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How Full-Spectrum Doula Care for Low-Income Californians During Pregnancy and Early Parenthood Can Improve Their Health and Reduce Costs to the State

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University of California-San Francisco

In the United States, both maternal and infant mortality rates—despite the relatively high amount spent on health care, nationally—are strikingly greater than in similarly developed countries. State governments committed to reducing often preventable deaths would do well to explore the advantages of offering full spectrum “doula care”—a type of health care intervention during pregnancy and the period right after birth that is showing highly positive results for people and public budgets. Full-spectrum doulas are helpers who provide non-clinical physical, emotional, and informational support to a person during pregnancy, childbirth, and the postpartum period. The benefits of doula support include not just improved health care and outcomes for birthing people and their infants but also potential cost savings to state budgets experiencing ever-rising costs for other kinds of healthcare and family supports.

Once signed by the governor, Senate Bill 65 (SB 65), also known as the California Momnibus Act, would fund several initiatives to improve health care and social services for birthing people. The original bill would have expanded Medi-Cal coverage to include full-spectrum doula care, extended Medi-Cal eligibility for postpartum people, funded training for an expanded midwifery workforce, collected more maternal and infant mortality data, provided earlier access to public assistance for eligible families, and guaranteed income support for pregnant Californians. This legislation would do more than just expand full-spectrum doula care, a positive step, because the additional initiatives promise to further the full range of improvements policymakers are championing.

Doula-Supported Pregnancies Have Better Health Outcomes

A systematic review compared results for women who got continuous support during labor from a staff member, doula, or person in the individual’s social network to results from care without such support. Doula-style support:

  • Reduced likelihood of cesarean delivery or instrument-assisted delivery
  • Lowered the use of epidural or other pain medications, which can increase complications in labor and recovery
  • Avoided low infant Apgar scores, the test that clinical staff use to assess infant health immediately after birth
  • Led to more positive ratings from parents about their birthing experience
  • Increased the likelihood of spontaneous vaginal birth, that is labor that does not have to be induced or require surgical intervention, and shortened the period of labor

Furthermore, studies among Medicaid recipients show that doula-supported births are associated with reduced preterm births, cesarean deliveries, and increased breastfeeding initiation.

Doula-Supported Pregnancies Reduce Costs

Beyond benefits to those giving birth, an analysis of Medicaid-funded births showed, taken alone, reductions in the cesarean delivery rate among doula-supported births in California could lead to a cost savings of between $50 and $250 million dollars annually. However, cost savings to Medi-Cal and other social services are likely to be higher if we take into account all the beneficial health and social impacts typical for this kind of intervention. For example, although medical costs in California are estimated to be $57,584 for each preterm birth, the total costs are actually closer to $75,000 when we include special education, early intervention services, and productivity loss. Additionally, these figures do not take into account other ways that doula-supported births might prove cost-effectiveness, such as by reducing instrument-assisted deliveries and the use of pain medications as well as by boosting infant Apgar scores.

California Can Address Racial Disparities in Maternal and Infant Mortality Rates

There are persistent racial disparities in the health outcomes of birthing people and infants in California. For example, there is an almost 10-fold higher risk of pregnancy-related mortality due to cardiovascular disease among Black birthing people compared with other racial and ethnic groups. Similar disparities are seen in the leading risk factors for infant mortality: preterm birth (birth before 37 weeks of gestation) and low birth weight (less than 5 pounds, 8 ounces). While California’s overall preterm birth rate is 9%—lower than the national rate of 10.2%—racial disparities among Black and other infants of color compared with White infants exceed disparities at the national level. The state’s preterm birth rate is 12.2% among Black infants, 11.2% among American Indian/Alaska Native infants, 9.1% among Hispanic infants, and 7.7% among White infants. Black infants in California also have a 2.4-fold higher risk of having low birth weight compared with White infants.

Although California is a leader in progressive social policies, the state is seven years behind other states, such as Minnesota and Oregon in funding doula care for Medicaid recipients. The recently finalized 2021-2022 California budget funds a few initiatives from the original SB 65, including Medi-Cal coverage for full-spectrum doula care, but does not include funding for other important initiatives such as midwifery training, and data collection and monitoring. The revised SB 65 has passed the state legislature and is awaiting the governor's signature. Once signed, implementation of the remaining initiatives would lead to greater improvements in health and health care for pregnant Californians and new parents. As a result, long-standing disparities in health outcomes could be steadily reduced in future years, with promising results for all children and families. Ambitious legislation is on the table, but unless all initiatives are funded, the effects are likely to be less dramatic than they could be.

Read more in Renee Mehra, Shayna D. Cunningham, Jessica B. Lewis, Jordan L. Thomas, and Jeannette R. Ickovics, “Recommendations for the Pilot Expansion of Medicaid Coverage for Doulas in New York State.American Journal of Public Health 109, no. 2 (2019):217-219; and Renee Mehra, Lisa M. Boyd, Jessica B. Lewis, and Shayna D. Cunningham, “Considerations for Building Sustainable Community Health Worker Programs to Improve Maternal Health.” Journal of Primary Care Community Health (2020).