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

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 Misinformation spread amongst doula communities about the Medicaid reimbursement process (often based on outdated information) was found to be a significant barrier to implementation.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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by an internal award at the University of South Florida. Adetola Louis-Jacques time was supported by the Robert A. Winn Diversity in Clinical Trials Award ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Institutional Review Board of the University of Florida and the University of South Florida gave (deemed exempt) ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study upon reasonable request to the authors.