Applying the Theoretical Domains Framework to Explore Doula Perceptions of Medicaid Coverage: Barriers and...

Currently, more than half of the US states have either expanded Medicaid to cover doula care or will implement doula care into Medicaid services. However, little is known about doulas' experiences with Medicaid. Doula uptake of these services is critical to support low-income clients. We explored Florida doulas' experiences and perceptions of Medicaid reimbursement to identify barriers and facilitators to implementing doula benefits in Florida.

We conducted seven focus groups and seven in-depth interviews during Spring and Summer 2022 with 31 doulas who have provided perinatal support to at least two families in Florida in the past year. We used Braun and Clarke's codebook thematic analysis, combining team-based inductive coding with deductive theme development guided by the theoretical domains framework.

Most participants (71%; n = 22) reported not engaging with Medicaid due to misinformation, low reimbursement rates, and a complicated reimbursement structure. Doulas who work with Medicaid patients reflected on frustrations with insurers and the financial impact of delayed reimbursements. Misinformation spread among doula communities about the Medicaid reimbursement process poses a significant barrier to implementation. Doulas relied on one another for information, as they reported that few resources have been made available by Medicaid or managed care organizations for guidance on reimbursement processes. This highlights an opportunity for Medicaid education to ensure client access to doula services and to support the maintenance of the doula workforce.

Doula care is associated with improved perinatal outcomes, yet structural barriers hinder access to doula care for low-income families in Florida (and beyond), creating further health inequities.