Applying the Theoretical Domains Framework to the Implementation of Medicaid Coverage for Doula Services: Doulas’ Perceptions of Barriers and Facilitators in the State of Florida

Abstract As of September 2023, more than half of US states have either expanded Medicaid to cover doula care or are in the process of implementing 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 with and perceptions of Medicaid reimbursement. We conducted seven focus groups and seven in-depth interviews with 31 doulas providing perinatal support. An inductive approach to thematic analysis was used to generate primary findings. A deductive approach was then applied to these themes, drawing on the Theoretical Domains Framework to enhance understanding. Most participants reported wanting to engage with Medicaid to support marginalized communities, but not doing so due to misinformation, low reimbursement rates and a complicated reimbursement structure. Doulas that work with Medicaid patients reflected on their frustrations with insurers and the financial impact of delayed reimbursements. Misinformation spread amongst doula communities about the Medicaid reimbursement process (often based on outdated information) was found to be a significant barrier to implementation. Doulas relied on one another for information, as they reported 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 maintenance of the doula workforce. Doula care is associated with better perinatal outcomes, but structural barriers hinder the ability for low-income families to receive doula care in Florida, creating further health inequities.