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

Abstract Racial inequities in severe maternal morbidity and mortality (SMM/M) continue to increase and constitute a national public health crisis.1-3 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 people.4-6 Although doula care has been shown to benefit birth and postpartum outcomes7-9 by intervening on systemic barriers to health,10 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.5 Providing doula care in Medicaid may be an effective tool to reduce inequities in SMM/M because Medicaid programs pay for 42% of all pregnancy care in the US, and 68% among Black people.11 Although the new doula care programs espouse evidence-based practices, there is little understanding of what components of doula care programs’ implementation subsequently affect racial equity in postpartum health outcomes. Guided by the i-PARIHS Implementation Science Framework,12 we propose to work within the multi-state Medicaid Outcomes Distributed Research Network (MODRN)13 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. Our innovative approach will partner with doula organizations and Medicaid beneficiaries and will draw on cutting-edge health services research methods to estimate the effects of doula care on postpartum health. We will use Medicaid administrative healthcare data from 7 states, including a racially diverse population with more than 254,000 persons with deliveries annually (17% of all Medicaid-covered deliveries).