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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.
Our findings must be considered in light of limitations. First, the retrospective nature of the self-reported results carries the risk of recall and social desirability bias, particularly when women were asked whether they would have liked to have had a doula in their recent birth. Women’s actual birth experiences may have influenced their response to this question; also, the reasons that women desired but did not have a doula are not directly assessed. Second, while the LTM3 contains unique information about doulas and childbirth for a nationally representative sample of women, it is based on self-report, and does not include diagnostic or clinical data. As such, our categorization of medically indicated versus nonindicated cesarean sections was not confirmed by medical record data. However, we conducted extensive sensitivity analyses around these definitions, all of which produced consistent results. The survey was conducted online, though it uses validated methodologies and the weighted sample is consistent with data on the US childbearing population.17 Future prospective studies may help to examine this issue more fully.



Finally, sample size was limited, inhibiting our ability to detect smaller differences between groups. For example, the impacts of doula care for minority populations (eg, Native American or Asian women) or on less frequent outcomes (eg, preterm birth) could not be assessed in this sample because only several women may fall into these categories, which is not enough data to generate stable estimates. Nonetheless, this analysis provides the first nationally representative data comparing a quality-of-care outcome (cesarean without definitive medical indication) based on access to and reported desire for doula care. In summary, we found that women with doula support had lower odds of nonindicated cesareans compared with women without doula support and compared with women who desired but did not have doula support. Additionally, women who desired but did not have doula support had higher odds of cesarean without definitive medical indication, compared with those who did not desire doula care. These results, which should be confirmed by future prospective studies, suggest that increasing access to doula care for at-risk women who desire intrapartum doula support (eg, black, uninsured, or publicly insured women) may facilitate decreases in rates of nonindicated cesareans.

Acknowledgments

The authors are grateful to Carol Sakala, PhD, MSPH, of Childbirth Connection, and Eugene Declercq, PhD, for their guidance on the use of data from the Listening to Mothers surveys and for helpful input on the analysis and interpretation. The manuscript also benefited from insightful feedback provided by Patricia M. McGovern, PhD, Debby L. Prudhomme, CD (DONA), and Mary R. Williams, LPN, CD (DONA).


Author Affiliations: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis (KBK, LBA, JJ, LKJ); Medica Research Institute, Minnetonka, Minnesota, and Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis (PJJ); and Department of Family Medicine and Community Health, University of Minnesota Medical School and University of Minnesota Physicians, Minneapolis (DKG).


Funding Source: This research was supported by a grant from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD; grant number R03HD070868) and the Building Interdisciplinary Research Careers in Women’s Health Grant (grant number K12HD055887) from NICHD, the Office of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (KBK, DKG, PJJ); acquisition of data (KBK); analysis and interpretation of data (KBK, DKG, LBA, JJ, PJJ, LKJ); drafting of the manuscript (KBK, LBA, JJ, PJJ, LKJ); critical revision of the manuscript for important intellectual content (LBA, DKG, PJJ); statistical analysis (LBA, JJ); provision of study materials or patients (KBK); obtaining funding (KBK); administrative, technical, or logistic support (KBK, LKJ); and supervision (KBK).


Address correspondence to: Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455. E-mail: kbk@umn.edu.

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