Table of Contents

• Introduction
• Context
• Legislative Timeline
• What AB 904 Requires
• Why This Bill Was Introduced
• The Role of Doulas
• Implications for Doulas
• Practical Guidance for Doulas
• Future Outlook

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Introduction

In September 2023, the California Legislature passed Assembly Bill 904 (AB 904), authored by Assemblymembers Lisa Calderon and Sabrina Cervantes, with Assemblymember Marc Berman and Senator Susan Rubio serving as coauthors. Governor Gavin Newsom signed the measure into law later that month, officially setting in motion a set of changes that will expand the role of doulas in California’s health care system.

For doulas, this bill represents an important development. It signals a shift from isolated pilot projects and limited Medicaid coverage toward a more integrated role within California’s broader health care infrastructure. This update provides doulas with a clear, detailed overview of what AB 904 requires, why it was introduced, the history of doula coverage in California, and what to expect moving forward.

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Context

Before AB 907, California passed SB 65 (Skinner, 2021), also known as the California Momnibus Act. SB 65 represented a landmark step in the state’s maternal and infant health policy. Among its many provisions, it:

• Created the California Pregnancy-Associated Review Committee (CA-PARC) to investigate and report on pregnancy-related deaths and severe maternal morbidity, with an explicit focus on racial disparities.
• Expanded the Fetal and Infant Mortality Review (FIMR) process at the county level to improve accountability and prevention efforts.
• Established the Midwifery Workforce Training Act, directing the state to support training for both certified nurse-midwives and licensed midwives, particularly in underserved communities.
• Required the Department of Health Care Services to examine implementation of the Medi-Cal doula benefit, including barriers to access and utilization.
• Made maternal health equity central to state policy, recognizing the disproportionate impact of maternal and infant mortality on Black, Native American, and low-income families.

SB 65 laid the foundation for AB 907 by establishing maternal health equity and workforce expansion as core legislative priorities. AB 907 builds directly on this groundwork, with an emphasis on strengthening the midwifery pipeline and ensuring sustained investment in community-based, culturally responsive maternity care.

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Legislative Timeline

Understanding the legislative journey of AB 904 helps put the law into perspective:

• February 14, 2023 – Bill introduced in the California Assembly.
• March 29, 2023 – Amended in Assembly.
• June 26, 2023 – Amended in Senate.
• September 7, 2023 – Amended in Senate again.
• September 12, 2023 – Passed in Senate.
• September 13, 2023 – Passed in Assembly.
• September 18, 2023 – Officially enrolled.

The multiple amendments reflect ongoing negotiations between policymakers, insurers, Medi-Cal administrators, and health equity advocates about how best to design and enforce the bill’s requirements.

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What AB 904 Requires

At its core, AB 904 requires health care service plans and health insurers in California to establish maternal and infant health equity programs that specifically include doulas.

Key Provisions

1. Deadline for Action
   • By January 1, 2025, every California health care service plan and health insurer must develop a maternal and infant health equity program.
2. Program Goals
   • Programs must address racial health disparities in maternal and infant health outcomes.
   • Doulas are a required part of this strategy.
3. Integration Options
   • Plans and insurers can meet this requirement by:
     • Incorporating doula services into existing maternal mental health programs, or
     • Expanding current doula programs already in place.
4. Medi-Cal Plans
   • Medi-Cal managed care plans are considered compliant if they cover doula services as part of Medi-Cal benefits. Since January 1, 2023, doula care has been a covered benefit under Medi-Cal.
5. Reporting and Oversight
   • The Department of Managed Health Care (DMHC), in consultation with the Department of Insurance, must collect data and submit a report to the Legislature by January 1, 2027.
   • This report will evaluate doula coverage, quality of care, and overall program impact.

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Why This Bill Was Introduced

AB 904 builds on a growing recognition of persistent problems in maternal and infant health in the United States and in California.

National Context

• The U.S. has the highest maternal mortality rate among high-income countries, with roughly 1,200 pregnancy-related deaths each year.
• About 60% of these deaths are preventable.
• The U.S. also lags behind in infant mortality rankings, coming in 33rd out of 36 OECD nations.

California Context

• California has achieved the lowest maternal mortality rate in the country due to targeted maternity care improvements.
• Racial disparities remain:
  • Native American infants: 11.7 deaths per 1,000 live births.
  • Black infants: 8.7 deaths per 1,000 live births.
  • State average: 4.2 deaths per 1,000 live births.
• Black and Native American birthing people continue to experience higher maternal mortality rates and report discrimination and bias in care.

Legislative Findings

The Legislature emphasized:

• Racism and bias in health care as contributors to poor maternal and infant outcomes.
• Links between climate change and negative birth outcomes (heat exposure, wildfire smoke).
• The need to expand equitable access to maternal care services.

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The Role of Doulas

AB 904 highlights doulas as a frontline strategy in reducing maternal and infant health disparities.

Evidence Supporting Doula Care

Research consistently shows doula support can:

• Lower cesarean birth rates.
• Reduce preterm birth.
• Improve communication between patients and providers.
• Increase overall satisfaction with the birth experience.

California Pilot Programs

• Insurers such as Blue Shield of California, HealthNet, and Anthem have piloted doula programs.
• Participants reported improved outcomes and positive patient feedback.
• These pilots built momentum for broader insurance coverage.

Medi-Cal Doula Benefit

• Beginning January 1, 2023, doula care became a covered Medi-Cal benefit.
• AB 904 extends the expectation of coverage into the private insurance market, creating consistency across the state.

Implications for Doulas

The passage of AB 904 could reshape the doula profession in California in several ways:

1. Expanded Access and Demand
   • More families—both on Medi-Cal and private insurance—will be eligible for covered doula care.
   • Doulas may see increased client demand statewide.
2. Closer Integration with Health Care Systems
   • Hospitals, clinics, and insurers may develop formal partnerships with doulas.
   • Some doulas may be invited to participate directly in structured health equity programs.
3. Standardization and Accountability
   • Because the DMHC will collect data, doulas may need to adopt standardized documentation practices.
   • Insurers could introduce credentialing or training requirements for reimbursement.
4. Equity-Focused Practice
   • Programs will prioritize reducing racial health disparities.
   • Doulas working in communities disproportionately affected by inequities may see particular opportunities for engagement.

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Practical Guidance for Doulas

AB 904 opens up new possibilities, but doulas may need to take proactive steps to prepare for changes in coverage, documentation, and integration into health care systems.

1. Understand Insurance Basics

• Learn how insurance reimbursement works. While Medi-Cal already covers doula care, private insurers may develop unique processes for claims submission.
• Familiarize yourself with billing codes, claim forms, and documentation standards.

2. Strengthen Documentation Practices

• Keep detailed client records, including visit notes and outcomes, as insurers may request this information for reimbursement or program evaluation.
• Consider using secure digital tools for record-keeping to align with health system standards.

3. Monitor Credentialing Requirements

• Some insurers may introduce credentialing requirements (e.g., training hours, certification, or background checks).
• Stay engaged with doula organizations and professional networks to learn about any emerging standards.

4. Build Relationships with Health Systems

• Reach out to local hospitals, clinics, and community health centers to learn about partnerships forming under AB 904.
• Establish connections with Medi-Cal managed care plans in your region.

5. Stay Informed About Policy Updates

• The DMHC’s upcoming report in 2027 will shape the long-term future of doula coverage.
• Advocacy groups, doula organizations, and state health agencies will likely issue updates as implementation unfolds.

6. Educate Clients

• Many families may not know that doula services will soon be covered by private insurance.
• Be prepared to explain eligibility, potential costs, and how to access coverage once plans finalize their programs.

7. Maintain Flexibility

• Implementation will likely vary between insurers. Some may roll out coverage quickly, while others may take longer.
• Doulas should be ready to adapt to different processes across health plans.

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Future Outlook

Looking ahead, AB 904 has the potential to:

• Increase demand for doulas statewide.
• Normalize doula services across both Medi-Cal and private insurance.
• Influence national policy by providing a model for other states.

For doulas, this legislation creates opportunities for growth, professionalization, and deeper integration into California’s health care system.

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