摘要：Objectives. We compared childbirth-related outcomes for Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes from a national sample of similar women and estimated potential cost savings. Methods. We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279 008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births. Results. The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states’ reimbursement rates, birth volume, and current cesarean rates. Conclusions. State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates. In 2009, 4.1 million babies were born in US hospitals. 1 Childbirth is the most frequent reason for hospitalization in the United States, and charges for maternity and newborn care exceed those for any other category of hospital expense for both public and private payers. 2 Hospital costs for childbirth totaled $27.6 billion in 2009, 3 and state Medicaid programs paid for 45% of all US births that year, indicating an extraordinary public-sector investment in hospital-based childbirth care. 3,4 Costs are higher for cesarean deliveries and for births with clinical complications. 5,6 Delivery-related complications are increasingly common and occur with highest frequency among women of color and low-income women. 7,8 Racial/ethnic minorities have higher rates of cesarean delivery and worse birth outcomes than their White counterparts. 9,10 Medicaid beneficiaries have a higher risk of preterm birth (< 37 weeks gestation) and low birth weight (< 2500 g) than do privately insured women. 11,12 The strong link between income, race/ethnicity, and adverse birth outcomes has been well documented, 13–15 but effective means of reducing this disparity are lacking. 16 In a time of increasing fiscal pressures on health care systems and state Medicaid budgets, the need to stem the rising cost of maternity care is urgent. 4,17 The sizeable public health and financial stake in childbirth care has engendered a growing interest in potential clinical models and policy tools that payers, hospitals, and health care providers can employ to achieve the triple aim of improved patient outcomes and better population health at lower cost. 17,18 The midwifery model of maternity care and freestanding birth centers have shown great promise, 19 as have home-visiting programs. 20,21 Provisions of the Affordable Care Act are designed to increase access to these services via Medicaid coverage, among other policy tools. 22,23 Another type of low-intervention care is continuous labor support from a birth doula, a type of care that is not typically reimbursed by health insurance. 24 Unlike physicians, midwives, and obstetrical nurses, who provide medical care, doulas provide support in the nonmedical aspects of labor and delivery. 25,26 The Doula Organization of North America (DONA), the largest organization of certified doulas, defines a birth doula as a “person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after birth.” 27 Randomized controlled trials provide strong evidence for the clinical benefits of continuous labor support. 28,29 A recent Cochrane systematic review of the effects of continuous labor support revealed higher rates of spontaneous vaginal birth and lower odds of cesarean delivery, lower rates of regional anesthesia (e.g., epidural), lower rates of instrument-assisted delivery (i.e., forceps and vacuum), shorter labors, and higher levels of satisfaction among women who received labor support. 28 The review indicated that labor support was most effective when provided by an individual such as a doula, who was not on the hospital’s staff and was not a family member or close friend without specialized training. 28 In the United States, most doulas are middle-aged, married, and well-educated White women from upper-middle-class households. 24 Although limited information is available about the characteristics of women who use doula care, it is likely that lack of insurance coverage for these services restricts financial access for low-income women, and limited racial/ethnic diversity of doulas (84% are White) may also influence the diversity of potential clients. 24,30 In the US context, observational associations between doula care and positive birth outcomes may reflect a population of women with greater resources, better health status, and specific birth experience intentions or higher-risk women with access to doula care through a specific program or intervention. 31,32 Although the clinical benefits of doula services have been well documented, few studies have examined doula care in a policy context, where legislators debate statutory changes, administrators implement programs, regulators oversee enforcement, and payers make coverage and benefits decisions and negotiate reimbursement rates with providers. Limited research explores doula care among the low-income and racially/ethnically diverse women who compose approximately half of the US childbearing population and are at elevated risk for adverse birth outcomes and poor obstetric care quality. 10 We compared childbirth-related outcomes for racially/ethnically diverse Medicaid recipients who received prenatal education and childbirth support from trained doulas with those for a national population of similar women and estimated potential cost savings associated with offering coverage for birth doula care as a Medicaid benefit.
