Category 1: Training, credentials, and competencies Theme 1: Cultural competence and supporting vulnerable populations	Doula vignettes:   Regardless of the type of training that they’ve already taken, [doulas] absolutely should have some type of cultural competence training, and they should definitely be aware of how to support Black and brown people, especially since we have the highest rate of mortality in the state. You can’t properly serve any birthing people if you don’t know how to properly serve the ones that need the most support. So, if that’s not within the requirements of Medicaid reimbursement, then it’s definitely doing a disservice to the state, because a lot of our Black and brown families are using Medicaid.   If you’re not made aware, or if you’re not familiar with it, if you’re not comfortable with information that’s out there, with the information that’s needed in order to properly serve, then you run the risk of literally causing more harm or more trauma in a person’s birth space.   She’s going to be able to support in a way that is needed, because she knows what’s going on, and she actually cares about what’s going on, because she sees it. I think a lot of the time people don’t see it and not because they don’t want to see it, because they can't really relate to it. So, I think that should definitely be something added to the training so that they can understand what’s going on. This is not us just complaining or anything. This is really happening to our sisters here, and we’re dying at an alarming rate for things that could have been prevented.   In addition, there needs to be some kind of measure in place to show that the people are actually absorbing what is being taught to them, and not on a low level, but on a high level, because as I’ve mentioned before, about my nursing school textbooks… there is biased information still present in the book. So, if you have someone who is not familiar with people of color, and then they read whatever in the book, or they learn whatever, or they don’t learn whatever in a doula training, then they’re not necessarily going to get out here and know how to support people of color. So, I would definitely say, making sure that there’s some kind of teach back or test or something to make sure that they get it.   I’ve not yet worked with a trans person, and I would not take an opportunity to. I receive a person as a client, and say, ‘oh, sure I’ll be happy to come and help’ and use that as my opportunity to learn... That’s not the proper time to do that. We need to be aware. You need to be thoroughly aware of how to properly serve people from a different culture or a different background before you get into that space, because you don’t want to ever run the risk of affecting their dignity while they’re within that space.
	Licensed provider vignettes:   So I do think that it's really important to ensure that we have representation across the field – all fields in the medical industry, but that we're also culturally humble when caring for the patient and really sensitive to the fact that we're not able to speak for everyone, or assume culture and expectations, and all of those things for every person. So I do think that when it comes to black and brown women, or women specifically, who aren't white, they [may] come to the table with post-traumatic experiences dealing with bias in health care.   We're getting a larger population of Hispanics and Creole, especially in the Lower Sussex County, especially with the chicken plants being here. I think it would be wonderful if we could help some of these patients, and if we were able to have some bilingual translators/doulas that would definitely make a difference. I think we have to look at it in the equity piece and access to care because sometimes they've not had any prenatal care at all. They've just arrived here a couple of days ago and come in and deliver not really knowing anything. So I think that if we had those doulas present that that would take away a lot of angst for those patients. It's got to be pretty scary coming into a new country, a hospital, and not speaking the same language and our translation services that we have that are by phone, that a lot of them really don't speak Creole. So that communication piece is not really happening, and it can be kind of scary, especially if they need a stat C section, and you're not able to communicate … It pulls your heartstrings.   With all the inequities that are still going on today, especially with black birthing people…I think it is another layer of support and care for them, particularly. I know there is a huge push nationwide because, really a lot of the doulas are within their community. These doulas look like them, and they can form relationships prior to coming into the hospital, especially if there were any complications going on, especially with the patients. They're there, they have the full understanding and can really provide a lot of education and resources for these moms prior to coming into the hospital, during labor, and even post-delivery. I think that's a real added benefit to for a lot of these moms.   I think the real value in doulas in low-income populations are support. I mean, women are scared to give birth. And because of what they read and what they hear, and statistics, and so they are scared to give birth, and I think, knowing that they have that support and have a Doula is really important. And in my view, that's probably the most important thing right is just peace of mind. I think it's the most important thing.
Category 1: Training, credentials, and competencies Theme 2: Perspectives on credentialing and certification policy	Doula vignettes:   I know after the first training I didn’t feel prepared really to serve the clients. It was only a two-day training and then we did some continuing education online. I really, honestly, I didn’t feel prepared afterward. I didn’t feel confident enough to go out and serve these clients. I didn’t feel like I knew enough. But as I started to practice, I did learn by doing.   So, training-wise, it's important to not limit people to specific organizations just because they have bigger names. That's actually dangerous for a doula, and for the people that they support as well.   We don't want just anybody subscribing to and saying, Yeah, I'm a doula. No, there absolutely does need to be some kind of certification.
	Licensed provider vignettes:   In that training has to be basic knowledge of pregnancy. I'm not talking, you know they don't have to be at the level of a nurse, midwife, or anything like that, but a basic understanding of pregnancy, and a basic understanding of the process of labor, the options that patients have for different things in the labor process that can help them through the labor process. When is it time to say we're done.   I think that doulas need to demonstrate a level of competency by having a certification from an organization such as DONA. And so they want to present themselves with the best credentials that they can, so that they can feel like they're part of the team and so that they can be accepted as part of the team.   I ask them (other nurses), what are the things that you would want, and what are things that you don't want, and all of them have said minimum standards. And so they either want a certification from something like DONA, or some kind of minimal qualifications.   If everyone has ... at least the same certification ... you know they've met a certain level of competency. And you can feel safe that they are doing what they should be doing for the patient.   It cannot just be all OJT [on the job training]. There has to be a level of content in a classroom setting, whether it's an online or whether it's an in-person classroom setting where they can learn about childbirth. If they're going to establish the level of trust, they have to understand the complications of childbirth…There needs to be information on, not heavy physiology and anatomy, but understanding the birth process.
Category 2: Logistical considerations for policy & practice change Theme 1: Financial considerations	Doula vignettes:   I think I think financial support is one of the biggest [challenges], because a lot of the black and brown women that I plan to support are from communities that are underserved. And so the doulas that are in those communities also may have a financial burden if they have to pay for [training], you know, extensive classes for doing what they just naturally do. So, I think that needs to be considered, because there's some people that really cannot afford a doula, but they want a doula, and to be denied support like that because of finances, it's just to me, that's a travesty. And again, there are plenty of doulas who live in underserved communities, and financially may not have the money… one thousand five hundred dollars to take training…This is ridiculous.   We need to be able to sustain our own households because a lot of times as a doula, we can't show up for our clients when we’re mentally drained and burnt out ourselves because we can't even pay our own bills.   I have a lot of Black young women who would love a doula. A nineteen-year-old right now, and I looked at her, and I was like, ‘Listen, this is something that you need. This is not a luxury. This is a necessity. Let me show you. Here's a resource so that you can be able to get this for free.’ So, if we have more money being funneled into programs like this on top of having those who do have access to Medicaid, this is not an extra expense, but this is something that is a part of the package.
	Licensed provider vignettes:   Many of them are not businesspeople, right? This may be their first time having to go through a process like this, so I'd like it to be as simple as possible, and really be able to have a return on investment for the doulas in this community, because we are really trying to address disparities right? And likewise I think that they need to have an equitable income for these services. I think that we've learned some lessons in other states that have really looked at reimbursing doulas and we've seen that they've had some low salaries there, so that's a concern for me as well.   A labor can last a really long time 48, 56 hours. That doula may need to hand off to another doula. Does that mean that she misses out on reimbursement because she's needed to do that hand off? You know. Sometimes we may not be contacted by a pregnant person until later in their pregnancy, and so we may only be able to see them once or twice before they even go into labor. Or maybe they're having a premature labor right? And so would that impact their reimbursement in a negative way?… And also, what does the postpartum coverage look like? We do have opportunities for postpartum care and when we're thinking about maternal mental health and families that may not have a lot of resources. For example, maybe they don't have a primary support person in their home. Maybe they have to go back to work early. Maybe they have a baby who's had a NICU stay – on and on. What does that look like from a postpartum perspective? Can we engage doulas to become postpartum doulas, and potentially help specifically like our first-time families, or those with the lower socioeconomic status? Or, again, just those without resources. I think that that would be an amazing thing to be able to explore.   I think what we've heard from the doulas that the certification is expensive. Some of them have said they haven't gotten the certification because it's expensive. If that's the case, then the State could support that. I think if there are – with accepting Medicaid again, I think there's gonna be a lot of responsibility on documentation, record keeping, billing, to ensure that there is not any fraud. And so I think the doulas are going to need support with that. Yeah, how to how to document how to make sure that they have great a good accounting for the money trail there.
Category 2: Logistical considerations for policy & practice change Theme 2: Administrative and legal concerns and assistance	Doula vignettes:   Historically, it's been very challenging for people of color to get ahead when it comes to certain things…if for Medicaid billing [we] have to jump through hoops and file this paperwork that it's ridiculous, and it's just kind of another form of discrimination. And some people may say that it's not, but it really is. It keeps us from achieving the goals that we really are set out to achieve. So, it would be nice if there were certain forms that need to be filled out… It needs to be minimum, and it needs to be very well compensated for all that we do.   That's [administrative support] very important, and I will say that I think it's important to make sure that it doesn't create a barrier, because I can see creating a barrier with it being too extensive or too much or not having adequate support to complete whatever needs to be completed…So, when it's time, we can get out there and get it done. But yeah, definitely, having support for billing and adequate support, not just saying there's support, but actual…like maybe aids showing like ‘click here.’ Do that, like actual things that walk people through the steps, and then having that support that's available to teach as well. I think that's extremely important.
	Licensed provider vignettes:   A way to resolve like grievances, you know, like some sort of a responsible party within the State that can address any kind of concerns that are coming up, and you know, some way for that to be addressed if there is unsafe practices or something that's happening.   And there's a lot of medical legal stuff going on there. So if you have a lay doula in the community, what's the medical legal responsibility when they walk into the hospital because now the hospital takes responsibility to some degree. Unless by legislation you remove hospital responsibility, that's a problem.
Category 3: The whole care team: Relationship between doulas and medical partners Theme 1: Building cooperative and collaborative relationships	Doula vignettes:   We are all here literally to do the same job. Get this baby first, and make sure that the birthing person is safe. Period. Period.   To be honest, we are all a team, the mother, the father, or whoever our support person is, the doctor, the nurse, the doula. We are all there for one particular thing, that is to make sure the baby comes out healthy. So, we are all together in this one hundred and fifty percent.   I don't want to call them ‘meet & greets,’ but something where providers are introduced to the role of doulas as well as meet doulas ... You actually sit down and talk to us. We can have an open back and forth discussion so everything can get laid out ... making sure that we come together, and having that open dialogue, I believe would be helpful.   I think it should be required for medical providers to have some type of continuing education regarding what doulas do. Also, maternal and infant mortality - I think that they should be aware of that, and what's actually going on, especially in their state. And I think that they should be aware that doulas are a part of the birth team.
	Licensed provider vignettes:   [Doulas] can serve as a liaison between the clinical provider and you know those who kind of spit out a lot of medical jargon and help to ensure that the birth parent understands what that jargon means, so that they can make an informed decision.   A doula is very valuable because they're interacting with the patient; they’re in many ways a ‘go between’ between the patient and the medical team.   Start with educating the team and having that general understanding of ... the service that [doulas] provide, and fully understanding the benefits to it, and how we can partner together…. And once you understand it, then that's how you would be able to form a partnership to be able to provide this service for the patients.   I think provider and care team education [is important] because there is definitely going to be a huge differing of opinions about doulas. And you know another thing in medicine that we view as the end all be all is evidence-based. So I know there's evidence that doulas improve birth outcomes ... I think the medical community is always more likely to embrace things that [are] evidence-based so I think that really educating… would be really important.
Category 3: The whole care team: Relationship between doulas and medical partners Theme 2: The role of a doula	Doula vignettes   I'm not here to cut your pockets. I'm not here to undermine your authority. I'm not here to change, or even question your knowledge…you know your expertise. I'm just here to also offer extra because this is what the client is asking for.   I would never argue with anybody else on the birth team, because then that's causing more stress for my client, you know. So, I do it very respectively. If I do have to speak up about something, I ask questions, you know, and that's just how I show up in the birth space in the hospital setting.
	Licensed provider vignettes   Doulas provide a consistent presence of someone who is supportive, and who they trust and that the family trusts, which reduces the patient's anxiety, reduces the patient's fear, and it makes just for a calmer birthing experience.   If [doulas] develop a bond with a patient who's scared… with the comfort of a doula that they know and says, “Okay, just remember, these were the things we talked about from pain control perspective. We talked about breathing, we talked about nitrous, we talked about IV medication, and we talked about the epidural,” in the moment when a nurse is saying, “Okay, your pain’s a 7 all of a sudden, are you thinking you want an epidural?” If you don't have someone to kind of bring them back to what their full options are, they might take that as a suggestion instead [of a question].   I like to think of [the role of the doula] as social capital. Somebody to listen to what a provider may be saying, and a second ear at times, or to run things by, or to give primary advice to a mom. I think that works well in the labor process. It's an extra level of support and comfort for that patient ... to help guide that mom if she needs to get to an obstetrician or if she doesn’t need to get to an obstetrician, or to run something by about the normalcy of certain findings.