An Examination of Challenges in Improving Doula Reimbursement

Despite the United States having multiple legislations addressing racial health equity, there are still significant racial inequities in birth outcomes (Ogunwole et al., 2022). This capstone project aims to develop a policy brief with a focus on examining the challenges facing the improvement of doula services reimbursement in the United States. The project will examine and map the barriers to improving doula reimbursement as well as the challenges such barriers create in the accessibility of quality doula care, especially among underserved populations. The policy brief will develop evidence-based recommendations to inform the design of reimbursement policies for doula services to make such services accessible to low-income and marginalized communities and improve maternal and infant health outcomes among these communities.

Research Question/Public Health Problem

The main objectives of the proposed capstone project are to i) further improve the understanding of the role of doulas in improving health, ii) identify the key challenges and barriers to effective doula reimbursement, iii) assess and highlight the accessibility and utilization challenges to doula care due to doula reimbursement challenges, iv) and provide actionable recommendations to improve doula reimbursement processes and practices. To meet these objectives, the policy brief project will be guided by the following research question: What are the key barriers to improving doula reimbursement rates, and how do these challenges affect the accessibility and quality of doula care for underserved populations?

Although they are non-medical professionals, doulas provide the much needed emotional, physical, and educational support during pregnancy, childbirth, and postpartum, especially among underserved communities (Knight & Rich, 2024). However, there are various challenges and barriers to adequate and effective reimbursement of doulas that discourage doulas from offering their services to low-income clients. Notably, these barriers and challenges are linked to social reimbursement structures and policies and reimbursement rates. For instance, a study by Applequist et al. (2024) found that the major perceived barriers to the implementation of Medicaid coverage for doula services are delayed reimbursements, misinformation on doula impact, low reimbursement rates, and a complicated reimbursement structure. Besides the lack of recognition of the role of doulas in childbirth, doulas are also expensive to hire (Darvish et al., 2024). From a doula’s perspective, despite their willingness to provide their care services at the community level, the price tag for their services is not affordable to many (Mosley et al., 2023). As a result, this makes financial constraints a major barrier to the utilization of doula services among the low-income birthing population (Mitchell et al., 2023). For this reason, there is a significant need for a policy solution to the reimbursement of doula services and to achieve equitable access to such services.

Relevance to Public Health

Improving the reimbursement for doula services is directly relevant to public health. To begin with, doulas provide maternity care across the continuum, leading to improved maternal and infant health (Falconi et al., 2022; Knocke et al., 2022). Besides improving maternal health, doula care also helps reduce racial inequities among low-income pregnant and postpartum people (Safon et al., 2023). In addition, doulas are associated with providing culturally sensitive and respectful care to low-income and minority racial or ethnic groups (Mallick et al., 2022). Further, doula services have also been noted to improve critical gaps that impact maternal health outcomes, including supporting the continuity of maternal care and advocating for patients (Attanasio et al., 2021). At the same time, doulas have the potential to improve maternal and infant health outcomes, thereby reducing the occurrence of complications during and postpartum by providing necessary care and education.

Methods

The project utilizes both community surveys and in-depth interviews. A sample will be drawn from the target communities across various counties. The surveys will focus specifically on identifying the various reimbursement challenges for doulas and how the existing reimbursement policies affect the ability of doulas to serve low-income clients. The interviews will seek to deeply understand the reimbursement barriers from the providers’ and policy perspectives. Notably, the interviews complement a previous community survey conducted at the Magnolia Medical Foundation, where individuals from target counties were asked about their issues with reproductive care, patient care, hospital availability, and maternal health care.

What Do You Expect to Learn from the Project?

I expect to improve my knowledge and understanding of specific barriers and how they affect effective reimbursement for doula services with a focus on policy and reimbursement structures as barriers to effective reimbursement. In addition, I also expect to understand the various policy gaps in doula service reimbursement and how they have contributed to current maternal health inequities, as well as how I can apply research evidence to close such gaps.

Format of Final Project

The following is the format of the final project:

• A succinct title of the project
• An executive summary
• Scope of the problem/ rationale for action on the problem
• The proposed policy option(s)
• Policy recommendations
• Sources consulted or recommended
• Full reference
• Contact details

References

Applequist, J., Wilson, R., Perkins, M., Evans, V., Daniel, A., Rookwood, A., Simmons, E., & Louis-Jacques, A. F. (2024). Applying the theoretical domains framework to the implementation of Medicaid coverage for doula services: Doulas’ perceptions of barriers and facilitators in the state of Florida. MedRxiv, 2024.01.06.24300904. https://doi.org/10.1101/2024.01.06.24300904

Attanasio, L. B., Dacosta, M., Kleppel, R., Govantes, T., Sankey, H. Z., & Goff, S. L. (2021). Community perspectives on the creation of a hospital-based doula program. Health Equity, 5(1), 545–553. https://doi.org/10.1089/HEQ.2020.0096/SUPPL_FILE/SUPP_APPS2.DOCX

Darvish, N., Gómez, A. M., Marshall, C., McDonald, R., Rouse, L. T., Dinsmore, L., Hecht, H., Berhanu, R., Rajan, G., & Sandhu, J. (2024). What do community doulas think about the future of the doula workforce? Maternal and Child Health Journal, 1–13. https://doi.org/10.1007/S10995-024-03943-1/TABLES/4

Falconi, A. M., Bromfield, S. G., Tang, T., Malloy, D., Blanco, D., Disciglio, R. S., & Chi, R. W. (2022). Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. EClinicalMedicine, 50. https://doi.org/10.1016/j.eclinm.2022.101531

Knight, E. K., & Rich, R. (2024). “We are all there to make sure the baby comes out healthy”: A qualitative study of doulas’ and licensed providers’ views on doula care. Delaware Journal of Public Health, 10(1), 46. https://doi.org/10.32481/DJPH.2024.03.08

Knocke, K., Chappel, A., Sugar, S., De Lew, N., & Sommers, B. D. (2022). Doula care and maternal health: An evidence review. In ISSUE BRIEF. https://www.marchofdimes.org/research/maternity-care-deserts-report.aspx.

Mallick, L. M., Thoma, M. E., & Shenassa, E. D. (2022). The role of doulas in respectful care for communities of color and Medicaid recipients. Birth, 49(4), 823–832. https://doi.org/10.1111/BIRT.12655

Mitchell, A. W., Sparks, J. R., Beyl, R. A., Altazan, A. D., Ariel Barlow, S., & Redman, L. M. (2023). Access, interest, and barriers to incorporation of birth doula care in the United States. The Journal of Perinatal Education, 32(4), 181–193. https://doi.org/10.1891/JPE-2022-0027

Mosley, E. A., Lindsey, A., Turner, D., Shah, P., Sayyad, A., Mack, A., & Lindberg, K. (2023). “I want…to serve those communities…[but] my price tag is…not what they can afford”: The community-engaged Georgia doula study. Perspectives on Sexual and Reproductive Health, 55(3), 200–209. https://doi.org/10.1363/PSRH.12241

Ogunwole, S. M., Karbeah, J. M., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health equity considerations in state bills related to doula care (2015-2020). Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 32(5), 440–449. https://doi.org/10.1016/J.WHI.2022.04.004

Safon, C. B., McCloskey, L., Gordon, S. H., Cole, M. B., & Clark, J. (2023). Medicaid reimbursement for doula care: Policy considerations from a scoping review. Medical Care Research and Review : MCRR. https://doi.org/10.1177/10775587231215221

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  An Examination of Challenges in Improving Doula Reimbursement