Potential Benefits of Increased Access to Doula Support During Childbirth

August 28, 2014

Increasing access to continuous labor support from a birth doula may facilitate decreases in non-indicated cesarean rates among women who desire doula care.

Objectives

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).

Methods

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.

Results

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).

Conclusions

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.

F

our 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.

METHODS

Data

Data are from the Listening to Mothers III (LTM3)

survey, a nationally representative sample of women who

gave birth to a single infant in a US hospital between July

1, 2011, and June 30, 2012 (N = 2400). The survey was

commissioned by Childbirth Connection, funded by the

Kellogg Foundation, and conducted online by Harris Interactive

using validated procedures.17,24 Women aged 18 to

45 years who were participating in one of several online

panels maintained by Harris Interactive formed the pool

of potential respondents, with checks to ensure that each

respondent only participated once. After data collection

was complete, responses were weighted by propensity to be

online as well as several demographic variables to enhance

comparability with the national population of women

who gave birth in 2010, the most recent year for which

birth certificate data were available for this purpose.17

The Listening to Mothers surveys are the only nationally

representative samples of childbearing women

that contain information about doula care alongside selfreported

clinical experiences, perceptions, and decisions

about childbirth. In addition to asking whether a woman

had support from a doula, the survey also asked about

awareness of and level of familiarity with this type of care,

and whether women who knew about doula care would

have wanted to have this type of care. The latter question

is particularly useful as it may help at least partially

address selection issues in who chooses to have a doula.

Variable Measurement

The 2 main predictors of interest were having doula

support and, among those who did not have doula support

but had a clear understanding of what a doula is, desire for

doula support. Women were categorized as having doula

support if they reported receiving supportive care during

labor from a “doula or trained labor assistant.” Those who

did not use doula support during labor were asked if they

had heard of doulas and whether they had a clear understanding

of this type of caregiver. Those with a clear understanding

of doulas were then asked whether they would

have liked to have doula support during their most recent

birth; those who responded affirmatively were categorized

as reporting “desire for doula support” in this analysis.

Measurement of cesarean birth was based on selfreported

mode of delivery (vaginal or cesarean). Women

with cesarean deliveries were asked to provide the main

reason for the cesarean, which we categorized as a definitive

medical indication for this procedure or a nondefinitive

indication. We based these categorizations on

professional standards used for accreditation measures25

and confirmation by our clinician co author (DKG).

The following reported reasons for cesarean were considered

definitive medical indications: baby being in the

wrong position for birth, problems with the placenta,

fetal monitor showing fetal distress during labor, and

maternal health condition that called for cesarean delivery.

All other reasons cited were categorized as being

potential reasons, but not definitive medical indications

for cesarean; these included prior cesarean, labor taking

too long, provider concern regarding the size of the

baby, fear of labor and vaginal delivery, being past the

due date (for women whose pregnancies are <41.5 weeks

gestation at delivery), having a narrow pelvis, or citing

no medical reason for their cesarean. The term nonindicated

cesarean refers throughout the manuscript to this

type of delivery. Detailed information about the proportion

of women with each of the reasons for cesarean

delivery is provided in the

eAppendix

(available at

). We conducted multiple sensitivity analyses

around the classification of reasons for cesarean as

medical indications, and results were substantively unchanged

when we categorized any combination of the

following reasons as definitive indications: labor taking

too long, provider concern regarding the size of the baby,

and having a narrow pelvis.

www. ajmc.com

Sociodemographic covariates included age, race/ethnicity

(white, black, Hispanic, or other/multiple race),

education (high school or less, some college or associate’s

degree, 4-year college degree, graduate education/

degree), 4-category census region (Northeast, Midwest,

South, West), nativity (foreign- or US-born), partnership

status at the time of the LTM3 survey (unmarried without

partner, unmarried with partner, or married). Pregnancy

characteristics included parity (first-time vs experienced

mother), pregnancy intention (unintended pregnancy

or not), agreement with the statement “birth is a natural

process that should not be interfered with unless medically

necessary,” and primary payer for maternity services

(private, public [ie, Medicaid or other government

programs], or none reported). We also conducted sensitivity

analyses around the inclusion of control variables

for labor support from a partner, spouse, family member,

or friend, and results were robust to these specifications.

Analysis

We first examined the descriptive statistics for the overall

sample (N = 2400) with 1-way tabulation. We also explored

doula care and desire for doula care (among those

without access) by sociodemographic and pregnancy characteristics,

using 2-way tabulation with x2 tests to identify

significant differences. We then conducted multivariate

logistic regression analyses to identify characteristics predicting

use of and desire for doula care, and to estimate

the adjusted odds of cesarean delivery overall (vs vaginal

birth) and nonindicated cesarean delivery (vs vaginal

birth) by use of doula support and desire for doula care.

We built 3 models to test these relationships: 1) comparing

women with doula support to those who did not have

doula support, 2) comparing women with doula support

to those who expressed a desire for doula care but did not

have a doula, and 3) among women who did not have doula

support but did have a comprehensive understanding

of this type of caregiver, comparing women who had an

expressed desire for doula support with those who did not.

All analyses were conducted using Stata v.12 and weighted

to be nationally representative. This study was granted

exemption from review by the University of Minnesota

Institutional Review Board (Study Number 1011E92983).

RESULTS

Characteristics of the study population are reported in

Table 1

. Approximately 6% of women in the sample gave

birth with doula support. Among those without doula

support, 59% were aware of doula care; among women

aware of doula care, 27% reported wanting a doula, but

did not have one. Just over 30% of women in the sample

had a cesarean delivery, and 10% of women with no definitive

medical indication for a cesarean reported that

they delivered via cesarean. Nearly half the sample had

private health insurance coverage for their birth (45.5%).

Other characteristics are broadly representative of the US

childbearing population.

Table 2

reports doula support and desire for doula support

by sociodemographic and pregnancy characteristics.

A higher percentage of younger women (18-25 years) reported

doula care, compared with women aged 35 and

older (9.5% vs 1.9%). Younger mothers were also more

likely to desire doula support, with 37.1% of women aged

18 to 24 years expressing this view, compared with 22.5%

of women aged 35 and older. Having doula support did

not differ significantly by race/ethnicity, but there were

strong racial/ethnic variations in desire for doula support,

with 21.6% of white women, 38.8% of black women,

29.8% of Hispanic women, and 43.5% of other/mixed

race women reporting that they would have liked to have

doula support. First-time mothers (vs experienced moth

ers) had higher rates of both doula support (8.8% vs 4.0%)

and desire for doula support (33.5% vs 22.5%). While there

were no differences in doula support by primary payer,

there were significant differences in desire for doula support,

with 39.3% of uninsured women and 32.6% of women

with public coverage wanting doula support, vs 21.1%

of privately insured women.

Multivariate logistic regression results for doula support

and desire for doula care by sociodemographic and

Table 3

pregnancy characteristics are shown in . 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.

DISCUSSION

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

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

This analysis shows that 10% of women with no definitive

medical indication for cesarean delivered by cesarean,

representing potentially modifiable risks and costs.

Cesarean delivery is more costly than vaginal birth (approximately

$28,000 vs $18,000 for commercial payers),

and 31.3% of US births in 2009 to 2011 were via cesarean

delivery.31 From the perspective of a payer, including doula

care as a covered benefit would require an investment

in professional doula services, and the financial impact

would depend on cesarean rates and risk factors in the

covered population as well as reimbursement rates related

to these services. However, the potential value for this investment

is substantial. For example, while fees for doula

care vary widely, they average around $1000, and with an

approximate $10,000 mean difference between the cost of

a vaginal and cesarean delivery, the decision to cover 10

doula-supported births would be cost-neutral if 1 nonindicated

cesarean were avoided among these. Of course,

continuous labor support is important for women who

have cesarean deliveries and offers quantifiable benefits to

these women as well.4 Further, the positive outcomes associated

with doula support may accrue over time, so the

financial rationale for insurance coverage of doula care is

strong, especially since cost is a known barrier to access.5,15

Women who report that they would like to have doula

care are the same women who stand to benefit most from

the known effects of continuous labor support.4,5 Black

women (vs white women), women with public health

insurance (Medicaid and other government-funded programs

which primarily serve low-income women, vs private

insurance), and women without health insurance (vs

those with private insurance) have higher risks of adverse

birth outcomes, but are often least able to afford doula

care or access culturally competent care.20 Our findings

show that these same groups of women are more likely to

report desiring but not having access to doula care, with

limited resources being a likely explanation (although this

is not directly assessed). While the associations identified

in this analysis cannot be interpreted causally, our findings

indicated that women who reported wanting a doula

but not having one experienced higher cesarean rates than

women who did not report wanting doula care, and lower

rates than women who had a doula. This suggests that

the association between doula support and lower cesarean

rates is unlikely due to selection bias (ie, the idea that

women who choose to have doulas are those who would

have had lower rates of cesarean anyway), which is consistent

with findings from randomized controlled trials.4

Our study extends these findings to a broader, nationally

representative population. However, more and better data

are needed to replicate these findings in a community and

policy context. Facilitating access to doula care through

health insurance benefits or coverage policies may be an

opportunity for research on this topic, by utilizing randomization

or staggered starts in implementation.

Not surprisingly, a majority of certified doulas (89.4%)

believed that doula care should be reimbursed through

health insurance,15 but there are real barriers to a wide

implementation of reimbursement to a new category of

services, especially services that are provided in a medical

context but not by a healthcare professional. The state of

Oregon has addressed this challenge by adapting language

about reimbursement for nontraditional health workers

to include trained, certified doulas.22

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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