The Difference Between
Doulas, CHWs and Peer Support Workers

The need to expand the maternal mental health workforce to address shear numbers of professionals needed, and to address racial, ethnic and cultural needs of the U.S. population, is well established. Its also well established that grassroots professionals also sometimes referred to as lay or community professionals can help to fill these pressing gaps.

This fact sheet provides an overview of the differences between these professions, specifically: doulas, community health workers (CHWs), and peer support specialists -shedding light on their roles, qualifications, and contributions toward maternal mental health. 

Recomended Citation: Policy Center for Maternal Mental Health. (2024, April). The Difference Between
Doulas, CHWs and Peer Support Workers [Fact Sheet]. http://www.2020mom.org/lay-professionals

Doulas

Doulas are nonclinical trained professionals who can provide emotional, physical, and informational support during pregnancy, delivery, and after childbirth.- ASPE Doula Issue Brief Doulas have yet to be defined in federal code. 

Check out these drafted bills that bring clarity to doula work and potential future definition; 
S.2465 - DOULA for VA Act of 2023 118th Congress (2023-2024)

H.Res.395 - Recognizing the work and contributions of doulas towards improving pregnancy, birth, and postpartum outcomes.

H.R.4605 — 118th Congress (2023-2024)

“Doulas are non-medical professionals trained to give physical and emotional support in childbirth. Doulas offer constant, uninterrupted attention and encouragement to the birthing person. They are skilled in comfort and relaxation techniques for labor (like position changes, breathing exercises, massage) and experienced in giving non-judgmental emotional support. Additionally, doulas can provide extended support during pregnancy and after giving birth.”  - Black Mamas Matter 

“A doula is a trained professional who provides continuous physical, emotional and informational support to their client before, during and shortly after childbirth to help them achieve the healthiest, most satisfying experience possible”.-DONA International

Doulas provide perinatal support, including physical, social and emotional support, as well as information and education during one or all of these periods; 

• Pregnancy 

• Birth 

• Postpartum 

• After the end of pregnancy

The care is not limited to mental health support, but can also include mental health resources, education, and emotional support.

The landscape of doula certification and regulation in the United States varies significantly across states. Since doulas offer non-medical support during childbirth and postpartum periods,doulas are not licensed. 

Some doulas pursue training or certification from doulas groups or organizations. Other doulas may learn through apprenticeships, shadowing, or other more informal methods.

There are hundreds of organizations that offer doula training and certification, ranging from large-scale organizations from DONA International and Childbirth and Postpartum Professional Association (CAPPA), to smaller, local programs.

Find more information about certification and state by state requirements at the National Health Law Program.

Regarding Medicaid reimbursement and certification requirements, states have adopted diverse approaches. Most states relied on certifications from independent training organizations rather than implementing uniform regulations or standards.

Currently, there are 12 states and Washington, D.C. providing Medicaid coverage for doula services as of February 2023. An additional 5 states are in the process of implementing coverage as of 2023..Doulas in these states generally must complete one of these approved programs to qualify for payment from Medicaid.

Read more on state policies at the National Health Law Program.or National Academy for State Health Policy.

CHWs

A community health worker (CHW) is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served. A CHW serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery.- CDC

Check out these federal regulations that reference and help define CHWs: 

42 U.S. Code § 280g–11 - Awards to support community health workers and community health

A community health worker (CHW) is a frontline public health professional that shares life experience, trust, compassion, cultural, and value alignment with the communities they serve.

CHWs can work in a variety of settings and health issue areas, including disease control and prevention, maternal and infant health, oral health, and addressing social determinants of health and racial and ethnic disparities.- Association of State and Territorial Health Officials

Community Health Workers provide education and care coordination. This is not limited to the perinatal period or to mental health support. 

Care can include but is not limited to; 

• Helping people understand their health or social conditions  

• Making home visits to high-risk patients

• Providing informal counseling

• Determining eligibility for health care plans

For most states offering certification, the health department (or an equivalent) is the credentialing authority or administrative home. However, associations, certification boards, or other state agencies can perform those functions.

State programs are broken up in the following way; 

• Certification programs (AZ, CT, CO, KY, MA, MD, NJ, NM, NY, OH, OR, UT, and TX)

• Privately run by independent credentialing boards (FL, MO, PA, VA) 

• CHW association or CHW association-led committee (AR, KS, SC, SD, IN, NV, NC).

To learn more about state by state approaches to Community Health Worker certification - check out State Approaches to Community Health Worker Certification | ASTHO.

States can provide Medicaid payment for CHW services under state plan or Section 1115 demonstration authority. Several states require managed care organizations (MCO) to provide certain CHW services or include CHWs in care teams. In addition, other states allow but do not require MCOs to provide such services.

In a KFF review of CHW coverage policies in place as of July 1, 2022 and planned for FY23, 29 of 48 states reported allowing Medicaid payment for services provided by CHWs.This is up from 21 states in 2021. 

To read more about the CHW Medicaid Reimbursement strategy across the states, check out this Issue Brief - Medicaid Coverage of Community Health Worker Services | MACPAC.

Peer Support

Peer support workers are people who have been successful in the recovery process who help others experiencing similar situations. Through shared understanding, respect, and mutual empowerment, peer support workers help people become and stay engaged in the recovery process and reduce the likelihood of relapse. Peer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking a successful, sustained recovery process.- SAMHSA

Check out these federal regulations that reference and help define Peer Support; 
42 U.S. Code § 290bb–39 - Peer-supported mental health services

42 U.S. Code § 290ee–2a - Peer support technical assistance center

A peer supporter is an individual with a life-altering lived experience of psychiatric, substance use, or other challenges who has made a personal commitment to his or her own recovery and has a desire to use what was learned from one’s own lived experiences to assist others with similar challenges. - National Association of Peer Supporters

Peer Support Specialists provide mental health, substance use disorder, transitional, and recovery support. This is not limited to the perinatal period. 

Maternal mental health peer training programs do not qualify as required training to become a state-certified peer specialist. Rather, these trainings are helpful to understand the nuances of serving the maternal/paternal (perinatal) population.To get more info about peer-specific maternal mental health training - check out the Policy Center's Add-on Training.

All 50 states have a state-sanctioned training and testing program. To check out the differences in state requirements - check out this resource.

Comparative Analysis of State Requirements for Peer Support Specialist Training and Certification in the United States. 

To be recognized as a peer support specialist in your state, a person must determine what type of training is required in the state or county. Doors to Wellbeing has a comprehensive list of training (and state certification requirements) and appropriate contact information in each state. Costs, payment options, and educational requirements also depend on location.

Although every SMHA uses Medicaid to reimburse providers for some of the mental health services provided, Medicaid does not reimburse for any or certain types of peer support services in all states. In 37 states, Medicaid provides reimbursement for some kind of peer support services. The type of peer support services reimbursed by Medicaid varies between states. To check out state by state requirements and reimbursement strategies, check out NRI’s 2022 State Profiles and Medicaid Behavioral Health Services: Peer Support Services | KFF