May is International Doula Month.  Lamaze International and Connecting the Dots recognize and appreciate the beneficial role both birth and postpartum doulas serve in helping families thrive not just survive through the childbearing year.  After all, Lamaze International’s Healthy Birth Practice #3 is all about continuous support.

A new research study published earlier this month, The cost-effectiveness of professional doula care for a woman’s first two births: A decision analysis model is an exciting study on the benefits of doulas because it examined the impact of doulas through a different lens, the economic perspective.  There are many studies over the years that have examined the impact of having professional labor support on birth outcomes, but evaluating doula care from the financial side is not nearly as well researched.

With ever-increasing scrutiny on methods to improve maternal and infant mortality and morbidity, particularly for Black families and families of color, insurance companies, state Medicaid programs and other health care services funding programs all around the USA are exploring (and in some cases have already initiated) doula care as a covered benefit.

The research study I review here runs a theoretical model looking at both the cost-effectiveness and the cost savings when a nulliparous woman has professional labor support for their first birth and the impact on the second birth.  The researchers found that:

Professional doula care during a woman’s first labor and birth leads to fewer cesarean births, fewer adverse maternal outcomes, and improved quality-adjusted life years (QALYs) in the woman’s first and subsequent births.

Having a professional doula with a woman during her first labor and birth could be both cost-effective and cost-saving when reimbursement for this care is less than $884. Doula support costing $884-$1360 remains cost-effective because the additional expenditure for care is accompanied by higher quality-adjusted life years.

When the model was adjusted to include contemporary cesarean rates (26% in this population), doula support was both cost-effective and cost-saving when reimbursement for this care was less than $1153, and doula support costing $1153-$1808 remained cost-effective. Given the limitations of a decision analysis model, this estimated cost-effectiveness threshold is likely conservative.

If a professional doula provided care during labor to all low-risk nulliparous women in the United States using the current cesarean birth rate, this model estimates that this would result in $247 million in savings and 10,483 additional QALYs every year.

This cost-effectiveness analysis adds to the literature supporting the integration of professional doula support into a woman’s first labor and signals the need for increased doula care reimbursement.

I interviewed the three primary researchers for this study: Karen Greiner, Jesse Remer, CD/BDT(DONA), PCD/PDT(DONA), LCCE, FACCE, and Ellen Tilden, Ph.D., CNM. I am sharing our discussion here:

Sharon Muza: Why did you feel it was important to look at the economics of having a doula attend births, in particular, a first-time parent’s birth.

Karen Greiner: A number of studies have looked at the association between having a professional doula present during labor and birth and improved maternal and neonatal outcomes, including the decreased rate of cesarean deliveries and shorter duration of labor. That being said, very few studies had looked at the economic effect of having a professional doula during one’s birth. We felt it was important to derive evidence-informed estimates of the effect professional doulas have on societal costs and improved health outcomes. We hope our findings will be used to help inform policy decisions to integrate doula care into the standard maternity care system and encourage increased reimbursement for doula care. We specifically looked at costs and outcomes when a professional doula was present during a woman’s first birth only given we wanted to isolate the immediate and downstream effects of doula care on a US woman’s typical reproductive life course.

Ellen Tilden: Building on Karen’s important comments, I felt it was important to provide a strong estimate of how much doula care contributes to health care cost savings and to project what cost-effectiveness would be if all low-risk women birthing their first child received doula care. There is increasingly compelling collective evidence that doula care leads to improved perinatal outcomes and improved experience for people in labor and their families. Recently, this evidence was robust enough to generate a more meaningful cost-effectiveness model, and we wanted to act on this opportunity to examine how the improved outcomes stemming from doula care contribute to improved maternity care costs. From my perspective, this kind of cost modeling is one meaningful way of making the value of doula care visible. With rare exceptions, doula care in the US is paid for by individuals and families. And yet, we know that doula support leads to important improvements in birth outcomes. So by creating this cost model, our team offers strong estimates of the kinds of reimbursement for doula care that match the value they bring to improving perinatal outcomes.

SM: What was your pre-study hypothesis and did the results confirm your initial beliefs?

KSG: Our pre-study hypothesis was that having a doula during a woman’s first labor and delivery would be cost-effective, which is what we found in our model. We had hoped having a professional doula would also be cost-saving using a baseline cost of $1,000 for a doula’s services, but instead found having a doula resulted in increased quality of life and increased costs, ultimately making it cost-effective rather than cost-saving.

SM: How would you explain the difference between cost-effectiveness and cost savings to the layperson?  Why is it important to include both of these measures?

KSG: Cost savings refers to when one strategy results in lower costs and higher quality of life compared to the alternative strategy. In other words, that strategy saves money and improves outcomes for society. Alternatively, cost-effectiveness refers to a strategy which results in lower costs and higher quality of life (as above) or higher quality of life in relation to higher costs. In order to be cost-effective, this strategy needs to remain below the determined willingness-to-pay threshold or the amount of money society is willing to pay to gain one additional quality-adjusted life year or one year of perfect health. Ideally, we would like all strategies to be cost-saving, but many interventions in medicine cost a significant amount of money, thus why we use a willingness-to-pay threshold to allow us to determine when a strategy is overall cost-effective or not.

SM: Your results indicate that there are significant cost savings to providing doulas for first time birthing people.  What do you believe are the barriers to making this happen? “If a professional doula provided care during labor to all low-risk nulliparous women in the United States using the current cesarean birth rate, this model estimates that this would result in $247 million in savings and 10,483 additional QALYs every year.”

KSG: I think the biggest challenge is finding ways to smoothly integrate doulas into all maternity care teams in a way that enhances the care provided to laboring women without disrupting the essential medical care provided by nurses, nurse midwives, and physicians. Making large system changes takes time and requires input and support from all parties involved in the care of women during labor and delivery. Of course, another barrier is from the insurance companies/Medicaid and finding ways for doulas to be reimbursed for their services just like the other health professionals involved in the care of a laboring woman. We hope our research will encourage further discussions on the benefits of moving toward an integrated model of maternity care.

Jesse Remer: The largest barrier to creating more access to doula care for birthing people is social and financial prioritization. This means creating a system that prioritizes the relevant cost savings in relation to birth outcomes especially for populations most impacted by poor birth outcomes such as African American women and infants which are at highest risk societally.

Many healthcare establishments are implementing the Institute for Healthcare Improvements (IHI) Triple Aim initiatives:  (1) Improving the patient experience of care (including quality and satisfaction); (2) Improving the health of populations; and.(3)  Reducing the per capita cost of health care. Many doula studies show the value of the doula for aims 1 and 2.  For example here in Oregon, we have the social prioritization through the Traditional Healthcare Worker Act (THWA). However, the financial prioritization was a missing link. We’ve had to build a pathway for reimbursement with no prior data from which to base reimbursement/savings and the lack of adequate reimbursement has been a barrier to doula enrollment.

We hope this study will increase the tools for effective implementation of doula care in multiple ways---through increased community programs, integrated models and individual doula groups--by giving evidence to the (3) third aim in Triple aim (cost savings).

SM: What is quality-adjusted life years (QALYs) and why is this measurement important to use in this study?

KSG: A quality-adjusted life year (QALY) is a measure used for valuing health outcomes. One QALY is equal to one year of life multiplied by the utility of a specific outcome, where a utility is a quantitative measure representing the strength of a person’s preference for that outcome. QALYs are an essential component of cost-effectiveness models because they allow researchers to associate a value with specific health outcomes rather than looking at costs alone.

SM: Your research indicated that there is both cost savings and cost-effectiveness in providing doulas to nulliparous birthing people when the doula compensation is $884 per birth, which includes prenatal and postpartum visits and the birth. Do you believe that is a realistic fee for doulas across the nation given that most births occur in urban settings where the cost of living is higher and corresponding assumption of higher doula fees?

JR:  From a cost-effectiveness of $884 to $1360 our study suggests that this fee is the starting place for reimbursement which hopefully means further comprehensive funding within community-based or integrated programs. We hope this study will contribute to the financial conversations of overall implementation and impact of doula programs (including impact on lowering other interventions other than cesarean birth, increased breastfeeding rates, bonding, etc) and may allow navigation of expanding doula services through integration by insurance reimbursement including Medicaid, versus private insurance, versus private pay or a mix thereof. For example, in the creation of the integrated role of doulas at the Providence Women’s Clinic, in Portland, OR, the possible reimbursement was a contributing factor to the decision to hire doulas.

SM: What are the barriers as you see it to having doulas for all birthing people if there are both economic and maternal benefits as documented in your research and in previous doula studies?

KSG: In addition to what we mentioned above, it is important to recognize that not all women will request a doula during their labor and delivery. That being said, as health care professionals, it is our role to provide women the opportunity to have access to a professional doula if this is something they desire as part of their labor and delivery care.

JR: The biggest barrier to having doulas for all birthing people is the creation of adequate reimbursement programs and culturally specific doula care at easily accessible points of contact for the birthers. We have the information now that suggests it’s not for lack of want: From the Listening to Mothers III survey,  among women who had a good understanding of doulas and doula support in labor, black women, who are at highest risk for poor outcomes,  were most likely to say they would have liked to have had such support (39% versus 30% Hispanic and 22% white) versus the 6% of families being served by doulas today.  Some examples of effective integrated models reside here in Oregon where doula reimbursement is underway in programs like Project Nurture, a methadone treatment program for pregnant parents in treatment that include peer support counselors and doulas or the community-based Sacred Roots Program with the Black Parent Initiative. These programs receive multiple funding sources that include reimbursement dollars from the Oregon Medicaid THWA and are integrated within the system to be a part of the birthing persons' referrals within the system.

SM: For the purpose of your research, you estimated that the average labor time of a vaginal nulliparous birth was 7.1 hours and 4.1 hours as the average for a multiparous birth including both first and second stage for women who arrived at the hospital in spontaneous labor and assuming all women had epidural analgesia in the second stage. I have been to approximately 500 births as a doula and this seems on the short end of things in my experience, especially since recent ACOG guidelines recognize second stage with an epidural can be 6 hours or longer. Can you speak to this and how longer labors would impact your analysis?

KSG: The length of labor used in our model was derived from a large multicenter retrospective observational study using data from the Consortium on Safe Labor. This data considered only women who presented in spontaneous labor, in order to estimate the duration of natural labor in the United States. If a longer labor time had been included in the model this would increase costs regardless of whether a doula was present or not. We included two studies which demonstrated having a professional doula decreased a woman’s time in labor by approximately one hour compared to not having a doula. Therefore, the results of the model would be impacted if the length of labor was found to be even shorter or longer with a professional doula present compared to no doula.

SM: How are inductions accounted for in your research, as we know that 23% of parents were induced in 2014 and that definitely impacts the length of labor and the increase in cesareans?

KSG: This is a great question. In our model, we included only women who arrived at the hospital in spontaneous labor. To the best of my knowledge, we do not have data looking at the effect of having a professional doula present during one’s induction of labor and the maternal outcomes. This would be interesting to study, although very challenging given outcomes for induction of labor (specifically rate of cesarean births) depend on the indication for induction and gestational age at which a woman is induced.

SM:  What happens next?  Who should be using this information and what should they be doing with it?  Insurance companies? Maternal Mortality Review Boards? Consumers? Professional doula organizations? Hospitals? What should be done with this information?

JR:  Everyone whose aim it is to improve maternal outcomes can use this information as validity to the cost-effectiveness and relevance of doula care during implementation.   When I started my career twenty years ago, organizations were asking “why doulas”? Now they are asking “How do we get/fund doulas?”. This study is timely and relevant. Many doula initiatives across the country are being looked at state-by-state.  As the Policy Chairman of the Oregon Doula Association, I see that we field calls weekly. Here in Oregon, the  Oregon Doula Association (ODA) did a doula workforce development assessment funded by a grant from the Oregon Health Authority in order to assess the barriers to the implementation of our THWA initiatives. Some of the biggest barriers in the implementation of the THWA have been reimbursement modeling and systems. This study contributes to the needed evidence-based understanding of the doulas' role in meeting maternal health initiatives.

About the Researchers

Karen Greiner

Karen Greiner is a student pursuing her MD and Master’s in Public Health at Oregon Health & Science University in Portland, OR. As a future Obstetrician & Gynecologist, she hopes to follow her passion for working with women from diverse, underserved backgrounds and to use her MPH training to conduct epidemiologic research related to reproductive health issues and access at the population level. As a medical student, Karen served as the Co-President for OHSU’s Medical Students for Choice chapter and has presented numerous research projects at the American College of Obstetricians & Gynecologists and the Society for Maternal-Fetal Medicine annual meetings. Her research interests include cost-effectiveness analyses, obstetric and abortion care. In addition, her first publication from 2018 looked at the association between insurance type and pregnancy outcomes among women with a hypertensive disorder of pregnancy.

Jesse Remer

Jesse Remer is a visionary in the birth field.  She brings her skills as a doula, trainer, educator, speaker, writer, change agent advocate, and resource to support the creation of new models of maternity care.  She founded the largest doula practice in Oregon, Mother Tree Birth Services, then became a leading expert in the integration of doulas within the system both at a hospital and state level. She is a staff doula with the Providence Women's Clinic,  a founding member of the Oregon Doula Association (ODA) and chair of the Policy & Advisory Committee and a contributing leader to the Gateway Doula Group Doula Billing Hub. Her latest work in trauma-informed care is her passion.

Ellen Tilden

Ellen Tilden, Ph.D., CNM, is an Assistant Professor in the School of Nursing Department of Nurse-Midwifery and School of Medicine Department of Obstetrics and Gynecology at Oregon Health and Science University (OHSU).

Her midwifery training began with an apprenticeship within a home and birth center maternity care team in Berlin, Germany and she subsequently received her nursing and nurse-midwifery training at the University of California, San Francisco, graduating in 2000. Since this time she has been practicing full-scope nurse-midwifery in a variety of settings.

Ellen completed her Ph.D. in 2015. Her postdoctoral research and training are currently supported by a women's health BIRCWH career development award from the National Institutes of Health Office of Research on Women's Health and National Institutes of Child Health and Development.

Ellen is a health services researcher focused on healthcare systems factors that impact obstetric procedure use, particularly modifiable drivers of cesarean delivery. She has published her research in the Journal of Midwifery and Women's Health, Birth, the American Journal of Obstetrics and Gynecology, and the New England Journal of Medicine. Her research approach is inter-disciplinary and she works closely with perinatologists and epidemiologists, employing tools from economics, causal inference, and other disciplines.

Her overarching research goal is to define risk-appropriate care for healthy women and their children in the U.S.

References

Approaches to limit intervention during labor and birth. ACOG Committee Opinion No. 766. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e164–73.

Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, (7).

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to mothers III.

Greiner, K. S., Hersh, A. R., Hersh, S. R., Remer, J. M., Gallagher, A. C., Caughey, A. B., & Tilden, E. L. (2019). The Cost‐Effectiveness of Professional Doula Care for a Woman's First Two Births: A Decision Analysis Model. Journal of midwifery & women's health.                  

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