title: Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.
abstract: BACKGROUND
  One in nine US infants is born before 37 weeks' gestation, incurring medical costs 10 times higher than full-term infants. One in three infants is born by cesarean; cesarean births cost twice as much as vaginal births. We compared rates of preterm and cesarean birth among Medicaid recipients with prenatal access to doula care (nonmedical maternal support) with similar women regionally. We used data on this association to mathematically model the potential cost-effectiveness of Medicaid coverage of doula services.
  
  
  METHODS
  Data came from two sources: all Medicaid-funded, singleton births at hospitals in the West North Central and East North Central US (n = 65,147) in the 2012 Nationwide Inpatient Sample, and all Medicaid-funded singleton births (n = 1,935) supported by a community-based doula organization in the Upper Midwest from 2010 to 2014. We analyzed routinely collected, de-identified administrative data. Multivariable regression analysis was used to estimate associations between doula care and outcomes. A probabilistic decision-analytic model was used for cost-effectiveness estimates.
  
  
  RESULTS
  Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7 vs 6.3%, and 20.4 vs 34.2%). After adjustment for covariates, women with doula care had 22 percent lower odds of preterm birth (AOR 0.77 [95% CI 0.61-0.96]). Cost-effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986 (ranging from $929 to $1,047 across states).
  
  
  CONCLUSIONS
  Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost-effective for state Medicaid programs.
authors.affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
authors.forename: Katy B
authors.initials: KB
authors.lastname: Kozhimannil
authors.affiliation: Division of Health Care Policy & Research (HCPR), Mayo Clinic, Rochester, MN, USA.
authors.forename: Rachel R
authors.initials: RR
authors.lastname: Hardeman
authors.affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
authors.forename: Fernando
authors.initials: F
authors.lastname: Alarid-Escudero
authors.affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
authors.forename: Carrie A
authors.initials: CA
authors.lastname: Vogelsang
authors.affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
authors.forename: Cori
authors.initials: C
authors.lastname: Blauer-Peterson
authors.affiliation: Departments of Population Health Science & Policy and Obstetrics, Gynecology, and Reproductive Sciences, Center for Health Equity and Community Engaged Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Howell
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000191:economics* / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D059037:Doulas / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016015:Logistic Models; D008484:Medicaid; D018803:Models, Economic; D015999:Multivariate Analysis; D016017:Odds Ratio; D011247:Pregnancy; D047928:Premature Birth / Q000191:economics* / Q000453:epidemiology; D011295:Prenatal Care / Q000191:economics* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Medicaid; cesarean delivery; doula; preterm birth