Staff: Allison Egan, Jen Masdea, Ben Wood, Kristin Mikolowsky, Joanne Lau, Destiny King
Doulas provide vital non-medical support during pregnancy, labor, and postpartum. Their assistance helps reduce adverse outcomes such as preterm labor, preterm birth, and non-medically necessary cesarean sections. Also, their care contributes to improved breastfeeding rates and lower rates of postpartum depression and anxiety.
The doula care landscape is rapidly evolving in Massachusetts. In December 2023, MassHealth, the state’s comprehensive health coverage for low-income residents, began reimbursing doulas leading to a surge in provider registrations. However, rural areas remain underserved, with fewer registered doulas and lower uptake of doula care among MassHealth-insured residents. With a reduced number of hospitals or long distances between hospitals, minimal access to public transportation, many residents of rural areas of Massachusetts have less access to obstetric care, particularly for high-risk pregnancies.
To support the understanding and dismantling of doula care barriers in rural Massachusetts, HRiA’s Innovation Incubator is funding the Rural Doula MassHealth Registration Initiative. Increasing access to local, culturally responsive doula care in rural areas will help prevent adverse pregnancy, birth, and postpartum health outcomes.
Our Approach
The team conducted a comprehensive assessment to learn about the challenges connected to doula care access. The assessment included an environmental scan, statewide survey, and interviews with doulas and maternal health experts. An advisory group comprised of doulas, researchers, and advocates was formed to help shape the strategy. Members of the group include:
- Hued Mama’s Co.
- The Massachusetts Law Reform Institute
- The Massachusetts Department of Public Health Doula Workforce Team
- Majestic Yoga Studio
- Boston Medical Center
- Beth Israel Deaconess Medical Center
The majority of these members are practicing doulas. Also, there are five additional rural and urban-based full-time practicing doulas joining the group. During this process, the HRiA team built local and national relationships within the maternal health space, ensuring community wisdom and firsthand insights guided the work, bringing forth solutions that were responsive and equitable.
Preliminary Insights
The statewide survey captured responses from 53 doulas currently providing services across Massachusetts. Survey demographics reflect:
- 66% of respondents report that they provide services in rural areas of Massachusetts.
- 70% of respondents report that they provide at least some services through MassHealth.
- 85% or more of respondents reporting they provide services to low-income clients, Black and Hispanic or Latina/o/x/e clients, and clients not born in the United States.
The team was struck by the sheer amount of labor involved in providing doula care. Doulas can bill for time spent directly with clients. Yet, many essential aspects of their work, such as preparation, travel, and extended hours during labor and delivery (often 24-48 hours), are difficult or impossible to reimburse under current systems, including MassHealth. The commitment and depth of care doulas provide far exceeds what is formally recognized or compensated.
We asked doulas to help us understand what they perceived as the biggest barriers to serving clients in Massachusetts.
- About 63% of doulas said that it is difficult to make a living providing doula care. That rate increased significantly when we focused on doulas who identify as BIPOC 78%.
- MassHealth enrolled doulas and doulas that serve rural clients identified low reimbursement rates as their biggest barrier to serving clients.
- 28% of MassHealth-enrolled doulas reported that hospital policies prevent them from attending births. When we stratified by the MassHealth-enrolled and non-MassHealth-enrolled groups, that number increased to 41%.
When asked about the largest barriers for clients in rural areas receiving doula care, 87% of doulas stated low client awareness of services. Other responses included:
- 62% – Long travel distances to care facilities.
- 58% – Doula care not provided in the client’s preferred language.
- 56% – Limited number of doulas in rural areas.
- 53% – Challenges finding doulas in rural areas who share the clients’ racial, ethnic, and/or cultural background.
- 55% – Lack of transportation for clients of rural-serving doulas.
Next Steps
As data analysis continues, insights will shape a community engagement plan. In December 2025, a public report and presentation of findings will be released.
Year two of the initiative will focus on foundational efforts, laying the groundwork for a longer-term strategy. The strategy will include policy and advocacy development responsive to:
- Increasing client awareness of doula services and benefits.
- Improving doulas’ ability to enroll through the MassHealth program.
- Working with our state and national partners to advocate for doula autonomy and increased reimbursement rates for doula services, and more as they are further integrated into the Massachusetts medical system.
- Continuing support for enhanced doula training and networking in Massachusetts.
With a deeper understanding of these issues, the team can collaborate with their expansive network of doulas, researchers, and maternal health providers to increase the number of doulas registered with MassHealth, particularly in Western Massachusetts and Cape Cod.