Maternal enrollment in Medicaid and access to doula care: a mixed-method assessment

Embargo Date
2027-01-17
OA Version
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Abstract
Medicaid is the primary payer for almost half of all US births. Medicaid enrollment can enable access to timely prenatal care. Yet only 68% of Medicaid-covered pregnant people attend prenatal visits during the first trimester. Late receipt of prenatal care may in part be driven by delayed Medicaid enrollment. Understanding timing of Medicaid enrollment may illuminate a path to increasing equity in accessing timely prenatal care. Enhancements to prenatal care can improve maternal health outcomes. Timely Medicaid enrollment may help enable access to such enhancements, including Medicaid-financed benefits that support maternal health. Perinatal doula care can help reduce cesarean delivery and preterm birth rates, and reduce racial inequities among PPP. This has prompted growing interest by Medicaid to support doula services. The goal of this dissertation is to improve our understanding of Medicaid as a policy lever to improve maternal health. I seek to achieve this by characterizing 1) timeliness of Medicaid enrollment prior to and during pregnancy, as well as at delivery hospitalization; (2) the research landscape on doula care policies in Medicaid programs; and (3) the policymaking process related to Medicaid support of doula care services. This dissertation includes three studies. In the first, An Assessment of Medicaid Enrollment Timing Among Medicaid-Covered Deliveries, I use the Transformed Medicaid Statistical Information System — a national database of Medicaid claims — to measure timing of Medicaid enrollment among Medicaid-covered deliveries, and associations between sociodemographic characteristics and timing of enrollment. In the second, Medicaid Reimbursement for Doula Care: Policy Considerations from a Scoping Review, I distill key policy considerations related to the inclusion of doula care as a Medicaid-covered benefit. In the third, Access to Perinatal Doula Services in Medicaid: A Case Analysis of 2 States, I conducted semi-structured interviews with key policy informants to explore facilitators and barriers to Medicaid reimbursement of doula care in Oregon and Massachusetts. Given the value of maternal Medicaid coverage and the significance of doula care, there is an urgent need to better understand patterns of Medicaid enrollment and the evolution of state Medicaid policies on doula care.
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2025
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