Taja Iglesias remembers the isolation of her own labor, specifically the feeling that her request to avoid an epidural was being ignored by medical staff. Now, she runs The Momager Co. in Alexandria, Virginia, where comfortable couches and piles of baby toys create a sanctuary for expecting parents. Her goal is to ensure others have a birthing bestie, a doula who acts as an advocate and emotional anchor during one of life’s most vulnerable moments. While these professionals offer critical support that improves breastfeeding rates and lowers maternal anxiety, many find that the promise of government coverage remains a distant reality for those who need it most.
Across the United States, there is a growing movement to integrate doula care into Medicaid to combat alarmingly high maternal mortality rates. Currently, twenty six states and Washington, D.C., reimburse doulas through Medicaid, with dozens more considering similar laws. In Virginia, legislation even allows non family members in delivery rooms to bolster patient support. However, having a policy on paper does not always translate to care in the clinic. Research conducted by Desirae Leaphart Mensah shows that despite the legal framework, fewer than one percent of Medicaid births in Virginia utilized doula services during the early stages of implementation.
The disconnect stems from a grueling combination of bureaucracy and low pay. To accept Medicaid patients in Virginia, doulas must navigate a complex certification process involving fees and mountains of paperwork that often discourage providers before they ever see a client. Once certified, the financial return is starkly different from private practice fees; while private clients may pay thousands of dollars for comprehensive care, Medicaid typically reimburses around eight hundred dollars per pregnancy. Kenda Denia of Birth in Color notes that this rate fails to reflect the actual value of the service or the costs associated with traveling to clients’ homes for prenatal and postpartum visits.
For practitioners like Iglesias, the restrictions go beyond money. State guidelines limit the number and duration of visits, leaving little room to build the deep trust necessary for effective advocacy during birth. Because she feels the state mandated training is incomplete and overly restrictive, Iglesias has chosen not to seek official certification herself. Instead, she focuses on raising independent funds to provide care for marginalized parents outside the system. Until policymakers bridge the gap between legislative intent and practical application, many expectant parents will continue to find themselves without an advocate when they need one most.
