Methods

This survey was administered from November 11, 2019 to January 1, 2020 to birth doulas who provide services in Washington state. Eligible survey respondents were active birth doulas in Washington state ages 18 and older who could read and write in English. For the purposes of this study, an “active” birth doula is someone who has practiced as a birth doula in the past two years. All preparation, information-gathering, data collection, and analyses for this research project took place at the University of Washington in Seattle, Washington. This project is considered exempt by University of Washington’s Human Subjects Division. The Center for Excellence in Maternal and Child Health at the University of Washington’s School of Public Health provided funding for incentives provided to survey respondents.

Data collection

A survey instrument was designed to address the study’s aims to: 1) understand how Washington state could structure Medicaid reimbursement to best support birth doulas and birthing individuals using Medicaid; 2) explore how birth doulas serve their clients and how they are compensated; and 3) gather information about the demographics of the birth doula workforce in Washington state. To develop the survey instrument, the researcher used two surveys as guiding forces. One was conducted in 2018 by the National Health Law Program (NHeLP) in California. The survey sought to gauge doulas’ interest in Medicaid reimbursement in the state. The second survey was conducted in 2016 in Washington State by Kim James, founder of the database DoulaMatch.net, and the Governor’s Interagency Council on Health Disparities. These survey results have not been published.

To understand the nature of Medicaid reimbursement and the birth doula landscape in Washington state, the researcher conducted informational interviews with 13 people who either provide services to birthing individuals or advocate for perinatal health initiatives. Several interviewees are members of Doulas For All Washington State, a workgroup that is advancing equitable access to support during pregnancy, birth, and early parenting for all families. The researcher asked interviewees to share their knowledge about being a birth doula, community-based doula programs, and/or potential issues to consider as Washington state implements Medicaid reimbursement for birth doulas. About half of the interviewees reviewed early versions of the survey instrument, and the researcher made changes to items based on their feedback. 

The final web-based survey instrument consisted of 45 items. Although respondents were encouraged to complete the survey in its entirety, only three items were required to determine eligibility. The remaining 42 questions were optional and utilized multiple choice, checklists, a 5-point Likert scale, or were open-ended. Members of the research team who did not develop survey items and two doulas who do not live in Washington State tested the instrument. The non-Washington state doulas were compensated with $15 gift cards. They provided information about how long it took them to complete the survey and offered technical feedback about the survey instrument. The survey opened to the study population on November 11, 2019. After collecting 87 survey responses, the researcher changed items related to race/ethnicity to acknowledge the impact of enslavement.

Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Washington. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies. The researcher used convenience sampling to administer the survey to the target population. Survey links were sent via email to 773 doulas in Washington state who had active profiles on DoulaMatch.net and shared with members of Doulas for All Washington State. Four organizations based in King County, Washington – Open Arms Perinatal Services, PALS Doulas, Global Perinatal Services, the Swedish Doula Program at Swedish Health Services – also shared the survey with birth doulas. The researcher shared the survey with the Washington State American College of Nurse-Midwives (ACNM) affiliate, as certified nurse-midwives may work closely with doulas. Of the 773 email addresses from DoulaMatch.net, 29 were no longer valid.

The survey remained open until January 1, 2020. As an incentive, all survey respondents were eligible to win one of nine $20 gift cards. Email addresses collected to deliver the incentives were not linked to the participant’s survey responses.

Data analysis

For all categorical and continuous variables, the researcher conducted an exploratory descriptive data analysis using R statistical software (Vienna, Austria). For items that required range responses, the researcher calculated a mean using the respondents’ numeric answers. If respondents indicated that they were African American or Black but specified their Somali ethnicity, they were later reclassified as African (Somali). If people selected more than one race or ethnicity, they were classified as multiethnic/multiracial in the final analysis.

For open-ended survey items, the researcher conducted a thematic analysis using qualitative methods. Respondents were asked: (1) “Did you face, or are you currently facing, any barriers to obtaining certification?” (2) “Will Medicaid reimbursement benefit birth doulas in Washington state?” (3) “Are there any potential barriers that birth doulas could face when the HCA begins Medicaid reimbursement for their services?” (4) “Will Medicaid reimbursement for birth doulas benefit childbirthing people in Washington state?” (5) “Are there any potential barriers that childbirthing people using Medicaid (Apple Health) could face when the HCA begins Medicaid reimbursement for birth doula services?”

The researcher, who has qualitative coding experience, drafted an initial codebook using language in the survey items. Additional codes were added to the codebook as the researcher reviewed the responses. All responses were coded using Dedoose Version 8.0.35, a web application for managing, analyzing, and presenting qualitative and mixed method research data (Los Angeles, California).