Massachusetts has a workforce of dedicated and diverse doulas who stress the need for an approach to expanding access to their services that is equitable and centered on addressing racism and discrimination in the health care system, particularly as it relates to maternal health.

In a new report, "Expanding doula support services in Massachusetts: Considerations for successful implementation," the Betsy Lehman Center outlined a series of findings that can inform the state’s efforts to make doula support services more available and affordable to MassHealth members, with a special focus on ensuring equitable access for Black and other birthing people of color.

The report was based on a survey that drew responses from 137 doulas in the state, as well as a series of focus group conversations involving 25 doulas and two dozen consumers who had used doula services or might use them in the future. In designing the project, the Betsy Lehman Center consulted with other state agencies as well as subject matter experts to help frame the study, which the Center conducted in 2021.

Key findings from the study included:

• The state has a foundational group of experienced, dedicated doulas on which to build a more robust network of community-based practitioners.
• Doula support services are largely paid out of pocket, making it difficult for doulas to keep costs affordable for consumers while also earning a living wage.
• The state’s credentialing and compensation decisions will impact the effectiveness of expansion efforts, especially the ability to recruit and retain a diverse workforce that is well-prepared to meet the needs of MassHealth members.
• Other factors that complicate efforts to expand use of doula services include workforce development issues and consumers’ lack of familiarity with doula services.

In addition, a strong takeaway from the focus group conversations with both consumers and doulas is that policymakers will need to explicitly address racism in any approach to expansion if they are to succeed in extending equitable and culturally congruent doula support services to Black and other birthing people of color. Specific recommendations include:

• Engage doulas of color in the policymaking and program development process to ensure they have the supports they need to provide care to MassHealth members;
• Set workforce development goals to meet the increased demand for culturally congruent doula services;
• Engage consumers of color in the policy and program development process, developing robust strategies to reach these priority communities proactively with information about the new benefit and how to access it; and
• Identify and address barriers to access to care prior to the implementation of programs or policies to expand doula services.

Several other states, including Minnesota, New Jersey, New York and Oregon, offer insights that can be used to improve consumer access to these services while ensuring a well-trained workforce that is committed to equity and fairly compensated for this important work.

Inclusive, thoughtful planning is required and is more likely to lead to successful implementation of efforts to expand doula support services in the state, the report concluded.