Tricare's Childbirth and Support Demonstration Overview - Part 1

First doula client in California

My first experience as a doula remains vivid in my memory, especially now as I reflect on those early days when insurance coverage was just a brief overview in our trainings. Doula support at the core has remained steady, but everything else to do with it has rapidly evolved. I recall that birth walking through the halls of Naval Medical Center San Diego (Balboa), guiding my client through her contractions. Her husband was deployed, and I had volunteered with an organization that provided doula support for military families. While she was the first of many clients, I often think of her. Little did I know, that moment was the beginning of my journey to where I am today.

That initial foray into doula work plunged me into a world filled with unique challenges, navigating the regulations of overseas military bases, leading doulas when I was still learning as a newer doula myself, educating our military families and community as a whole about doulas. There were times when I’d be supporting families without a backup doula due to fellow doulas either moving or having a baby of their own. I often found myself in uncharted territory I was completely unprepared for, embracing the rhythm of the season, trusting my instincts and staying attuned to God's guidance. I prayed that I was making the right choices throughout the journey. I ventured alongside clients to learn about Japan's birth cultures and delved into SOFA status regulations when military families faced bogus restrictions on home births or placenta encapsulation, taught new doulas, built relationships with our local base programs and hospitals, said goodbye to many great doulas who became close friends. Consistency and continuity became a key player amidst the constant turnaround. When the time presented an opportunity I was able to attend a Senate of Armed Forces Committee Meeting back in the states and yes, I was that person who boldly handed out educational material to other attendees about doulas and the military. Not sure if that was allowed, but I did it anyways. Always hoping it would fall into the hands of the right person.

Camp Lester Naval Hospital, Okinawa. Photo Credit: Military Bases.Com

During this period, I dedicated myself to establishing private organizations on military bases and cultivating relationships within the Military Treatment Facility. I recalled advice to find a champion in the hospital, and I did—an incredible nurse who sadly lost her life and baby to HELLP syndrome. It would not be the only time a difficult circumstance resulted in another pivot. One particularly memorable moment this nurse and I had together; during a birth, the provider was visibly irritated as the parents asked questions to better understand their care. Afterward, she encouraged me to keep pushing forward despite the ongoing attitudes from some providers, a message that resonated deeply with me because at this point in time, I was one of the only active working doulas on island and I felt like I had no one in my corner to call and talk me through these experiences within the Military Healthcare System. Yet I persisted because there was a need for change and support not only for families but birth professionals who supported within and outside our military structure.

“ To all healthcare providers: if your hospital has a doula policy, I encourage you to review it, involve your trusted local doulas, and familiarize yourself with other certifying organizations. Ask your team what purpose does this serve and why it’s being implemented. I do not, as many others, align with just one certifying body, hold a membership, or answer to organizations that I am not certified through. Therefore, I will not be signing any policies that reflect them. ”

In the beginning there were times I would often look for support from my certifying body. They had little to no presence overseas, limited experience with military contexts nor did they offer support to fellow military spouses like myself. When I finally touched base, it was advised not to reinvent the wheel, but the reality was that there was no wheel to begin with. That was an eye opening experience which told me they were not in a place to provide guidance or feedback regarding doula support in the military system. Support and resources for birth professionals in my community were truly non existent aside from what was created on a local level. This was also a time before the internet became what it is today, making connections while living overseas resulted in limited access to information and being shared like it is today. Despite limitations, our community flourished. Ways were sought to educate military leaders, I participated in working groups on the island, and connected with larger organizations to raise awareness beyond the Pacific—even though we often felt dismissed or overlooked. No one wanted to talk about birth apparently even though there were glaringly big issues that needed addressed the system.

One of many educational group talks with military families. 

At times, it seemed the hospital might stop allowing doulas altogether, and those moments were isolating. Eventually, I found strength in two remarkable mentors, Gerri Ryan and Linda Herrick, close friends and colleuges, and a military community that courageously advocated for better birth experiences and options. Despite harsh interactions and criticism from those unwilling to learn or support, I knew I was on the right path.

I remember discussing Tricare coverage with fellow doulas, feeling uncertain about where to begin. I just knew it had to come from the top. I never imagined that I’d be here today talking to you about Tricare and doula coverage, witnessing how everything seems to come full circle.

Here we are 2024 and I’ve been back stateside since 2017. When the news broke that Doula coverage for Military Families was being introduced as a bill, it was a moment filled with anticipation and apprehension. A group of doulas who had dedicated much of their careers to understanding the needs of military families came together to make formal recommendations to the appropriate personnel. Yet, no one ever reached out or followed up with us after it was submitted. To this day, when I read the Federal Register, I can’t help but notice some of the very same language from our documents appearing in there.

I remain skeptical that any doulas were consulted or had a seat at the table, despite our numerous meetings and phone calls. There are only so many people one can speak to before realizing they all seem to lead back to the same individuals.

Nearly three years after the CBSD demonstration was voted into the NDAA and integrated into Tricare, I anticipated challenges. Some of which I hadn’t foreseen or fully understood, especially since, as a doula, I’ve never worked with insurance. With many states now adopting Medicaid coverage, doulas are grappling with this new territory of billing, medical terminology, insurance codes, and everything else that comes with it. When this demonstration launches overseas, it limits access to coverage only in the private sector. It also creates another obstacle of military spouse employment, navigating SOFA status regulations, the ability of military spouses to work in host nations, and the fact that many military members give birth on base OCONUS limits access of the program those who are seen by a host nation provider.

Another shift I'm noticing is an increasing interest from organizations and businesses that are suddenly keen to connect with the military doula community, despite having shown little to no interest in the past 16 years of my experience as a doula. I can’t help but question whether their motives stem from a genuine desire to support our military birthing community or if they're simply looking to profit or gain influence. As a result, I’ve chosen to approach these interactions cautiously, especially with those who have never engaged with military doulas, birth professionals, or families, or who seem to have ulterior motives.

In closing this section, I find the current guidance from the DHA and its contractors to be quite chaotic. While one contractor has made commendable efforts to keep new doulas well-informed, the overall lack of support remains troubling. Recently, it has come to my attention that only one certifying body is being consulted by one of the Tricare contractors, despite its limited grasp of the unique needs within our military doula communities, both CONUS and OCONUS. This exclusive approach risks fostering inconsistencies and misunderstandings throughout the system.

More to come….

Tips to Becoming a Doula and Supporting Military Families

In recent years, the demand for doula support has surged, thanks in part to increased insurance coverage and growing recognition from larger companies. With the ease of access provided by the internet, doulas are becoming a familiar resource for expectant families.

However, when it comes to military families, there’s still progress to be made. In the past two years, Tricare initiated a pilot program to cover doula services. While there’s much to explore and refine, positive changes are on the horizon. As this initiative develops, my hope is that it will become a permanent option, enabling more doulas to integrate into our Military communities—a goal I've passionately followed for over a decade.

With over 150 doula training organizations available, it can be daunting to figure out where to begin, especially when considering state-specific requirements if they exist. Navigating this landscape doesn’t have to be overwhelming; let’s break it down together and help you get started towards becoming a certified doula and providing support.

Tip 1: Choose a workshop time and location with Oceanside Doula Trainings.
CAPPA is a recognized organization by Tricare. I offer both online and in-person workshops to accommodate your needs. If there aren’t any upcoming sessions in your area, consider organizing one!

Tip 2: Verify Your MyCAA Eligibility
Explore your eligibility for the MyCAA program, which can provide additional funding to help you get started on your path.

Tip 3: Don’t let finances stand in the way
Whether you’re utilizing funding or self-paying, enrolling in a workshop is crucial. The initial investment can be around $1,000, but don’t let that intimidate you. You can take your time and pace yourself. The first step is to secure your spot in a workshop.

Final Tip: Stay Connected
I’m here to help! If you have any questions, feel free to reach out. Having worked with Tricare since the inception of this pilot program and as a military spouse (retired) for 26 years, I understand how essential it is to increase the number of doulas in our system. Let’s make this journey together!

Working with honesty.....

Being a birth doula and entrepreneur was a very lonesome journey in the beginning while overseas. The first few years were hard to work on establishing a continuum of care and awareness in a place where people move all the time. While I had peers who worked in the birth community here, I felt like I kept hitting brick walls as growth was ever impending on this island. There were times I felt like no one understood the dynamics of our birth community. I am lucky to have a great, supportive birth community in San Diego, but sometimes when you need someone to talk too, calling on the phone with the time difference makes it more difficult. Many times, I found myself relying on my husband to lend a listening ear and mentorship.  I am proud that, even through the rough patches and learning curves, I held on to what I believed and did my best to hold up integrity.

Hindsight is always 20/20.  As I reflect on the past 5 years, I wouldn’t be where I am today if it wasn’t for being consistent, dedicated, and good old fashion hard work.  Even through all the frustrations, ups and downs, just the sheer roller coaster ride of emotions in learning how to establish an organization and a good working relationship with others. I am happy to see what we’ve become today and how this network has grown.

 I want to take a few moments to talk about how getting frustrated and integrity pertains to our profession as a doula. 

Let’s look at what happens when frustrations mount with a doula trying to get her business started and gaining cliental might not be working out for her as easily as hoped for. A choice can be made. Operate with integrity or give into being upset.

What is integrity? By definition: the quality of being honest and having strong moral principles. 

“When I felt those frustrations, I quickly learned to take a step back, reevaluate what my goals were and speak with my mentors back in San Diego to help me grow.”

Giving into those frustrations begins the slippery slope of what I would call The Cascade of Interventions for Doulas. When frustration develops, a doula might start throwing oneself at the foot of any expectant woman who walks by. Whether at the store, gas station or soliciting services for free. In some cases,  a doula may begin pleading with the mother to have her come to the birth even when the birth partner doesn’t want a doula. If that route doesn’t work, jealousy and anger may start to rear its ugly head. The individuals may start acting out of emotion when they see other doulas working.  These negative emotions often lead to  hurt feelings and ultimately relationships destroyed. 

For a doula that is starting to grow a business, I have found that integrity does play an important role.  When confronted with situations requiring integrity, I will take a step back and reflect on what the pros and cons of my choices will be and how it could affect what I represent in the community.

Let's ask ourselves, “How can any of this benefit our expectant families?” 

I want to share with you some tips that as a doula and businesswoman have worked for me and I hope can work for you.

·      Be consistent. This does take time to establish when you are first starting up a business. Remember in everything you say and do, consistency leaves a good reputation with the people you serve. The external impression of your business shouldn’t differ much from the internal.

Bottom line- be consistent in what you believe about being a doula, pricing, and services you offer. Don’t be a butterfly floating from one flower to the next.

·      Be a likeable and reliable. I do understand we will not jive with everyone who crosses are path, but we should respect the other person for whom they are. If we are always being negative and gossiping with a down right bad attitude about everything, people will notice and probably will get tired of being around you.  Being reliable is crucial to someone being able to trust you.

Bottom line- Our reputation and relationships are all we have and it takes time to establish a good rapport within your community. I wished it were easy to say building strong relationships happen overnight. It just doesn’t. I often run into skeptics or those who’ve had bad experiences with doulas before. So their guard is up. Build bridges. Don’t burn them.

·      Online Presence. *DING *DING! This is a HUGE factor in the growth of a business. With social media dominating the Internet, it’s imperative to keep integrity. I recently read an article about companies starting to research potential employees through social media. In a 2014 Social Recruiting Survey, data shows 93% of hiring managers will review a candidate’s social profile before taking on that person.

Bottom line- I can’t say it enough, people are always watching. Be mindful of mixing online friendships and business. Do you want potential clients seeing your personal profile and what’s being posted daily? 

·      Learn your area and audience. Every area is going to have unique differences and a diverse audience.  Think about who your audience will be. Maybe you want to keep things low key and take on limited cliental. Perhaps you want to reach out and go big. What if you desire to volunteer?

Bottom line- There are plenty of pregnant women to go around. We can’t serve everyone.  We each have something to contribute to our community and if it hasn’t been done yet, then connect with those who can help and get something going.  Some areas will have next to nothing. It takes a lot of time and dedication to establish even the understanding of what a doulas role is. You may find yourself walking into a well established community. There’s a place for you too if we treat one another with courtesy and respect.

I hope that something can be taken away from this. I remember being that new doula and wanting to take on the world. I was willing to help anyone. I was ready to hit the ground running. Therefore, I understand what it is like to want to at least have more than one woman on the books. Integrity plays a big role in how not only how the community views a business but how long term people can trust. Be honest. Be genuine. Be humble. Treat others with respect and be courteous. Maintain healthy relationships that lift you up and get rid of the negativity. 

My mission has and always will be to provide resources and a continuity of care for families in the military through the use of birth & postpartum doulas and other birth professionals who contribute their life to this amazing work.