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The American Journal of Managed Care August 2014
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Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson,
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James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
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Andrew M. Goldsweig, MD; Kimberly J. Reid, MS; Kensey Gosch, MS; Fengming Tang, MS; Margaret C. Fang, MD, MPH; Thomas M. Maddox, MD, MSc; Paul S. Chan, MD, MSc; David J. Cohen, MD, MSc; and Jersey Che
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Potential Benefits of Increased Access to Doula Support During Childbirth
Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
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Potential Benefits of Increased Access to Doula Support During Childbirth

Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
Increasing access to continuous labor support from a birth doula may facilitate decreases in non-indicated cesarean rates among women who desire doula care.
Sociodemographic covariates included age, race/ethnicity (white, black, Hispanic, or other/multiple race), education (high school or less, some college or associate’s degree, 4-year college degree, graduate education/ degree), 4-category census region (Northeast, Midwest, South, West), nativity (foreign- or US-born), partnership status at the time of the LTM3 survey (unmarried without partner, unmarried with partner, or married). Pregnancy characteristics included parity (first-time vs experienced mother), pregnancy intention (unintended pregnancy or not), agreement with the statement “birth is a natural process that should not be interfered with unless medically necessary,” and primary payer for maternity services (private, public [ie, Medicaid or other government programs], or none reported). We also conducted sensitivity analyses around the inclusion of control variables for labor support from a partner, spouse, family member, or friend, and results were robust to these specifications.



Analysis

We first examined the descriptive statistics for the overall sample (N = 2400) with 1-way tabulation. We also explored doula care and desire for doula care (among those without access) by sociodemographic and pregnancy characteristics, using 2-way tabulation with x2 tests to identify significant differences. We then conducted multivariate logistic regression analyses to identify characteristics predicting use of and desire for doula care, and to estimate the adjusted odds of cesarean delivery overall (vs vaginal birth) and nonindicated cesarean delivery (vs vaginal birth) by use of doula support and desire for doula care.



We built 3 models to test these relationships: 1) comparing women with doula support to those who did not have doula support, 2) comparing women with doula support to those who expressed a desire for doula care but did not have a doula, and 3) among women who did not have doula support but did have a comprehensive understanding of this type of caregiver, comparing women who had an expressed desire for doula support with those who did not. All analyses were conducted using Stata v.12 and weighted to be nationally representative. This study was granted exemption from review by the University of Minnesota Institutional Review Board (Study Number 1011E92983).



RESULTS

Characteristics of the study population are reported in Table 1. Approximately 6% of women in the sample gave birth with doula support. Among those without doula support, 59% were aware of doula care; among women aware of doula care, 27% reported wanting a doula, but did not have one. Just over 30% of women in the sample had a cesarean delivery, and 10% of women with no definitive medical indication for a cesarean reported that they delivered via cesarean. Nearly half the sample had private health insurance coverage for their birth (45.5%). Other characteristics are broadly representative of the US childbearing population.



Table 2 reports doula support and desire for doula support by sociodemographic and pregnancy characteristics. A higher percentage of younger women (18-25 years) reported doula care, compared with women aged 35 and older (9.5% vs 1.9%). Younger mothers were also more likely to desire doula support, with 37.1% of women aged 18 to 24 years expressing this view, compared with 22.5% of women aged 35 and older. Having doula support did not differ significantly by race/ethnicity, but there were strong racial/ethnic variations in desire for doula support, with 21.6% of white women, 38.8% of black women, 29.8% of Hispanic women, and 43.5% of other/mixed race women reporting that they would have liked to have doula support. First-time mothers (vs experienced mothers) had higher rates of both doula support (8.8% vs 4.0%) and desire for doula support (33.5% vs 22.5%). While there were no differences in doula support by primary payer, there were significant differences in desire for doula support, with 39.3% of uninsured women and 32.6% of women with public coverage wanting doula support, vs 21.1% of privately insured women.



 
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