Currently Viewing:
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.
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.


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:

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. 

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up