Other doulas echoed the sentiment in conversations with officials from the Office of Professional Regulation, according to a state study prompted by a related law last year.
Those conversations are why administrators recommended that lawmakers create a voluntary certification process for doulas, rather than setting a higher bar like a licensure requirement. One certified nurse midwife, who was not named in the study, said they work with immigrants and refugees in Chittenden County.
They said the needs of immigrants are not being met — and that access to culturally relevant doula services could create better birthing outcomes and overall more positive medical experiences.
Now, private insurance companies might consider covering doulas as well. BlueCross BlueShield of Vermont started a pilot program last year to gauge member interest in doulas and has seen positive results, said spokesperson Sara Teachout.
While the pilot is still ongoing, the company could mirror the state and provide coverage for certified doulas down the line, Teachout said.
