y Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI)

Last month there were great discussions after a study was published by the University of Minnesota, examining the potential cost savings to Medicaid if doulas worked with Medicaid clients, helping to reduce interventions and cesareans. Latst week and today, regular contributor, Christine Morton and her colleague Monica Basile, take a look at that study and another from Oregon, and share thoughtful insight about topics that might still need to be addressed if costs savings were to be effectively realized in a two part blog post. Today the authors discuss concerns about reimbursement and program sustainability alongside a caution against relying too heavily on arguments that position the doula as primarily a money saver and a cesarean reducer. Find part one here. - Sharon Muza, Community Manager, Science & Sensibility

© Patti Ramos Photography

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.

Acknowledgements:

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.

References

Baicker, K, Kasey S. Buckles, and Amitabh Chandra. Geographic Variation In The Appropriate Use Of Cesarean Delivery: Do higher usage rates reflect medically inappropriate use of thisprocedure? Health Affairs 25 (2006): w355-w367; doi: 10.1377/hlthaff.25.w355

Caceres, Isabel A., Mariana Arcaya, et al., Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004-2006: The Case against Case-Mix Artifact, PLoS ONE 8(3): e57817. doi:10.1371/journal.pone.0057817

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues, Health Affairs 32, NO. 3 (2013): 527-535; doi: 10.1377/hlthaff.2012.1030

Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. 2011. Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality. Palo Alto, CA: CMQCC. (Available at http://www.cmqcc.org/white_paper)

Pilliod, Rachel; Leslie, Jennie; Tilden, Ellen; et al. Doula care in active labor: a cost benefit analysis. Abstract presented at 33rd Annual Meeting/Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM), San Francisco, CA, February 11-16, 2013, American Journal of Obstetrics and Gynecology, Volume: 208 (1); S348-S349.

About the authors

Monica Basile

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 Morton

Regular contributor 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, which will be published by Praeclarus Press in Fall 2013. For more on Christine, please see Science & Sensibility's Contributor page.

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