The American Journal of Managed Care August 2014
Potential Benefits of Increased Access to Doula Support During Childbirth
Women who report that they would like to have doula care are the same women who stand to benefit most from the known effects of continuous labor support.4,5 Black women (vs white women), women with public health insurance (Medicaid and other government-funded programs which primarily serve low-income women, vs private insurance), and women without health insurance (vs those with private insurance) have higher risks of adverse birth outcomes, but are often least able to afford doula care or access culturally competent care.20 Our findings show that these same groups of women are more likely to report desiring but not having access to doula care, with limited resources being a likely explanation (although this is not directly assessed). While the associations identified in this analysis cannot be interpreted causally, our findings indicated that women who reported wanting a doula but not having one experienced higher cesarean rates than women who did not report wanting doula care, and lower rates than women who had a doula. This suggests that the association between doula support and lower cesarean rates is unlikely due to selection bias (ie, the idea that women who choose to have doulas are those who would have had lower rates of cesarean anyway), which is consistent with findings from randomized controlled trials.4 Our study extends these findings to a broader, nationally representative population. However, more and better data are needed to replicate these findings in a community and policy context. Facilitating access to doula care through health insurance benefits or coverage policies may be an opportunity for research on this topic, by utilizing randomization or staggered starts in implementation.
Not surprisingly, a majority of certified doulas (89.4%) believed that doula care should be reimbursed through health insurance,15 but there are real barriers to a wide implementation of reimbursement to a new category of services, especially services that are provided in a medical context but not by a healthcare professional. The state of Oregon has addressed this challenge by adapting language about reimbursement for nontraditional health workers to include trained, certified doulas.22