Comprehensive recovery during the postpartum period is central to both immediate- and long-term maternal health, as postpartum people frequently require support managing chronic conditions, breastfeeding, mood disorders, weight management, contraceptive planning, and cardiometabolic health 1, 2. Despite the crucial nature of the “fourth trimester” and the myriad complications that need to be addressed, the frequency and quality of postpartum care are variable in the United States. Rates of postpartum visit attendance are lower for Medicaid-insured and racially minoritized patients, and components and delivery of postpartum care differ based on individual needs 1. The largest variations in postpartum care content affect those with multiple disadvantaged identities, including type of health insurance, geography, race, and ethnicity 1. Variable access to care, high maternal mortality rates, and growing dissatisfaction and distrust with healthcare institutions have all sparked interest in expanding the perinatal workforce to include alternative, community-based models of support 3. We specifically focus on solutions to the fragmented care in the postpartum period. Important clinical approaches to community-based care include the midwifery model of care and home-visiting nurse programs, but we aim to examine the supportive, as opposed to clinical, services in the year postpartum. These non-clinical roles, such as doulas, community health workers (CHWs), and patient navigators, can specifically address unmet needs and improve the quality of postpartum care 2, 3. We seek to highlight the differences between doulas, patient navigators, and CHWs as supportive roles in the postpartum period. We use Medicaid coverage and requirements to inform our analysis, as it is the largest single payer of maternity care, and many of its enrollees face the structural and systemic inequities we aim to improve through expansion of the maternal workforce 3. We explore our local system in Massachusetts as a case study to examine how payment for postpartum support roles can be implemented at the state level and to compare Massachusetts regulations to those of other states. A doula is a “non-clinical support worker who provides continuous emotional, informational, and physical support for individuals before, during, and after labor” 3. The doula scope of practice includes providing comfort, information, and resources to their birthing clients during pregnancy, labor, and the postpartum period 3, 4. Among Medicaid enrollees, doula care is associated with a 47% lower risk of cesarean delivery and 29% lower risk of preterm birth. Medicaid-insured individuals with doulas were also 46% more likely to attend a postpartum visit 4. While there are doula training programs that solely focus on the postpartum period, we examine the more common role of the birth doula, as postpartum doulas are not the focus of Medicaid coverage 5. Birth doulas are still expected to assist clients after childbirth, and are typically eligible for reimbursement for postpartum visits through Medicaid 5. While provision of birth doulas is linked to an increase in postpartum visit attendance for Medicaid enrollees 4, doula services in the postpartum period warrant further study. CHWs differ in their scope of practice within the perinatal landscape. CHWs are public health workers who serve as liaisons between the healthcare system and their communities, helping to improve cultural competence, patient/community education, and increase access to resources and care 3. CHWs typically receive generalized training and can work across different medical specialties, including obstetrics. CHW involvement in the perinatal landscape, however, has led to the development of the perinatal CHW training programs to better address the unique needs of birthing and postpartum people 3. Perinatal CHWs have not been robustly studied as a tool to improve postpartum care, but in general patient populations, CHWs may improve patient satisfaction and access to preventative and social services 3. Like CHWs, patient navigators (PNs) are trained as non-medical support for patients across different medical contexts. Their role is to identify barriers and improve access to patient care, offer health education, and provide social support for patients 6. Given the success of PNs in healthcare promotion among underserved patients, PNs have been suggested to improve health disparities in perinatal care 2, 6. As alternative models of care for birthing people gain traction in the United States, it is critical that we clarify the roles of doulas, CHWs, and PNs and assess their potential in improving maternal care. These roles may be utilized across the perinatal period, but we specifically focus on their potential to support postpartum people. The Massachusetts Medicaid program (MassHealth) began reimbursing doulas in December 2023, and the Commonwealth released a provider manual with specific credentialing requirements for doulas to become MassHealth providers 5. In Massachusetts, doulas must demonstrate a basic understanding of maternal anatomy and physiology; common medical interventions during pregnancy, childbirth, and the postpartum period; common potential complications; labor and delivery comfort measures; best practices for supporting members in advocating for their needs and making informed decisions using a trauma-informed approach; and basic newborn care 5. They may meet these competencies through a doula certifying organization or through an experience pathway. They may be reimbursed up to 1700 for prenatal visits, labor and delivery support, and postpartum visits up to 12-months postpartum 5. MassHealth does not directly reimburse CHW services 7. However, CHWs in Massachusetts can be supported to provide services to Medicaid enrollees through other mechanisms, including grant programs or value-based care models that reimburse group practices such as community health centers and other clinical sites for quality. While they do not directly reimburse CHWs, Massachusetts has its own Board of Certification of Community Health Workers 8. There are no state-led programs specific to perinatal CHWs, but the generalized training requirements of CHWs are expected of CHWs working across all fields. Core competencies of CHWs in Massachusetts include outreach methods and strategies, individual and community assessment, effective communication, cultural responsiveness and mediation, education to promote healthy behavior change, care coordination and system navigation, use of public health concepts and approaches, advocacy and community capacity building, documentation, and professional skills and conduct 8. Similarly, PN services are not directly reimbursed by MassHealth. There are also no state or national requirements to become a PN. Like mechanisms that support CHWs in group practices or health systems, PNs may still provide services to Medicaid enrollees, but the information surrounding PN training and coverage in Massachusetts is limited, and there are no state-level PN training programs specifically focused on improving maternal health. The broad definitions of doulas, CHWs, and PNs have been established, and each has been suggested to improve postpartum care in the United States. However, there are clear distinctions between each of the roles, and gaps in knowledge remain about their competencies and benefits. Although doulas have been most robustly studied as a potential solution to the maternal health crisis due to their specialized role in perinatal care, there is no national consensus on doula core competencies. According to the National Health Law Program's Doula Medicaid Project, 25 states and Washington DC are actively reimbursing doula services through Medicaid as of January 2026 5. While Medicaid coverage for doulas is increasingly common, each state varies in certification requirements, reimbursement rates, and billing structures. Massachusetts caps its reimbursement rate at 1700, but this ranges across states, with a maximum total reimbursement rate at 3500 in Washington and 1045 in Oklahoma 5. Most states have generalized training requirements for doulas which can be met through accredited doula organizations, but training may vary between national and community-based doula training programs 3. Some community-based doula organizations, which emphasize cultural humility and social determinants of health, are integrated within the communities they serve and take a justice-centered approach in their training 3. Larger, national doula organizations may have less focus on the unique needs of underserved birthing people. Doula coverage in the postpartum period is also variable by state. Some states, like Connecticut, will only reimburse for a specific number of total client visits, inclusive of pre- and post-natal visits, while some have a set number of visits (Delaware), or even minutes (Colorado) that are reimbursable in the postpartum period 5. Certain states do not define the postpartum period, while others define the postpartum period as up to 6- or 12-months after delivery 5. What is generalizable for doulas across the United States, however, is their emphasis on patient comfort and support, especially during labor. Their role is also notable for its training in maternal health and focus on patient education surrounding perinatal topics. The doula model of care, despite variation in state regulations and Medicaid coverage, is designed to support and empower patients in their maternity care. CHWs and PNs are less commonly looked upon as supporting solutions to the maternal health crisis, and therefore, there are few programmatic evaluations available to support policy change. However, CHW competencies are more standardized across the country due to their widely accepted commitment to being community-based (as opposed to the differences between larger and community-based doula organizations). The role of a CHW, as indicated by perinatal CHW models, can also be a useful tool in the perinatal period. Their competencies differ from those of doulas, as their focus is less on emotional support and instead more toward clinical navigation and connecting patients to healthcare and community resources 8. While well standardized in terms of competencies and expectations, CHW Medicaid reimbursement varies by state, and not all states have a CHW certification program. Massachusetts has a certification program and no Medicaid coverage, while states like New York and Louisiana are flipped, reimbursing CHWs yet providing no state-level CHW training 7. There is no state-by-state analysis of PN training programs and Medicaid coverage, and PN training appears to vary by organization. However, in the Navigating New Motherhood 2 trial 2, a postpartum PN training program designed to assist patients into the year postpartum was meticulously outlined and tested for its effectiveness. The core elements of this navigator professional development include principles of patient navigation, knowledge of prenatal and postpartum care, health education and health promotion principles, cultural sensitivity and health equity, care coordination and community resources, and electronic medical record systems 2. This training program blends the maternal health training doulas receive with the clinical navigation and referral skills of the general CHW and PN, which could be an effective way to improve the postpartum system of care in the United States. While equipped with an obstetric-oriented education, postpartum PNs would still differ from the doula emphasis on supporting and empowering patients, especially throughout the prenatal period and during delivery. Postpartum support roles vary in their emphasis on specific competencies. Postpartum PN and CHW training requirements and expectations are most notable for their clinical care coordination, as they are more integrated within healthcare systems and can be involved in appointment scheduling and referrals. Doula competencies do not highlight clinical tasks such as ensuring continuous healthcare access and appointment coordination. Rather, doulas play a significant role in patient education, empowerment, and advocacy. Medicaid agencies and commercial payers should be cognizant of these critical distinctions to ensure that expectations for each postpartum support role align with their expertise and unique contribution to maternal care. National attention and funding for doula programs in particular have increased in the last decade. Given the growing investment in doula services as a potential method to improve birthing experiences and outcomes, it is crucial to define their role in the perinatal landscape and coordinate doula training expectations and Medicaid reimbursement requirements across states. Given the CHWs’ agility in clinical care coordination, increased training programs and Medicaid support for perinatal CHWs may assist in improving the disjointed postpartum system in the United States. PNs are another outlet that remain untapped in the postpartum system; the core competencies and training requirements of the postpartum PN reveal that they are uniquely positioned to coordinate care and are well educated on patient perinatal experiences and postpartum needs. As clinicians, community members, policymakers, and advocates work to improve maternal care in the United States, there is an opportunity to better standardize Doula, CHW, and PN training requirements and competencies needed to support Medicaid funding. An in-depth cost analysis of each supportive role would also allow Medicaid agencies to better understand the unique benefits of each role. Doulas, CHWs, and PNs may each be essential in transforming the postpartum system of care. This work is funded by the CVS Health Foundation: Mass General Brigham Grant #GR0127667. The authors declare no conflicts of interest.
Anghel et al. (2026) studied this question.