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Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One

by 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.  Today and next Tuesday, 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. – Sharon Muza, Community Manager, Science & Sensibility

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How can doula supported births help reduce the cesarean rate and realize cost savings within Medicaid-funded births? Two studies published last month 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.

  1. 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. 
  2. 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.
  3. 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.
  4. 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). 
  5. 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 breakpoint 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 barrier.  In part two of this topic, running on Tuesday, April 2nd,  we discuss our 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 cesarean reducer.

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 this procedure? 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): 527535; 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

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.

Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized , , , , ,

  1. March 28th, 2013 at 11:05 | #1

    This is a fascinating post!
    Thank you both for offering this data in a way that begs examination of multiple perspectives. It really brought so many questions to my mind on several issues. I appreciate the challenge to take a meta view of the overlapping issues of care, compensation, and how beneficial or not these constructs are in the work we do. I would love to see more conversation about how we must discuss models not only of care, but of leadership in our organizations. The next generation of birth professionals needs us to have this discussion now, so that they can give the care and receive the compensation needed in the future. The leadership behind the models of doula care needs to see the potential in a reframe that this piece suggests. I can’t wait to read the next installation.

  2. March 28th, 2013 at 12:26 | #2

    Thank you Walker, for your comment. In Part 2, we briefly touch on the role of professional organizations and who should be at the table in discussions around payment and care models. Stay tuned!

  3. avatar
    Dale Kaplan
    March 28th, 2013 at 12:49 | #3

    Fabulous article!
    I have been working dilently since last August in the 3rd party reimbursement areana. I have over 15 years of health and life insurance sales and claims experience. In August I met Tammy Ryan the 3rd party reimbursement coordinatior with DONA INT and we have been forging ahead with my efforts here in Maryland regarding the reimbursement of my doula hospital services to my clients. I see more who can not pay me so offering the reimbursement option helps…that said I have gotten paid twice by BCBS but that was from the husband of the expectant mom and his employer was a self insured group. I have had to send all of my medicare claims into the 2nd and 3rd appeals and now my original BCBS claim from last August is in the hands of the Maryland Ins Commissioner!!! What actually needs to happen is that the doula is in the commercial insurance carriers plan documents. If that does not happen than we will continue to have the excuse of no payment since we were not written into the benefit package prior to enrollment of benefits. I do have plans to speak to our delegate in Annapolis regarding our HR bill for consideration for next session…..the insurance carriers need to see an on slaught of claims not being paid for the doula services to then get on the ball to have us be included.
    Sincerely,
    Dale Kaplan CD Coola Doula
    Owings Mills, MD.

  4. avatar
    Susan Lane
    March 29th, 2013 at 21:09 | #4

    I agree with much of what is in this article. In Minnesota we have a doula bill in the legislature that will be detailed over the next nine months and continued in January 2014. Our motive for the bill is that doula care is evidence-based care and as such should be a basic human right for all women giving birth. We are requesting Medicaid (which also in MN implies funding for a higher level of income than the poverty level via MN Care, our expanded program for low-come women) because we are emphasizing disparities of care between both the Euro and immigrant women in our state, and the African American and Native American women who have outcomes well below those of the aforementioned groups. MN is at the bottom of the disparities barrel nationally – and we have only a about a dozen doulas in the AA and NA communities, only 4 black CNMs in the entire metro area, and one black CPM to my knowledge. To which I say, a hearty DUH! in relation to that disparity.
    Mn is one of two states that does indeed have a standardized higher education curriculum for Community Health Workers and an accredited certification program of 14 credits available through all community, state, and some private colleges. Even so, our CHW program is underutilized, with over 500 certified and possibly only 2 or 3 full time employed. The reasons for this are myriad, but it’s possible that a specified birth worker curriculum could change that. Discussions on this topic have only just begun but will be part of the testimony next year about the doula bill. We see doula care as a powerful workforce issue.
    Meanwhile, it would be my opinion that public funding for doula care should be flexible enough to support many models until firm data is available, and maybe always. Whether a community-based program, a CHW program, a hospital-based program, an independent agency-program like Everyday Miracles (the one in the study, which by the way had a much lower C/s rate in 2012 that the one in the study, and amazing outcomes for birth weight and breast feeding), the one element I believe to be key to reducing disparities would be that all models employee peer doulas – doulas of the same race, ethnicity and community.
    This is indeed a human rights issue at core. But the core of the human rights issue should be the babies, in my opinion, since they are the ones most likely to experience the most severe damage from bad birth policies and practices, including the damage they experience when their primary caregiver is clinically depressed or experiencing PPD or PPTSD. Babies, as a human rights issue, should be allowed to be exclusively nurtured by their biological mother until 12 weeks of age. I presented data supporting that proposition on another mother-friendly bill in the legislature this season. Other issues are the longer term breastfeeding rate, and the need for babies to be with their imprisoned mothers for a minimum of six months (I am forgetting which state allows that now) to name the couple that come to mind under the same ethical heading.
    The primary argument for doula care in my opinion is the supremacy of the mother-baby biological diad, and the rights of babies to life, liberty, and the pursuit of happiness which is defiled if they are denied evidence-based biological nurturance at the beginning of life.
    Doulas demonstrably contribute to many improved outcomes for mothers and thus babies, and even for fathers. The data regarding improved outcomes with doula care is reliable. That improved outcomes lead to reduced costs at some point is common sense. I know researchers hate common sense, but since the likelihood is slim that we will obtain significant cost-benefit data of the highest quality in the near future, I again repeat that a moral argument is our best case along with any good, if not perfect, cost assessment. (A “C” level study is good enough for most Medicaid funding now ).
    That is also the most likely to be politically persuasive Even in Minnesota, the politically crazy state, we have supporters on both sides of the isle for different reasons, but all moral or ethical. We have the pro-life, and we have the pro-choice, for example. Birth and the welfare of babies is a cross-political issue, and we should, with great caution and mutual respect, promote that as well. All legislators in this climate like to show that they can comprise when the issue is right.
    Nonetheless, we welcome chants, prayers, good juju from all sources. And send same. Thanks for getting this discussion going on this esteemed site

  5. March 31st, 2013 at 15:51 | #5

    Thanks so much to Monica and Christine for this important article, which among other contributions, helps demonstrate how important it is to understand research methodologies & to be able to analyze them for possible flaws! One more reason that I’m so proud to be Christine’s co-author of “Birth Ambassadors:…”!

  6. April 2nd, 2013 at 15:00 | #6

    Thank you so much for this important analysis of how to frame the issues around expanding the doula model of care. Deeply appreciate the many layers of what appears, at face value, to be a simple topic.

  7. April 9th, 2013 at 14:37 | #7

    Great insight and catch with the methodology behind the research. The question is not should Medicaid cover doula’s in order to reduce costs associated with c-sections and other interventions. The question is why are Medicaid eligible women and women with other forms of health insurance denied the right to have doula’s covered as part of their health/birth team. What gives any government agency or insurance carrier the right to say you don’t get a doula or figure out how to pay for them out of pocket. Shared decision making? Clients as part of their own health care process? Where is the fairness in this equation?

  8. avatar
    Kris
    January 26th, 2014 at 04:46 | #8

    One thing that the study and your article do not mention is the Medicaid cost of the baby. Doulas also save taxpayers countless dollars by keeping more babies out of the NICU. Doulas should be standard care. They are evidence-based practice and worth every penny for moms and babies. Not to mention if doulas were standard care, we would need more of them…more jobs for more women leads to fewer women on Medicaid. I am a doula and I am a senior BSN student. However, I do no like the idea of hospital based doula services in which the doula meets the client for the first time when the mother comes into the hospital in labor. Doulas want to know their client and understand their hopes and desires for the birth. They need to build rapport with the client in order to be most effective.

  1. November 20th, 2013 at 14:36 | #1
  2. December 2nd, 2013 at 08:45 | #2