Nursing Clio is happy to have Paula Michaels as a guest author today. Michaels is a Senior Lecturer at Monash University (Melbourne, Australia), where she teaches history and international studies. An historian of Russia and Central Asia, her research explores the intersection of medicine, politics, and society. She is the author of two books: Curative Powers: Medicine and Empire in Stalin’s Central Asia (University of Pittsburgh Press, 2003) and Lamaze: An International History (Oxford University Press, 2014).
The question of the contraceptive mandate has garnered the lion’s share of attention regarding the impact of the Affordable Care Act (ACA) on women’s health services, most notably in the recent Hobby Lobby and Wheaton College decisions. As unquestionably important and pressing as these issues are, what has earned virtually no discussion is the opportunity that the ACA offers to improve the quality of care for women who choose to become pregnant. The potential for doulas—trained, experienced labor companions—to significantly improve health outcomes, raise patient satisfaction, and lower costs has not received the consideration it deserves.
It is no exaggeration to say that maternity care in the United States today is a travesty. Americans spend a lot of money for some of the worst outcomes in the developed world. Even in cases when mother and baby are physically healthy, many women, especially among the roughly one-third who have Cesarean sections, find themselves disappointed with their childbirth experience. At double the rate recommended by the World Health Organization, there is a c-section epidemic in this country, and it is a major factor in the high cost of American maternity care.
This state of affairs reflects the irrationality of a system too enamored with the bells and whistles of technology. Fetal monitoring, labor induction, epidural anesthesia, and other interventions have a positive, even life-saving role in obstetric care, but in cases of normal birth, they can derail an otherwise uncomplicated, natural process. Their routine use can lead down a slippery slope of spiraling interventions, driving up costs, and lowering health outcomes for mother and baby.
We have good evidence that the use of doula services can improve birth outcomes and raise women’s feelings of satisfaction, yet access to doulas remains largely limited to those who can afford it as an out-of-pocket expense.
The cost can range from $400 to over $1000–no small amount on top of the several thousand dollars of physician and hospital fees associated with even a routine delivery. Some insurance companies may reimburse new parents who file a claim for doula services, but they typically do not guarantee that coverage in writing.
A report issued in March by the American College of Obstetricians and Gynecologists asserts that “one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.” Such constant companionship lowers the incidence of c-sections and increases maternal satisfaction.
One way that continuous labor support like that offered by a doula contributes to the reduction of c-section rates is through the role it plays in pain management. A study of several non-pharmacological methods of pain management in labor and birth concluded that constant companionship proved the most effective approach.
The medical community and natural childbirth advocates are engaged in a long-running and hotly contested debate over the pros and cons of drugs for pain relief in obstetrics, but there is no question that epidural anesthesia is a costly choice. Approximately three-quarters of American women use epidural anesthesia, despite the fact that there are other, cheaper, safer, adequately effective options, most notably nitrous oxide.
For those women who, for whatever reason, wish to avoid using epidural anesthesia, the encouragement and support of a doula can help them meet this objective. Women who do not wish to forgo pain medication entirely, but seek to avoid the potent effects of epidural anesthesia should be able to access nitrous oxide, and more women might feel comfortable choosing a less powerful anesthetic if they have a knowledgeable, trained, professional caregiver at their side.
The implementation of the ACA provides an opportunity to think about how we can bring a more rational and common sense approach to American maternity services, offering women the choices and the care that they deserve. Given the evidence that doulas can improve health outcomes, lower costs, and raise patient satisfaction, expanded access to their services should be a no-brainer. Two states—Oregon and Minnesota—have already moved in this direction, covering doula services under the Medicaid expansion. More should follow suit.
Whatever the ultimate resolution of the contraceptive mandate, the ACA is clearly here to stay and the need for reform in maternity services should be a front-burner issue. American women and their babies deserve better than what they are getting. Greater access to doula services would be a simple, significant step toward that goal.