Open Letter: Barriers to Pregnant Servicemembers
Open letter on Tricare Childbirth and Breastfeeding Support Demonstration: Barriers to Pregnant Servicewomen
To all honorable members of the Senate and House Armed Service Committee, members of congress, state and federal representatives, and civil servants, I humbly request your attention on a matter of grave importance for our nation’s 350,000 female servicemembers. As you may or may not be aware, the United States is the highest ranked nation among maternal mortality rates in the developed world, in addition to 36/36 of developed countries (breastfeeding scorecard) and 25/43 of developed countries on the Mother’s index. Ranking factors include provisions such as paid family leave and participation of women in government among other education and socio-economic factors. Since addressing all of the risk factors would be beyond the abilities of this letter, I will humbly provide personal testimony on one observed problem set; barriers for pregnant service members.
I write to you today, not only as a practicing birth and postpartum doula, childbirth educator, reproductive rights and trauma-informed victim advocate, veteran Air Force pilot, and mother, but as a voice for our sons and daughters, mothers and fathers. It’s necessary that I reach out to communicate an implementation issue with a FY21 National Defense Authorization Act provision: The Extramedical Maternal Health Providers Demonstration Project. This provision directed the Secretary of Defense to set up a “demonstration project designed to evaluate the cost, quality of care, and impact on maternal and fetal outcomes of using extramedical maternal health providers under the TRICARE program to determine the appropriateness of making coverage of such providers under the TRICARE program permanent.” One of the main components of the demonstration was to provide access to childbirth support persons or “doulas”. Unfortunately, my team of dedicated servicemembers and advocates has identified limitation in the existing operations language which undermine the intent of this demonstration.
1. It was identified that Tricare has limited this benefit to only those seen at off-base hospitals and treatment facilities. This has caused an inequity amongst Tricare beneficiaries but particularly for active-duty servicemembers who are mandated to be seen at Military Treatment Facilities with no option to go off-base unless referred by their Primary Care Manager or if they are willing to incur personal costs; neither of which is readily available or ideal given the national average cost
for hospital birth is close to $19,000. PCMs refuse to refer out for care as there is a cultural practice of harassing and denying women autonomy in their birth options, that is far more systemic than this letter can address. However, I have personally filled multiple hospital complaints fallen on deaf ears and been flat out ignored in my most recent two pregnancies. See below note 6 “on trauma.” This is one of many reasons why I am an advocate for homebirth.
2. Additionally, on credentialing of non-medical personnel. Tricare limits the credentialing bodies of eligible doulas to only 5 organizations, which introduces further limitations on those doulas like myself, desiring to participate in this trial. The Big 5, are simply the fastest path forward, and monopolize the birth worker market without providing a pathway to those who are highly competent in the field credentialed or not! The expense for credentialing is roughly $1,500, on top of annual membership fees. As a doula certified under Doula Training International, I have to meet the exact same certification guidelines as those of BirthWorks International, Childbirth and Postpartum Professional Association(CAPPA), Doulas of North America (DONA) International, International Childbirth Education Association (ICEA) or ToLABOR. One might recognize that credentialing for smaller-footprint doula training organizations is a lengthy and cumbersome process, and as it stands could be significantly improved. As doulas are non-medical personnel, it is ethically called into question why an insurance contractor would have any jurisdiction over open market doula care. Although DTI are dedicated to the best possible outcomes for their clients and doulas, the fact remains that doula populations vary state by state and even within regions of those states, meaning that in many locations there is no doula coverage under the Tricare provisions. Much like how in certain regions, there is no or extremely few available Certified Nurse Midwives. Therefore, a model that would benefit, is the one currently being used in California for Medicaide, allowing doulas to submit direct for reimbursement, regardless of certification. A similar Tricare policy was in place for a period, allowing for direct reimbursement of medical devices with a prescription for a breast pump and supplies which I recall utilizing during my first and second pregnancies. How is it, that a servicemember can serve her country, deploy, and still not get the same medical benefits of those under Medicaide? We can and we must do better.
As much as I want to praise the efforts to expand care under the current language, I must emphasize the continued missed opportunities to meet our servicemembers where they are. As far back as the 2016 RAND study on Female Officer Retention I participated in, I’ve witnessed marginal efforts to achieve “win-wins”. A relaxed hair standard and uniforms cut for my body type do not equate to win-wins, they only superficially masquerade as wins, following decades of oppression and stalled efforts at progress. A true win, is one that honors women’s unique challenges as service members, then works to correct them at every level. Until servicemembers have full birth autonomy, we are not able to credit this demonstration or birth as a service member, a win.
This letter is easy to write, as my lived experience has been the rough draft. And yet I am prepared for it to be imperfect in its call to action. As a doula, my personal compass compels me to do what I can to make birth outcomes better for all. At this time, I would have to incur additional out of pocket expense, for no gainful outcome to cross-certify. The reason I chose Doula Training International (DTI) as a doula certifying option, is they are locally based in Austin TX where I reside affording me a community of mentors, educators and care-taker support, their program is highly inclusive, trauma informed, and recognizes the LGBTQIA+ pregnant population. They have some of the highest ranked courses and outcomes among doulas and birthing persons in the birth community. Many doulas quit DONA to certify with DTI. You see doulas aren’t in this business for credentials and certainly not the pay, the hours, the sheer mountain of crap surrounding birth work etc., we are in it for the SERVICE. DTI is redefining the doula model of care in a modern and progressive approach that honors individuals and aides their holistic experience as one that is respected, consent based, and evidence driven. My loyalty to DTI is unwavering for these many praise worthy cultural breaking practices, and I propose that we allow the birthing person to hire their doula based upon merit without limiting the credentialing source. This further honors their right to choose the best care team to meet their needs. As a servicemember, I can comment on the barriers to us in birth. This is my unvarnished observation, if you want to truly get to the root issues beneath the data you are most likely being presented on a spreadsheet….here is the human story behind the powerpoint.
1. Many hospitals limit birth attendants to just one person. This is compelling, as most women will not choose their doula over their spouse or significant other or even their mother figure. Please bear in mind, that I have had to opt out of many hospital births for this reason, staying in the lobby supporting virtually, especially during COVID.
2. Military mothers PCS during their pregnancy, yes there are provisions designed to limit this, but it still happens, a lot. I frequently get contacted by women in the late stages of pregnancy desperate for doula care, fearful of their new birth provider, in tears because their spouse has to watch their older child and they don’t want to birth alone….or even mothers who are threatened and refused care if they don’t follow certain hospital policies upon arriving in a new state with new rules. This is an outcry. A doula can help soothe this transition and provide continuity, support and gentle reassurance.
3. Added to this, is that many military members are not birthing close to their own support systems or family members, they have to go to extreme lengths to secure childcare, or if married to a military member (mil to mil) this can complicate the family care plan as I have learned that toxic leadership still exists in MANY organizations demanding that families rely on their care plans instead of allowing time off to care for the pregnant person. This is another outrage. An EO or IG complaint is not the answer. Many military families see this time off as a burden to the organization if they take it, stigma is real. Doulas specialize in helping the pregnant person normalize their experience, we are guardians of their story.
4. On doulas, most of us are not full-time. We have day jobs, or other professional roles, families of our own, and in that spirit we must be available for the inherent on-call aspect of spontaneous childbirth. This is a huge time commitment on the part of the doula, for 4 weeks, I must ensure I do not travel, do not consume alcohol, and have backups for my personal and professional responsibilities in place. Accordingly, in many cases back up doulas are necessary as life can not pause for a doula to be at the ready like a full-time medical provider with a shift change. Therefore, this policy doesn’t account for the unpaid work of doulas, and back-up doulas, who are often just free-lance consultants in the community. Backups are a necessary and uncompromising aspect of doula work, as we must support each other for a thriving doula population to meet the birth community’s needs. I argue, that backup doulas should also be included in this provision.
5. Tricare should include abortion doulas, this is medical procedure with high potential for trauma for reasons we know too well. To limit doula care is cruel, inhumane and further stigmatizes the right to a women’s reproductive health care options, negating her birth autonomy as “less than”.
6. On trauma, I frequently observe second, third, and fourth time mothers with varying aspects of trauma in their births, while this is devastating to report, it is an indicator of the practices that continue to exist in the field. Due to the prevalence of medical trauma, and non-evidence based practices prevalent by my own and peer’s experience in Military Health System, my personal belief is that service members should be able to birth at the location of their choosing, with the
provider and doula of their choosing through medical insurance, and at this time that is not the case. This absolutely ties directly into Maternal Mental Health conversations that are outside the scope of this letter, but I urge you to pay attention to the correlations and stay curious. 1 in 5. Stop minimizing birth experiences, birth IS social justice.
7. On cost, while the cost per birth may seem like an unpalatable investment, the figures simply don’t suggest this. At 35,000 births annually (estimated) the cost of doulas is notionally $350,000 under Tricare’s Operation Manual 6010.59-M April 1, 2015 (Change 104, Dec 23, 2021) ch 18. The current unit I work in, has an $8 million dollar fiscal year operations budget by comparison. The doula program is pennies to the dollar with incredible preventative impact such as the potential to reduce anxiety prescriptions by one-quarter, improve rankings in the mother/breastfeeding indices, and demonstrate internationally that thriving women and children from ALL walks of life, ALL backgrounds, are indelible human rights shielded by lady liberty’s torch of our twenty-first century American Dream.
If you are still with me, I’d like to beg your assistance in championing our proposal.
As our team researched this issue, we discovered that the congressional intent for this provision was not for it to be limited in nature but inadvertently the legislative language limited it in such a way. Our team is working to garner congressional support to include an amendment in the next FY’s NDAA to have this
demonstration opened to all Tricare beneficiaries not just those seen off-base and to fulfill the original intent of the demonstration. We believe this will provide a more accurate data set for evaluation at the end of the demonstration and rectify a clear inequity for pregnant servicemembers. [I have attached our full legislative proposal and would love the opportunity to discuss with your office more specifics.] If I leave you with anything after this, I hope it’s that you afford the 35,000 service member pregnancies that happen each year a small “win” with meaningful action. When would be a good time to chat?
Natalie M. Winkels
Founder, Doula, Childbirth Educator
Par Avion Doula LLC
paraviondoula@gmail.com
www.paraviondoula.com
