Implementing Doula Care in Medicaid to Advance Racial Equity in Severe Maternal Morbidity

Severe maternal morbidities encompass life-threatening adverse events in pregnancy and postpartum. Racial inequities in severe maternal morbidity and mortality (SMM/M) continue to increase and constitute a national public health crisis. Doula care—that is, care from birth workers who are outside the traditional medical care system to support people during pregnancy and postpartum—has been proposed as an intervention to address medical and structural racism which drive systematically worse pregnancy outcomes in Black and other birthing people of color. Although doula care has been shown to benefit birth and postpartum outcomes by intervening on systemic barriers to health, few empirical studies have been conducted in Medicaid populations, as state Medicaid programs have not historically included doula care. This is now changing, as more state Medicaid programs are implementing doula programs in an effort to address racial inequities. Furthermore, approximately one million birthing people of color each year are enrolled in Medicaid. The project team proposes to work within six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network to study how doula programs are implemented within each state and how variation in implementation may affect racial equity in SMM/M during the postpartum period.

The overarching question this research is intended to inform is: What is the most effective way that state Medicaid programs can implement doula care to improve postpartum health among Black people and people of color? The specific aims of this study are to:

• Assess implementation of new state Medicaid doula programs, including efforts focused on racial health equity and Medicaid beneficiary experience of connecting with and using doula care in the postpartum period
• Evaluate the extent to which doula care facilitates equity in the quality of postpartum care, postpartum treatment for chronic conditions (cardiovascular and mental health/substance use disorders) and experiences of postpartum care
• Estimate the effects of state Medicaid doula care programs on racial equity in postpartum severe maternal morbidities

The project team will collect data from doulas and Medicaid patients in each of six participating sites, and we will analyze Medicaid health care records to understand how implementing doula programs in Medicaid may affect racial equity in SMM/M and other outcomes. In addition to studying SMM, the project team is interested in person-reported health and well-being, high-quality care for chronic conditions and patient experiences of discrimination or medical racism. These outcomes will be assessed during the postpartum period.

The primary intervention group is Black, Indigenous, or other persons of color (BIPOC) who are in the postpartum period (primarily Black people in the group of states) and who access doula care in Medicaid programs. The comparators will include White postpartum persons who access doula care as well as BIPOC postpartum persons who do not access doula care. These intervention and comparison groups correspond directly to patient concerns (e.g., why should I engage with a postpartum doula?), doula provider concerns (e.g., how can I best serve and advocate for postpartum patients?) and Medicaid administrator concerns (e.g., how can we ensure that doula program implementation advances racial equity in postpartum population health?).

Stakeholders include state and national doula organizations, Medicaid patients, Medicaid agency officials and leading researchers in the field of health equity. These stakeholders will be active participants in the study design, data collection and dissemination of results. These findings can be used by pregnant people of color who are seeking the best quality of care and a positive and supportive postpartum experience. Findings can also be used by doulas who are seeking to understand the best way to participate in Medicaid to serve BIPOC communities. Finally, findings can be used by Medicaid administrators who are actively engaged in work to address the maternal mortality crisis in their respective states. Ultimately, this research aims to directly inform best practices to implement doula care programs in Medicaid in ways that will ensure that such care is accessible and relevant to the populations who can benefit most—that is, those who face the combined effects of poverty and racism.