Research to Study Medicaid's Doula Care for People of Color

The Patient-Centered Outcomes Research Institute (PCORI) is funding research led by Academy Health and the University of Pittsburgh to identify the most effective way that state Medicaid programs can implement doula care to improve postpartum health among Black people and other people of color.

PCORI notes that 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.

A story on the Academy Health website notes that the project team proposes to work with six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN) 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 story quotes principal investigator Susan Kennedy, M.P.P., M.S.W., senior director of AcademyHealth's Evidence-Informed State Health Policy Institute: “This is an urgent question for approximately 1 million birthing people of color each year who are enrolled in Medicaid, and for their families. Findings from our research will 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 populations facing the combined effects of poverty and racism.”

Beginning in August 2023, the study will be conducted by university research teams from the MODRN. The research will include doula organizations that have explicit goals of Black racial equity, as research partners as well as engaging with Medicaid patients and state Medicaid agency officials. The study will draw on the research infrastructure and existing partnerships of MODRN, which is a well-established collaboration between university researchers and state Medicaid agencies in 13 states.

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 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 AcademyHealth story also quotes co-principal investigator Marian Jarlenski, Ph.D., M.P.H., associate professor of Health Policy and Management in the School of Public Health at the University of Pittsburgh: “This study represents the first multi-state study focused on how to implement doula services in a way that can advance racial equity in Medicaid programs. By learning from Medicaid patients, doulas, and state Medicaid agency stakeholders, our findings will provide new and much-needed evidence on how doula care can interrupt the structural and interpersonal racism that people experience during pregnancy and postpartum, and, in turn, facilitate access to evidence-based and lifesaving care and support.”