First Advisor

Sherril B. Gelmon

Term of Graduation

Spring 2023

Date of Publication


Document Type


Degree Name

Doctor of Philosophy (Ph.D.) in Health Systems and Policy


Health Systems and Policy




community health worker, doulas, healthcare access, healthcare policy, maternity care



Physical Description

1 online resource (xii, 348 pages)


Doulas are trained, nonmedical support professionals that provide continuous emotional, informational, physical, and practical support before, during, and after childbirth. Doula care has been shown to reduce the cost of birth-related healthcare, reduce adverse birth outcomes, and increase patient satisfaction and positive birth experience. In 2011 Oregon became the first state to authorize payment expenditures of doula care through Medicaid as a strategy to reduce birth-related health disparities and increase culturally and linguistically appropriate healthcare delivery. The intention of the set of policies and administrative rules was to mandate access to doulas and other types of Traditional Health Workers (THWs) for Medicaid-enrolled families.

Access in healthcare is approximated and measured in many ways, often emphasizing utilization. The Patient Centered Model of Access to Healthcare conceptualizes access as occurring at multiple points across a process of identifying, finding, obtaining, and utilizing healthcare for both patient populations and healthcare systems; the financing of doula care is one of many potential factors that could increase or diminish access to care. Utilizing this conceptualization of access, the research question of this dissertation was: What are the emerging Medicaid policy and system factors that would increase access to doula care in Oregon?

This study utilized a modified Delphi survey to identify the barriers and facilitators to doula care access in Oregon, determine priority barriers and facilitators, and identify possible actions to influence the most influential barriers. First, the Patient Centered Model of Access to Healthcare was modified, and further refined with qualitative data, to identify seven health system levels and six access points, or dimensions of access, occurring between the steps of identifying healthcare needs, seeking and reaching healthcare, healthcare utilization, and health outcomes. Data were collected through a three-round Delphi survey of healthcare system professionals who work closely with the policy topic to represent the healthcare system and policy perspectives, a set of pre-survey focus groups of participants recruited through Oregon Women, Infants, and Children (WIC) to represent the patient perspective, and a final set of interviews recruited from the initial focus groups to review survey and focus group findings for additional input and consensus.

The findings of this study demonstrate that the most important barriers to access include general and adequate knowledge of doulas across all healthcare system levels, with specific emphasis on patient and healthcare provider knowledge of Medicaid coverage of doula services, patient knowledge and understanding of the role and benefits of doula care, and healthcare provider knowledge of how to refer patients to doulas. The next most influential barriers to doula care access focused on the challenges to create an equitable and sustainable doula workforce to provide culturally and linguistically appropriate care, and the buy-in to THW program development and utilization from Coordinated Care Organizations (CCOs) and the Oregon Health Authority. To effectively increase access to doulas, as is mandated in Oregon legislative and administrative policies, the following recommendations would further support doula care access: direct and detailed communication to patients from their healthcare providers and CCOs about doulas, social needs screening and referral tools that include birth-related support for healthcare providers, and further technological and administrative support to CCOs to ensure data reporting and referral pathways related to THW tracking and utilization requirements.


©2023 Courtney Elizabeth Crane

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