In the past five years, more than thirty US states have added doula services to their Medicaid programs, a policy shift meant to improve maternal health outcomes, particularly for Black and Indigenous women who face disproportionately high mortality rates. Doulas provide continuous physical, emotional, and informational support during pregnancy, labor, and postpartum. A 2017 Cochrane review found that continuous labor support reduces the likelihood of cesarean delivery by roughly 25 percent and shortens labor by about 40 minutes. But while Medicaid administrators have been busy crafting reimbursement codes, something else has been happening in parallel: rural maternity wards have been closing at an alarming rate. Since 2010, over 200 rural labor and delivery units have shuttered, leaving entire counties without a single hospital that delivers babies. The result is a strange and troubling asymmetry. In wealthy urban areas, a pregnant person on Medicaid can theoretically access a doula reimbursed by the state, but in rural America, that same person may have to drive ninety minutes or more to reach a delivery room staffed by exhausted nurses who are stretched to the breaking point. The policy ambition of doula coverage collides with the workforce crisis in rural obstetrics, and neither side of the equation is being addressed with the urgency it deserves.

When Coverage Expands Faster Than the Workforce

The doula benefit is a textbook example of a policy that looks good on paper but ignores the supply side. As of late 2024, at least 32 states and the District of Columbia had some form of Medicaid doula coverage, according to the National Health Law Program. Reimbursement rates vary but typically fall between $400 and $800 per birth. In Oregon, one of the early adopters, the benefit has been in place since 2014. Yet utilization rates remain stubbornly low: fewer than 5 percent of eligible enrollees actually use a doula, according to a 2023 study in Health Affairs. The reasons are not mysterious. Most doulas are concentrated in cities. Rural areas have very few trained doulas, and those who exist often cannot afford to accept Medicaid reimbursement because the paperwork is burdensome and the payment is delayed. The policy assumes a workforce that does not yet exist.

Meanwhile, rural maternity wards are disappearing. A 2024 report from the March of Dimes found that more than 2.2 million women of childbearing age live in counties with no hospital-based obstetric care. The closures are driven by financial pressures: low patient volumes, high malpractice insurance costs, and an inability to recruit and retain nurses. A typical rural labor and delivery unit may handle fewer than 200 births per year, far below the volume needed to break even. When a unit closes, the nearest facility may be an hour or more away, and that facility itself may be understaffed. The result is a system in which coverage expansion and service contraction happen simultaneously, but for different populations.

The tension between policy ambition and staffing reality is not unique to maternal health. A similar pattern appears in chronic disease management, as seen in a related story about hypertension patients filling prescriptions but not receiving counselling. In both cases, coverage expands while the workforce to deliver the service remains inadequate. Doulas cannot substitute for delivery nurses. They are not trained to manage complications, administer medications, or perform emergency procedures. A doula is a complement, not a replacement. But when a hospital has no nurses to staff the delivery room, a doula benefit is irrelevant for the patient who cannot get to a hospital in the first place.

The workforce pipeline for both doulas and maternity nurses is decades behind the coverage expansion. Doula training programs are short—typically 30 to 50 hours—but they are not standardized, and there is no national certification. Many doulas enter the field as a side gig or volunteer role, not as a full-time career. Nursing, by contrast, requires a rigorous educational pathway, but nursing school capacity has been flat for a decade. Clinical placement slots are a major bottleneck: hospitals must agree to host students, and rural hospitals, already understaffed, often lack the preceptors to supervise them. The policy machinery that writes reimbursement codes does not build training programs.

The Doula Coverage Revolution – and Its Blind Spots

Let us examine the doula coverage expansion more closely, because it contains lessons that apply to the broader workforce problem. States from Oregon to New York have added doula benefits, often as part of broader maternal health initiatives following the COVID-19 pandemic, which exposed deep racial disparities in maternal mortality. The evidence base is strong, yet the implementation has been uneven.

Reimbursement rates are a major barrier. In many states, the fee falls below $600 per birth, which, after accounting for travel, phone calls, and time spent on call, translates to an hourly wage well below minimum wage for many doulas. A doula may spend 12 to 24 hours with a client during labor, plus prenatal and postpartum visits. At $500, that is roughly $20 per hour before expenses. Rural doulas face additional costs: longer drives, fewer clients, and more time on unpaid travel. Unsurprisingly, most doulas practice in urban areas where they can supplement Medicaid clients with private-pay clients who might pay $1,000 to $2,000. The policy creates a benefit that few providers can afford to offer.

Training infrastructure is another blind spot. Doula training programs exist, but they are concentrated in cities. Organizations like DONA International and ProDoula offer workshops, but these often require travel to a major city and cost several hundred dollars. For a rural resident who wants to become a doula, the upfront investment and time commitment can be prohibitive. Some states have tried to address this by funding doula training programs, but the scale remains small. New York’s doula pilot program, launched in 2019, trained roughly 200 doulas, but the state has over 200,000 Medicaid births per year. The ratio is absurd. Meanwhile, frontier counties with fewer than six people per square mile may have zero doulas within a hundred miles.

The utilization data tell a stark story. In Oregon, which has had Medicaid doula coverage since 2014, a 2021 evaluation found that only about 3 percent of eligible women used the benefit. In Minnesota, a similar rate was reported. The reasons include lack of awareness among enrollees, difficulty finding a doula who accepts Medicaid, and cultural mismatches between doulas and clients. But the fundamental issue is supply: there simply are not enough doulas, especially in rural areas. The policy is like opening a restaurant in a town with no chefs. The menu is printed, but the kitchen is empty.

There is also a deeper equity concern. The doula benefit is often framed as a tool to reduce racial disparities, since Black women are three to four times more likely to die from pregnancy-related causes than white women. But if the doulas who do exist are mostly white and urban, the benefit may not reach the populations that need it most. Some states have attempted to mandate cultural competency training or to prioritize doulas of color, but these efforts are hamstrung by the overall shortage. The policy's blind spot is not just geographic; it is demographic.

Rural Maternity Wards: A Staffing Crisis Exposed

While doula coverage struggles to take off, rural maternity wards are in freefall. The American Hospital Association reports that over 200 rural hospitals have closed their labor and delivery units since 2010, and many more have stopped delivering babies altogether. The primary driver is financial: a rural obstetric unit typically loses money. But the proximate cause is often staffing. Hospitals cannot find enough nurses to run the unit safely, especially for 24/7 coverage. A labor and delivery unit needs a minimum of one nurse per laboring patient, plus a charge nurse and a surgical nurse for cesareans. When a hospital has only two or three nurses trained in obstetrics, a single vacation or illness can force the unit to close temporarily—and sometimes permanently.

Nurse-to-patient ratios in rural labor and delivery are often unsafe. The Association of Women's Health, Obstetric and Neonatal Nurses recommends a one-to-one ratio for active labor, but rural hospitals frequently operate at two or three patients per nurse. During surges, such as when multiple women arrive in labor simultaneously, the situation becomes dangerous. Travel nurses have been a stopgap, but they cost hospitals two to three times the salary of a staff nurse, and they often leave after a few months. Rural hospitals cannot compete with urban systems that offer higher pay, better benefits, and more opportunities for career advancement. The result is a revolving door of temporary staff and chronic understaffing.

Recruitment is difficult for reasons beyond money. Rural areas often lack employment opportunities for spouses, good schools, and cultural amenities. A nurse who moves to a small town may find that their partner cannot get a job, or that their children have limited educational options. The on-call lifestyle of obstetrics is particularly punishing in a rural setting, where a nurse may be the only one covering nights and weekends. Burnout is endemic. Studies suggest that the average tenure of a rural obstetric nurse is less than two years. The hospital spends a fortune recruiting and training, only to lose the nurse to burnout or a better offer in the city.

The consequences for patients are severe. When a rural maternity unit closes, women must travel farther for care, which increases the risk of delivering en route or arriving in advanced labor. A 2022 study in JAMA Network Open found that women in counties that lost obstetric services had higher rates of preterm birth and neonatal intensive care unit admissions. The travel burden falls disproportionately on low-income women, who may not have reliable transportation or the ability to take time off work. In some parts of the Great Plains, the nearest delivery hospital is over 100 miles away. The policy of expanding doula coverage does nothing for these women, because they cannot even get to a facility that has nurses to deliver their baby.

The parallel with a Kenyan neonatal ward that stocks oxygen concentrators but lacks pulse oximetry sensors is striking: equipment and coverage exist, but the human infrastructure to use them is missing. In rural America, the Medicaid doula benefit is the oxygen concentrator, and the nurses are the sensors that are not attached.

One Condition, Two Americas

Consider two pregnant women, both on Medicaid, both due in the same month. One lives in a gentrified neighborhood of Portland, Oregon, where she can find a doula who accepts Medicaid and who will meet her at a hospital with a well-staffed labor and delivery unit. The other lives in a frontier county in Montana, where the local hospital closed its maternity unit three years ago. According to the March of Dimes, frontier counties in Montana have among the highest percentages of women living more than 30 minutes from a hospital with obstetric services—over 40 percent in some counties. She must drive 90 miles to the nearest delivery hospital, which is itself understaffed and has a high turnover of nurses. A 2020 report from the Montana Department of Public Health and Human Services noted that the state's rural maternity units had an average nurse vacancy rate of 18 percent, compared to 8 percent in urban areas. The first woman has access to continuous labor support from a doula and a nurse who is not overwhelmed. The second woman may have no doula at all and may be cared for by a travel nurse who just arrived last week. Both are covered by Medicaid. But the coverage looks radically different on the ground.

This is the two Americas of maternal health. In wealthy urban areas, the workforce is relatively abundant, though still strained. Doulas are available, and hospitals are staffed, albeit sometimes thinly. In poor rural areas, the workforce has collapsed. The doula benefit is a mirage: it exists in the policy manual but not in the community. Meanwhile, the hospital may have closed its delivery unit entirely, or it may operate with a skeleton crew that cannot guarantee safe care. The gap is not just about money; it is about the distribution of people trained to do the work.

Medicaid pays for the doula but not for the nurses who staff the unit. The doula benefit is a line item in the state budget, but the cost of keeping a rural maternity unit open is not similarly supported. Rural hospitals often receive lower reimbursement rates from Medicaid than urban hospitals, even though their costs per birth are higher due to low volume. The financial incentives are misaligned. A rural hospital that closes its maternity unit saves money, but the state pays for the doula benefit that no one uses. The policy is not just disconnected from reality; it is actively perverse.

Wealthy counties often have both doulas and well-staffed hospitals. Poor counties often have neither. The disparity is not a natural accident; it is the result of decades of underinvestment in rural healthcare infrastructure and a policy framework that prioritizes coverage expansion over workforce development. The same pattern appears in other areas of healthcare, such as diabetes clinics that dispense medication but lack screening services. Coverage without workforce is a promise that cannot be kept.

Why Training Pipelines Lag Policy

The root cause of both problems—the underutilized doula benefit and the rural nurse shortage—is the same: training pipelines that are not designed to meet the needs of the current policy environment. Doula certification is relatively quick, but the training infrastructure is thin and geographically concentrated. Nursing education is more robust, but it is capacity-constrained. The number of nursing school graduates has been roughly flat for a decade, despite growing demand. The American Association of Colleges of Nursing reports that over 80,000 qualified applicants were turned away from nursing programs in 2023 due to insufficient faculty, clinical placement sites, and classroom space.

Clinical placement slots are the most stubborn bottleneck. Nursing students need hands-on experience in hospitals, but rural hospitals often cannot accommodate them. A rural hospital may have only one or two nurses on a unit, and those nurses are too busy to supervise a student. Urban hospitals, by contrast, have more staff and a culture of teaching. The result is that nursing students are concentrated in cities, and they tend to stay there after graduation. Rural hospitals become training deserts, unable to grow their own workforce. Loan forgiveness programs exist, but they are not large enough to offset the salary and lifestyle gap.

Doula training faces a similar geographic mismatch. Most doula training organizations hold workshops in major cities. Online training exists, but it is less effective for learning hands-on skills like comfort measures and positioning. Rural residents who want to become doulas often have to travel long distances and pay for lodging, which adds to the cost. A few states have experimented with mobile doula training units that travel to rural areas, but these are pilot programs, not systemic solutions. The policy of covering doula services assumes a workforce that can be created overnight, but training takes time, money, and infrastructure.

Payer rules ignore supply-side constraints entirely. Medicaid agencies set reimbursement rates and eligibility criteria without consulting the workforce. They do not ask whether there are enough doulas to serve the population, or whether rural hospitals have the nurses to staff delivery rooms. The assumption is that the market will respond to the incentive of reimbursement. But the market cannot respond quickly when the training pipeline takes years to produce a nurse, or when the doula workforce is largely volunteer and part-time. The policy is written as if supply is infinitely elastic, but it is not.

The disconnect between policy and training is a recurring theme in health systems. A similar dynamic appears in South African TB clinics that dispense medication but lack contact tracing software—the tools exist, but the workforce to use them is missing. Until policymakers start paying attention to the supply side, the pattern will continue.

What a Workforce-Aligned Policy Would Look Like

If the goal is to improve maternal health outcomes for all Medicaid enrollees, policy must be redesigned to align with workforce realities. The first step is to tie reimbursement to local workforce availability. Instead of a flat fee for doula services, states could offer higher rates in rural areas to attract and retain doulas. Some states have begun to do this: Oregon, for example, offers a $200 bonus for doulas who serve rural clients. But the bonus is not enough to cover the cost of travel and lost time. A more aggressive approach would be to set reimbursement at a level that makes doula work financially sustainable in low-volume areas, perhaps $1,500 to $2,000 per birth.

Second, training programs must be brought to underserved regions. Mobile doula training units, funded by Medicaid or state health departments, could travel to rural communities and offer certification courses. These units could be paired with mentorship programs that pair new doulas with experienced ones for their first few clients. The cost would be modest compared to the potential savings from reduced cesarean sections and preterm births. Similarly, nursing schools could establish satellite clinical placement sites in rural hospitals, supported by federal grants and loan forgiveness for preceptors. The Health Resources and Services Administration already runs a Nurse Corps loan repayment program, but it is underfunded and oversubscribed.

Third, create rural nurse residency loan forgiveness programs that are large enough to make a difference. A nurse who commits to three years in a rural maternity unit could receive $50,000 in loan repayment, paid incrementally. This is not a new idea, but the scale has never matched the need. The federal government spends far more on coverage expansions than on workforce development. A rebalancing is overdue.

Fourth, require Medicaid managed care plans to map staffing gaps and report on workforce availability. If a plan has a network of doulas that covers only urban areas, it should be required to develop a plan for rural coverage. Similarly, if a rural hospital in a plan's network cannot maintain safe nurse-to-patient ratios, the plan should be held accountable for ensuring access to care, perhaps by funding travel or telehealth support. The current system allows plans to claim network adequacy without verifying that the workforce exists to deliver services.

Finally, pilot integrated doula-nurse team models in rural areas. Instead of treating doulas and nurses as separate workforces, design a team-based approach where doulas handle continuous labor support and postpartum education, while nurses focus on clinical monitoring and emergency response. This could reduce the burden on nurses and improve patient experience. A few demonstration projects are underway in states like Minnesota and New Mexico, but they are small. Scaling them would require a shift in how Medicaid pays for maternity care, moving from fee-for-service to bundled payments that cover the entire care team. The evidence suggests that team-based care improves outcomes and reduces costs, but the administrative barriers are significant.

None of these ideas is a silver bullet. The workforce crisis in maternal health is the result of decades of neglect, and it will take years to reverse. But the current approach—expanding coverage without expanding the workforce—is a recipe for failure. The doula benefit will remain underutilized, and rural maternity wards will continue to close. Patients will be left with a policy that promises more than it can deliver. The alternative is to recognize that coverage and workforce are two sides of the same coin. You cannot have one without the other.

Yet even the most thoughtful workforce-aligned policies face inherent trade-offs. Higher reimbursement rates for rural doulas could strain state Medicaid budgets, potentially triggering cuts elsewhere. Expanding nurse residency programs may reduce staffing in urban hospitals that also face shortages, creating a zero-sum competition. And integrated team models require coordination across siloed funding streams—Medicaid for doulas, hospital budgets for nurses—that rarely align. The risk is that well-intentioned reforms end up redistributing scarcity rather than solving it. Policymakers must weigh these trade-offs openly, acknowledging that workforce development is a long-term investment with no quick fixes. The question is not whether to act, but how to act without pretending that the choices are easy.