Doulas as Facilitators to Black Birthing People's Needs in Pennsylvania in the Context of Medicaid Coverage.

Introduction: Longstanding racial inequities in maternal mortality require tailored approaches to improving outcomes for Black birthing people. Doulas provide continuous emotional, physical, and informational support and have been shown to improve perinatal outcomes, particularly for Black birthing people. In response, some states have implemented Medicaid doula benefits. In January 2025, Pennsylvania-where ∼35% of births are Medicaid-covered-launched such a policy, allowing certified doulas to enroll as Medicaid providers. Methods: As part of a larger mixed-methods study on the effects of Medicaid policies on maternal and child health, the study team examined doulas' experiences participating in Pennsylvania Medicaid. Semi-structured interviews were conducted with 30 doulas statewide from December 2023 to March 2025 to examine the policy's implications for doulas and Black birthing people. Transcripts were analyzed using latent content analysis, applying inductive and deductive coding. Results: Doulas reported persistent racial inequities in health care, including delayed pain management and pressure on Black birthing people to accept unwanted interventions. They described advocating within a system marked by clinician bias and profit-driven hospital models. While some doulas viewed the Medicaid policy as improving credibility and expanding access for Medicaid recipients, concerns emerged regarding administrative burdens, credentialing, enrollment, and scale-up, especially for Black doulas, who play a central role in supporting Black birthing people. Discussion: This study highlights the need to support doulas in navigating Medicaid processes while also addressing structural barriers within the health care system. Insights from other states can inform implementation efforts in Pennsylvania. Health Equity Implications: These findings underscore that Medicaid doula policy must go beyond reimbursement alone to ensure that community doulas can connect with clients and provide continuous, holistic support both within and outside the health care system-unencumbered by credentialing requirements, enrollment barriers, or payment structures that constrain the scope and reach of their work. Reimagining such policy to center the experiences of both Black doulas and Black birthing people is a necessary step toward dismantling the systemic conditions that drive racial inequities in maternal mortality.