University of Minnesota researchers say an alternative form of supportive care for pregnant women promotes better outcomes and can reduce health care costs.
Doulas are non-medical professionals who provide emotional and physical support to mothers before, during and after childbirth. That support can include birth education, massage and words of encouragement. The word "doula" comes from ancient Greek.
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Previous studies have shown an association between doula support and lower cesarean rates. But the U of M analysis of Medicaid records is the first to show that doulas can also help lower rates of highly expensive premature births.
Study author Katy Kozhimannil, associate professor in the School of Public Health, said women with doula care had a 22 percent lower rate of preterm births compared to women who didn't have doula support.
"Any intervention that can really move the dial on preterm birth is something that's important and worth paying attention to," Kozhimannil said.
Preterm births are more common among African-American mothers and contribute to infant mortality rates among black Minnesotans that are double and triple the rates for whites.
Kozhimannil said her study's findings make a strong case for doulas, particularly as Minnesota looks for ways to reduce health inequities among different racial groups.
Doulas in Minnesota typically receive $300 to $400 per Medicaid case.
But Kozhimannil said her research indicates states could pay doulas nearly $1,000 per Medicaid client and still break even.
"On average across all the states that we looked at, the cost-neutral point, the point at which the benefits and costs equal one another, would be $986 a birth," she said.
Across the 12 states analyzed, including Minnesota, the U of M study estimated that doula-supported births could eliminate more than 3,200 preterm births and save Medicaid $58 million each year.
Only two states, Minnesota and Oregon, mandate Medicaid coverage of doula services. It's an option in other states. Minnesota's law has been in effect for about a year and a half.
Julie Schwalbach got her doula certification just as the state began paying for the service. She has attended around 40 births so far, primarily for Medicaid patients.
This week, she met for an initial review of a birth plan with 25-year-old Ashley Von Holdt.
Von Holdt's third child, a girl, is due in April. Schwalbach was there for her second child's birth, and Von Holdt found the assistance reassuring.
"Just hearing your voice, you sounded very calm," Von Holdt told her. "When you touched my arm you just had a really soft hand and it was just really comforting to me."
Schwalbach and Von Holdt were connected through Everyday Miracles, a Minneapolis nonprofit that provides pregnancy services to people enrolled in state-sponsored health plans.
Doula and public health intern Kayla Waldecker said the center works with many women who don't have any family or community support during their pregnancies. Had she not been at some of the births she has attended, Waldecker said, "the mother would have been completely alone."
Minnesota's reimbursement law has helped Everyday Miracles expand its available pool to around 50 doulas. But it has been challenging to recruit enough doulas to meet client demand.
Waldecker said that's partly because the state program pays only around $300 for six doula visits and the birth. Private pay for doulas typically starts at $800 and can go much higher.
"I don't think the work that doulas do for Medicaid patients should have to be some sort of service project," Waldecker said. "If we're going to have true equality in care, then Medicaid patients need to have the same access to providers that those that can pay out of pocket have."
Waldecker said the U of M study should help Minnesota doulas make the case for higher reimbursement rates.