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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
Currently Reading
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
The Effect of Depression Treatment on Work Productivity
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
Economic Implications of Weight Change in Patients With Type 2 Diabetes Mellitus
Kelly Bell, MSPhr; Shreekant Parasuraman, PhD; Manan Shah, PhD; Aditya Raju, MS; John Graham, PharmD; Lois Lamerato, PhD; and Anna D'Souza, PhD
Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan
Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
Does CAC Testing Alter Downstream Treatment Patterns for Cardiovascular Disease?
Winnie Chia-hsuan Chi, MS; Gosia Sylwestrzak, MA; John Barron, PharmD; Barsam Kasravi, MD, MPH; Thomas Power, MD; and Rita Redberg MD, MSc
Effects of Multidisciplinary Team Care on Utilization of Emergency Care for Patients With Lung Cancer
Shun-Mu Wang, MHA; Pei-Tseng Kung, ScD; Yueh-Hsin Wang, MHA; Kuang-Hua Huang, PhD; and Wen-Chen Tsai, DrPH
Health Economic Analysis of Breast Cancer Index in Patients With ER+, LN- Breast Cancer
Gary Gustavsen, MS; Brock Schroeder, PhD; Patrick Kennedy, BE; Kristin Ciriello Pothier, MS; Mark G. Erlander, PhD; Catherine A. Schnabel, PhD; and Haythem Ali, MD

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.
A unique contribution of this analysis is that we are able to distinguish that doula support during labor and birth, not the desire for doula support, is associated with lower odds of nonindicated cesarean, compared with nonsupported births. Two key findings support this contribution: first, women who desired but did not have doula support had almost 50% greater chances of delivering via cesarean and more than 70% higher odds of having a nonindicated cesarean delivery, compared with women who did not desire doula care. This indicates that women who would like to have had a doula are not necessarily those who have fewer obstetric interventions, but that they may benefit from greater counseling and support before and during labor about the use of these interventions, especially when there is no definitive medical indication. Secondly, we show that the association between doula care and reduced chances of cesarean delivery and nonindicated cesarean delivery was relatively stable when comparing women with doula care to women who wanted but did not have doula care, who may be a more similar comparison group than women without doula care overall. Given the current clinical and policy focus on the potential maternal and neonatal risks of nondefinitively indicated caesarean deliveries,29,30 these findings have immediate and actionable implications.

There is a large unmet demand for doula care among American women, many of whom would likely benefit substantially from the evidence-based benefits associated with continuous labor support.4,15 Only 6% of women reported having support from a doula when they gave birth in 2011 or 2012, up from 3% of women in 2005.16 However, our findings indicate that over 40% of women are not aware of doula care, which translates into approximately 1.6 million women of the 4 million US women who give birth each year. Of those who are aware of what a doula is and the type of care they provide, 27% indicated that they would definitely want this type of support, which would mean an additional 1 million US women using doulas each year. Based on the findings from this analysis, if these women’s odds of nondefinitively indicated cesarean were lowered by 80% rather than elevated by 70%, the result could be an improvement in quality, safety, and a decrease in costs of childbirth. Identifying barriers to doula access is a crucial step in addressing this unmet need. While the survey data used in this analysis did not contain details on why women who wanted a doula did not have access to this service, prior research indicates several potential barriers and challenges; the most salient of which is concern about the out-of-pocket expense.5,15,20,22 Especially for families with low incomes or limited savings, doula services at costs ranging from several hundred to several thousand dollars,18 may be perceived as unaffordable in the context of other expenses related to childbirth and infant care (eg, car seats, diapers, feeding supplies) as well as changes such as loss of income during unpaid maternity leave.18,20 Additional barriers might include logistical challenges, such as distance from a doula for rural women, objections from husbands/partners or family members, or cultural issues, such as seeking but not finding a doula with a similar heritage or linguistic background.5,15,20

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