Providing women on Medicaid with doula support during pregnancy and childbirth can help lower the rate of premature births — and the high costs associated with them, suggests a new study by University of Minnesota researchers.
A doula is someone (almost always a woman) specially trained to provide physical and emotional support to mothers during pregnancy, labor and delivery. (Doulas should not be confused with midwives, who provide medical care during childbirth.)
Earlier research by the same team of U of M researchers reported a strong association between doula support and lower Caesarean rates among Medicaid recipients. The new study is, however, the first to find that doula support also reduces the risk of premature birth among Medicaid recipients — by 22 percent, according to the U of M’s analysis.
The new study is also the first to put a cost-savings figure to those findings. It estimates that the amount of money spent by Medicaid programs on doula services would be offset by an average of $986 per birth due to decreases in the costs associated with preterm and Caesarean births.
“One of the neat things about this study is it provides a missing piece of the puzzle,” said Katy Kozhimannil, lead author of the study and an associate professor in the U of M’s School of Public Health, in an interview with MinnPost. “We know that doula care has benefits. We know that doctors recommend that women have doulas in order to generally prevent unnecessary use of Caesareans. So doctors recommend it. The health benefits are clear. What has really been missing is the translational policy piece, the cost-benefit piece.”
Details and implications
For their study, which was published online last week in the journal Birth, Kozhimannil and her colleagues gathered data on preterm and Caesarean births among doula-supported Medicaid recipients in Minnesota and then compared it to data on preterm and Cesarean rates for a 20 percent sample (more than 67,000 women in all) of non-doula-supported Medicaid recipients in Minnesota and 11 other Midwestern states.
Minnesota is one of only two states (the other is Oregon) that require their Medicaid programs to cover doula services.
The doula-related benefits found in the U of M study are significant — and potentially very important. As background information in the study points out, one in nine babies in the United States is born preterm (before 37 weeks’ gestation). These babies are at greater risk than full-term babies of developing a wide range of medical problems, including lung damage, brain hemorrhages, infections, vision loss and cerebral palsy.
About one-third of all infant deaths are from preterm-related causes.
In addition to greater health risks, preterm births are associated with much greater medical costs. During their first year, babies born prematurely incur medical expenses that are 10 times higher than those for full-term babies. The cost to the U.S. health-care system of preterm births has been estimated at $26 billion a year. A significant amount of that money is spent by Medicaid, which pays for about half of all births in the U.S.
The U of M study estimates that in just the 12 states used in its analysis, doula-supported Medicaid births could reduce the number of premature births by 3,200 each year, for an annual savings to Medicaid of $58 million.
‘An unmet need’
Here in Minnesota, about 5,000 babies are born prematurely each year, according to the Minnesota Department of Health (MDH). As is true across the country, racial and economic disparities are reflected in these births. Preterm births in Minnesota are more common among non-Hispanic black and Native American mothers than among white mothers. Low-income mothers are also more likely to have premature babies.
Interestingly, research by Kozhimannil has shown that these are some of the same groups of women who express a high interest in having the support of a doula during pregnancy and childbirth.
“There is actually an unmet need and a desire for doula support among those who stand to benefit the most,” said Kozhimannil.
Yet the barriers to accessing doula services — even in Minnesota, where Medicaid covers such services — are many.
“We have a very active doula community,” explained Kozhimmanil. “We’re one of only two states where Medicaid pays for doula services. But even under the best of conditions, on the ground, it’s really hard to get a doula if you’re a Medicaid beneficiary — and for that doula to get paid.”
Many customer service representatives for health plans are unaware that their plans cover such services — or even what a doula is, she said. In addition, the process for becoming a certified doula with state and managed care providers is complicated and costly — barriers that are particularly problematic for low-income women who want to become doulas.
Reimbursement rates for doulas are also quite low — an average of about $400 per birth in Minnesota.
Breaking down the barriers
Kozhimmanil hopes that this latest study’s findings will help persuade policymakers to make it easier for Medicaid recipients to access doula services — and for doulas to receive adequate reimbursement for their services.
“I understand the reticence on the part of Medicaid programs or any health plan to add a covered service for birth,” she said. “Birth is really common. Medicaid is the most frequent payer for birth, and you have to be really judicious when you’re adding new things to pay for.”
But, as the findings from this latest study show, “there is really no good reason for Medicaid programs and health plans not to really seriously consider how to expand benefits to include doula services,” said Kozhimmanil.
You’ll find an abstract of the study on the website for the journal Birth, but, unfortunately, the study itself is behind a paywall.