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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
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Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
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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, MA; Rohan Parikh, MS; Rebecca Symes, BS; and Elliott S. Fisher, MD
Potential Role of Network Meta-Analysis in Value-Based Insurance Design
James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
Massachusetts Health Reform and Veterans Affairs Health System Enrollment
Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Contemporary Use of Dual Antiplatelet Therapy for Preventing Cardiovascular Events
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 Chen, MD, MPH
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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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Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
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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.


The annual costs of US maternity-related hospitalizations exceed $27 billion. Continuous labor support from a trained doula is associated with improved outcomes and potential cost savings. This study aimed to document the relationship between doula support, desire for doula support, and cesarean delivery, distinguishing cesarean deliveries without a definitive medical indication.

Study Design

Retrospective analysis of a nationally representative survey of women who delivered a singleton baby in a US hospital in 2011-2012 (N = 2400).


Multivariable logistic regression analysis of characteristics associated with doula support and desire for doula support; similar models examine the relationship between doula support, desire for doula support, and 1) any cesarean or 2) nonindicated cesarean.


Six percent of women reported doula care during childbirth. Characteristics associated with desiring but not having doula support were black race (vs white; adjusted odds ratio [AOR] = 1.77; 95% CI,1.03-3.03), and publicly insured or uninsured (vs privately insured; AOR = 1.83, CI, 1.17-2.85; AOR = 2.01, CI, 1.07-3.77, respectively). Doula-supported women had lower odds of cesarean compared without doula support and those who desired but did not have doula support (AOR = 0.41, CI, 0.18-0.96; and AOR = 0.31, CI, 0.13-0.74). The odds of nonindicated cesarean were 80-90% lower among doula-supported women (AOR= 0.17, CI, 0.07-0.39; and AOR= 0.11, CI, 0.03-0.36).


Women with doula support have lower odds of nonindicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.

Am J Manag Care. 2014;20(6):e340-e352

Responses from a nationally representative survey of women who gave birth in 2011-2012 show:

  •  Six percent of women reported doula support during childbirth.
  •  Black and publicly insured women were almost twice as likely as white, privately insured women to report wanting but not having doula care.
  •  Women with doula-supported births had substantially lower odds of nonindicated cesarean compared with those who did not have doula support and compared with women who desired  but did not have doula support.
  •  Increasing access to continuous labor support from a doula may facilitate decreases in nonindicated cesarean rates among women who desire doula care.

Four million infants are born each year in the United States, and the associated healthcare costs are substantial. In 2009, 7.6% of all hospital costs were attributable to maternity and newborn care, totaling over $27 billion.1 Almost half of childbirth-related hospital stays (47%) were covered by private health insurance; 45% of stays were billed to Medicaid programs.1 Maternity and newborn care is the top expenditure category for payments made to hospitals by both public payers and private health insurance companies.2 The average total costs of maternity (prenatal, labor and delivery, and postpartum) and newborn care for commercial payers was $27,866 for a cesarean delivery and $18,329 for a vaginal delivery in 2009.3 While payments by Medicaid programs were less overall, cesareans remain about 50% more costly than vaginal deliveries, at $13,590 for a cesarean delivery and $9131 for a vaginal delivery.3 Ensuring access to evidence-based, high-value care during childbirth is a clinical and financial imperative for healthcare providers, healthcare delivery systems, and health insurers.

A growing evidence base suggests that continuous labor support confers measurable clinical benefits to both mother and baby.4-6 Continuous labor support is the care, guidance, and encouragement provided by those who are with a pregnant woman in labor that aims to support labor physiology and mothers’ feelings of control and participation in decision making during childbirth.4 In a meta-analysis of randomized controlled trials, women who received continuous labor support reported greater satisfaction,7,8 had higher rates of spontaneous vaginal birth,9-11 higher infant Apgar scores,8 shorter labors,7,8 and lower rates of regional anesthesia (eg, epidural labor),12 cesarean deliveries,7,12 and forceps or vacuum deliveries.4,11,13 While many different individuals can and commonly do provide continuous labor support (including obstetric nurses, husbands and partners, close friends, and family members), the strongest results were achieved when continuous labor support was provided by someone who was not part of the woman’s family or social network or employed by the hospital.4

Doulas are trained professionals who provide continuous, one-onone emotional and informational support during the perinatal period. They are not medical professionals and do not provide medical services, but work alongside nurses, obstetricians, midwives, and other healthcare providers. A core function of the work of a doula is the provision of continuous labor support.14 Use of doula care is rising in the United States,4,15,16 but remains low: approximately 6% of women who gave birth in 2011 and 2012 reported receiving care from a doula.17 There are substantial barriers to access to doula care, especially for low-income women and women in minority communities. 5,6,15 The cost of birth doula services varies widely, but averages between $300 and $1200 and may include 1 or more prenatal or postpartum visits in addition to support during labor and birth.18,19 As health insurance programs do not typically offer coverage for these services,15 many women who would benefit from doula care are unable to access it.5,15,20 In addition, with a few notable exceptions (eg, HealthConnect One, International Center for Traditional Childbearing, and Everyday Miracles), most doulas are white upper-middle class women serving other white upper- middle-class women.15 These organizations employ doulas from underserved communities and also offer doula services to lower-income women and women of colot. The lack of diversity in the doula workforce is likely exacerbated by lack of third-party reimbursement and payment for doula care, further disadvantaging underrepresented groups who may be best served by a doula who shares their language, culture, or background.20

Women of color and low-income women are at greater risk of delivery-related complications and have higher rates of adverse birth outcomes than white, privately insured women.21 However, when low-income and women of color have access to doula care, they experience better outcomes than Medicaid recipients in general, with lower cesarean delivery rates and higher breastfeeding initiation rates.5,6 Recent research on the potential benefits of doula care, especially among low-income women, has ignited discussion regarding reimbursement of doula care by health insurance programs, including Medicaid programs. The state of Oregon has implemented a program for Medicaid coverage of birth doulas, and Minnesota passed legislation. in May 2013 that lays the groundwork for Medicaid reimbursement for trained doulas starting July 1, 2014.22,23 

The goal of this study was to characterize women who used doula services and those who desired but could not access doula support among a representative sample of US childbearing women. We also explored the relationship between doula support, desire for doula support, and cesarean delivery, distinguishing nonindicated cesareans. If desire for doula services is related to higher rates of nonindicated procedures, this could serve to identify opportunities to better serve at-risk women who may benefit from access to continuous labor support.



1. Corry MP, et al. Caesar’s Ghost: The Effect of the Rising Rate of CSections on Health Care Costs and Quality. Washington, DC: National Health Policy Forum, Mar 30, 2012. Accessed Jun 26, 2013.

2. Andrews RM. The National Hospital Bill: the most expensive conditions by payer, 2006. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Statistical Brief No. 59.

3. Truven Health Analytics. The Cost of Having a Baby in the United States: Truven Health Analytics Marketscan Study, January 2013.

4. Hodnett E, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7:15:7:CD003766. [Epub ahead of print].

5. Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O’Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013;103(4):e113-e121.

6. Kozhimannil KB, Attanasio LB, Hardeman RR, O’Brien M. Doula care supports near-universal breastfeeding initiation among diverse, lowincome women. J Midwifery Womens Health. 2013;58(4):378-382.

7. Morhason-Bello IO, Adedokun BO, Ojengbede OA, Olayemi O, Oladokun A, Fabamwo AO. Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial. Aust N Z J Obstet Gynaecol. 2009;49(2):145-150.

8. Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. J Obstet Gynecol Neonatal Nurs. 2006;35(4):456-464.

9. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. The impact of intrapartum analgesia on labour and delivery outcomes in nulliparous women. Aust N Z J Obstet Gynaecol. 2002;42(1):59-66.

10. Kashanian M, Javadi F, Haghighi MM. Effect of continuous support during labor on duration of labor and rate of cesarean delivery. Int J Gynaecol Obstet. 2010;109(3):198-200.

11. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital: a randomized controlled trial. JAMA. 1991;265(17):2197-2201.

12. McGrath SK, Kennell JH. A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth. 2008;35(2):92-97.

13. Madi BC, Sandall J, Bennett R, MacLeod C. Effects of female relative support in labor: a randomized controlled trial. Birth. 1999;26(1): 4-8.

14.DONA International. What is a doula? Available at: http://www. Accessed August 19, 2014.15. Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues. 2005;15(3): 109-116.

15. Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues.

16. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006.

17. Declercq E, Sakala C, Corry M, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth: Listening to Mothers II: Report of the Third National Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2013.

18. How much do doulas cost? Available at: pregnancy/giving-birth/doula/how-much-do-doulas-cost/. Accessed August 20, 2014.19. Doula services. Discover Birth website. Accessed August 11, 2013.

19. Doula services. Discover Birth website. Accessed August 11, 2013.

20. Morton CH, Bastille M. Medicaid coverage for doula care: reexamining the arguments through a reproductive justice lens, part one. Science & Sensibility website. http://www.scienceandsensibility. org/?p=6461. Published March 28, 2013. Accessed August 11, 2013.

21. Bryant AS, Washington S, Kuppermann M, Cheng YW, Caughey AB. Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates. Paediatr Perinat Epidemiol. 2009;23(5):454-462.

22. Tilman T, Gilmer R, Foster A. Utilizing doulas to improve birth outcomes among underserved women in Oregon. Salem, OR: Oregon Health Authority House Bill 3331 Implementation Committee; 2012. Available at:

23. MN Doula Bill Chapter 108, Sec. 11, Subd. 28b. Available at: https://

24. Terhanian G, Bremer J, Smith R, Thomas R. Correcting data from online surveys for the effects of nonrandom selection and nonrandom assignment. Harris Interactive White Paper. 2000:1-13. of_Nonrandom_Selection

25. Perinatal care core measures. In: Specifications Manual for Joint Commission National Quality Core Measures (v2010A1).Oakbrook Terrace, IL: Joint Commission; 2010.

26. Scott KD, Klaus PH, Klaus MH. The obstetrical and postpartum benefits of continuous support during childbirth. J Womens Health Gend Based Med. 1999;8(10):1257-1264.

27. Nommsen-Rivers LA, Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. Obstet Gynecol Neonatal Nurs. 2009;38(2):157-173.

28. Mottl-Santiago J, Walker C, Ewan J, Vragovic O, Winder S, Stubblefield P. A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Matern Child Health J. 2008;12(3):372-377.

29. Ecker J. Elective cesarean delivery on maternal request. JAMA. 2013; 309(18):1930-1936.

30. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 561: nonmedically indicated early-term deliveries. Obstet Gynecol. 2013;121(4):911-915.

31. Osterman MJ, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996-2011. NCHS Data Brief. 2013;(124): 1-8. 

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