A recently published study evaluating the cost-effectiveness of birth doula care found that women who received doula support during pregnancy and labor had lower rates of both preterm and cesarean birth, compared to those who did not. Not only are these findings affirming to doulas, but they have the potential to change how policy makers and insurance providers value our services since the study quantifies the potential cost savings associated with lower rates of preterm and cesarean birth.

The study, “Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery,” was undertaken by a team of public health researchers at the University of Minnesota, the Mayo Clinic, and the Ichan School of Medicine at Mount Sinai, and published this month in the journal Birth (1). The team was led by Dr. Katy B. Kozhimannil, who has completed a DONA International birth doula training herself, and who has previously studied the association between doula support on cesarean rates (2, 3), as well as reducing disparities in breastfeeding (4). She talked with The DONA Doula Chronicles about this most recent study, her interest in doulas and why she chose to focus her research on the cost-effectiveness of doula support.

For the current study, Dr. Kozhimannil and her team reviewed data from 1,935 women who received doula support through a community-based doula organization for singleton pregnancies between 2010 and 2014. The rates of preterm and cesarean births in this group were compared to those of women in the same geographical area with singleton births in 2012 who did not have doula support (sample size 65,147). All births were funded by Medicaid. This final criteria for the data provided demographic consistency across the two samples. In reviewing the data, researchers accounted for maternal age, race-ethnicity, hypertension and diabetes across both groups. The purpose of the study was to compare the rates of preterm and cesarean birth in both groups and measure how costs to expand access to doula care might be offset by associated reductions in preterm and cesarean birth among doula-supported births. Cost modeling was then used to determine the average amount – across states – at which doula services could be reimbursed by state Medicaid programs without increasing overall costs, $986 per birth.

The study found that women who received doula care in the form of labor support and at least one prenatal visit (most participants in the doula program received multiple prenatal visits from their doula) were less likely to have a preterm birth or birth via cesarean at full term, compared with similar women regionally.

Preterm birth rates:
Medicaid-funded births regionally 6.3%
Doula supported, Medicaid-funded births 4.7%

Cesarean birth rates:
Medicaid-funded births regionally 34.2%
Doula supported, Medicaid-funded births 20.4%

Preterm birth rates were particularly important to the research team because they are the leading cause of infant death. Dr. Kozhimannil told us, “Infant mortality has been getting better over the last century in US, but the disparity between black and white infants has not changed in the last hundred years. Black infants are still three times more likely to die than white infants. Anything that we can do to move the dial on reducing disparities in infant death, we need to be paying attention to.”

In the Birth article, Dr. Kozhimannil writes that doula support may help address the “constellation of risks for preterm birth by reducing stress, improving nutrition, improving health literacy, providing referrals and connections to resources, and improving emotional well-being.”

Researchers estimate that ensuring broad access to prenatal and birth doula support for women whose maternity care if covered by Medicaid could save $58.4 million a year across the 12 study states. Why is this important to the doula profession? Dr. Kozhimannil explains:

“The clinical evidence of the health benefits of doula support are very clear and not in dispute. For policy makers and insurance companies, there is an additional need for cost information in order to understand how to increase access to evidence-based support. This was an important gap. The missing piece was the financial analysis.”

Looking ahead, Dr. Kozhimannil feels that this study is a good first step in producing the evidence that policy makers and insurance companies need in order to develop clear, effective strategies to improve access to doula services at reimbursement rates that are reasonable for doulas. Because the community based doula organization did not systematically collect data on the number of prenatal doula visits for all participating women, the researchers could not analyze how many visits are needed, on average, to have the full impact on reducing preterm birth rates seen across the doula supported women. Exploring this in future studies will help provide important information on how much support is needed during the prenatal period to reduce preterm birth rates and, with it, infant deaths.

These results of Dr. Kozhimannil’s study further reinforce that the support and education doulas provide make a difference in birth outcomes. Last year the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine issued a joint statement on cesarean birth which stated that doula support was “one of the most effective tools to improve labor and delivery outcomes” (5). Doulas often consider most of our impact as happening during labor and birth, but Dr. Kozhimannil’s study clearly demonstrates that the prenatal support provided by birth doulas may also have important positive effects on birth outcomes.

— Adrianne Gordon, CD(DONA), MBA, Blog Manager

1. Kozhimannil, Katy B. et al. (2016). Modeling The Cost-Effectiveness Of Doula Care Associated With Reductions In Preterm Birth And Cesarean Delivery. Birth, n/a – n/a. Web.

2. Kozhimannil, Katy B. et al. (2013). Doula Care, Birth Outcomes, And Costs Among Medicaid Beneficiaries. Am J Public Health, 103.4, e113-e121.

3. Kozhimannil K.B., Attanasio L.B., Jou J., Joarnt L.K., Johnson P.J., Gjerdingen D.K. (2014). Potential benefits of increased access to doula support during childbirth. American Journal of Managed Care, 20(8): e111-e121.

4. Kozhimannil K.B., Attanasio L.B., Jou J., Joarnt L.K., Johnson P.J., Gjerdingen D.K. (2014). Potential benefits of increased access to doula support during childbirth. American Journal of Managed Care, 20(8): e111-e121.

5. American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. Obstet Gynecol, 123, 693–711.

Additional Resources
Study abstract: http://onlinelibrary.wiley.com/doi/10.1111/birt.12218/abstract

University of Minnesota press release on the study: http://www.health.umn.edu/news-releases/study-doula-care-cost-effective-associated-reduction-preterm-and-cesarean-births

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