No abstract

Context: Community-based birth doulas support pregnant women, transgender men, and gender non-binary individuals during the perinatal period and provide essential services and expertise that address health inequities, often taking on additional roles to fill systemic gaps in perinatal care in the United States (US). Despite the benefits that community-based birth doulas provide, there is little research exploring the work-related conditions and stressors community-based doulas experience. To address this gap, we examined the work experiences, related stressors, and stress management strategies of individual community-based birth doulas.Methods: In this qualitative, descriptive study we conducted 18 interviews in March through June 2021 with individuals who self-identified as community-based doulas working in underserved communities in the US. We analyzed the interviews for themes, which we defined and finalized through team consensus.Results: The doulas reported engaging in specific strategies in their work to address perinatal inequities. They also described facing several work-related stressors, including witnessing discrimination against clients, experiencing discrimination in medical environments, and struggling with financial instability. To mitigate these stressors and job-related challenges, interviewees reported they relied on doula peer support and reconnected with their motivations for the work.Conclusions: Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided is needed to strengthen and sustain this critical part of the perinatal workforce.

Evidence of doulas’ positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations’ barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities.

Context: Navigators in the federal Insurance Navigator Program ("Navigator Program"), who are employed by organizations in states with Federally Facilitated Marketplaces, provide enrollment assistance, outreach, and education to individuals who are eligible for health insurance coverage. Such work is central to public health efforts to address inequities but continues to be poorly understood and undervalued. More information is needed to understand the components of navigators' equity work and how decreases in program funding have affected their service provision. Objective: To examine navigators' labor at a granular level to better understand and highlight the equity work they do, the training and skills required for this work, and the Navigator Program-based challenges they face. Design: This was a descriptive qualitative study using data collected from interviews conducted in February-May 2021. We used a thematic analysis approach to develop major themes and subthemes. Setting: This was a national study. Participants: We conducted 18 semistructured interviews with 24 directors, navigators, and other professionals at organizations funded as federally certified Navigator Programs. Main Outcome Measures: Components of navigators' work; required training and skills; and challenges faced in accomplishing the work. Results: We identified 3 major themes: (1) navigators' health equity work goes beyond required responsibilities; (2) equity skills are built on the job; and (3) financial instabilities challenge navigators' health equity work. Conclusion: Navigators bring specialized and essential skills and services to underserved communities. They are trusted sources of information, advocates, resource connectors, and, most significantly, health equity workers. However, the Navigator Program fails to support navigators' work and the communities they serve in the long term. To facilitate organizations' capacities to train, keep, and support navigators in this health equity work and to guarantee long-term enrollment assistance for underserved communities, efforts to stabilize funding are needed.