This blog post by Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI) was originally posted on Lamaze International’s Science & Sensibility Blog in two parts (March 28th & April 2nd, 2013). Reposted here with permission.
How can doula supported births help reduce the cesarean rate and realize cost savings within Medicaid-funded births? Two studies published in early 2013 offer the opportunity to address this complex question.
We support the goal of increasing access to doula supported care to childbearing people of diverse racial/ethnic and class backgrounds, and we are pleased that discussions are taking place about how doulas may be able to help reduce racial disparities in maternal and infant health. We recognize that work toward these goals requires policy advocacy, which depends heavily on economic arguments for the benefits of doula care.
However, by limiting the discussion of benefits to the economic impacts of reduced cesareans, advocacy for Medicaid funding of doula supported births—without specifying the doula model of care and without according true value to the doula’s impact—may have unintended consequences for individual doulas, and the organizations that represent them. One such consequence may be that the resulting system will continue to perpetuate a model of economic marginality and potential exploitation for the doulas who serve a low income population of childbearing people.
The AJPH study by Katy Kozhimannil and colleagues in Minnesota received a lot of media attention when it appeared last month, even live coverage in the Huffington Post. This study compared 1,079 selected Medicaid doula patients in Minnesota to Medicaid patients nationwide for their total cesarean rates. They found that doula clients of a community program in Minnesota had a rate of 22.3% while national Medicaid had 31.5%. The authors reported three scenarios, all assuming that if states reduced cesarean rates, by offering doula services, there would be varying levels of cost savings, depending on the cesarean rate achieved, and by reimbursing doulas between $100-300 per birth.
In our view, the Minnesota study design raises several methodological questions, which are applicable to this study and to future research on doula-attended births. We outline those questions here, as well as raise several more substantive concerns about the implications of the study’s stated conclusions.
- Why did the researchers not compare Minnesota Medicaid doula clients to Minnesota Medicaid women who gave birth? Minnesota has a much lower rate of total cesarean that the US as a whole (27.4% during this time period), and this would have been a better matched comparison. A better comparison would be doula attended births vs. non-doula attended births at the same facility. It is not clear from the study whether the doula program whose data was utilized served women at one or multiple hospitals in Minneapolis.
- Why did the researchers not limit their investigation to primary cesareans? Doulas typically support women in labor rather than women undergoing repeat cesareans. The total cesarean rate includes repeat cesarean so it will be much higher than the primary cesarean rate, which is more applicable to doula clients. Including total cesarean rates means that the researchers are comparing a limited universe (doula support of women in labor) to all births (thus including repeat and primary cesarean). The data source for this study, (Nationwide Inpatient Sample), however, does not have this information.
- Cesarean rates are very dependent on the parity distribution of the birthing population, so first time mothers need to be compared to first time mothers and multiparous women to multiparous women. This information is not available in the data source used by the researchers, but in future studies of this type, it is critical to verify that the proportion of each is the same in the intervention and control populations.
- States are implementing a number of payment reform models to reduce cesareans among women covered by Medicaid, with limited success. In part, that is because cesareans are influenced by a number of factors, with payment incentives only one. (Many of these issues are covered in the CMQCC white paper on improvement opportunities to reduce cesareans, which argues that a multi-pronged strategy is necessary).
- Because hospital rates of cesarean have been shown to have high geographic variation in a number of studies (Baicker 2006; Main et al 2011; Caceres 2013; Kozhimannil 2013), it may be more feasible to have comparison groups of hospitals with similar primary cesarean rates. Until we understand what accounts for variation in cesarean rates between institutions (unit culture; facility policies and protocols), it may be premature to assess the independent effect of labor support by a trained doula.
While doula support is associated with fewer cesareans across the board (Hodnett 2012), the methodological issues described above are likely to over estimate the benefits of doula-attended births in terms of reducing the cesarean rate for Medicaid covered births. This, in turn, raises questions about the purported cost savings. In the Minnesota study, the cost break point is no more than $300 dollars for the doula per birth. In most cities, doulas charge well above this amount for fee-for service care.
A cost-benefit analysis by Oregon Health & Science University researchers for the Oregon State Legislature was presented at the Society for Maternal Fetal Medicine in February 2013, which found that doula care in labor provides a cost benefit to payers only when doula costs are below $159.73 per case. In that study, data sources are not entirely clear, but do seem to come from the OHSU facility where a hospital-based doula program is in place. In that program, doulas are on call on weekends only and come to assist in a labor when requested by the woman during her prenatal care or when she arrives at the hospital. A case-control study claiming the benefits of this doula model at OHSU was published as an abstract, and although it claims “women receiving doula care were statistically less likely to have an epidural during labor (p = 0.03), have an episiotomy (p = .03), or cesarean delivery (p = .006) and on average, doula attended women had a shorter hospital stay compared to the control group (p = .002),” nowhere does it show what the actual rates were. This is important, because, they are likely to be relatively low overall, given that OSHU is a teaching hospital, with midwives and family practice physicians providing maternity care.
There are several types of doula models; not all have the same components. The community-based doula model, as exemplified by the HealthConnectOne approach has a solid evidence base. This model employs doulas who are trusted community members, and provides extensive prenatal and postpartum support in addition to continuous labor support. Doulas work collaboratively with community organizations, have extensive training in experiential learning and cultural sensitivity, and are paid a wage commensurate with their value and expertise, serving an important workforce development and grassroots empowerment function. Some so-called community doula programs do not incorporate all these components.
Hospital-based programs usually assign or utilize an on-call doula, who has not met the mother in advance and is not likely to follow up postpartum. Some advocates of Medicaid doula programs utilize the community health worker (CHW) model, which seems to mirror the community-based doula (CBD) model but with important differences. The American Public Health Association has defined CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.” Yet, despite their widespread utilization in public health over the past several years, the conditions of their training, job opportunities, and even job description are idiosyncratic, and highly varied, and this “lack of CHW identity and standards of practice has led employers to contribute to the confusion about who CHWs are and what they do.” While the CHW and CBD models offer important job opportunities to members of under-resourced communities, their wages are often on the low side, with full time work paying $35,000 to $42,000 annually. According to a health careers website, “CHWs often are hired to support a specific health initiative, which may depend on short-term funding sources. As a result, CHWs may have to move from job to job to obtain steady income. This short-term categorical funding of health services is a challenge to the stability and sustainability of the CHW practice.”
In cost-benefit or cost effectiveness studies, it is critical to clearly specify the doula model of care on which the economic model is based. It seems the doula model in the Minnesota study incorporates extensive pre- and post- partum contact and that there is an attempt to match doulas and clients in terms of race/ethnicity and language, but this is not always possible. The study does not indicate what the doulas in the Minnesota program were paid, however, and that information was unavailable on their website.
Before we move to the topic of reimbursement, we want to note that the type of doula model is critical for assessing the benefits of doula-attended births. The research clearly shows different outcomes for doulas who are affiliated with hospitals compared to those who work independently (Hodnett, 2012). If a cost benefit model shows little gain in terms of outcomes, or yields a price point in the low hundreds of dollars, it may be that findings are affected by the assumptions embedded in the calculations.
More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model. Neither should doulas be promoted as a primary means to reduce cesarean rates. Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barriers, some of which are acknowledged by the Minnesota researchers, who note at the end of their paper that:
Recruiting a diverse population of trained doulas, however, may be difficult in the current environment. It is likely that doula work will not become more lucrative or appealing unless more people are willing to pay for these services or third-party reimbursement becomes more common. Doulas themselves report that their work is emotionally satisfying but not financially rewarding. Broadening the payer base will likely enhance the feasibility of a doula care business model for a wider range of women and facilitate recruitment of doulas from low-income communities, communities of color, and immigrant communities.
While acknowledging that doulas are mostly white, middle class, relatively educated women, the authors stop short of recommending, as we do, that an important step toward the goal of increasing access to doula care is the need for individual doulas and doula organizations alike to take a close look at ways in which doula culture itself is white and middle-class centered in terms of its priorities, the content of training programs, and the accessibility of doula training and certification. This is not to minimize efforts to promote diversity in the doula community that are currently underway, particularly those of the International Center for Traditional Childbearing, HealthConnectOne, and other community programs such as Everyday Miracles and Open Arms Perinatal Services.
However, greater attention needs to be paid to issues of privilege and oppression within the doula community at large. Advocates need to consider how the prioritization of the cesarean rate as a primary research or policy issue reflects a certain level of unexamined privilege. For those facing spotty access to health care, cultural and linguistic incompetence in care settings, the detrimental effects of the prison industrial complex and the child welfare system on families, and the effects of poverty, racism, and/or homophobia in general, there are other, perhaps equally pressing concerns surrounding childbirth than over-medicalization. Certainly, unnecessary cesareans and over-medicalization are detrimental to everyone, but we need to understand how the effects of these problems play out differently for differently situated people and not limit advocacy to these issues.
The authors also propose that a below market reimbursement for services ($100-300) is a feasible business model and would be sufficient to recruit doulas from “low-income communities, communities of color and immigrant communities.” This claim raises serious concerns on our part, two social scientists who have conducted qualitative research on doula practice and have spoken with hundreds of doulas about the economic conditions under which they work. The assumptions embedded in the above quote assume the emotional rewards balance the economic ones, without acknowledging that even doulas who charge market rates find it challenging to make this occupation financially sustainable. How then, can a doula program based on Medicaid funding be sustainable with such a low reimbursement rate? Further, while hospital, volunteer, and community-based doula practices alike require loyal and committed doulas who work within them, it is not clear that any doula practice, let alone one that pays so little, can scale to meet the needs of the nearly two million women whose births are covered by Medicaid each year in the U.S. Doulas themselves, as representatives and members of the communities they serve, should be at the forefront of driving policy decisions about the work they do.
Most concerning, this claim implies that only doulas from marginalized groups would be interested in, or willing to work for, such low wages. According to Sheila Capestany, Executive Director, Open Arms Perinatal Services, a community-based doula program located in Seattle, Washington, this assumption about the doula as community health worker may lead to unanticipated consequences:
If we believe that Medicaid clients with doula support at their births will have improved outcomes (in terms of racial/ethnic disparities in cesareans and breastfeeding, etc.) that have been persistent and worsening for such a long time in the current US maternity system, then the American way is to regard these doulas as experts in supportive care in labor and reimburse them in a manner that reflects and respects that expertise and value. Otherwise, we will potentially create a system of institutionalized racism that we are ostensibly trying to eradicate.
Ms. Capestany speaks from long experience of involvement in community doula programs in the state of Washington, which had doula services covered under its Maternity Support Services (a Medicaid program) from 1992 through 2004, well before Oregon’s recent policy.
Advocates for Medicaid funded doula services can learn valuable lessons from the Washington experience. At the start of this public payment for doula services, doulas were a new concept, the newly formed doulas of the Pacific Association for Labor Support (PALS) viewed the program as a way to obtain clients and achieve their desire to provide doula care to a high-need population. The payment (about $40 per visit as a community health worker, with up to four visits per client, including the birth) was at most, around $160.
One critical policy issue was determining whether doulas in training could use births paid by Medicaid for certification purposes. After some discussion and debate, it was decided that as an issue of social equity, women who were poor should not be the ‘training ground’ for aspiring doulas, and the program required certification. Early on, this was not a barrier. However, as the doula concept spread, and more childbearing people were willing to pay out of pocket for personalized labor support, it become challenging for the local organization, PALS, to find certified doulas who were willing and able to provide services for Medicaid clients. Program managers at PALS reported that another concern was that some doulas provided a lower quality and level of services to their Medicaid clientele compared to what they offered their private paying clients, because of the differing remuneration. One of the ironic inversions in the Washington program was that white middle class doulas were caring for low-income clients (about a third of whom were people of color). Yet the few doulas of color who sought to provide fee-for-service doula care reported they were often not hired by prospective clients, who were primarily white, and upper to middle class professional couples.
In 2004, when Washington’s Maternity Support Services program was revised with the intent to incorporate doulas more formally as part of the care team, and to increase the reimbursement rate to $250, its application was reviewed by the federal government, which questioned the use of non-licensed providers. In response, Washington state withdrew the doula component in order to save the remaining elements of the program. Nearly a decade later, advocates for including doulas in Medicaid plans are proposing fees of at most, $300 per birth, with an unspecified model of doula care, and claiming this will address long standing racial/ethnic disparities in neonatal and maternal health outcomes, as well as reduce cesarean rates. Open Arms Perinatal Services, does record lower cesarean rates among the women served by Open Arms doulas. But importantly, Open Arms pays its community-based doulas at the low end of the market rate in Seattle, or $700, as a matter of work equity. Open Arms also has doulas who volunteer their services, who represent half their doula population.
It is crucial that policy discussions focused on improving maternity care bear in mind that high cesarean rates are primarily a problem of obstetric culture and practice. The solution to this problem, then, needs to involve reforming obstetric practices from within, and cannot rest wholly on the shoulders of doulas. The most recent Cochrane Collaboration report on doula care points out that in addition to doula support, if reductions in cesarean rates are to occur, “Changes to the content of health professionals’ education and to the core identity of professionals may also be important. Policy makers and administrators must look at system reform and rigorous attention to evidence-based use of interventions that were originally developed to diagnose or treat problems and are now used routinely during normal labours” (Hodnett, 2012).
Cesarean rates are influenced by a complex set of drivers and constraints that operate at the individual, hospital and state level. Studies on cost-benefit analyses that do not account for the variation in state and hospital rates as well as facility-level policies and protocols affecting clinical practice have the potential to obscure, rather than clarify, the problems at hand and the role of doulas in solving them. Proposing the doula as a bandage to a gaping wound may staunch some of the blood flow but it won’t address the underlying problem, which is a massive hemorrhage. A policy approach that neglects obstetricians, nurses and hospitals, in ongoing quality improvement efforts to reduce non-medically indicated cesareans, and instead focuses on the underpaid, least valued member of the team, the doula, may be less likely to succeed in its goals to improve maternity outcomes.
We agree that “broadening the payer base” beyond the traditional fee-for-service private doula model is an important component of increasing access to doula care, and we support the policy advocacy efforts that are needed to secure more diverse sources of funding for doula services. At the same time, we caution against relying too heavily on arguments that position the doula as primarily a money saver and a cesarean reducer. Doulas need to be recognized and compensated fairly for the valuable, multifaceted, and often, unquantifiable, contributions they make to building healthy families and communities. At the same time, doulas cannot be held entirely responsible for reforming maternity care as we know it.
Policy discussions of doula care must acknowledge this, and must carefully consider the sustainability of the reimbursement and overall structure of the programs they propose. The fact that doulas and policy advocates are turning their attention to ways in which doulas can help reduce racial disparities in birth outcomes is heartening, and much more effort is needed toward this goal. We encourage the development of a research and advocacy agenda that prioritizes work equity and social justice equally to cost savings, and we look forward to continued conversations about how to bring this into fruition.
The authors thank Elliott K. Main, MD for his assistance in assessing the methodology of this study; Sheila Capestany, MPH, MSW for her perspectives on doula models of care and several anonymous reviewers for their critical comments.
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About the authors
Monica Basile has been an active birth doula, childbirth educator, and midwifery advocate for 17 years, and holds a PhD in Gender, Women’s and Sexuality Studies. Her 2012 doctoral dissertation, Reproductive Justice and Childbirth Reform: Doulas as Agents of Social Change, is an examination of emerging trends in doula care through the lens of intersectional feminist theory and the reproductive justice movement.
Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth in America, which will be published by Praeclarus Press in early 2014.