A new study from the School of Public Health finds Medicaid program coverage of doula services would likely be cost-effective because doula support is associated with lower rates of preterm and cesarean births. This statistical analysis of more than 67,000 Medicaid-funded births estimated that, on average, a Medicaid reimbursement rate of $986 for doula support would be cost neutral to the program. That is, the amount the Medicaid program spends on doula services would be offset by decreases in the costs associated with preterm and cesarean births at an average reimbursement rate of $986.

The study findings were recently published online in the journal Birth.

“Previous studies have shown health benefits of doula support for mothers and their babies and obstetricians recommend that people who are pregnant have doula support,” says study lead author and associate professor Katy Kozhimannil. “This analysis brings these recommendations into the context of the financial decisions Medicaid programs and other health plans make when they consider which services to cover.”

According to the National Vital Statistics Reports, in 2013 nearly one in nine births in the U.S. was preterm, and one in three was born by cesarean. More than one-third of all infant deaths in 2010 were attributed to preterm-related causes and preterm birth costs the U.S. health care system more than $26 billion annually.

The study compared preterm and cesarean birth rates for doula-supported births among Medicaid beneficiaries in Minnesota with preterm and cesarean birth rates for an approximate 20 percent sample of births to Medicaid beneficiaries in 12 states in the West North Central and East North Central U.S.  The cost-effectiveness analysis compared usual care and benefits against usual care plus doula support during pregnancy, labor and delivery.

While prior studies have shown a reduction in cesarean rates associated with doula care, this is the first study to show statistically lower rates of preterm birth among Medicaid beneficiaries with doula support. Given the longstanding racial disparities in preterm birth and infant mortality, the study’s findings on preterm birth are particularly relevant for equity concerns.

“For doula support to influence preterm birth, it’s important that the doula has a chance to build a relationship over the course of the pregnancy, making multiple visits, and providing support that is personally relevant for each pregnant person,” says Kozhimannil.

The study also found:

• After adjusting for covariates, Medicaid beneficiaries with doula care had 22 percent lower odds of preterm births, compared with Medicaid beneficiaries generally.
• Cesarean delivery rates were 56 percent lower among doula-supported full-term births, but doula support was not associated with lower cesarean rates among preterm births.
• On average, across the 12 states studied, access to doula-supported deliveries among Medicaid beneficiaries in these states could save $58.4 million and eliminate 3,288 preterm births per year.

“Taken together, the strength of the research on known health benefits, recent clinical recommendations, and these new data on cost-effectiveness present a strong case for Medicaid programs and other health plans to consider including doula services as a covered benefit,” says Kozhimannil. “These findings provide  strong rationale, from both a value and an equity perspective, to expand access to doula support, especially among those communities at greatest risk of preterm birth and poor birth outcomes.”

Currently, the states of Minnesota and Oregon have laws allowing Medicaid reimbursement for doula services, but uptake has been hampered by implementation challenges and low reimbursement rates.

~ This post was originally published as a press release from the Academic Health Center