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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
Impact of Hypertension on Healthcare Costs Among Children
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
Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model
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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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.
Multivariate logistic regression results for doula support and desire for doula care by sociodemographic and pregnancy characteristics are shown in Table 3. Adjusted odds largely reflect similar patters as the crude estimates presented in Table 2. Women with lower odds of doula support included: aged 25 to 29 years and over 35 years (vs aged 18-24 years) (AOR = 0.47, 95% CI, 0.24-0.91; and AOR = 0.19, 95% CI, 0.07-0.48), experienced mothers (vs first-time mothers) (AOR = 0.57, 95% CI, 0.34-0.98), and women whose pregnancies were unintended (AOR = 0.53, 95% CI, 0.28-0.99). Similar patterns emerged in predictors of desire for doula support: women aged 30 to 34 years (vs women aged 18-24 years) had lower odds of desiring doula care (AOR = 0.49, 95% CI, 0.28-0.84), as did experienced mothers (vs first-time mothers) (AOR = 0.67, 95% CI, 0.46-0.98). Factors associated with higher odds of desire for doula support were black race (vs white) (AOR = 1.77, 95% CI, 1.03-3.03), public or no health insurance coverage (vs private coverage) (AOR = 1.83, 95% CI, 1.17-2.85; and AOR = 2.01, 95% CI, 1.07-3.77), having a college degree (vs high school or less) (AOR = 1.79, 95% CI, 1.02-3.16), and having a planned cesarean delivery (AOR = 1.83, 95% CI, 1.14-2.93).

Table 4 presents the unadjusted (crude) and adjusted odds of cesarean delivery and cesarean without definitive medical indication by doula support and desire for doula support, controlling for sociodemographic and pregnancy-related characteristics. In each comparison, unadjusted results were similar in direction and magnitude to results from the adjusted models. Doula support was associated with a nearly 60% reduction in odds of cesarean delivery (AOR = 0.41, 95% CI, 0.18-0.96) and 80% lower odds of nonindicated cesarean delivery (AOR = 0.17, 95% CI, 0.07-0.39), compared with not having doula support. When comparing women who had doula support with those who indicated a desire for doula support but did not have it, women who had doula support had substantially lower odds of cesarean delivery overall (AOR = 0.31, 95% CI, 0.06-0.33) and of nonindicated cesarean delivery (AOR = 0.11, 95% CI, 0.03-0.36), compared with those who expressed a desire for doula care. Additionally, women who wanted doula support but did not have it had higher odds of cesarean delivery (AOR = 1.48, 95% CI, 1.00-2.19) and nonindicated cesarean delivery (AOR = 1.73, 95% CI, 1.10-2.73), compared with women who did not express a desire for doula support.


This analysis found that, among a nationally representative sample of US women who gave birth in 2011-2012, women with doula support had substantially lower chances of having a cesarean delivery and even lower rates of nonindicated cesarean, compared with women without support from a birth doula. This is consistent with prior research.4,5,26 However, prior observational research has noted the challenge of selection bias; that is, disentangling the desire for doula care from birth outcomes, given that measured and unmeasured characteristics associated with choosing a doula may also impact choices about delivery mode.27,28

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