Menus Subscribe Search

Follow us


(PHOTO: MICHAELJUNG/SHUTTERSTOCK)

(PHOTO: MICHAELJUNG/SHUTTERSTOCK)

Doulas Do It Better

• March 15, 2013 • 4:00 AM

(PHOTO: MICHAELJUNG/SHUTTERSTOCK)

Providing doulas to low-income mothers-to-be could save Medicaid millions.

Here’s a quick medical quiz: What’s the most common reason for hospitalization in the United States? Take a stab. Respiratory distress? Cardiac arrest?

Try childbirth. As researchers at the University of Minnesota’s School of Public Health observe, more than four million babies are born in American hospitals every year, and from maternal checkups to newborn care, moms-to-be rack up more charges than any other patients. In 2009, those costs totaled nearly $30 billion.

Maternal health care is a big burden on Medicaid, which pays the expenses of low-income patients and annually foots the bill for 45 percent of all births. What’s more, low-income moms have disproportionately high rates of complication and Caesarean section. According to the Minnesota researchers, Medicaid mothers are more likely to give birth prematurely, or to low-weight babies, than more affluent women.

Writing this month in the American Journal of Public Health, Katy Backes Kozhimannil and her colleagues propose a novel way to reduce birth complications and bring down maternal Medicaid costs at the same time: use doulas.

Unlike an obstetrician or delivery nurse, a doula—from the Ancient Greek term for “female servant”—possesses no formal medical training (which also differentiates her from a midwife). Instead, she’s on hand during labor to provide counsel and emotional support to mothers and their partners, not unlike a coach on the sidelines of a tennis match, or a guide leading a first-time climber up a mountain. In addition to serving as a mother’s advocate in the delivery room, doulas also provide pre- and post-partum advice on homebirth, nursing, and infant wellbeing. In an age of high-tech medicine and mommy blogs, a doula fills a rather more traditional cultural role: she’s a confidant, a mentor, a hand to hold in the worst of labor pains.

A 2011 Cochrane Review looked at 21 studies involving 15,000 pregnancies and found that women who were provided a doula’s “continuous support” during childbirth experienced shorter labors, fewer Caesarians, and were less likely to require the use of instruments—forceps, vacuums—or epidural drugs. “Continuous support during labour has clinically meaningful benefits for women and infants and no known harm,” the review concluded. “All women should have support throughout labour and birth.”

Unfortunately, all women don’t. “The women who stand to benefit the most from doula care have the least access to it—both financially and culturally,” Kozhimannil notes. “Most doulas are white middle-class women serving white middle-class women.” And because few private insurers cover a doula’s services, any woman who wants one in the delivery room is forced to pay for the care—often $400 to $800—out-of-pocket.

Kozhimannil wondered if state Medicaid programs might actually reap long-term cost savings by providing their poor patients with doulas, thus avoiding the astronomical hospital bills associated with premature labor, Caesarean section, and neonatal intensive care. (At the moment, just five states allow public funds to pay for labor coaches, according to the Kaiser Family Foundation.) If doulas really did decrease the risk of complicated pregnancies, it would make sense to invest in their services up front, in the same way that it’s cheaper for an insurer to pay for a customer’s gym membership now than to treat her diabetes later.

Everyday Miracles is a Minneapolis non-profit that provides Spanish- and Somali-speaking doulas to mothers on Medicaid—precisely the kind of women that Kozhimannil argues most need their support. The organization’s 22 doulas assisted more than 1,000 births between 2010 and 2012, so Kozhimannil compared their outcomes with 280,000 Medicaid-funded births, presumably few of which were doula-assisted. She found that, as was predicted, Everyday Miracle mothers had 30 percent fewer Caesarean sections than regular Medicaid mothers.

Kozhimannil then projected how much states might save were doulas able to lower C-section rate among all low-income moms as much as they had among Everyday Miracle moms. (According to the University of Minnesota, the average Medicaid payment is about $9,000 for a vaginal birth, but significantly higher—$13,600—for a Caesarean delivery.) Assuming Medicaid could negotiate a standard $200 fee for doula birth services, most states would save at least $2 million a year, and the average would cut costs by $7 million. Populous states stand to see an even bigger windfall: with fewer surgical births, California alone might recoup some $200 million in obstetrics costs.

In the end, of course, it’s about more than money. For low-income expectant mothers and their infants, the stakes are so much higher. But if economic logic is what’s required to compel state governments to act, well, that’s good medicine of a different sort.

Kevin Charles Redmon
Kevin Charles Redmon is a journalist and critic. He lives in Washington, D.C.

More From Kevin Charles Redmon

A weekly roundup of the best of Pacific Standard and PSmag.com, delivered straight to your inbox.

Recent Posts

November 24 • 12:00 PM

Yes, Republicans Can Still Win the White House

If the economy in 2016 is where it was in 2012 or better, Democrats will likely retain the White House. If not, well….


November 24 • 11:36 AM

Feeling—Not Being—Wealthy Cuts Support for Economic Redistribution

A new study suggests it’s relative wealth that leads people to oppose taxing the rich and giving to the poor.


November 24 • 10:00 AM

Why Are Patients Drawn to Certain Doctors?

We look for an emotional fit between our physicians and ourselves—and right now, that’s the best we can do.


November 24 • 8:00 AM

Why Do We Elect Corrupt Politicians?

Voters, it seems, are willing to forgive—over and over again—dishonest yet beloved politicians if they think the job is still getting done.



November 24 • 6:00 AM

They Steal Babies, Don’t They?

Ethiopia, the Hague, and the rise and fall of international adoption. An exclusive investigation of internal U.S. State Department documents describing how humanitarian adoptions metastasized into a mini-industry shot through with fraud, becoming a source of income for unscrupulous orphanages, government officials, and shady operators—and was then reined back in through diplomacy, regulation, and a brand-new federal law.


November 24 • 4:00 AM

Nudging Drivers, and Pedestrians, Into Better Behavior

Daniel Pink’s new series, Crowd Control, premieres tonight on the National Geographic Channel.


November 21 • 4:00 PM

Why Are America’s Poorest Toddlers Being Over-Prescribed ADHD Drugs?

Against all medical guidelines, children who are two and three years old are getting diagnosed with ADHD and treated with Adderall and other stimulants. It may be shocking, but it’s perfectly legal.



November 21 • 2:00 PM

The Best Moms Let Mess Happen

That’s the message of a Bounty commercial that reminds this sociologist of Sharon Hays’ work on “the ideology of intensive motherhood.”


November 21 • 12:00 PM

Eating Disorders Are Not Just for Women

Men, like women, are affected by our cultural preoccupation with thinness. And refusing to recognize that only makes things worse.


November 21 • 10:00 AM

Queens of the South

Inside Asheville, North Carolina’s 7th annual Miss Gay Latina pageant.


November 21 • 9:12 AM

‘Shirtstorm’ and Sexism in Science

Following the recent T-shirt controversy, it’s clear that sexism in science persists. But the forces driving the gender gap are still being debated.


November 21 • 8:00 AM

What Makes a Film Successful in 2014?

Domestic box office earnings are no longer a reliable metric.



November 21 • 6:00 AM

What Makes a City Unhappy?

According to the National Bureau of Economic Research, Dana McMahan splits time between two of the country’s unhappiest cities. She set out to explore the causes of the happiness deficits.


November 21 • 5:04 AM

Sufferers of Social Anxiety Disorder, Your Friends Like You

The first study of friends’ perceptions suggest they know something’s off with their pals but like them just the same.


November 21 • 4:00 AM

In 2001 Study, Black Celebrities Judged Harshly in Rape Cases

When accused of rape, black celebrities were viewed more negatively than non-celebrities. The opposite was true of whites.


November 20 • 4:00 PM

Women, Kink, and Sex Addiction: It’s Not Like the Movies

The popular view is that if a woman is into BDSM she’s probably a sex addict, and vice versa. In fact, most kinky women are perfectly happy—and possibly healthier than their vanilla counterparts.


November 20 • 2:00 PM

A Majority of Middle-Class Black Children Will Be Poorer as Adults

The disturbing findings of a new study.


November 20 • 12:00 PM

Standing Up for My Group by Kicking Yours

Members of a minority ethnic group are less likely to express support for gay equality if they believe their own group suffers from discrimination.


November 20 • 10:00 AM

For Juvenile Records, It’s ‘Justice by Geography’

A new study finds an inconsistent patchwork of policies across states for how juvenile records are sealed and expunged.


November 20 • 8:00 AM

Surviving the Secret Childhood Trauma of a Parent’s Drug Addiction

As a young girl, Alana Levinson struggled with the shame of her father’s substance abuse. But when she looked more deeply into the research on children of drug-addicted parents, she realized society’s “conspiracy of silence” was keeping her—and possibly millions of others—from adequately dealing with the experience.



November 20 • 6:00 AM

Extreme Weather, Caused by Climate Change, Is Here. Can Nike Prepare You?

Following the approach we often see from companies marketing products before big storms, Nike focuses on climate change science in the promotion of its latest line of base-layer apparel. Is it a sign that more Americans are taking climate change seriously? Don’t get your hopes up.


Follow us


Feeling—Not Being—Wealthy Cuts Support for Economic Redistribution

A new study suggests it's relative wealth that leads people to oppose taxing the rich and giving to the poor.

Sufferers of Social Anxiety Disorder, Your Friends Like You

The first study of friends' perceptions suggest they know something's off with their pals but like them just the same.

Standing Up for My Group by Kicking Yours

Members of a minority ethnic group are less likely to express support for gay equality if they believe their own group suffers from discrimination.

How Old Brains Learn New Tricks

A new study shows that the neural plasticity needed for learning doesn't vanish as we age—it just moves.

Ethnic Diversity Deflates Market Bubbles

But it's not in the rainbow and sing-along way you'd hope for. We just don't trust outsiders' judgments.

The Big One

One in two United States senators and two in five House members who left office between 1998 and 2004 became lobbyists. November/December 2014

Copyright © 2014 by Pacific Standard and The Miller-McCune Center for Research, Media, and Public Policy. All Rights Reserved.