Assessing the readiness of Massachusetts hospitals for the expansion of Medicaid to cover doula services

Abstract

In the United States, Black women are 3-4 times as likely to die from childbirth or experience poorer birth outcomes of labor and delivery compared to their white counterparts. Research has identified birth doulas as one way to close the racial disparity gap in birth outcomes. Birth doulas are non-clinical trained professionals who work with birthing individuals to provide emotional, physical, and information support during the perinatal period. Research has shown that doulas reduce unnecessary cesarean births, increase breastfeeding, and improve birthing experiences, among other clinical outcomes. However, given the high out-of-pocket cost or high-risk requirements to receive doula services, birth doulas are underutilized. Many state-level Medicaid payors have expanded to cover doula services, including Massachusetts, who expanded coverage in December 2023. This expansion could mean more doulas in the clinical space and more patients bringing their own doulas who are unfamiliar with hospital policy and culture, potentially creating problems within the clinical space. The objectives of this project were to: 1) identify barriers and facilitators within hospital infrastructure to the Medicaid policy expansion; 2) qualitatively assess infrastructure readiness of Massachusetts hospitals to welcome and support MassHealth doulas and their birthing clients; and 3) assess what Massachusetts hospitals can do to be more supportive and doula inclusive. Virtual qualitative interviews were conducted with doula program administrators and practicing doulas both internal and external to the hospital system in Massachusetts. Themes generated from the interviews included mixed doula experiences with the care team where participants experienced gatekeeping, being treated as a support person instead of a non-medical care team member, and a lack of doula access and inclusivity in the clinical setting. Participants perceived varied readiness of Massachusetts hospitals to support MassHealth doulas in the clinical space and identified ways hospitals can be more supportive such as creating and enforcing inclusive policies and eliminating logistical barriers to delivering care. Massachusetts hospitals who implement these suggestions would allow doulas to fully do their jobs, and given their effectiveness in improving birth outcomes and closing the racial disparity gap, is one potential solution in combatting the current maternal health crisis in the U.S.