# Community-Based Doulas and Medicaid Expansion: A Resource-Based Approach to Support the Well-being of Low-Income Postpartum Women

## TL;DR

This study explores how Medicaid expansion in Colorado affects access to doula care for low-income postpartum women and identifies resources that support their mental health.

## Contribution

The study introduces a resource-based approach to understanding how Medicaid expansion and community-based doulas can improve postpartum mental health outcomes.

## Key findings

- Community-based doulas and postpartum women identified multi-level resources that protect against postpartum mood disorders.
- Medicaid expansion increased access to doula care but raised concerns about reimbursement and autonomy.
- Lactation support, family support, and community navigation were highlighted as key protective resources.

## Abstract

Background
Doula care across the perinatal period may significantly reduce the odds of perinatal mood and anxiety disorders particularly in communities experiencing deprivation. In 2023, SB23-288 was passed in Colorado titled “Improving Perinatal Health Outcomes” which requires doula services to be covered under Medicaid. The purpose of this phenomenological qualitative study was twofold: 1) To examine perceptions of SB23-288 among a purposive sample of community-based doulas who provide care for women experiencing low socioeconomic status (SES), and 2) To explore perceptions among both community-based doulas and low-SES postpartum women themselves, of multi-level resources that are most protective and may mitigate the risk of postpartum mood disorders.
Methods
A purposive sample of 16 low-SES postpartum women and 9 community-based doulas were recruited to participate in 30–60-minute interviews. Coding followed a constant comparison method and was an iterative process including a deductive, theory-driven approach based on the Conservation of Resources Theory and Socioecological Models and an inductive, data-driven approach.
Results
Four major themes emerged related to doulas perceptions of strengths and concerns of SB23-288: 1) Improved access to care for low-income individuals, 2) Cautious optimism for Medicaid coverage, 3) Reimbursement-related challenges, and 4) Concern with doula autonomy. Analyses also revealed concordance between doulas and postpartum women’s perceptions of individual-level (e.g., lactation support) interpersonal-level (e.g., family support), and community-level (e.g., navigating healthcare and financial support) resources that promote postpartum mental health. Low-SES postpartum women also shared that knowledge related to postpartum physiology and physical recovery, connections to educational classes to provide peer support, and outdoor exposure were additional resources that promoted their mental health.
Conclusions
These findings underscore the vital role that community-based doulas play in supporting low-SES postpartum individuals and highlights both the opportunities and challenges presented by the expansion of doula care for under resourced individuals. The alignment between community-based doulas and low-SES postpartum women’s perceptions of multi-level supports emphasizes the importance of holistic, community-centered care and additional training on multi-level and comprehensive resources to meet the needs of low-income clients.