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Doula support linked to lower C-section rate among Medicaid moms, U study finds

Women on Medicaid who give birth with the support of a trained doula are 40 percent less likely to have a C-section than counterparts who have their babies without that support.

A birth doula is someone (almost always a woman) specially trained to provide physical and emotional support to mothers during labor and delivery.
CC/Flickr/Neil Coleman

Women on Medicaid who give birth with the support of a trained doula are 40 percent less likely to have a Caesarean section than Medicaid recipients who have their babies without that support, according to a University of Minnesota study published Thursday in the American Journal of Public Health.

This finding suggests that providing Medicaid coverage for birth doulas might save taxpayers money. State Medicaid programs pay for almost half of all U.S. births. In the United States, a C-section costs, on average, about $10,000 more than a vaginal birth ($27,866 versus $18,329 in 2010). Among Medicaid births, the average costs are $9,100 for a vaginal birth and $13,600 for a C-section.

A birth doula is someone (almost always a woman) specially trained to provide physical and emotional support to mothers during labor and delivery. A doula is not the same as a midwife, who provides medical care during childbirth.

“Payers, including state Medicaid programs that facilitate access to doula services via coverage polices, could capture cost savings associated with reduced cesarean delivery rates,” the U of M researchers conclude. “Doula care may also hold promise for addressing persistent racial/ethnic disparities in birth outcomes.”

Comparing data

For the study, the U of M researchers compared two sets of birth outcomes among Medicaid recipients. One data set came from Everyday Miracles, a non-profit Minnesota doula organization. It included all 1,079 single-baby births that the group’s doulas had attended for Medical Assistance (Medicaid) recipients between January 2010 and April 2012. The other data set was a national sampling (279,008) of single-baby births in 2009 for which Medicaid was the primary payer.

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(The Everyday Miracles doulas were able to provide labor and delivery support services to those 1,079 Minnesota’s Medical Assistance mothers because a managed care organization reimbursed the doulas for related services, such as educating the mothers about breastfeeding and the necessity of using infant car seats.)

An analysis of the two data sets revealed a 22.3 percent Caesarean rate among the doula-supported births and a 31.5 percent rate among Medicaid beneficiaries nationally.

After controlling for factors associated with high-risk pregnancies and C-sections, such as gestational diabetes, race/ethnicity, hypertension and age, the U of M researchers found that doula-supported Medicaid births were 40.9 percent less likely to result in a C-section.

They also found that states could reap significant savings by paying doulas to support Medicaid mothers during pregnancy and delivery. Minnesota, for example, would have saved $3 million in 2009 by reimbursing doulas $300 to assist Medical Assistance women during childbirth, according to the researchers’ estimates.

A trusted advocate

Katy Backes Kozhimannil
Katy Backes Kozhimannil

Katy Backes Kozhimannil, the study’s lead author and an assistant professor at the U of M’s School of Public Health, wasn’t particularly surprised by the study’s results.

“I think having a trusted, knowledgeable source of support that’s with you continuously during labor is an important aspect of enduring labor and delivery for a lot of women,” she said in a phone interview earlier this week. “Most women who give birth haven’t been hospitalized before. It’s their first experience in a medical care system, and it can be a very frightening thing.”

“A doula can help a mom move through the physical pains of labor and also through the questions of choices and care,” she added. “I think that having an advocate in that decision-making process is really important for women.”

Most women who currently use doulas come from white upper-middle-class households. That’s primarily because doula services, which range from $300 to more than $1,800, depending on geographic location and the doula’s level of experience, are typically not covered by health insurance policies.

But it’s the women who currently lack access to doula care who are most likely to benefit from having that support during childbirth, said Kozhimannil. Other research has shown that low-income women and those from racial and ethnic minorities have the highest rates of childbirth complications.

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Supports previous research

The U of M study had several limitations. It used doula data from just one organization in a single state, for example, and its two data sources came from different time periods. In addition, some selection bias may have occurred in the study, given that the doula-supported Medicaid recipients were women who chose those supportive services.

“Largely, though, those women looked a lot like Medicaid recipients generally,” said Kozhimannil.

The U of M study’s results echo findings from previous research. Other studies have found strong evidence that continuous physical and emotional support during childbirth helps mother and child alike. Indeed, a 2011 Cochrane Review meta-analysis of 23 clinical trials from 16 countries involving more than 15,000 women from a variety of backgrounds found that continuous labor support resulted in fewer C-section deliveries, fewer epidurals and less use of pain medications. In addition, babies born to mothers who received continuous support during childbirth were less likely to have low Apgar scores.

The meta-analysis found that the continuous labor support could come from a doula, midwife, nurse, husband, partner, mother or friend, but it was most effective when provided by someone who was neither a hospital employee nor a relative or close friend of the mother.

In other words, from someone very much like a doula.

‘A good starting point’ 

“There are systemic issues within our payment system and our health delivery system that don’t serve women well,” said Kozhimannil. “And, frankly, I don’t think they serve clinicians well all the time. Nobody feels our current system is optimal.”

“How women give birth and how babies come into the world is fundamentally important,” she added. “And anything that we can do as a society — as a system — to support that is an important and worthy thing. I think there are many ways to focus on this issue, and doulas are a good starting point.”