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.
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
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-
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.
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.
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
). 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.
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.
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).
Characteristics of the study population are reported in
. 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
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
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,
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
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
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
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. http://www.
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. http://
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
Am J Public Health.
6. Kozhimannil KB, Attanasio LB, Hardeman RR, O’Brien M. Doula care
supports near-universal breastfeeding initiation among diverse, lowincome
J Midwifery Womens Health.
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
Aust N Z J Obstet Gynaecol.
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
9. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. The impact of
intrapartum analgesia on labour and delivery outcomes in nulliparous
Aust N Z J Obstet Gynaecol.
10. Kashanian M, Javadi F, Haghighi MM. Effect of continuous support
during labor on duration of labor and rate of cesarean delivery.
11. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous
emotional support during labor in a US hospital: a randomized
12. McGrath SK, Kennell JH. A randomized controlled trial of continuous
labor support for middle-class couples: effect on cesarean delivery
13. Madi BC, Sandall J, Bennett R, MacLeod C. Effects of female relative
support in labor: a randomized controlled trial.
14.DONA International. What is a doula? Available at: http://www.
dona.org/mothers/index.php. 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.
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: http://www.parents.com/
August 20, 2014.19. Doula services. Discover Birth website. http://www.
discoverbirth.com/for-parents/doula-services. Accessed August 11,
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.
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.
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. http://www.academia.
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
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.
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.
29. Ecker J. Elective cesarean delivery on maternal request. 2013;
30. American College of Obstetricians and Gynecologists. ACOG committee
opinion no. 561: nonmedically indicated early-term deliveries.
31. Osterman MJ, Martin JA. Changes in cesarean delivery rates by
gestational age: United States, 1996-2011. NCHS Data Brief. 2013;(124):