Editor’s note: We are excited to welcome guest blogger, Dr. Katy Kozhimannil! Dr. Kozhimannil has recently brought national attention to the importance of the doula role for positive birth outcomes, especially in under-served populations. We’re grateful to her for sharing a little about her experience and her research here on the blog. 

by Katy B. Kozhimannil, PhD MPA

A doula supports a laboring woman.

It makes sense to me that pregnant women with personal, emotional, and physical support during labor and delivery have better birth experiences. I did not have a doula when my son Paul was born in 2008.  I could not afford one at that time.  However, I had taken a newborn care class, and the instructor for that course (Teresa) was training for her certification in childbirth education and needed to observe births for her training. Teresa offered to support me during labor for free, so that she could observe my son’s birth and fulfill her training requirements.

My labor experience was best characterized by the phrase “cascade of interventions.” I was overwhelmed and frightened, but there was one moment that stopped the feeling of inertia that seemed to hover around me: when Teresa stood next to me, held my hand, and told me that I could ask whether I had time to rest before making a decision.  The medical team, standing next to me in scrubs waiting to take me to the operating room for a cesarean, confirmed that the situation was not urgent and agreed to wait an hour and reassess. The tide turned in my direction.  I felt a renewed sense of ownership and agency in the birth process.

When I felt the urge to push, I was so grateful for the chance to do something and to feel like I could participate in the birth process. I had a vaginal delivery, and – with Teresa’s help – I regained control of the decision-making during my son’s birth.  Incidentally, I also think Teresa saved my health insurance company a lot of money – approximately $4000 by my calculations (the difference between the costs of a cesarean vs. vaginal delivery).  But she never even got a thank you note.

Unfortunately, many women can’t afford to pay out-of-pocket for doula care, and most health insurance companies don’t pay for doulas.  But labor support is incredibly important.  There is good empirical evidence for this. A 2012 Cochrane review conclusively finds that continuous labor support is associated with many positive outcomes for moms and babies (more spontaneous vaginal births, fewer epidurals, shorter labors, higher infant Apgar scores, and greater satisfaction) and no known negative impacts. These effects are most consistent when labor support is provided someone who is not a friend or family member and not a member of the hospital staff – someone like a doula.

For a year and a half, I have had the pleasure of collaborating with Everyday Miracles, a Minnesota-based non-profit organization that aims to reduce health disparities by providing perinatal education and doula services to low-income women. Everyday Miracles employs a diverse group of doulas (including Somali, Latina, Hmong and African-American doulas) and attempts to match doulas to clients based on language and race/ethnicity.

Given the strong evidence base for the health benefits of doula care, we gathered and analyzed data to look at both the health and cost impacts of doula care among low-income women. In a paper published this spring in the American Journal of Public Health, we reported that cesarean rates were about 40% lower for doula-supported births, compared with similar women nationally. We also estimated potential financial impacts to states Medicaid programs associated with cesarean rate reductions of this magnitude and suggested that states investigate whether reimbursing birth doulas may result in improved birth outcomes and potentially even generate cost savings within their Medicaid programs.

Minnesota took up this challenge, and our state legislature has decided that doula care is a service worth providing to Minnesota’s mothers.  On May 23, 2013, Governor Dayton signed “the doula bill” (SF 699, HF 768) into law as part of the Omnibus health bill (SF 1644, HF1233).  Starting in July, 2014, Minnesota Statues Chapter 108, Sec. 11 will allow Medicaid payment for services from a certified doula for pregnant women in our state.  The passage of this legislation resulted from more than a decade of work by doulas, mothers, community members and led by the Minnesota Better Birth coalition.

The “doula bill” was a great policy victory for mothers, families, and doulas in our state, and as implementation unfolds, I hope that it will lay the foundation for improving birth for moms in Minnesota and beyond.  While the potential “cost savings” of offering health insurance reimbursement to birth doulas is a compelling rationale in a policy context, I think that the fundamental goodness and power of a positive birth experience and the ability of doulas to facilitate such an experience far outshine any benefits that could be measured in dollars and cents.

Dr. Kozhimannil is an assistant professor at the University of Minnesota’s School of Public Health where  she conducts research to inform the development, implementation, and evaluation of health policy that impacts reproductive-age women and their families. She is the mother of two sweet little ones.